Abstract. The study aimed to explore what elements of the solution-focused brief therapy (SFBT) process clients perceive as helpful, and how their perception varies by level of engagement. The replication of the SFBT model from the perspective of clients residing outside the United States was also examined. A mixed-methods design was used in a naturalistic setting in Poland. Clients (N = 346; 74% women) aged 18 to 67, receiving psychotherapy in private practice, were surveyed. Thematic analysis revealed eleven main themes. The SFBT-specific themes replicate the original model, but a more orderly organisation of the core elements emerged than those that exist. The elements perceived as helpful varied significantly by level of engagement. The two generic themes identified suggest that allowing the client to vent, while working on awareness and understanding, is an essential environment within which the solution-focused co-construction process takes place.

Keywords: solution-focused approach, process research, client perception, therapeutic engagement, Bruges model, mixed methods

Introduction

Solution-focused brief therapy (SFBT) is a co-constructed process which assumes that clients are the experts on their own lives and possess all the capabilities and resources needed to solve their problems or overcome obstacles, even if they are not aware of them (de Shazer, 1985, 1988; Lipchik, 2011). The model was developed by Steve de Shazer, Insoo Kim Berg and their colleagues at the Brief Family Therapy Center (BFTC) in Milwaukee, from clients’ feedback on what had helped them reach their goal (de Shazer, 1985, 1988; de Shazer & Berg, 1997; McKeel, 2012). SFBT is now applied across cultures. Higher effectiveness has been found for clients not residing in the United States, where it originated (Neipp & Beyebach, 2022; Stams et al., 2006). Yet no previous study has looked at the extent to which clients outside the United States perceive the SFBT-specific elements as helpful.

Clients may perceive different elements as helpful depending on their needs and expectations. Some want to change; others want to change other people; others still do not know what they want. Depending on the client’s engagement, several types of relationship have been identified in the SFBT model, with the recommendation to adjust the intervention accordingly (de Shazer, 1988; Isebaert, 2016). Little research has sought to provide empirical evidence for these recommendations.

The present study aimed to identify to what extent the elements of the original model were reflected in the feedback of non-American clients, and to explore how the perceived helpfulness of specific solution-focused (SF) elements varied by level of engagement. A naturalistic study was conducted with Polish clients in individual psychotherapy. Replicating the model can provide empirical support for its cross-cultural adequacy.

Studies on the client’s perspective offer a view of the therapeutic process different from the therapist’s (Metcalf & Thomas, 1994), and therefore additional information on how to shape the process and adapt it to the client’s actual needs (Hodgetts & Wright, 2007). Since therapy is a cooperative enterprise in which therapist and client both play an active role (de Shazer, 1985), identifying which element is most helpful for which client can help practitioners adjust the intervention better. SF trainers can then emphasise not only the method and the questions, but also their timing.

The solution-focused process

The SF process rests on co-construction, during which the therapist influences how the client builds their view of the problem situation by choosing which questions to ask and which answers to comment on (de Shazer, 1985, 1988). Questions are based directly on the client’s answer. Together they co-construct the goal of therapy, the preferred future, or deconstruct exceptions to identify previous solutions or personal resources (de Shazer, 1994).

Specific questions or actions used by the therapist in session were identified as core elements by the model’s designers: (1) the miracle question (asking the client to visualise their life if a miracle solved the problem), (2) scaling questions (ratings of various aspects from 0 or 1 to 10, often used to spot progress and exceptions), (3) the break (the therapist stops interacting with the client, often by leaving the room, to prepare the feedback), and (4) the end-of-session feedback (closing the session by complimenting the client on strengths and resources and giving suggestions or tasks for after the session) (de Shazer & Berg, 1997). Suggestions follow the central philosophy of SFBT: repeat what already works, change what does not, do not fix what is not broken (de Shazer, 1985). All four elements must be present to say that the SFBT model was used (de Shazer & Berg, 1997).

Later, Gingerich and Eisengart (2000) added pre-session change (asking about progress already under way before the first session) and separated the miracle question from goal setting (establishing the goal of therapy), and scaling questions from the search for exceptions (exploring situations where the problem is absent), giving three further core elements. But the new requirement for an intervention to count as SFBT became “at least one element included” (Gingerich & Eisengart, 2000). These seven elements became a standard in research and practice.

Other authors proposed further core elements, such as the search for strengths or solutions (identifying personal resources and strategies already possessed) (Kim & Franklin, 2009), coping questions (exploring how the client has coped, to look for strengths and solutions), and the focus on progress (examining what has changed for the better between sessions; Trepper et al., 2014).

