Solution Focused Brief Therapy Treatment Manual

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Solution Focused Brief Therapy Diamond Approach Treatment Manual – Version 1: November 2023

Table of Contents

Introduction Evidence-Base of Solution Focused Brief Therapy ADOPT The Stance of the The Solution Focused Diamond A: Autonomy is Sacred D: Difference-led O: Outcome-led P: Presuppose the best T: Trust capability The Language of Solution Focused Brief Therapy Overview of the Diamond Approach ● Desired Outcome ● Description ○ History of the Outcome ○ Resources for the Outcome ○ Future of the Outcome ● Closing References

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Introduction What is Solution Focused Brief Therapy? Solution Focused Brief Therapy (SFBT) is an evidence-based therapeutic approach (Kim, Jordan, Franklin, & Froerer, 2019) that takes the radical perspective that clients are competent, capable, and have the resources necessary to make desired changes in their lives. SFBT is a language-based therapeutic approach that is founded on building hope through co-construction (Connie, 2018; de Shazer et al, 2007). SFBT is an approach founded on the belief that clients do not need to re-experience problematic events, do not need to be re-traumatized, or dread coming to therapy in order to achieve healing and lasting change. Solution Focused Brief Therapy maximizes what is good in people’s lives and utilizes this goodness to help clients achieve greatness! SFBT was created in the early 1980’s by Steve de Shazer, Insoo Kim Berg, and their colleagues at the Brief Family Therapy Center in Milwaukee, Wisconsin (Lipchik, Derks, LaCourt, & Nunnally, 2012). These founders specifically went about developing an approach to psychotherapy that challenged the methods of traditional psychotherapy. They built an approach that did not require individuals to focus on problems, did not encourage the retelling the traumas of their past, and did not spend quality time digging for the route cause of the current symptoms, which often only frustrated clients. Instead, these founders created an approach that oriented clients to focusing on and detailing how life would be different when they were managing life better, living consistently with their dreams and desires, and acting in accordance with the best version of themselves.

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SFBT is a unique therapy type, in which it is not intended to be an ongoing, lifelong therapy approach, and is transformation-oriented and action-based. Elliott Connie and Dr. Adam Froerer built on this future-oriented foundation and developed The Diamond Approach of SFBT. The Diamond Approach focuses specifically on helping the client articulate their desired outcome, describing the details of their lives that indicate the desired outcome is present, and honoring the agency of clients at all times. By shifting the control into the hands of the client in a conscious-specific format, SFBT practitioners have seen greater progress in shorter amounts of time, and progress even in cases which have been exceptionally complex. Agency and consent, as in all things, are key to helping clients transform their lives consistent with their desired outcomes. This is the shift in focus, and the miracle, of the Diamond Approach.

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Evidence-Base of Solution Focused Brief Therapy Since its founding, Solution Focused Brief Therapy has been tested and studied in multiple ways and with multiple different populations with positive outcomes (Kim, Jordan, Franklin, & Froerer, 2019). There is a growing body of evidence that supports the evidence-base of SFBT. Several meta-analyses of SFBT research have shown that SFBT produces positive outcomes with various populations (ranging from small to very large effect sizes). Table 1 below shows the known meta-analyses and the statistical effect sizes. Each study supports the effectiveness of SFBT.

Table 1. Solution Focused Meta-Analyses Author(s)

Publish Year

Title of Study

Population

Effect Size

Stams, Dekovic, Buist, & de Vries

2006

Efficacy of Solution Focused Brief Therapy: A Meta-Analysis

Personal behavior change in adults

0.37**

Kim

2008

Examining the Effectiveness of Solution-Focused Brief Therapy: A Meta-Analysis

Various personal behavior changes

0.26*

Park

2014

Meta-Analysis of the Effect of the Solution-Focused Group Counseling Program for Elementary School Students

Elementary students in Korea

Self-esteem = 1.61***; School adjustment = 1.35***; Interpersonal relationships = 1.07***; Self-efficacy = 1.03***

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Gong, Hsu

2015

A Meta-Analysis on the Effectiveness of Solution-Focused Brief Therapy: Evidences From Mainland China and Taiwan

Various populations in China and Taiwan

Overall = 0.99***; Schools = 1.01***; Medical settings = 0.94***; Mainland = 1.03***; Taiwan = 0.92***; Follow up = 1.07***

Kim, Franklin, Zhang, Liu, Qu, & Chen

2015

Solution-Focused Brief Therapy in China: A Meta-Analysis

Internalized problems in Chinese population

Overall = 1.26***

Carr, Hartnett, Brosnan, & Sharry

2016

Parents Plus Systemic, Solution-Focused Parent Training Programs: Description, Review of the Evidence-Base and Meta-Analysis

Parent with children who misbehave

0.58**

Gong, Hsu

2016

The effectiveness of Solution-Focused Group Therapy in Ethnic Chinese School Settings: A Meta-Analysis

