In our managed care era, group therapy, long the domain of traditional psychodynamically oriented therapists, has emerged as the best option for millions of Americans. However, the process can be frustratingly slow, and studies show that patients actually feel worse after months of group treatment than when they began. Can and should "the group" speed a person's progress? Now, in this "must have" book, marriage and family therapist Linda Metcalf persuasively argues that the collaborative nature of group therapy actually lends itself to time-limited treatment. She combines the best elements of group work and the popular solution focused brief therapy approach to create new opportunities for practitioners and patients alike. Among the topics covered in this valuable guide are:
how to learn the model
how to design a group and recruit members
how to identify exceptions to a group member's self-destructive behaviors and thoughts
how to help members focus on their successes rather than their failures
how to keep the group solution focused when therapists or members fall back into old patterns
This unique resource also includes case examples and session transcripts to follow, together with reproducible forms that can be used as they are or tailored to a therapist's needs. Solution Focused Group Therapy is an up-to-the-minute, highly accessible resource for therapists of any orientation. Managed care companies in particular will welcome this model, which deals so effectively and economically with today's biggest problems, including eating disorders, chemical dependencies, grief, depression, anxiety, and sexual abuse.
Chapter One: Changing Directions in Group Therapy Even if you're on the right track, you'll get run over if you just sit there. -- Will Rogers The adolescents in the early morning process group stumbled into the group therapy room. Some of the kids dove toward the large pillows on the floor; the rest reluctantly approached and flopped onto the couches. The tech (mental health technician or MHT) followed them in, flipped through his roll sheets, found their names, and attempted to gain their attention by threatening them. Those who listened were acknowledged, and those who did not listen were asked to move closer to the tech. For the most part, the teens stared at me, wondering what they would be expected to do that day. I looked at them and noticed their reluctance to be there. It was a typical Monday morning in 1990 at a local psychiatric facility in Texas. Here I facilitated group treatment for various mental health problems, such as chemical dependency, anger, dysfunctional family dynamics, sexual abuse, and depression. I had used such theoretical models as strategic therapy, structural therapy, and family-of-origin therapy in running the groups, orienting each group session around what the treatment team deemed helpful to the patients. On that Monday morning I decided to try something new. I wanted to begin integrating into the context of the adolescent group some of the solution focused brief therapy ideas I was currently using in individual therapy sessions. I had set up a video camera in the corner of the room beforehand so that I could view the entire process later. Some of the teens seemed to be surprised and caught off guard when I began the group with a different type of question than what they were used to. "Look back over the weekend and tell me what seemed to go slightly better for each of you," I said. Silence. It was the kind of silence where you wonder if you're speaking some alien language. I was thankful when, after a few minutes and a repetition of the question, Dylan spoke: Well, I visited my family on Sunday, and we did not fight. That's good for them but bad for me. When I got back here last night, one of the techs asked how things went, and when I told him, he said I stuffed my feelings and that if I kept it up, eventually I would probably explode again. That's how it always is. I go along and do okay until my old man does something stupid, and then I blow up. That's how I got sent here. LM: So, Dylan, was this the first time you were able to not fight? DYLAN: Since I've been in here it is. LM: You know, you said someone called it stuffing your feelings. I think it sounds as if you just self-disciplined yourself. DYLAN: [Stares, without commenting] LM: In fact, I'm quite impressed with you. I wonder what your parents would say they noticed about you while you were self-disciplining yourself this weekend. DYLAN: Everybody seemed to have a pretty good time. It was quiet. We actually talked without anybody getting too mad. It was pretty different. LM: Did anyone in the group happen to see Dylan when he came back last night from his visit? SUSIE: I did. He seemed cool. His parents didn't look mad like they usually do. TOM: Yeah, I'm his roommate. He seemed okay. Usually he comes back upset, but last night he was better. DYLAN: But isn't it bad if I keep on stuffing these feelings and don't say what I need to tell my parents when they make me mad? LM: I don't know. What usually works best for you, telling them how you feel and getting mad or self-disciplining yourself like you did last weekend and somehow talking to them calmly? DYLAN: Self-disciplining myself. The adolescent process group was part of an inpatient treatment program, and the clients were assigned to the group by a treatment team consisting of a psychiatrist, a