The core elements are co-constructed across sessions through presuppositional language: the therapist assumes their existence (de Shazer, 1985, 1988). Co-construction succeeds when the client responds to the presuppositions by providing information about the given element. To play their part in co-construction, clients must be ready to answer SF questions. Timing is therefore relevant.

To help practitioners adjust their intervention, several types of relationship have been described according to the client’s engagement, with recommendations on which elements to favour.

Level of engagement in SFBT

At the BFTC, three types of therapist-client relationship were observed according to the client’s attitude to the problem (de Shazer, 1988): (1) the visitor, when the client has no complaint but comes at someone else’s request; (2) the complainant, when the client acknowledges a problem but expects others to solve it, either failing to see their own role in the change or, seeing it, being stuck for action; (3) the customer, when the person shows readiness to do something to solve the problem, ready to move from words to deeds.

Although they were not defined in terms of readiness to change (de Shazer, 1988), Barbara McFarland (1995) drew a parallel with the stages of the transtheoretical model (Prochaska et al., 2008; Prochaska & DiClemente, 1982), likening the visitor to precontemplation (the client has no intention of taking the necessary steps), the complainant to contemplation (the client thinks about the need to change but is not ready to commit), and the customer to preparation (concrete action plans form) or action (the plan is implemented), depending on whether the client can identify action tasks.

This distinction was also emphasised in the Bruges model developed at the Korzybski Institute, where the therapist-client relationship is defined by level of engagement. A fourth type was proposed, the consulting relationship, for clients ready to act who do not know how, lacking awareness of their resources and strengths (Isebaert, 2016). Moreover, the BFTC labels were changed to reflect the relationship rather than the individual. But the proposed categories are not identical. The non-committed level includes not only involuntary clients but also voluntary clients who are not specifically asking for help. Searching refers to clients who ask for help but are not ready to act, not only because they expect change from others, but also because their goal is unclear. At the expert level, clients are aware of their resources and of the steps to take (Isebaert, 2016).

The BFTC and Bruges models are currently the only two distinct descriptions of the client’s level of engagement in use in SFBT. Both agree that the intervention should differ by level. At the visitor or non-committed level, identifying a working goal is difficult; the therapist should therefore look for strengths and resources, compliment, and raise awareness of the situation by exploring worst-case scenarios (de Shazer, 1988; Isebaert, 2016; McFarland, 1995). At the complainant or searching level, the miracle question, scales, and the search for pre-session change and exceptions may help clients see their role in the solution and increase hope and motivation (Isebaert, 2016; McFarland, 1995). At the customer or consulting level, a workable goal can be defined, alongside the search for and reinforcement of strengths and solutions to increase the client’s awareness (Isebaert, 2016; McFarland, 1995). Finally, at the expert level, reinforcing the client’s strengths and capabilities used to reach the goal is enough (Isebaert, 2016).

As evidence of the relationship between intervention and level of engagement, Phillip Ziegler (2010) added to the BFTC model labels describing the therapist’s corresponding role: visitor/host, complainant/sympathiser, customer/consultant. By neglecting the client’s engagement, the therapist risks co-constructing elements the client is not ready for.

Previous studies on what clients find helpful in SFBT

Overall, little research has addressed the client’s view of the psychotherapeutic process (Hodgetts & Wright, 2007). Findings indicate that clients perceive SF-specific elements as helpful, such as problem-free talk, hopes for the future, analysis of progress and the central philosophy (Northcott et al., 2021; Quick & Gizzo, 2007). They also value the same generic aspects as clients of other approaches (Elliott & Williams, 2003; Hodgetts & Wright, 2007; Timulak, 2007): the therapeutic relationship, the therapist’s characteristics, and the chance to talk about their life or feelings while feeling understood (Metcalf & Thomas, 1994; Northcott et al., 2021; Shilts et al., 1997). But not all clients valued the same elements. For example, talking about feelings was perceived as helpful only by aphasic patients in emotional distress (Northcott et al., 2021).

Variability in the perceived helpfulness of specific SF questions was observed, and was reflected in the answers too. Clients answered scaling questions more easily than the miracle question (McKeel, 2012). The former were perceived as useful for seeing progress and that their situation was not so bad, while the latter made them uncomfortable, while also giving them hope and clarifying the goal. Likewise, clients more readily identified changes between sessions than before therapy began, but the percentage of clients able to answer varied between studies, from 30% to 62.2% for the latter (Allgood et al., 1995; Johnson et al., 1998; Lawson, 1994), and from 56% to 80% for the former (Herrero de Vega & Beyebach, 2004; Reuterlov et al., 2000).