Group therapy with Chinese Children

Immediate = 1.03***; Follow up = 1.09***

Schmit, Schmit, & Lenz

2016

Meta-Analysis of Solution Focused Brief Therapy for Treating Symptoms of Internalizing Disorders

Various clinical samples with youth, adolescents, and adults

0.24*

Kim, Lee, & Park

2017

The Effect of Solution-Focused Group Counseling: Effect Size Analysis by Multilevel Meta-Analysis

Emotional, social and behavioral problem in Korea

1.223***

Zhang, Franklin, Currin-McCu lloch, Park, & Kim

2017

The Effectiveness of Strength-Based, Solution-Focused Brief Therapy in Medical Settings: A Systemic Review and Meta-Analysis of Randomized Controlled Trials

Medical settings

Psychosocial outcomes = .34*; Health-related outcomes = .28*

Hsu, Eads, Lee, & Wen

2021

Solution-focused brief therapy for behavior problems in children and adolescents: A Meta-analysis of treatment effectiveness and family involvement

Children and adolescents (and their families)

0.43** (no effect size difference for family involvement) Externalizing behaviors = 0.43**; Internalizing behaviors = 0.18*

Solution Focused Brief Therapy Diamond Approach Treatment Manual – Version 1: November 2023

Franklin, Guz, Shang, Kim, Sheng, Hai, Cho, & Shen

2022

Solution-Focused Brief Therapy for Students in Schools: A Comparative Meta-Analysis of the U.S. and Chinese Literature

Children and adolescents

0.176*

Franklin, Ding, Kim, Zhang, Hai, Jones, Nachbaur, & O’Connor

2023

Solution-Focused Brief Therapy in Community-Based Services: A Meta-Analysis of Randomized Controlled Studies

Adults in Community-based agencies

0.654***

Karababa

2023

A meta-Analysis of Solution-Focused Brief Therapy for School-Related Problems in Adolescents

Children and adolescents

1.80***

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* = small effect size ** = medium effect size *** = large effect size

Beyond just knowing that SFBT has been shown to be effective, it is also valuable to know that it has worked with many individuals from various cultures and countries around the globe. Table 2 provides a representation of various cultures served by SFBT. This table is a small representation of the locations and populations SFBT has been used with effectively. Other studies in various countries may be available and will be added as we become aware of them.

Table 2: Cultures Served Effectively by Solution Focused Brief Therapy Country/Culture

Supporting Paper(s)

Chili

Schade, Torrez, & Beyebach (2011)

China

Gong & Hsu (2015); Gong & Hsu (2016)

German

Jonas, Leuschner, & Tossmann (2016)

Finland

Maljanen, Knekt, Lindfors, Virtala, Tillman, Harkanen, & Helsinki Psychotherapy Study Group (2015)

Solution Focused Brief Therapy Diamond Approach Treatment Manual – Version 1: November 2023

Korea

Kim, Lee, & Park (2017); Park (2014)

Latino/a

Suitt, Franklin, & Kim (2016)

Netherlands

Stams, Dekovic, Buist, & de Vries (2006)

Persian

Abbasi, Mohammadi, M. Zahrakar, Davarniya, & Babaeigarmkhani (2017); Hosseinpour, Jadidi, Mirzaian, & Hoseiny (2015)

Spain

Neipp, Beyebach, Nunez, & Martinez-Gonzalez (2016)

Taiwan

Gong & Hsu (2015)

Thailand

Ngammoh, Inang, & Koolnaphadol (2017); Pennapha (2015)

Turkey

Nedim & Kaya (2017)

United States

Kim (2008); Richmond, Jordan, Bischof, & Sauer (2014).

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This body of supporting research is building a solid case that the innovative approach to mental health care espoused by SFBT, works effectively and is now being recognized by governments and government agencies for its effectiveness. The Office of Juvenile and Delinquency Prevention (OJJDP) and the Substance Abuse and Mental Health Services (SAMHSA) National Registry of Evidence-Based Programs and Policies (NREPP), two federal agencies have evaluated the relevant SFBT evidence and have granted the solution focused approach a “promising practice” status. “Beyond the federal registries, two states in the United States have also included SFBT on their websites as evidence-based interventions. Oregon’s Addiction and Mental Health Services Department lists various treatment approaches as evidence-based for addiction and/or mental health disorders, co-occurring disorders, or prevention approaches. Currently, SFBT is listed as evidence-based for mental health disorders (Oregon Health Authority: Addictions and Mental Health Services, 2017). Similarly, the state of Washington has listed solution-based casework as an evidence-based practice through the

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Washington State Department of Social and Health Services: Children’s Administration (2017)” (Kim, Jordan, Franklin, & Froerer, 2019). It is anticipated that more and more states and federal agencies will also follow suit and recognize SFBT for the effective treatment it is. SFBT has been shown to be effective in working with the following presenting problems and/or populations (among others): children with behavior problems (Carr, Hartness, Brosnan, & Sharry, 2016), individuals with medical concerns (Gong & Hsu, 2015), emotional issues (depression, anxiety, etc.), social issues (Kim, Lee, & Park, 2017), self-esteem concerns (Park, 2014), substance abuse (Smock, Trepper, Wetchler, McCollum, Ray, & Pierce, 2008), and marital satisfaction (Abbasi, Mohammadi, Zahrakar, Davarniya, & Babaeigarmkhani, 2017).

