Dressed to Kill

Angela stepped in from the pages of Vogue; cool, assured and with an air of authority. She had been planning to kill herself when she read about Solution Focused Brief Therapy in The Times and decided to give it a go before carrying on with her plan. She had been drawn by the future focus and the apparent lack of need to talk about the past. She said she knew perfectly well the source of her problems but had no intention of talking about it.

Angela’s adult life had been one of extremes. Having performed well at school she went so far off the rails that in her late teens she became a homeless heroin addict. A suicide attempt brought her to the attention of the mental health services and a successful rehabilitation programme. Picking up the threads of her life, Angela continued her education and became an accountant. Unfortunately, the past, as she put it, crept up on her and after a disastrous spell in a psychiatric hospital she once again became a homeless heroin-addict. It was barely possible to equate the ultra-fashionable, expensively dressed woman before me with the “bag lady” she had been through her late twenties. It was an attempted rape that “woke her up” a second time. She fought off her attacker and in doing so was reminded of her determination to survive. This time she went ‘cold turkey’ alone, came off the heroin, cleaned herself up and began the long climb back into a more liveable life. Over the next few years, she built a successful career in the burgeoning financial services industry eventually securing a senior position in a small private investment company. With an expensive apartment, successful career and looks that had survived the ravages of homelessness and heroin she seemed to have her life in control until, once again, the past caught her out.

Hearing music from her neighbor’s radio Angela found herself at his front door screaming abuse in his face. The next morning, on a crowded underground she punched a commuter for accidentally pushing her. She knew the signs: this was the road back to paranoia, drugs, homelessness, and death. This time rather than try to cope once again with the horrors of post-traumatic stress, Angela decided to go straight to death. She could not face the whole awful process yet another time. It was only the newspaper article that held her back.

All this she explained in the first few minutes of our meeting before expressing a hope that she might just get on with her life without the past dragging her back.

Once we have desired outcome, especially one that can begin immediately, we are likely to dispense with the miracle and begin with the less dramatic, less memorable, “Let’s imagine you wake up tomorrow. . .?” However, Angela seemed to be asking for something she was doubtful could happen and like many clients who have suffered childhood abuse she believed only the eradication of the past would give her back a future. In these cases, the deployment of a “small miracle” can sometimes open a very large door: Let’s imagine that tonight, while you are asleep, a miracle happens; it’s only a small miracle, it doesn’t get rid of the past, but what it does is stop the past messing with your future. What’s the first thing you’ll notice as you wake up that tells you are free to get on with your life without the past dragging you back?

This was the opening into a rich and detailed description of Angela’s everyday life as she hoped to live it. Angela made good progress and according to brief therapy principles the time between sessions was stretched to accommodate this movement. The third session had been scheduled with a gap of two months, but after four weeks Angela asked for an emergency session.

She arrived thinking that she might need to be admitted to hospital. While this was not good news, it was a step up from suicide. I asked her what was it about this crisis and the way she was dealing with it that was keeping her on the side of life, no longer thinking of suicide. She said that the advances she had made in the course of our work together had been a huge and pleasant surprise. Stopping her self-harming behaviour (something she had never mentioned until this moment!) and managing to hang on to her job had been big factors, but much more importantly, her friends had noticed big changes. She was more engaged with life, easier to be with, more outgoing and, as her closest friend put it, “softer.” Angela had always appeared super-confident but for the first time she was beginning to feel it. Until the previous day when she had lost her cool once again. Thinking that her boss was being patronising, she had shouted at him in front of the whole office. She was afraid the paranoia was coming back, but after a little reflection, she decided that he actually was patronizing, and this had been troubling her for some time. On further reflection, she was even pleased that she had called him out, even though she might lose her job. We are always on the look-out for new behavior, even behaviors which at first sight might seem problematic. Any standing up to abuse, real or imagined is worth investigating. I asked Angela what had made the difference, what had decided her to stand up to her boss she said she had no idea but then told the following story.

Angela was sitting with her arms held stiffly out, mimicking her discomfort at having a child in them.

As Angela continued her story her arms lost their rigidity and began to fold around the baby.