A question therefore arises: what produces these differences? What makes an element or question helpful for one client and not another? Various explanations have been advanced concerning the exact words used by the therapist (Allgood et al., 1995; Herrero de Vega & Beyebach, 2004; Johnson et al., 1998), but the timing of the question, according to the client’s level of engagement, has rarely been taken into account. The few available studies show that at the complainant level, clients are not ready to define therapeutic goals, exploring pre-session change being more effective (Beyebach, 2014; Beyebach et al., 1996). Moreover, clients with no clear therapeutic goal valued the chance to vent more; if the therapist was not attuned to their needs, they expressed dissatisfaction (Northcott et al., 2021).

Aim

The present study aimed to answer two questions:

1. To what extent does the original SFBT model replicate in the feedback of non-American clients, and which elements are mentioned most often, consistent with the existence of a core?
2. How does the perceived helpfulness of specific elements vary with the client’s level of engagement? The BFTC and Bruges models were examined separately, to offer useful insight to SF practitioners and trainers whatever their preferred model.

By examining the empirical evidence, this study can strengthen the observations of practitioners and theorists (de Shazer, 1988; Isebaert, 2016; Lipchik, 2011; McFarland, 1995) and complement existing recommendations for adjusting the intervention to the level of engagement. Neglecting clients’ needs can lead to a longer rather than briefer process, or even to dropout (Beyebach, 2014; Lipchik, 2011). Thus, although it is a brief intervention, the general recommendation in SFBT is to go slowly (Fiske, 2008; Lipchik, 2011) and to lead one step behind (De Jong & Berg, 2012). Knowing which elements are helpful for which client can help practitioners adjust the intervention better while respecting the client’s pace in the co-construction process.

Methods

Participants and procedure

The study was conducted in a naturalistic setting. Data were collected from adult clients receiving individual SF psychotherapy in private practice.

Initially, three psychotherapists with similar SFBT training took part in data collection. Two later withdrew to devote themselves to other projects, leaving the third, the author, to continue. Given the mixed-methods design, to reach theoretical saturation of the answers (Giacomini et al., 2000) and ensure sufficient statistical power, data were collected over two years, from 2019 to 2021.

In total, 317 clients were recruited by the author in the Lesser Poland voivodeship, with a smaller proportion of answers obtained by a male therapist (N = 17) and a female therapist (N = 12), in Łódź and Silesia respectively. The majority were women and paying clients, aged 18 to 67 (see table 1). Twenty-seven clients did not give their age. The number of sessions ranged from 1 to 29, median 2 (1, 4). Some clients who had more than one session gave more than one answer, at different times.

Intervention

The three psychotherapists use SFBT in practice as their main approach, in line with the SFBT treatment manual (Trepper et al., 2014) and the requirements defined by the European Brief Therapy Association research group (Beyebach, 2000). At the time of collection, their practical experience ranged from three to five years. All were in the third of four years of psychotherapy training, corresponding to level three of three in SFBT in Poland. Training was provided by the Brief Therapy Centre in Łódź, in collaboration with experienced therapists and supervisors from the European Brief Therapy Association. The programme met the national requirements for certified psychotherapist qualification. Over the four years, participants accumulate about 370 hours of SFBT training and supervision, in addition to 900 hours of psychotherapy methods, clinical practice and personal psychotherapy.

Ethical considerations

At the start of therapy, clients were informed of the possibility of using information about the process in research, with a view to improving it. No incentive was given. Clients had no objection. They could object to collection throughout therapy. No identifying data were collected. Initially, ethical review was waived because of the specificity of the study, non-experimental, non-invasive and with no effect on subjects. The protocol was later submitted and received a favourable opinion from the ethics committee of the Polish Association of Solution-Focused Psychotherapy (no. 2/04.11.2022).

Data collection

Qualitative and quantitative data were collected simultaneously, following the concurrent mixed-methods design. Qualitative data were collected by asking clients a standard question at the end of the session: “Of what happened here today, what was most helpful to you?” Therapists asked the question at random, not of all clients, and regardless of complaint, number of sessions, type of relationship or observed level of satisfaction. The question was part of the therapeutic process. Clients in SFBT are often invited to evaluate the helpfulness of the intervention, in order to use their expert view to guide treatment (Fiske, 2008; Metcalf & Thomas, 1994).