Evolution of the Approach In addition to the evidence listed above, it should be noted that SFBT has evolved and changed over time (McKergow, 2016). Although the titles of these evolutionary steps have been debated and are somewhat controversial, it is clearly evident that changes have taken place. This evolution can be seen in the treatment/practice manuals that have preceded this one. McKergow (2016), called the original version of the approach, developed by Insoo Kim Berg and Steve de Shazer and colleagues, as the 1.0 version of SFBT. McKergow described later evolutionary steps, like BRIEF in London, developed by Chris Iveson, Evan George, and Harvey Ratner as the 2.0 version of SFBT. We see these evolutionary steps as valuable and important to the continuing development and clarity of the approach. The Solution Focused Brief Therapy Association (SFBTA) provided a treatment manual for working with individuals in 2013 that consistently laid out the 1.0 version of the approach

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(Bavelas, De Jong, Franklin, Froerer, Gingerich, Kim, et al, 2013). BRIEF provided a more recent practice manual that clearly and thoroughly outlines the SFBT 2.0 version, entitled BRIEFER (George, Iveson, & Ratner, 2017). This current treatment manual is a representation of a next evolutionary step and is based on the Connie-Froerer Diamond Approach to SFBT. Some might argue this is the 3.0 version of SFBT.

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ADOPT The Stance of the The Solution Focused Diamond Doing SFBT will require that you forget everything you learned previously about doing psychotherapy. You will need to realize that your role is not to assess the client for problems or character flaws, you do not need to analyze the root cause of the problem or hypothesize about what behaviors are sustaining the problem, nor will you need to develop a conceptualization about what will fix the problem or minimize symptomatology. Instead you will be asked to ADOPT an entirely different perspective of the client AND your role within the therapeutic context. ADOPTing the SFBT stance requires that before you even engage in any therapeutic work you recognize your privilege and power. Recognizing Your Power and Privilege Without understanding your own power and privilege within the therapeutic context you are at risk of overlooking important contextual variables that are paramount within the clients life, and therefore insufficiently co-construct with the client descriptions that are meaningful and useful. You may inadvertently do more harm than good, you may misinterpret, misunderstand, or misuse the client’s language, thus fracturing the therapeutic relationship in significant and irreparable ways. One focus of a SFBT therapist should be on giving up power to the client. Ways to give up power ● Acknowledge that you have it simply because of the chair you occupy in the room ● Share it with clients-honor their autonomy and agency ● Only talk about what the client invites you to talk about ● Abolish self-imposed limitations-stop looking at people as though they are only one thing

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● Avoid using stereotypical language (i.e. As an African American…, or from a woman’s perspective…)

In addition to enabling our client to claim power and privilege in the therapeutic room, it is essential that we use language in a way that fosters an egalitarian relationship between co-experts/co-constructors, i.e., the therapist and the client. The therapist is the expert of the therapeutic process and the client is the expert of the content of their lives. In order for SFBT sessions to be useful, both experts must simply co-construct a description of the client’s desired outcome. In the pursuit of building the desired outcome description it will be helpful if therapists let go of social constructions. The following is a list of ideas that will help in this pursuit. ● Don’t believe the client when they say, “I don’t know” ● Don’t believe that clients with “significant” presenting complaints/problems may not be suitable for SFBT ● Don’t believe that the client’s “best hopes” isn’t the best place to start ● Don’t believe that the client isn’t ready to think about things that are hopeful ● Don’t believe that you have some good advice or insight that the client needs in order to feel better ● Don’t believe that psychoeducation is the best way forward

Finally, sharing power with your client will enable you to foster a solid relationship with them; this is the foundation of ALL effective therapy. Effective SFBT therapists will 1) Listen

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with caring ears, 2) Convey warmth and acceptance of EVERY client answer, 3) Use the client’s exact language whenever possible, 4) Only talk about the client’s desired outcome, 5) Honor the problem (don’t ignore or minimize it), but focus on the parallel experience of strength and resilience that is evident along side the problem, and 6) Communicate through loving language that they believe completely in the client and their abilities. ADOPT the Stance Sharing power is only a portion of what can strengthen a therapeutic relationship. In addition there are five things you can do to foster a collaborative interaction with your client. These can be summarized with the acronym ADOPT. 1. A is for autonomy: Autonomy is sacred. Begin each session with asking the client to utilize their autonomy by asking what they would like to achieve as a result of the conversations. Carry through the session by honoring their autonomy by using their language and only including information they introduce you to. And finally, end the session by avoiding doing anything to shift the focus away from the description you constructed together during the session. 2. D is for difference: SFBT is a difference led approach. Focus on the three levels of difference throughout the session. 1- What differences (signs) are present when the desired outcome is a part of the client's life? 2- What impact/difference would these differences make? 3- What does it mean about the client that they are able to bring about/achieve these differences?