case manager, a nurse, and a psychologist. The patients also received individual therapy so that they could have personal time to discuss intimate issues. The group therapy component was added so that patients could learn how similar issues had affected others and how they were solving them. For the most part, the group sessions focused on confronting substance abusers and talking about recovery, describing sexual abuse experiences, toning down angry outbursts, discussing the effects of depression, or learning about unhealthy relationships. These sessions were a continuation of individual therapy, but in group therapy a problem focus was used as a theoretical basis. I continued to facilitate the adolescent group process with a solution focused approach for the next few weeks, always beginning the group with the same type of question and always looking for what was going better in the group members' lives. Dylan became one of my more outspoken group members, often interrupting other members to remind them to self-discipline themselves. The tech began to remark how this morning process group was easier to manage than the other groups and how the kids talked about how much they liked it because I seemed to like them. I noticed that several of the kids in the group who were previously referred to as "sleepers" had begun to talk more and to sit on chairs rather than on pillows. Some teens even moved to sit closer to me. Most seemed better able to recall issues they were working on each week, and the war stories decreased drastically. I was sold.
THE SOLUTION FOCUSED VERSUS THE PROBLEM-FOCUSED GROUP The wise don't expect to find life worth living; they make it that way. -- Anonymous In psychodynamic group therapy, members reveal their issues, express their unhappiness or distraught feelings, relate to and confront others who feel as despondent as they do, and search for insight that might lead to new behaviors and actions. Over the years, I have learned from many clients that while these groups are supportive, they are also unproductive, continuing for months and sometimes years on end and focusing just on what went wrong in the past. Clients emerge from those groups with insight yet wearing their hearts on their sleeves and ready to rationalize and defend why they had their particular disorders or complaints. There seemed to be few actual strategies that developed within those groups; instead, psychodynamic therapists offered so-called proven strategies that were described as "the way to recovery." When clients returned to a group session without having tried such strategies, they were considered "not ready to change" or "resistant." (Some clients have told me that they often left such groups feeling worse than when they began attending them.) When changing the direction of group therapy by integrating a solution focused approach, it is important for the therapist to give group members new ideas with which to construct new stories and to discourage them from adding to the pathological dialogue. For example, the change of atmosphere in the aforementioned adolescent group seemed to guide group members into more productive conversations, with more solution-friendly attitudes. However, the change took time and constant coaching and redirecting on my part to keep group members on a solution track instead of a problem track. Normally, the teens were told what they needed to do by the technicians and therapists. Dylan, for example, was told not to "stuff " his feelings. He previously lacked the confidence and self-awareness to understand his own competency, making him dependent on staff to solve his problems. Treatment was typically prolonged, since clients were not discharged until they performed the behaviors the treatment team decided they should perform. I offered Dylan an opportunity to become the sole expert on his life. This was a new process that sparked his curiosity and interest and pushed his participation to the next level. He began to respect himself in an environment that promoted such respect. When the group took a new direction, Dylan's apparent change of attitude, his new self-respect and positive beliefs about himself, became contagious. I believe that people enjoy being part of a solution focused process group primarily because it helps them find a comfortable place in the world, one in which their problems do not seem to take over. Such a safe experience offers an oasis to even the most despondent client. Despondent clients are more likely to give up their pathological descriptions when they discover that such descriptions are not going to be discussed. Instead, clients are invited to revisit the past and reminisce about the times when life was better. This experience often has the same uplifting effect as looking at old photographs of loved ones. As clients recall more pleasant times, they realize that life was not always so difficult; as each member hears others make this discovery, a kinship develops within the group, creating an atmosphere of hope. As clients realize that they have had successes in life, whether in the past or in dealing with a current situation, they seem to enjoy the idea that others, namely, fellow group members, have noticed such success. In solution focused group therapy sessions, the group helps to define the direction for its members to follow, validating and giving permission to each member to try new strategies.