Quantitative data, represented by the level of engagement, were identified by the therapist conducting the session. All therapists had been trained to identify the therapist-client relationship defined in the BFTC model (de Shazer, 1988) at the Brief Therapy Centre in Łódź. For the Bruges model, each therapist used the Bruges flowchart supplemented by the description of each level of engagement (Isebaert, 2016).

Data analysis

A three-step data transformation design was used. First, thematic analysis of the qualitative data to identify which elements of the SFBT process clients perceived as helpful. Thematic analysis was chosen as an adequate method for identifying a person’s beliefs and experiences. Raw data were coded manually in a spreadsheet. A coding framework was developed and continually adapted to capture all answers. Codes, categories and themes were built inductively, following current recommendations (Guest et al., 2012; Nowell et al., 2017). Codes and categories were labelled in the participants’ language. Themes were named only at the end, using current terminology, to show a relationship without influencing coding.

Second, themes were quantified to identify which elements of the SFBT process were most often identified as helpful. Finally, at the mixed step, odds ratios were calculated to identify how themes related to the quantitative data represented by the type of relationship. Fisher’s exact test was used to test significance when the distribution of themes by type of relationship was too low. All statistical analyses were carried out in R and R Studio (R Core Team, 2021; RStudio Team, 2022), with the packages “tidyverse” (Wickham et al., 2019), “psych” (Revelle, 2022) and “stats” (R Core Team, 2021).

Trustworthiness of the data

The trustworthiness of the qualitative analysis was ensured as follows. For credibility, three people took part in data collection. When two withdrew, collection by the remaining therapist was extended over two years to avoid moderator bias. Moreover, to avoid the influence of the therapists’ knowledge of the SFBT process on clients’ answers, no in-depth investigation was used to extrapolate further meaning. Audio recording was not chosen, clients’ short answers allowing direct transcription. Coding and categories were based on the clients’ language. Prolonged engagement made it possible to obtain information at different points in the process, by asking the same question at the end of various sessions to long-term clients.

The similarities observed between the answers collected by the author and by the other two therapists indicate the replicability of the data in various settings, that is, when sessions are conducted by different practitioners. The objectivity of the analysis was ensured by extending the recommendation of Guest et al. (2012) for the case where a second coder is not available: coding the whole data set three times instead of twice, at two-month intervals. Few inconsistencies were observed, each coding leading to more precise labelling and categorisation of the answers.

The author is a licensed psychologist, with a doctorate in social sciences in the discipline of psychology, with seven years’ experience of the SF approach in a therapeutic setting. Since 2020 she has been a certified psychotherapist according to the requirements of the Polish Council for Psychotherapy. She adheres to the SF philosophy and recognises the client as the expert on their own experience; she therefore considers that her views did not significantly influence the analysis or the results.

Results

Descriptive statistics

Descriptive statistics by level of engagement are presented in table 1.

No significant difference in age was found by level of engagement, in either the BFTC or the Bruges model, F(317,1) = 0.79 and 0.29, p = 0.375 and 0.588. Likewise, no significant difference in the distribution of levels by gender or by free versus paid treatment, either for the BFTC, χ²(2) = 1.41 and 2.60, p = 0.493 and 0.293, or for Bruges, χ²(3) = 1.01 and 5.44, p = 0.760 and 0.154. But significant differences were found by number of sessions, in the BFTC, χ²(4) = 42.37, p < 0.001, and in Bruges, χ²(6) = 50.43, p < 0.001.

The customer rather than the visitor level, OR = 2.68 [1.52; 6.23] and 5.33 [1.78; 16.02], z = 2.29 and 2.98, p = 0.022 and 0.003, or rather than the complainant level, OR = 3.73 [2.11; 6.59] and 7.27 [3.70; 14.28], z = 4.53 and 5.76, p < 0.001, was significantly more often identified when evaluation took place from the second to the fourth session, or at the fifth and beyond, compared with the first. No significant difference in the complainant/visitor distribution by number of sessions. Likewise, expert rather than searching was significantly more likely at the fifth session or beyond, compared with both the first and the second to fourth, OR = 63.19 [3.43; 1164.19] and 7.43 [1.39; 39.80], z = 2.79 and 2.34, p = 0.005 and 0.019. Expert rather than non-committed was also more likely at the fifth session or beyond compared with the first, OR = 66.73 [3.39; 1315.11]. In addition, consulting was significantly more often identified than non-committed or searching, OR = 6.30 [2.39; 16.57] and 5.78 [2.82; 11.70], z = 3.73 and 4.82, p < 0.001, at the fifth session or beyond compared with the first. No significant difference in the expert/consulting or non-committed/searching distribution by number of sessions.