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3. O is for Outcome: SFBT is an outcome lead approach. Begin each session focusing on the client’s best hopes (more to come about this later). Take every opportunity to ask questions that are embedded in hope, i.e. connected to the presence of the desired outcome/best hopes. Don’t focus on goals, or creating steps to achieve the desired outcome, rather get detailed descriptions of what impact the desired outcome has on the client’s life. 4. P is for presuppose: presuppose the best in your client. Start with small presuppositions and move to bigger presuppositions as the session progresses. a. Small presupposition could include things like, “What are your best hopes?” “What would be the first thing you would notice?” “Who else might notice?” b. Medium presuppositions could include things like, “What difference would experiencing that make?” “How did you do that?” “How would you let that person know that you were pleased that they had noticed?” c. Large presupposition could include things like, “What does it mean about you that you’re the kind of person who could do that [insert best hopes]?” “But if [insert problem] stopped impacting you so much, what would that tell you about your capability?” 5. T is for trust: Trust your client’s capability. Believe your clients abilities, even when all evidence points to the contrary. Disbelieve all aspects of hopelessness. “Argue” with the client when they insert doubt into the conversation by asking about the presence of the desired outcome, despite how unbelievable it might

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seem. Presuppose strength by saying things like, “suppose you do know” and “what thoughts come to your mind now once you take a minute to think about it”. Don’t rescue clients by providing answers when they are struggling to articulate a response. And, don’t set a bar by offering suggestions; clients will surprise you with how much they achieve when you leave them to their own devices.

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The Language of Solution Focused Brief Therapy From its inception, SFBT has had a focus on language. “Therapy happens within language and language is what therapists and clients use to do therapy” (de Shazer, 1994, pp. 3). Language has the “ability to solidify certain views of reality” (O’Hanlon, 2003, p. 60), and SFBT orients the client to certain realities due to the questions we ask (de Shazer, Dolan, Korman, Trepper, McCollum, & Berg, 2007). As clients answer SFBT questions their realities shift. Because language has the ability to solidify and shift reality, SFBT therapists should be attentive and purposeful with the language they use at each stage of the therapeutic process and within each individual session. SFBT emphasizes the client’s words and hopes (MacDonald, 2011). According to Froerer and Jordan (2013), SFBT therapists only preserve about 5-7% of the client’s words. This means that in an approach that is reliant on client language, therapists need to be very selective and purposeful about the small percentage of words they can select from the many words the client uses. SFBT therapists use various language tools to co-construct conversations with their clients. The goal of SFBT clinicians is to become fluent in SFBT language in order to most effectively co-construct conversations that are useful with their clients. Fluency is achieved when clinicians understand and appropriately utilize the language tools available, become proficient at structuring SFBT conversations consistent with the Diamond Approach, and consistently select client words within individual conversations that are in line with the clients’ desired outcome without violating the autonomy and agency of the client.

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General Focus of SFBT Diamond Approach Language The Diamond Approach will be outlined in detail below, but it is important here to highlight the general trajectory of Diamond Approach language. First, the language at the beginning of each session should focus solely on the client’s desired outcome from this session/work. Typically we begin sessions with the presuppositional question, “What are your best hopes from this session?”. However, it is rare that a client will develop a fully formed “best hopes” from this single question. Therefore, persistence will be needed to help the client articulate their desired outcome. The responsibility for making the questions answerable is the therapist’s, not the client’s. Every answer the client gives is the right answer. If the client is struggling to answer, that’s okay; that is the work of therapy. If the client is struggling, the therapist digs in a bit more and works to formulate questions that help the client get to an answer that can be used to build the desired outcome description.

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Overview of the Diamond Approach How Did We Get to The Diamond The Diamond was formulated after years of thinking about how to teach SFBT while carefully honoring the different ways clinicians do it. That process included a specific consideration for what works within Solution Focused Therapy. It was determined that broadly what is crucial to an effective Solution Focused conversation is the following:

● The outcome is always the entry point to the conversation ● There needs to be a detailed description about the presence of the client’s desired outcome in their lives ● The ending must honor the client’s autonomy and agency

In constructing the Diamond the intention was not to create something new. The intention was to provide a conceptual roadmap for how to structure a Solution Focused session. It is very much based on what SFBT professionals have done and conceptualized before, but it provides structure for clinicians upon which to base their work. That structure allows them to say at any point in the session what they are doing and why they are doing it. As much as the Diamond can inform the practice of the approach, it also serves as a unifying conceptualization of the many styles of the SFBT approach. It validates the many different effective pathways a clinician could take while tying the pathways together in an inclusive depiction of how to execute a SFBT conversation.