A BRIEF HISTORY OF SOLUTION FOCUSED BRIEF THERAPY If you are not part of the solution, you are part of the problem. -- Eldridge Cleaver Traditionally, when clients came to therapy, they did so with a desire to understand how their lives went wrong. They looked to therapists to give them explanations in the hope that understanding the root of the problem would tell them what to do differently in order to correct the problem. Thus, therapists oriented themselves in the past instead of the present and searched for why problems occurred, that is, for information they could give their clients. For some action-oriented clients, such explanations motivated them enough to try the strategies handed down to them by their therapists. For other clients, such explanations gave them more reasons to feel and act incompetent. When Milton Erickson began working with clients in the mid 1950's, he took a new approach to therapy, one that offered new ideas for therapists to consider. "He addressed himself consistently to the fact that individuals have a reservoir of wisdom learned and forgotten but still available. He suggested that his patients explore alternative ways of organizing their experience without exploring the etiology or dynamics or the dysfunction." With this new approach emerged a new sort of client: one who could leave therapy with identified tools to solve future problems independently. The therapist became someone who helped the client access these resources and put them into use. This respectful stance became one of the basic constructs of solution focused brief therapy. However, the solution focused approach was still years away, even though a brief therapy was emerging on the West Coast. At the Mental Research Institute, John Weakland, Richard Fisch, Paul Watzlawick, and others worked with clients within a time limit of ten sessions. Their purpose was to reorganize the thinking of clients instead of trying to promote insight. In the view of the therapists at MRI, problems occur when the actions in life are mishandled. The greater the effort a person makes to try to solve the problem through inappropriate actions, the more entrenched the problem becomes and the less responsibility the person takes to solve it. The problem-focused approach involves thinking that problems are interactional and can best be solved when clients do something different around the problem. In the 1980s, solution focused brief therapy took a different turn in reference to how problems are viewed. Steve de Shazer and his team at the Brief Family Therapy Center in Milwaukee began looking at "what has been working in order to identify and amplify these solution sequences." In this approach, the recognition that a client's problems do not constantly occur encouraged therapists to focus on those problem-absent times as exceptions and to investigate which features of those times could be used in constructing a solution to the presenting problem. By identifying the specific interactions, behaviors, and thinking that helped them in past situations, clients were more apt to regard themselves as competent and to realize that they could solve their own problems with minimal assistance. Therapeutic tasks began to develop from these exceptions that clients presented to their therapist. The therapist's task became one of creating opportunities for clients to see themselves as competent and resourceful. Sometimes that meant asking a client to observe for a few days the times when the problem occurred less often; other times the client was to carry out small, specific tasks that he identified as helpful in dissolving the problem. With these new, less intrusive actions, the therapist assumed a less directive role. In believing that clients are the expert on their own life, the solution focused therapist became a sort of facilitator, guide, or assistant to the client; the purpose of such a therapist was to create opportunities for clients to see themselves as the expert on their own life.