A similar tendency to identify clients at a higher level of engagement as they attend more sessions was therefore observed with both models. But it cannot be said how the transition from one level to another took place, in the absence of longitudinal follow-up, outside the scope of this research.

Thematic analysis

Eleven main themes emerged, in addition to the one containing low-frequency categories that fitted no other theme. Frequencies by theme, category and sub-category are presented in table 2, ordered chronologically according to their use in session rather than, as usual, by frequency. Nine themes concerned aspects specific to the SFBT process as described by other authors (de Shazer & Berg, 1997; Gingerich & Eisengart, 2000; Trepper et al., 2014). Themes 10 and 11 contained elements common to other approaches, not mentioned in the literature as core or characteristic SF elements, which I therefore labelled “generic”. The themes, with example quotes in italics, are described below, starting with those specific to the SFBT process.

Theme 1: goal. Among the SFBT-specific themes, the highest frequency was reached by goal, which groups the answers related to co-constructing the therapeutic goal. Three categories and six sub-categories were identified. Clients perceived as helpful (a) defining the goal, through a clear formulation of what they want, (b) becoming aware of what they need to get there, and (c) analysing the differences between the various options they have for living their lives. The helpfulness of visualising their preferred future was not always associated with the miracle question. Participants also valued their attitude to change, realising that they could actively influence it, that change is not so difficult, and that they could do it.

“All the questions you asked me about the concrete change in my behaviour were helpful; knowing what it is going to look like. Thanks to your questions, what I want is clear now, and it does not look so difficult” (female client, age not given).

Theme 2: exceptions. The theme of aspects related to co-constructing exceptions had less relevance, probably because clients see past events not as a source of solutions but rather of the problem. Three categories: (a) focusing on what works in their lives despite the problem, (b) analysing exceptions by looking at the differences between the situations where they did or did not manage to cope, to identify how they did it, and (c) becoming aware that their situation is not so bad. The latter was often mentioned with scaling questions (for instance: “I realised I am not at zero!”), in line with the purpose for which they were built (de Shazer & Berg, 1997).

“It was helpful to see the time perspective, to see how I already managed to function with the same problem” (female client, 27).

Theme 3: progress. This theme contained the answers related to co-constructing progress towards the goal. Clients valued talking about what changed for the better from one session to the next. Three aspects perceived as helpful: (a) being able to see improvements, everything they had already managed to change, (b) seeing that things are going in the right direction, and (c) realising that they had already reached their goal by being able to do what they had only dreamt of at the start of therapy. These aspects were sometimes associated with scaling questions.

“It was helpful to make the list, to summarise all the positive things that happened since the last session, to see what worked well and how” (male client, 32).

Theme 4: empowerment. Answers on the helpfulness of co-constructing aspects related to empowerment also grouped into three categories: (a) becoming aware of personal strengths and resources already possessed, such as positive traits, being a strong person, or having tools, (b) receiving confirmation of already doing the right thing, and (c) receiving compliments from the therapist. The last category was included in empowerment for consistency, although compliments are also part of the end-of-session feedback (de Shazer & Berg, 1997). Empowerment and the focus on strengths are relevant aspects of SFBT (Kim & Franklin, 2009; Trepper et al., 2014), present throughout the session.

“I realised that I can cope, because someone objective, who did not know me before, told me that I am doing something well. You know? It counts, when you hear compliments from someone outside your family or friends” (female client, 50).

Theme 5: action. The theme of aspects related to co-constructing the actions needed to reach the goal had the second highest frequency. Four categories: (a) the concrete focus on “know-how”, which helped clients know what to do next, what is worth trying, (b) establishing an action plan, (c) having a direction for the actions to take, and (d) identifying the first or next step. Some clients realised that they cannot do everything at once, and that one small step today is enough to make tomorrow different.

“From today’s session, I appreciated the focus on concrete aspects, the discussion about how to reach what I want, and those different action steps” (male client, 27).

Theme 6: central philosophy. A theme corresponding to the SF central philosophy was also identified, clients referring to the three elements described by de Shazer (1985). The most mentioned element related to changing what does not work. Clients valued as helpful understanding what they were doing wrong, or the differences between what helps and what does not.

“The comparison between the problem situations and what already works well at my job helped me understand. Now I realise what I was doing; what makes sense and what does not. I mean, it makes no sense to fight the situation” (female client, 29).

Other clients valued the awareness that they can do something different.