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Desired Outcome: The Transformation

All Solution Focused conversations should begin with the therapist and client co-constructing, as clearly as possible, the change/transformation the client wants as a result of the conversation. Transformation vs. Outcome The desired outcome is the transformation the client is seeking. It can be described as a “transformation” because an “outcome” might be too connected to a goal rather than an experience. “Outcome” identifies what the client wants, which is seminal to the Solution Focused conversation, but “transformation” makes room for the idea that this is a process. The transformation the Solution Focused conversation will center around is the difference the client is looking to experience from having come to therapy. In establishing the Desired Outcome, the clinician is inviting the client to tell them the transformation they are seeking. It is far more effective to view SFBT, not as a goal-oriented approach or a future-focused approach, but specifically as a change-focused approach. The conversation is focused on difference and change. In order to have the conversation, the clinician must identify what modification will take place as a result of this exchange. There is a strong inclination to ask the client why they have come to therapy. What makes SFBT different from other approaches can be found at the very onset of therapy. A Solution Focused clinician does not ask why the client has come. They ask what transformation they are in pursuit of, which can look like “What are your Best Hopes from our talking?” or “What

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difference do you hope being here will make in your life?” Those kinds of questions immediately orient the conversation toward change, difference, and transformation. Instead of a conversation about what brought the client to therapy, this is a conversation more about what they were motivated to experience a change in. The Desired Outcome or the transformation the conversation is focused on is often centered on an internal state, as described by Chris Iverson. The transformation is something the client wants to change within themselves such as more hope, more peace, more confidence, etc. Establishing a Desired Outcome for the conversation is navigating through the language to get to a place where the client is describing a transformation they want to occur within themselves. To simplify that, a strong hint for where one might find the state that makes up the Desired Outcome is what the client has control over. If a client says “I want to be able to smile as I do when it’s sunny outside”, the client has no control over how sunny it is going to be, but they do have control over their smile. Their smile corresponds with the state or transformation they are seeking. If the client is giving an external answer or referencing something that is outside of their control, the clinician must still be very accepting and thus must take on the responsibility of shifting from external to internal, to something the client can control. This highlights two important aspects to this approach: first, it reiterates that the conversation is oriented around difference, and it also reinforces the idea that this entire interaction is a co-construction. The clinician cannot dismiss the client’s contribution to the co-construction and must convey that they accept every response the client gives, usually by building it into their next question. Additionally, what may also help in establishing a good Desired Outcome is staying aware of the difference between what is unlikely and what is impossible. The Desired Outcome

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for the session does not have to be likely, but it does have to be possible. A client who is currently in jail, but who wants to be a movie star is hoping for something that does not have a good chance of happening, but what they are hoping for is not impossible. A Solution Focused clinician can hold onto and accept anything the client says that is possible even if it may seem very unlikely. A big obstacle to identifying a usable Desired Outcome is misunderstanding the clinician’s role in this therapy. A Solution Focused clinician is not there to solve problems. If one were to enter a session with a focus on solving problems, that may lead to a natural inquisitiveness about the problem. If the clinician accepts that their job is to facilitate change, they will become inquisitive about the process of change. This is similar to parenting. If a parent’s job is to prepare their child for life, they can’t always tie their child’s shoe; What they must do is raise the child into someone who can tie their own shoes and do other things for themselves. This is very much related to the stance that is necessary for Solution Focused work. In order to have these conversations and stay secure in this role, one has to hold certain beliefs about people and what they are capable of. Overcoming the misunderstanding of the clinician’s role in a session is made easy by seeing people in the appropriate way. This actually helps to overcome many of the obstacles that might surface in a Solution Focused session. When a client responds with “I don’t know”, having a belief in them can push through that in order to keep asking questions. The belief in people turns into perseverance. The Desired Outcome is well-established for the session once the clinician feels confident they can put the client’s answer into a description question, the most prominent description question being the Miracle Question. The clinician is ready to move on from Desired Outcome

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into the Description section once they are able to place the transformation the client is seeking, one they have control over, into a description question. It is important to remember that one cannot place things that are outside of the client’s control in functional positions in description questions. The day after the miracle cannot be dependent on the client's spouse’s change to sobriety for example or anything that they have no control over themselves.