It was a moving story and perhaps a turning point since Angela then went on to say that she felt a new confidence in herself and did not think we would need to meet again! Then just before leaving Angela, looking uncomfortable, blurted out, “Before I go there’s something I’ve got to say to you!”

I thought I was going to be told off and began running the past hour through my mind to find the cause! In fact, it was the reverse. She went on, “I know that if I had not come here I would now be dead, but I want you to be clear that you have not touched my life at all!”

Rather than be offended as Angela expected I felt I had been afforded the most wonderful of compliments and responded, “And I have to say that no one has ever paid me such a compliment, and you haven’t touched my life either. But I’ll always remember you!” “And I’ll always remember you!” She said and stepped back into the pages of Vogue.

These had been three very straightforward, description-focused sessions. The “small miracle” opened the door to a detailed description of Angela’s everyday life. As routine and hum-drum as the “behind-the-scenes” of most lives: making coffee, washing up, waiting for trains, sitting at computer screens, chatting to colleagues, meeting a friend and so on. Then a few minutes to begin looking at how much of this small miracle might already be happening. No summary, compliments, or tasks just a disciplined neutrality about whatever she decides to do tomorrow. Subsequent sessions were forensic examinations of progress. “What’s better?” with the emphasis on “How?” and following the ripples and counter-ripples of each achievement.

Angela’s final words were not the only comment on the value of detail. At one point during the last session, she remarked on the fact that she could never remember any of my questions. My half-joking response was that maybe it was because her answers were more interesting, which, of course, they are. A question such as “What might you notice as you are making the coffee?” places the client in a most inconsequential moment. If, as we hope sometimes happens, the client’s answer opens a new door to possibility, it is the door, not the question, that will be remembered. If the answer is as inconsequential as the question, both are likely to be forgotten. In this way, the client’s own words take centre-stage adding to the experience of it being all their own work.

Angela’s experience was not that our conversations had had no impact, she knew that they had saved her life. Nonetheless, like many clients she could not see the direct connection because everything she had done to turn her life around had come from her. The therapist had no part except that of a catalyst, an instigator of change. I might have walked with Angela, ahead, beside or behind, but every step she took was her own and only her own.

From Goals to Hopes

Several significant steps in the development of BRIEF’s work led towards this “hands-off, footprint-free” approach. One of the early, language-created short-comings of Solution Focused Brief Therapy was its use of the word “goal”. It is a word that carries with it the notion of something specific to be achieved and can easily divert the therapist’s attention towards overly specific outcomes and problem-solving. This has led to a confusion in de Shazer’s writing where sometimes he refers to “well-formed” and “achievable” goals (de Shazer, 1991, p. 112) and describes simple “problem-solving”, or complaint-focused, strategies by which they might be achieved (de Shazer, 1988, p. 93-96; 1991, p. 115-118). However, at other times, especially when describing 10 on a scale he defines the outcome as “the day after the miracle” (de Shazer, 1994, p. 231). This latter definition encompasses not just the specific goal, or problem resolution, but the whole way of life with which it is associated. It was the “way of life” outcome that most attracted the interest of my colleagues, Harvey Ratner and Evan George, and myself to BRIEF. We began to see the “miracle” not as the resolution of the problem, nor the achievement of a specific outcome; but more as the context or “way of living” within which the problem will resolve itself or the specific outcome will appear. This led naturally to an outcome-led start to the process, and from this, the word “hope” began to appear in our work. Not as a deliberate intervention, but as a sign of trust in our clients that they must be sitting with us for some good reason (Ratner et al., 2011).

A typical example of the process in which we move from a specific “goal” to a contextual or “way of living” outcome would be:

This is a specific outcome which could be tackled in many ways within a broad Solution Focused framework. For example, by looking for and amplifying exceptions or by describing a “miracle” in which the daughter does come home and extrapolating from this a plan of action aimed at encouraging “miracle” behavior. This would represent a “goal-directed” or “problem-solving” approach rather than the “way of life” approach the therapist in this case uses. The question most often used to begin the expansion from a specific outcome, being home on time, to a ‘way of life’ outcome, having a good relationship, is a “What difference?” question (Shennan & Iveson, 2008). For example:

We now have the hoped-for outcome within which the client can find her own way to the initial, more specific goal, and can move on to a description of one way this outcome might unfold. The client’s preferred future.