“I had not thought before that I could react differently to what my partner does. Now I know that instead of arguing with him, I can simply mind my own business and do what I want” (female client, 25).

In the category “repeat what already works”, two distinct sub-categories: doing more of what works for the given problem (“I discovered that I am doing the right thing, that I am going in the right direction, and I intend to carry on”, male client, 24), and generalising what works from one area of life to another (“I realised that if I am a champion at planning, I can use it in the relationship with my children”, female client, 34).

The lowest frequency of the third central philosophy, “if it is not broken, do not fix it”, is not surprising, most clients coming to therapy in order to change.

“I now realise that the problem is not where I thought it was, that the situation is not so bad and that I have nothing to change” (female client, 45).

Theme 7: hope and readiness to change. This theme contains the answers reflecting the feeling of hope that the situation will improve and the motivation to act. In line with previous research linking SF elements to these aspects (McKeel, 2012), I considered this theme SFBT-specific.

“I cannot wait to try this new idea. I am going to create a stressful situation just so I can try it” (female client, 23).

Theme 8: end-of-session feedback. This theme groups the answers relating to the end-of-session feedback. The perceived helpfulness of the therapist’s summary and suggestions provides further evidence of the relevance of closing sessions this way. As noted, compliments, although also part of the feedback, were counted as empowerment elements.

“The idea you gave me during the summary, to think about what taking risks can have that is good and bad for me, was helpful. I think it will help me get used to taking risks” (female client, 35).

Theme 9: the therapist’s SF attitude. Few clients mentioned the therapist’s SFBT-specific attitude as the most helpful part of the session, such as the absence of evaluations, advice or analyses of the past. Some also valued the therapist’s curiosity throughout the session, positivity and faith in their ability to produce change. On the other hand, more clients valued being heard and understood.

“For me it was helpful that you encouraged me to think without giving me advice like ‘do this or that’, because it is a difficult situation I am in” (female client, 37).

Theme 10: venting. The highest frequency was reached by the generic theme reflecting the client’s chance to say out loud what they feel or think and to share their thoughts with someone. Some clients justified the helpfulness of talking out loud by having to keep things to themselves, so as not to burden their loved ones. “Venting” was the most often valued element of the session. Some also mentioned the immediate effect of relief, feeling better.

“I feel a bit better now, because I could vent” (female client, 35).

Theme 11: awareness and understanding. The second highest frequency was reached by another generic theme, reflecting clients’ awareness and understanding of themselves or their situation. Clients valued understanding themselves better and knowing why they acted the way they did. It was also helpful to feel that they are normal human beings and not bad people to be blamed. A few clients valued awareness of their rights. A few found awareness of their limited influence on the situation helpful, so as not to try to change what cannot be changed.

“Now I understand why, in that situation, I reacted the way I did. I really want to understand my past” (male client, 29).

A similar number of clients valued understanding the situation better and having another perspective.

“I have another perspective now. This meeting completely changed my thoughts about my daughter” (female client, 49).

Others valued the chance to reflect on their situation by receiving difficult questions they would not otherwise have confronted, and answering them. It was also helpful to put their thoughts in order.

“You ask me difficult questions that irritate me, but also force me to think. I have never received such difficult questions, but they open my eyes to things I was not able to see before” (female client, 20).

The importance of the themes relative to one another

The two generic themes both had a significantly higher frequency than any SFBT-specific theme, from the least frequent (therapist’s SF attitude) to the most frequent (goal); odds ratios ranged from 6.12 [3.59; 10.43] to 1.82 [1.24; 2.65], z = 6.66 to 3.09, all p < 0.002 for venting, and from 5.75 [3.37; 9.82] to 1.71 [1.17; 2.50], z = 6.41 to 2.75, all p < 0.006 for awareness and understanding. No significant difference between these two generic themes, OR = 1.05 [0.74; 1.48], z = 0.27, p = 0.791.

