Why do we prefer client centered care at the brief therapy center?

I recently walked into a physician’s office for an appointment. My name was called by a nurse and I was soon asked to get on a scale to get my weight and then to sit down and roll my sleeve up for my blood pressure to be taken. I was at the doctor because I had a question about my earlobe and possibly stitching my earring hole which had torn. I was a bit annoyed that they wanted to collect this information. I also knew that if I protested, I would be treated differently and that it would needlessly make my appointment take longer. The general sense I had was that I was there to be treated, acted upon and that it would be ridiculous to question this process. However, I could not, not think in what way was my weight related to my ear? I might think that, in order to stitch my earlobe, they might need to apply some kind of anesthesia and, if that were the case, there might be an outside chance that knowing my blood pressure could be justified. All of this was happening in my brain, while I complied with what was asked of me! 

 It was obvious that the power embedded in that procedure might make sense in a medical office, especially if the questions required those numbers to be factored in. In my case, I still don’t think those measurements were necessary. I went along with them for the sake of getting to my questions and understanding that in some circumstances it is justified/needed.

How does Solution Focus therapy approach the power dynamics embedded in therapy?

In the context of mental health,we want to stay away from putting our clients into a passive stance. We want to steer away from procedure rigidity and instead focus on the client’s complaints and how they bring them to us. For several reasons, we find a medical stance induces a passive stance and we find this to be problematic. From an ethical point of view, we think it unnecessarily amplifies a power difference. As therapists, the same as MDs, we already have. When we add this layer of nuance it implies our expertise over their health, it reinforces a disempowered view of their health. It also puts unproductive pressure on the therapist to be the expert of “solving”.  We think it opens the door for dependency that ultimately doesn’t serve the client. We want the client to take responsibility, with our support and their willingness to consider our guidance, for their change, for their new actions 

We see our role in the interaction as client centered and collaborative. To do this, our frame matters. Labels matter.  We end up enacting these things as part of our social learning process, we call it a feedback loop and it can become a self-fulfilling prophecy. We want to make sure that our frame around our role is clear and empowering. We prefer to see our clients as people who have choices and who ultimately will row with us in the boat that is  solving the puzzle of what brings them in.They are in charge of sharing their story, goals, what they have tried and other relevant information. We help them by allowing their knowledge, experience, wishes and what they have tried  to determine what we can help them with.

Is insight useful from a solution focused point of view? 

In a large sense, when we take on patients we are agreeing to the concept of pathology as an explanation for why they are coming to our office. Sometimes this pathology reinforces insight which gives people too many explanations and makes it harder to implement change. 

There is another very obvious reality when we are accused of talking about clients rather than patients. We have been told that the only reason one would talk about clients is if money is the most important part of the transaction. In most models of therapy, there is the belief that, if the ‘patient’ does not pay for services, we cannot expect change to happen because they are not invested in their treatment. So, when we hear from therapists who point out that we are ‘only in it for the money’ it is disingenuous since most therapists do not work for free.  To ignore the reality that patients pay money to the therapist to receive treatment – and lots of it in certain situations!– is something that, in our view, determines whether they are patients or clients. Money exchanges hands. So let’s call a spade a spade. Our choice emphasizes choicefulness and whether we like it or not; healthcare costs money. Different countries have different models for where the money comes from, but that is an article for another time.

 Watzlawick talked about the fact that insight sometimes impairs change- in fact he coined the phrase that ‘Insight sometimes makes you blind’ Unlike other models that focus on the why, our model focuses on the how. When we use the term patient, we automatically fall into looking at people from a “why” and “sick”, “stagnant” and “passive” mindset. It takes a lot of work to motivate and undo that mindset with our clients  as well as with clinicians and families. Pathology implies an emphasis on biology and historical experiences. We focus on interactions. We focus on the place people have power over in the here and now instead of things we need to accept or consider as factors in what strategy to implement in the here and now.

How does Problem solving brief therapy empower people from the  beginning?

We want  our clients to see their role as engaging a professional on how to help solve a problem in their life. We stay away from illness, diagnosis, a construct that was invented for the use of professionals to  create a common language and for billing purposes. Diagnostics do not adequately address context, culture, positive intentions, world views, socio economic factors, personal preferences, values, beliefs, roles, systemic commands, and rules.  How does someone manage it, where do they have a choice for responding to the problem in a different way? We want to start with the client’s window, their descriptions and what they have tried. We want to use names that match the expectation we have for the therapeutic alliance.

Solution focus therapy emphasizes: How we see our role, impacts the outcome 

We want them to get a clear message that we will work together and that they will need to be invested in the process. To us a client signifies that people are making an investment in a service regardless of whether they are paying us or not. Karin Schlanger worked in inner city schools for most of her career, helping students and their families succeed: all this work was done pro bono, with very good results and positive change. They have a goal, they have something they want help with and they are consulting with us. We prefer this to the frame that someone is unhealthy, needs someone to ‘cure’ or correct them . We think that language matters so we emphasize it from the beginning and in the way we see the people who are coming in requesting a service.

 How do we help people overcome getting stuck in a diagnosis?

Often we hear that people “ overidentify” with their diagnosis. While we understand the need to use diagnosis for practical reasons, we think it is important to be able to see people’s complaints in other ways and not  narrow treatment in the diagnosis. We need people to see themselves as able participants, who have descriptions of things that bother them, that occur in a context and they are somehow being communicated/ acted out. We want people to easily distinguish the problem from their identity and when the system uses so much language that reinforces diagnostics,  there is a lot of risk  in people getting confused about how change and growth happens. Aside from those practical elements – we think it more ethical and respectful to refer to those who seek out our help as clients to emphasize their choice making ability and the limit to our reach, as a way to empower them and also stay away from making promises we can’t keep or worse, perpetuating helplessness and dependency.

 How can you make a powerful impact on mental health?

Next time you find yourself asking a depressed person, “since when have they been depressed and where does it come from and how do they cope?”, try to be a bit more centered on them as a person and what specifically they want your help with. “How is depression a problem for you?” “What does it look like for you?” We promise that, as a therapist, you will begin to see how it is much more interesting and productive to approach each person as whole and to be able to engage in a relationship that is from the beginning requiring their input to develop the process and options for care. We think people need to be less patient in the pursuit of change and to do that we need collaboration and clear expectations and respect from the first interaction. We need the mindset to be empowered- we choose clients over patients and they choose us with more confidence because they are feeling heard and respected.

 To learn more, join our upcoming workshop