A Preferred Future

As the session above continues a very detailed description of the morning unfolds and is followed by some further description of the client’s day. Then more description of the mother-daughter relationship after school but stopping short of the potentially troublesome evening. Finally, a few minutes to sketch out a scale: “How much of this miracle is already happening?” There is no attempt to address the specific issue of the coming home time. The assumption, borne out by client follow-up, is that the description will lead to an improved relationship between mother and daughter. They will do what every family must do – come to an agreement about mutual behaviours and boundaries. There was a similar description in the last session with Angela when she expressed worry about losing her job and wondered how she might approach her boss. Instead of focusing on the way she might approach him we focused on the likely consequence of a successful approach. As Angela began to answer, “He’d ring me about –” she suddenly broke off with a gasp “He already has! He rang me while I was on my way here to check if I was still up for a meeting we’d planned for tomorrow!” However, frequently it happens that clients bump into the fact that something they are hoping for has already happened without them noticing!

Clues (de Shazer, 1988) became BRIEF’s bible when it was first published in 1988 and, like the Bible, it is full of contradictions. The “specific” rather than “vague” goals that he argues for (p. 93) are confused with detailed descriptions or “pictures in words” (p. 187) to describe “life without the problem” which might consist of tens, or even hundreds, of differences far too many to be realistically thought of as goals. They can be more aptly described as “ways of living.” It was this realisation that led us at BRIEF to talk of the client’s “preferred future” (Ratner et al., 2011), rather than the client’s goals, and paved the way to move from “What brings you here?” (a request for problem information which is redundant to the therapeutic endeavour) to “What are your best hopes from our work together?” (a question designed to discover the client’s hoped-for outcome).

From this perspective, as illustrated in the case examples above, what de Shazer would have criticized as “vague goals” have become the preferred starting point for our work. Thus, a client who wants to give up drugs might wish to “have a normal life.” The therapist could ask “Let’s imagine you wake up tomorrow beginning to move towards the normal life that you are seeking.” A client who is isolated and depressed might want a future in which he is more self-confident. A suicidal client might want to wake up with the sense of a future, or, as in Angela’s case, “free to get on with her life.” All vague, even global outcomes, but ones that give the opportunity for the client to describe a way of living which might lead to problems being resolved “organically” without the therapist needing to know what they are.

Small changes are big changes

De Shazer was quite right when he said, “Goals need to be achievable but perhaps not so right when he said they also need to be hard to attain” (1988, p. 93; 1991, p. 112). The purpose of a very detailed preferred-future description is to make sure every aspect is well within the client’s range of possibilities. The more the hoped for future (or the miracle) can be located in the everyday routine of the client’s life, the more possible it would seem to be. Asking Angela, “What might you notice as you are making your coffee?” will elicit an answer very close to what has been happening for months, or years, yet, it will also describe part of a more desirable way of living.

Looked at from this perspective, the essentially linear idea that a small change can lead to a big change might be replaced by the idea that each small change is, in fact, part of the big change already happening. In the case of the mother wanting a better relationship with her daughter, the imagined “good morning” is not a small thing that might lead to a larger thing, but a small thing which is a consequence of the large thing (e.g. the miracle) already having happened.

For instance, a young mother struggling with serious and chronic eating difficulties described her experience of a single session and clearly demonstrates that the “small” is also the “large”:

Therapist Neutrality

This detailing of preferred futures has been described many times elsewhere (Connie, 2013; Ratner et al., 2011), but what has not been emphasized so much is the value of the therapist’s neutrality towards these descriptions. This is not a new idea. The Milan Group (Palazzoli et al., 1982) were heavily criticized for appearing to place neutrality above responsibility. At BRIEF, neutrality refers to a therapeutic stance which is overridden if there is a serious concern for the safety of the client, or others, or if any likely actions of the client are potentially harmful in other ways. When these concerns become paramount, the therapy ceases and the therapist becomes an “agent of society” exercising (depending on their role) their legal, professional or citizen responsibilities. It is never our right to dictate how others should behave. But we do have the right and responsibility to guard the outer boundaries of what is permissible in our society. We may not tell a parent how to raise a child, but we have a duty to do what we can to prevent harm to that child.