ASSUMPTIONS FOR FACILITATING SOLUTION FOCUSED GROUP THERAPY People gather into groups to discuss their situations and to learn from each other new perceptions and ways of thinking that may influence their solutions for living. In solution focused groups, the focus of the conversation is on those times when a group member's problem is not a problem. The beauty of such groups emerges when members observe how others are able to discover such problem-free times, motivating them to try and find such discoveries within themselves. When group members participate in this collaborative process, the strategies grow geometrically. The result? Group conversations become even more efficient in promoting discussion of problem-free times and clients become more action oriented. To explore the differences between problem-focused and solution focused group therapy, I will discuss several basic ideas adapted from the solution focused assumptions offered by O'Hanlon and Weiner-Davis in their book In Search of Solutions. These numbered points are guidelines for the solution focused therapist to use during group therapy. 1. Keep the group nonpathological, redescribing problems to open up possibilities. When group members describe themselves and their lives with a problem focus or a diagnosis, these descriptions continue to reinforce their beliefs about themselves, keeping them stuck in old actions. I have observed this situation particularly in groups for persons who were abused sexually. Group members may complain and express frustration over either their inability to be intimate sexually or emotionally because of the trauma or their inability to stop their promiscuous actions. These feelings are well founded and should command a therapist's respect. However, a therapist who validates these feelings may provide such group members with an explanation that will serve only to reinforce their destructive actions. The negative behaviors that trouble such clients may then become part of their personal belief system about themselves, thus discouraging any chance for escaping from the trauma and moving toward intimacy. When group members label themselves in such a problem-focused or pathological manner, I have found it helpful to offer a new description that invites them to think about the exceptions. Many people enter group therapy because it was mandated by a court or because it was suggested by their individual therapist or physician. Every client's diagnosis is important and should be respected for its purpose in defining the underlying fact that something has gone astray. However, according to Michael White (1990), "Since the stories that persons have about their lives determine both the ascription of meaning to experience and the selection of those aspects of experience that are to be given expression, these stories are constitutive of shaping the persons' lives. The lives and relationships of persons evolve as they live through or perform these stories." As members each describe the situation that brings them to the group, the solution focused group leader will kindly and respectfully suggest to each member a new description that employs hope. This is more easily understood after clients have had a chance to describe what they think the group needs to know about them. White refers to a need for redescription of disorders or complaints. Suggesting a new perception does not change the diagnosis or minimize the problem. The new perception simply normalizes and redefines the presenting problem so that the group member begins to perceive solutions to it. O'Hanlon and Weiner-Davis (1989) describe the positive effects of normalizing as follows: "If pressed to speculate about the cause of many difficulties that motivate people to seek therapy, we would say that these difficulties have come about from some random events that just stuck around long enough to become viewed as a problem. We tend to view these things not as pathological manifestations, but as ordinary difficulties of life." 2. Focus on exceptions to the problems discussed in group interactions. Exceptions are real events that occur outside of the problem context. In solution focused individual therapy the only observers of competency are the therapist and client. In group therapy the audience widens and more input is available. The following are examples of questions the therapist can ask in an effort to identify when problems do not occur and what group members do to accomplish these nonproblem times: Can you recall ways that you have handled disagreements more constructively? What is different about the times when you do not feel quite as depressed? Can you share with the group what you did when you successfully resisted the urge to drink? Changing the direction in therapy from problem focus to solution focus can dramatically change the beliefs of clients and motivate them in even the most dire of circumstances. The following case study is an example of what can happen in a person's life when a new description of a problem is offered (this client began in individual therapy and then continued the treatment process later in group therapy): Annette was grief stricken from a failed marriage, overwhelmed by the responsibility of having full custody of a rambunctious four-year-old, and worried about her twenty-year-old son, who had been arrested for using and selling drugs, and her twenty-four-year-old daughter, whose marriage had also failed. Annette had attempted suicide three times within the year by overdosing with prescribed medications. Her first attempt occurred shortly after her son left his second treatment center and her daughter filed for divorce and moved back home. Over a period of several months, Annette attended inpatient and then outpatient therapy, but she continued in her hopeless view of life. She made a second suicide attempt, believing that even her four-year-old son would be "better off." She had learned