Analysing the frequencies, to see whether a core stands out among the SFBT-specific themes, the results show that goal and action were mentioned more often, while exceptions and the therapist’s SF attitude were mentioned less. Goal was significantly more often mentioned as a helpful theme than exceptions, OR = 2.86 [1.69; 4.85], z = 3.90, p < 0.001, empowerment, OR = 1.70 [1.07; 2.68], z = 2.26, p = 0.024, hope and readiness to change, OR = 2.02 [1.25; 3.26], z = 2.88, p = 0.004, end-of-session feedback, OR = 1.95 [1.22; 3.13], z = 2.76, p = 0.006, and the therapist’s SF attitude, OR = 4.28 [1.93; 5.88], z = 4.28, p < 0.001, and marginally more than the central philosophy, OR = 1.54 [0.99; 2.42], z = 1.90, p = 0.057, and progress, OR = 1.50 [0.96; 2.34], z = 1.78, p = 0.075. Action was significantly more often mentioned than exceptions, OR = 2.55 [1.50; 4.36], z = 3.44, p < 0.001, hope and readiness to change, OR = 1.80 [1.11; 2.93], z = 2.38, p = 0.017, end-of-session feedback, OR = 1.74 [1.07; 2.81], z = 2.25, p = 0.024, and the therapist’s SF attitude, OR = 3.01 [1.71; 5.28], z = 3.84, p < 0.001, and marginally more than empowerment, OR = 1.51 [0.95; 2.41], z = 1.75, p = 0.081. Moreover, exceptions were significantly less mentioned than progress, OR = 0.52 [0.30; 0.91], z = 2.28, p = 0.022, and the central philosophy, OR = 0.54 [0.31; 0.94], z = 2.17, p = 0.03, and marginally less than empowerment, OR = 0.59 [0.33; 1.04], z = 1.81, p = 0.07. Finally, the therapist’s SF attitude was also significantly less mentioned than progress, OR = 0.44 [0.25; 0.80], z = 2.73, p = 0.006, empowerment, OR = 0.50 [0.28; 0.91], z = 2.27, p = 0.02, and the central philosophy, OR = 0.46 [0.26; 0.82], z = 2.62, p = 0.009.

Relationship between themes and level of engagement

Significant differences in the distribution of themes by level of engagement were found for goal, progress, action and venting (see table 3).

In the BFTC model, goal, progress and action were significantly more often reported at the customer than at the complainant level, OR = 2.04 [1.10; 3.75], 7.52 [3.41; 16.60] and 2.48 [1.31; 4.68], z = 2.28, 4.99 and 2.80, p = 0.023, 0.0001 and 0.005. Progress and action were more often reported at the customer than at the visitor level, OR = 27.87 [1.66; 468.25] and 3.43 [0.97; 12.10], z = 2.31 and 1.92, p = 0.021 and 0.055, the second difference reaching only marginal significance. Conversely, venting was more often reported at the complainant than at the customer level, OR = 4.99 [2.37; 10.53], z = 4.23, p < 0.001. No significant difference between complainant and visitor.

In the Bruges model, goal, progress and action were significantly more often reported at the consulting than at the non-committed level, OR = 3.88 [1.25; 11.99], 50.71 [3.03; 849.10] and 3.90 [1.40; 10.87], z = 2.35, 2.73 and 2.60, p = 0.019, 0.006, 0.009. Progress and action were more often reported at the consulting than at the searching level, OR = 7.03 [3.13; 15.78] and 2.66 [1.36; 5.18], z = 4.73 and 2.86, p < 0.004. Conversely, venting was more often reported at the non-committed or searching level than at the consulting level, OR = 9.26 [3.72; 23.05] and 5.09 [2.21; 11.74], z = 4.79 and 3.82, p < 0.001, and more often at the non-committed than at the searching level, OR = 1.82 [1.01; 3.27], z = 2.00, p = 0.045. No significant difference concerning the expert level, probably because of the small number of clients in this group.

Discussion

The present study explored which elements of the therapeutic process conducted according to the SF approach were perceived as helpful by clients outside American culture, and how their helpfulness varied by level of engagement. A mixed-methods design was used in a naturalistic setting.

With one exception, all the characteristics and corresponding core elements of the SFBT process, central philosophy included (de Shazer & Berg, 1997; Gingerich & Eisengart, 2000; Trepper et al., 2014), were identified by thematic analysis of Polish clients’ answers. The omission of pre-session change is not surprising, since not all clients can identify it (Allgood et al., 1995; Johnson et al., 1998; Lawson, 1994). The break was not mentioned directly, but it is an integral part of the end-of-session feedback (de Shazer & Berg, 1997), itself perceived as helpful. These results provide empirical evidence of the replicability of the SFBT model beyond the American culture in which it was built.

Moreover, clients perceived as helpful the same generic aspects identified in other approaches by previous qualitative studies, that is, the therapeutic relationship, as well as the awareness and insight that follow the chance to talk about one’s feelings and experiences (Timulak, 2007). This similarity provides further evidence against the critical voices denouncing the superficiality of SFBT (Neves, 2017; Stalker et al., 1999). These generic elements were more often perceived as helpful than the SFBT-specific ones.