Tips for a Good-Enough Best Hopes ● ● ● ● ●

You have a name for the best hopes (e.g., hope, confidence, peace, or happiness) You are excited about asking more detailed questions about the named best hopes The desired outcome is about a transformation of the client Something inside of the client changes (i.e., they have more hope) Something outside the client changes because the client changes (e.g., their family is getting along better) ● The desired outcome is based on the client’s currency (a.k.a., what is most meaningful to them) ● You feel confident that you can ask questions about this transformation for the bulk of the session (Taken from Connie & Froerer, 2023)

History of the Outcome Each of the types of description are about the presence of the desired outcome. The History of the Outcome is specifically about the presence of the desired outcome somewhere in the past. Begin this particular type of description by asking clients when they noticed their desired outcome showing up in their lives previously. Immediately in these questions, there is a presupposition that they have noticed the presence of their desired outcome before. Some clients may respond to this with the refute that they have never before had the outcome they are now seeking. Our response to that as Solution Focused practitioners is to continuously ask them to

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look closer. Whatever outcome the client is hoping for, it is impossible for them to have never had experienced it at all in their past. Peace, joy, enlightenment, or excitement, anything the client is now saying they would like to see in their life, they must have had some taste of that outcome at some point before. They’ve had it even if only for a fleeting moment or only in a small amount. It is our clinical responsibility to understand that they have experienced this outcome before and that we must ask about the presence of it, even if it might be hard for them to find. Even when a client tells us they have never been happy, it is our job to keep asking questions to allow them to look closer at their past.

From Exceptions to Instances to History of the Outcome Historically, the concept of “exceptions'' highlighted a portion of this idea but was specifically built on the understanding that there absolutely must have been a moment where the problem was not there or where the problem was less of a problem. This is how Steve and Insoo talked about it, but this was just an initial evolutionary step. Exceptions still included problem language, so BRIEF went on to make use of “instances”, where the desired outcome is present rather than just the problem being absent. Now, with History of the Outcome we can go even further assuming not only that there was a moment where the desired outcome was present but that it was noticed and the client had a relationship with it. An important aspect of the evolution to this point is that this is no longer just a set of questions that serve a technical purpose. This is building an entire description based on the presence of the outcome in the client’s past. Since this is an entire description, it then includes many other details. “When was the outcome present? What did you do to bring it about? Who else noticed? What did they notice? What difference did

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it make to the way you interacted with each other when it was present?” The addition of acknowledging that the client has had a past active relationship with their desired outcome allows them to describe it extensively while instances and exceptions are more static. We don’t treat the desired outcome in the future as a static moment, so the History of the Outcome allows us to do the same with the past. What’s so useful about this acknowledgement is that if a client can accept that they have had happiness or any desired outcome in the past, it makes it much more achievable and realistic to have more moments like that in the future. The key to having this particular kind of conversation with the client, as well as getting them to a point of accepting the presence of the outcome in their past, is persistence. We are not entitled to answers from the client, but we must persist in asking them questions that help them find moments like these in their past. What helps us to be so persistent in finding these moments is an enamourment with the client’s achievement. We, as the clinicians, should so deeply value the client’s attaining their desired outcome that we feel compelled to keep asking about the presence of it. When we persistently ask about the History of the Outcome, we ask the client a variety of noticing questions about. “How did you notice happiness was present in your life? Who else noticed? What role did happiness play on others around you?” We can ask any noticing question possible but in the past tense. Noticing questions are particularly useful in this kind of description because they continuously remind the client that they have had the outcome before, and with each answer to these questions, the client must acknowledge that assertion. One way of looking at this description is to view it as taking the desired outcome, which is quite internal, and making it external through noticing questions, asking about how it became noticeable to the client and the people around them. This is very similar to the description we build in the

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preferred future. The Diamond demonstrates that the Solution Focused approach is not exclusively a future-oriented approach. More accurately, it is a detail-oriented approach, and each type of description uses the same noticing questions only differing in the tense that they use, either past, present, or future. Another powerful kind of question we can use to ask about the past is a “legacy question”. Legacy questions give credit to the source of things the client is proud of. When someone says they are good with money, the most obvious legacy question we could ask is “Where did you learn that?” The common response clients give to these questions is to attribute it to someone important in their life like their grandmother or their father. Not only do legacy questions identify the origin of good things or things that bring the client pride, they also invite the client to take ownership of those things. “If your grandmother taught you this, how did you make it your own? How did you decide this was something you wanted to carry?” Knowing where you came from fills a significant amount of meaning into your understanding of who you are now, and legacy questions help accomplish this knowing. Additionally, legacy questions make all the change and difference at the center of our conversations relevant to the entire history of this person. Possible History of the Outcome Questions ● ● ● ●

How did you help the outcome to show up? What did you notice when the outcome showed up? What difference did it make to you when the outcome showed up? What differences did it make to your partner/friend/co-worker when the outcome showed up? ● When you were [insert the desired outcome] last time, how did you notice it? ● What were the clues? ● When was it present? (Taken from Connie & Froerer, 2023)

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Possible Legacy Questions ● Where did you learn to be [insert the desired outcome]? ● Where did you learn that you were the kind of person who was capable of being [insert desired outcome]? ● Who helped you realize that you had what it took to be [insert desired outcome]? ● What was that like? ● How did that process happen? ● How did you know you were receiving it? ● What did it mean to you that [insert important person] handed this legacy to you? ● How did you let them know you were pleased that you had inherited this legacy?