in her inpatient therapy that she was the daughter her mother never loved and the problem coworker who was a "pain in the neck." More pathologizing led to more self-pity, and Annette attempted to take her life for the third time. A coworker of hers made Annette's first appointment at my office after the third suicide attempt and accompanied her to the first session. By the time I met Annette, she had been in and out of a psychiatric facility for several months. (She was discharged each time with more medication for her depression, plus sleeping medication as well!) It truly seemed that Annette had the weight of the world on her shoulders. As I began to work with her, she would often remind me that no matter what happened next, she wouldn't be surprised; she had lived through practically everything. I agreed with her that it seemed that way. I was also interested in what her other therapists had done that was helpful. She replied, "They just listened for the most part. Their suggestions never really made sense to me because they had no idea where I was in my mind." Before I invited Annette into group therapy, we spent several sessions in individual therapy exploring the days and times when she did not overdose. This was a different experience for Annette. She had received assertiveness and coping training in her inpatient treatment, but these approaches apparently did not fit with her personality; thus, she never used the techniques offered in the training sessions. When she failed at carrying out the tasks assigned to her, she felt hopeless and again began having suicidal thoughts. I realized that I needed to step aside and not lead Annette. She had been led before and had rejected the direction. Instead, I encouraged her to focus on those times when she did not rely on medication to relieve her emotional pain. This took time and required many compliments from me on her ability to cope even slightly under these most stressful situations, situations she did not quite understand. Eventually, in individual therapy, we found that she felt less hopeless when she had social plans, such as a night out with girlfriends, a few hours of shopping, a brief trip, or lunch at her parents' house. I began to recognize at this point that the social setting of a therapy group might be helpful to her. Annette began to learn that her mother's and sister's influence on her lessened when she was assertive with them in a kind manner more fitting to her personality. Her new confidence eventually was recognized by her ex-husband, who began paying child support on a more regular basis when Annette learned to insist on a deadline. 3. When you notice a group member's competency in the group process, comment on it intermittently and gather other group members' thoughts on your discovery. A year after her first suicide attempt, Annette was finally no longer giving in to the destructive thoughts that had overwhelmed her on so many occasions. Now, with less medication in her medicine cabinet, she took walks when she felt stressed, instead of attempting to take her life. I asked Annette to become a part of a newly formed women's group. In her first group session she made few comments, except for telling her story briefly. Before the meeting ended, I said to the group, "I have a favor to ask. I would like you each to think about the stories you have heard tonight and share an idea or two with each other regarding some strengths you might have noticed in each other." After a few moments, several of the group members gave each other compliments. Annette sat quietly. Finally, a group member addressed Annette's bravery in withstanding an ordeal she had had with her older son; she remembered how difficult it had been for her to watch her own daughter follow the path of alcoholism. She told Annette that no matter what anyone would ever say about her, she was a truly loving parent who never gave up on her son. She said that as Annette talked about her son, she could see that she was concerned about him and yet able to set boundaries with him. The next group began with my usual question: "What went slightly better last week?" When solution focused groups meet for the first few times, members often have difficulty with this question, because it directs them toward solution talk when their assumption is that group therapy means coming to admit their faults and limitations. Instead of encouraging members to commiserate with each other, this question stretches their awareness of themselves and encourages them to notice the good days. Therapists may at first find themselves often redirecting the conversation toward solution perceptions; however, after the first two or three meetings, the atmosphere becomes more natural and group clients begin to partake in solution talk more readily. Annette had come in telling jokes during this second meeting, thus gaining the confidence of the group and helping to lighten the tone of the meeting. Now she responded to my question: "I've had one of the worst weeks ever. My boss thought I was resigning from my job when I gave him a letter of concern about my job description, and for about three days I had no job! Then I got rehired in another department. I think my son is doing something crazy again, but I didn't do any funny stuff this time. Instead, we just got down and talked. He's still at home, my daughter's left her husband again and come home again, and I still think I will never be alone. So I'm going out on Friday night this weekend, and if any of you want to go with me, hey, I'm ready." What occurred to change Annette's belief in herself? I'm not sure that it matters! For the next several weeks, she came to group meetings and shared her insights about the others' abilities. On several occasions she said to a group member, "Look at me. If I can do this, anyone can do this." The power of noticing a person's ability on the spot keeps the compliments real. Otherwise, the feedback can seem fake and contrived, and group clients may have trouble switching personal definitions of themselves. For example, Judy, an adolescent girl who viewed herself as ugly, nonsocial, and strange, once spoke up in a girls' group about being and feeling so "different." After Judy shared how odd she often felt when talking to others, I asked the group to describe to her how she seemed to come across when she talked to them. As each group member conveyed approval of her conversational abilities, Judy sat back, aghast. She then said that her mother often reprimanded her for appearing strange and that she had come to believe that her mother was correct. I then suggested to the group that perhaps they could help her show her mother the seemingly normal personality we were noticing. Judy was pleased and accepted these ideas readily. 