On the basis of these results, I propose a new organisation of the SFBT model, which takes account of the therapist’s SF attitude and of the chance for clients to vent and reach awareness and understanding, as the essential environment of the co-construction process (see figure 1). Moreover, I propose that SF questions sit at a lower level, as tools for co-constructing specific aspects. This contrasts with existing proposals, which place questions and their purpose at a similar level (Gingerich & Eisengart, 2000; Kim & Franklin, 2009; Trepper et al., 2014) or focus only on particular techniques (de Shazer & Berg, 1997). The proposed model emphasises the co-construction process, the essence of SFBT (de Shazer, 1985, 1988; Lipchik, 2011). It also goes beyond techniques by taking into account the relational aspect common to all psychotherapeutic approaches.

Practical implications

The results suggest that, from the client’s point of view, co-constructing the goal and action is the most helpful SF-specific aspect. But their perceived helpfulness did not differ significantly from co-constructing progress or the central philosophy, probably because of their interconnection. To know which actions to take to reach the goal, one must first be aware of the steps that led to progress, in order to know what is worth repeating or changing (central philosophy). Thus, if a minimum number of elements is to be considered (de Shazer & Berg, 1997; Gingerich & Eisengart, 2000), the emphasis should be on co-constructing goal, action, progress and the central philosophy.

But, to be helpful, the co-construction process must take account of the client’s level of engagement. The results show that co-constructing goal, action and progress is more helpful for clients at a high level, such as customers (BFTC model) or consulting (Bruges model). Conversely, the emphasis on the environment in which co-construction takes place, in particular by allowing the client to vent, is more helpful at low levels, such as visitor or complainant (BFTC), non-committed or searching (Bruges). These results provide empirical support for previous claims that, at low levels of engagement, it is difficult to identify a working goal (de Shazer, 1988; Isebaert, 2016).

The relative relevance of the various aspects of the therapeutic process by level of engagement suggests that practitioners should move away from the automatic application of the model, paying attention to what the client in front of them is engaged in. These results can help new SF practitioners avoid “problem phobia”, by allowing clients at low levels of engagement to vent, so that they can move towards higher levels and be ready to talk about goals and actions.

Limitations and further research

The results and suggestions should be interpreted in the light of the study’s limitations. First, all the psychotherapists were in professional training, not yet certified. Nevertheless, in the training years, one may be more inclined to follow the SFBT protocol purely. All had at least three years’ experience of the SF approach. In Poland, after the second year of specialised training, psychotherapists are sufficiently qualified to work under contract with the national health system.

Second, the data were mainly collected by a single psychotherapist, the author, also the sole coder and principal researcher for all aspects of the study. This may hinder the generalisation of the results, reflecting the personal way of working more than that of the SFBT model. But a practitioner-researcher can provide valid research if they follow methodological protocols (McCormack, 2009). As described in the analysis section, for greater trustworthiness of the qualitative analysis, I went beyond the general recommendations (Guest et al., 2012). Moreover, the results agree with previous studies, which indicates their transferability.

Third, the relative relevance of the various therapeutic elements may be specific to the characteristics of the sample. Paying clients, who came to psychotherapy in private practice of their own accord, may be more inclined to value the intervention centred on goal and action.

Future studies could replicate the results in other cultures and other populations, to test whether perceived helpfulness varies culturally. For more information, in-depth questions could be used. Greater trustworthiness could come from including more experienced psychotherapists. Generalisability could be increased by recruiting clients in other settings.

Conclusion

The present study provides empirical support for the need to adjust the SF intervention to the client’s level of engagement (de Shazer, 1988; Isebaert, 2016; Lipchik, 2011; McFarland, 1995). The law of the instrument, “if the only tool you have is a hammer, you tend to see every problem as a nail” (Maslow, 1966), applies to SF practice too. Relying excessively on co-constructing solutions risks losing touch with the actual client. The proposed model, based on the client’s perception, shows that the SF co-construction process can coexist with the generic therapeutic environment common to other approaches; it is not “either/or”. As one client put it: “Talking out loud helped me realise what I was doing wrong.” Once awareness is in place, the possibility of thinking about what one can do differently opens up. The emphasis on building a good environment where clients can vent is more appropriate at low levels of engagement, while the further a client moves towards high levels, the more helpful the SF-specific elements are. This echoes the earlier recommendation to go slowly and not to force the solution (Lipchik, 2011; Nylund & Corsiglia, 1994), without being problem-phobic either.