Resource Talk: Resource Talk answers the question of how someone made their accomplishments happen. It is assigning responsibility to the client for something positive in their lives. Assigning that responsibility to them should lead to an investigation of what the client did to make the positive thing happen. Some of it will be circumstantial, but some of it is attributional. There might be factors of their circumstances that helped make an accomplishment happen, but the accomplishment also came to be because of the skills, traits, and abilities the person possessed. A Solution Focused clinician has to treat any accomplishment, regardless of the perceived size of the accomplishment, as worthy of investigating. If there exists an accomplishment, that means there must be some circumstances that allowed it, and furthermore, there must be some attributes that allowed those circumstances to happen. It is necessary to refrain from judging the accomplishments and to consider the context surrounding these events in order to see a client’s accomplishments as worthy of investigation.

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Here, one can begin to see the influence the clinician might have in this therapeutic process considering that the client may not inherently value the accomplishment being described. It is through the questions of the clinician that said accomplishment may seem more worthwhile. This is the co-construction that is built into the Solution Focused conversation. Clients will talk about their everyday lives and experiences, but it is the job of the clinician to hear something valuable. The Solution Focused stance, how the clinician views the client, leads the clinician to hear something, find it impressive, and ask presuppositional questions about how the client made the accomplishments come about. These conversations are revolving around the client’s own familiar information; they’re about their accomplishments, their resources, and their contexts. What often leads to something useful in a Solution Focused conversation is the clinician’s perception of that information and the questions they ask about it. This demonstrates the role of co-construction in this therapeutic process. Doing effective Resource Talk is inquiring about something positive in all the ways you would similarly do in placing blame for something negative. If a child brings home an F on a test, it raises many questions about what they did wrong to receive an F. Resource Talk is noticing the A the child brought home, and asking about what they did right to receive an A. It requires a very exploratory inclination of the clinician regarding the resources and accomplishments of the client that leads them to look for all the ways those positive things came to be, have shown up, and continue to show up. The point of Resource Talk is to make people more fluent in what is positive about them. To do this well, the clinician must listen with the understanding that anything can be a resource, even gifts that the client possesses that might have

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been used or are currently used in harmful ways, such as inmates using unique ingenuity to obtain contraband, ingenuity that could also be quite useful in overcoming their vices. It is important to note that Resource Talk is different from building rapport or working on the therapeutic alliance. These can occur simultaneously, but Resource Talk itself is a distinct task. Mistaking this exchange for simply building rapport can distort its purpose into the idea that it’s only being done for the specific aim of the relationship between clinician and client while the true purpose should be building the client’s fluency in positive things and hearing themselves give fluent responses to the questions.

Possible Resource Questions ● ● ● ●

What makes the difference? What have you done to ensure that [insert desired outcome] is a likely possibility? What is it about you that makes this desired outcome a possibility? What have you seen from yourself that lets you know that you are on the pathway to achieving this kind of desired outcome? ● When you’re living your life, what makes you capable of doing all the things you seem to get done, despite [insert the current challenge they are experiencing]? ● How did you get this quality that is helpful to you? How did you foster it? Who helped you to develop it? ● What did you do in order to grow this ability or characteristic?

Future of the Outcome Steve de Shazer and Insoo Kim Berg introduced the miracle question, one of the first questions that officially shifted the focus of the conversation into the future. However, when they first introduced this question they phrased it as though the presenting problem was no longer an issue, (i.e., “Suppose you go to sleep tonight and a miracle happens. The miracle is that the problems that brought you here today are completely gone, what would be the first thing you

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would notice that would let you know your problems were no longer bothering you?”). This question was revolutionary to the psychotherapy field, however the phrasing of this question still required clients to filter their answer through a consideration of the problem. In the Future of the Outcome version of this question no problem-filter is necessary. The Future of the Outcome is completely contingent upon the desired outcome being present. A possible question might be, “Suppose you went home tonight and a miracle happened, the miracle is that now your desired outcome is present. What would be the first thing you noticed that would let you know, now you’re living in a world where your desired outcome is present?” This version of the question still orients the client to difference and to the future, without requiring the client to filter the answer through a consideration of the problem. Similar to the History of the Outcome and the Resources for the Outcome descriptions, in the Future of the Outcome the Desired Outcome is the central feature of the description. The Future of the Outcome conversation can be placed or oriented anywhere in the future, from a half an hour from now all the way to right before the end of someone’s life. Also, because this type of description is about the presence of the desired outcome, clinicians must remember that this description has nothing to do with the removal of someone’s problem. In fact, the problem is likely irrelevant. We don’t need to understand the relationship between the client’s problem and the presence of their desires; in fact there may actually be no relationship between these two things at all! Removing the problem is not the agent of change. When setting up a useful Future of the Outcome conversation in might actually be very helpful to hold all the problems and situations in the client’s life stable and consider them still relevant, but not that the client is different (given the presence of their internal desired outcome) they will