Being neutral is not easy. And what we write and what we do, as we at BRIEF are constantly reminded, are not always aligned. Our writing tends to reflect our ambitions more than our practice. And, the same was true of de Shazer who also aspired to a form of neutrality:

But whatever de Shazer’s aspirations to neutrality it is lacking in the cases described throughout all his books (de Shazer, 1985, 1988, 1991, & 1994). Time and again, client’s descriptions are turned into goals and action plans and hence become, in some way, the property of the therapist. At BRIEF, we have come to see these descriptions as just one set of possibilities which we have no right to expropriate or recommend as future actions. Instead, we see them as creating a realisation that more preferred ways of living are within the client’s range even if, by the time tomorrow arrives, these preferred ways of living turn out to be different from those imagined today.

Put very simply, what each of our clients does tomorrow is none of our business. Each client is responsible for the decisions they make. If we believe our own soft-spoken words, that each client is in the best-placed position to make their own decisions, we cannot attribute expertise to the client only on the condition that it fits with our view of the best way forward.

This neutrality is a discipline and one which may not sit comfortably with many Solution Focused practitioners. Nor, given de Shazer’s practice as cited above, is it essential. However, it is one which fits well with the underlying philosophy of de Shazer’s writings, and clearly demonstrates the therapist’s trust in the client as well as guarding us against our ‘better knowing’. But as a behavioral discipline it requires hard work and constant attention. There can be nothing robotic or unconcerned about the discipline of neutrality. Instead, it must sit side by side kindness and wishes for the well-being of others; as well as side by side with our need to be successful as therapists. Ultimately, neutrality is a pragmatic decision. Does it work? Does it fit with brevity? Our experience is that it does.

It is the same with “footprints.” Every time we sit down with a client, we must fervently wish that it will be a life-changing event, that the client will begin a new course towards a better future. We back up this wish by using techniques that we hope, a hope based on evidence, will create transformation. We also have to know that whatever the client does tomorrow has a history going back through generations and that tomorrow has always been possible. All we have done is ask the questions that bring that possible tomorrow, and its history, into focus. This raises the question of just how “co-constructed” is the future our clients aspire to and how much of our own lives are similarly “co-constructed” during our conversation with them. Hopefully, we are not too changed by every encounter so, at the end of a busy day, we can return to our families and friends not too different from how we set off in the morning. Whereas, we hope rather the opposite for our clients.

To return to Angela, her words suggest that she experienced whatever happened as entirely her own work. With every idea and action coming only from herself. How could it be otherwise, and what could be better than this realisation? What we hope Angela also experienced, as we do for every client, was a complete trust in her ability to make her own choices without pressure, however subtle, however well-meant, from the therapist to make those choices that best fit the hoped-for outcome.

Discipline

Solution Focused Brief Therapy, as with every other talking therapy, provides a set of guidelines for managing the therapeutic conversation. To follow these guidelines requires discipline and discipline can only be maintained with constant practice. One of the obvious disciplines of Solution Focused Brief Therapy is to avoid questions which seek an explanation of the problem. Information from these questions does not further the Solution Focused process. This does not mean that the answers to these questions are uninteresting, especially within a culture that privileges explanations, just that they are not useful within the Solution Focused model. Therefore, we must guard against our natural (culturally determined) curiosity and wish to understand.

Devising questions that are content-free is also a discipline which is hard, perhaps impossible, to maintain. We do this by seeking only descriptions of future possibilities. Though we might be less neutral about past achievements, the history of the preferred future, we do our best to follow the client with regard to what constitutes success. Using the client’s words, guarding against introducing our own words, interpretations, and ideas, and looking at the world through our client’s eyes, rather than our own, are all part of this discipline.

Similarly, the “sister” discipline of neutrality requires constant practice. Our good wishes for our clients provide an all too easy excuse for trying to influence the decisions they make, even just by summarizing what we think are the important parts of what they have said. Such good intentions are one of the most used excuses for the abuse of power. Whether it be by therapist to client, or state to citizen. If we were to ask our clients, “Would you prefer your therapist to guide you or to trust you?” What might they answer? And how might their answer influence our practice? Let us give the last words to another client who puts it all in a ten-word nutshell!