4. Avoid any tendency to promote insight and instead focus on the client's ability to survive the problem situation. Neff Blackmon, Ph.D., a marriage and family therapist who facilitates inpatient chemical dependency recovery groups, started using a solution focused approach in his private practice with groups of women who had survived sexual abuse. Although many of his clients had attended sexual abuse therapy groups for years, within a few weeks the women were dropping out of group therapy because they felt so much better. Instead of having them talk about the sad, unfortunate details of the abuse, Blackmon had encouraged them to focus on survivorship. While some group members needed what he referred to as a "running start" (i.e., the opportunity to talk briefly about the incidents that had happened to them), most of his clients found his approach refreshing, and some said they felt less violated by not having to recall the details of past events. His new focus also seemed to help group members watch for the successes (no matter how small) in their lives. He promoted this by asking questions such as the following: If you no longer had to come here or couldn't come here to therapy anymore, how would I know things were better by what you did versus what you said? If you were doing the right things for yourself during the next week and I pretended to be Martin Scorsese, filming you when you did those things, what would you point out to me to film? Another strategy that Blackmon used to help group members see themselves differently was to take them on field trips to baseball batting cages. His suspicions were that many group members needed a chance to have a physical outlet for expressing their feelings in healthy, strenuous, and "appropriately violent" ways. Once group members began to enjoy these activities, they began doing other activities together outside of group time. In Blackmon's words, "they learned to have fun instead of just being miserable." Encouraging new behaviors by providing group members with a dramatically different type of experience is a novel way of assisting them in discovering alternative ways of living and coping. Blackmon tells the story of one group member, Jody, the wife of a pilot, who cleaned up her garage and bought a cheap set of dishes at a discount store. She and a friend then went into the garage and threw the dishes, breaking them into pieces. "I was never allowed to be angry about the stuff that happened to me," she said. Blackmon was so impressed by her determination to live her life differently that he asked her these questions: "What other signs would there be for the wife of a captain of an airline that would say that she had it together?" "If I didn't see you again for a year and I ran into you somewhere after that year, how would I know you were better?" The woman began flying to Paris at least once a month to have fun and enjoy herself. What made a difference for her in the group setting? Blackmon momentarily stepped into her world and stimulated her to think of new ideas that were readily available to her. The strategy Blackmon used was important, since it did not force or require his clients to do things that were too out of the ordinary for them. I strongly caution therapists to refrain from urging their clients to engage in totally unfamiliar activities. Clients seem to be more likely to take on activities that are comfortable for them and in which they have some expertise. For Jody, flying was available and something she had done before; the experience seemed to provide her with an avenue of escape from the past. 5. Attempt to see group members as people who have complaints about their lives, not as persons with symptoms. The beliefs we carry around about people enter the therapy room with us. The therapist's empathy, compassion, and concern for others is important, but in solution focused group therapy what is especially important is the ability to make clients understand that they have strengths and coping mechanisms and have had past success in troublesome situations. Such a message provides clients with a feeling of relief, a feeling that can evolve into positive attitudes which then can result in productive actions. For example:
When Blackmon took his group to the batting cages, the message became "You can do this; you can have fun even though this trauma occurred in your life."
When Dylan thought of himself as self-disciplined, the message was "I've been successful but I didn't realize it before; I can stay calm with my dad."
Because she heard a message of "You're okay" from group members, Judy felt normal in the eyes of her peers and was more likely to try normal behaviors at home.
When Annette was described as having incredible coping abilities, she received a message that she could do something more constructive than rely on medication to solve her problem. These discoveries were made by the clients themselves, but it was their group who gathered together and set the stage for the discoveries that changed their beliefs. When we therapists think of our