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interact with EVERYTHING differently, even their problems, because they are discovering that they are a different version of themselves, a version that is capable of interacting with problems differently. Also, it is important to presuppose that this internal, desired outcome change, will impact everything. It won’t CHANGE everything, but it will IMPACT everything. Therefore we are free to ask questions like, “What would be the first thing you would notice?” or “What would be different about the way you eat your breakfast on a morning when your desired outcome was present?” or even, “What would be different about the way you walked on a day when you were feeling [insert desired outcome]?” The internal change will impact the interaction this person has with everything and everyone around them, because they are a different version of themselves. One of the major focuses of the Future of the Outcome conversation is to maintain the hope that was introduced by the Desired Outcome questions. At times people will answer the difference questions presented in the Future of the Outcome conversation, but will quickly follow these answers up with something like, “But that couldn’t happen because [presenting problem] is still happening or relevant in my life”. When client’s do this, we need to take their concern or skepticism seriously. However, it is our job to make sure that hope and change persist. We can use presuppositions in these moments by saying something like, “Well suppose, given that your desired outcome is present, suppose for a minute that it was possible, or that it did actually happen, what would you notice then or what difference would that make?” Presupposing change persisting serves to retain the hope that is being built by the co-constructed conversation. Again, it is important to remember that we aren’t trying to problem solve with this type of conversation. We are NOT saying, what do you need to do to take steps toward achieving this

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desired outcome. We are NOT saying, if you followed a successful path, in the future, and achieved that goal, what step would come first and what step would come after that. The Future of the Outcome isn’t about making a plan for success, but rather it is a description about difference. Remember, this is a difference-oriented approach. Remember this is a language-based approach, not a behavior-based approach. Important tips for setting up the desired outcome effectively ● Make sure that you use the client’s exact desired outcome language ● Use details that you know about your client and their life to make the situation seem real and plausible to them ● Make sure that the desired outcome appears suddenly/immediately in their life. They go from not having their desired outcome to having it all at once ● Make sure that the desired outcome appears outside of the awareness of the client. This is why a miracle is often helpful. ● Make sure that the client is obligated to discover the signs of the presence of the desired outcome. Since the desired outcome appeared suddenly (by a miracle) the client needs learn that it appeared by noticing one small difference or sign after another ● Make sure that the client is the only thing that changes when the desired outcome appears. The world doesn’t change and the client’s problems/challenges may not have changed. The desired outcome appearing is an indication that a new version of the client is present to interact with these unchanged elements in a new/different way.

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Possible Future of the Outcome Questions ● What is the first thing you would notice that would let you know that [insert desired outcome] were present? ● What would be the next thing you would notice? ● Who in your life would also realize that something was different about you when [desired outcome] was present? What would they notice that would let them know something is different about you? How would they let you know they noticed? What difference would it make to you if they noticed this about you? ●

Closing a session Closing a session is all about trust! We are trusting that the language we developed with the client throughout the session did indeed create a new reality. This new reality is present because the conversation literally changed the client to a new version of themselves because they considered and articulated things that were new and different. The work of the session has been completed! Because change has occurred no other work needs to be encouraged at this time. We need to honor and maintain the autonomy and agency of the client to use the session in whatever way is right for them. If we honor the client’s autonomy and agency we no longer need to do any of the following: ● Give compliments ● Summarize the main points or the takeaways from the session ● Assign homework or tasks to be completed between sessions If we do any of these things, we are violating the clients autonomy and we are reclaiming the power within a session. We are communicating that our opinion of what happened during the session is more important than their impression. We are communicating that we don’t trust that

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they will make the most of what happened in the session on their own, but that we know how they should continue to change going forward. We are communicating that we have been assessing them (even if our assessment is positive) and that we, as the experts in the room, know what is valuable about them. None of these things are helpful or convey trust in our clients. Instead of doing these things we have two simple tasks during the closing of the session. First, express gratitude. Any participation in the session is a gift from the client to us. They agreed to collaborate with us. They agreed to be vulnerable with us. They were introspective and worked throughout the session. Without them this work would be pointless. We express gratitude for their contributions. Second, we offer a return appointment if they feel like that would be helpful. This is not presuming that they will return, but rather, it is giving them the option to return if they want. A simple statement like, “If you would like to return for another appointment, you are more than welcome” will suffice. It might also come in the form of a simple question, “Would you like to meet again? If so, you are more than welcome.”

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References Abbasi, A., Mohammadi, M., Zahrakar, K., Davarniya, R., & Babaeigarmkhani, M. (2017). Effectiveness of solution-focused brief therapy (SFBT) on reducing depression and increasing marital satisfaction in married women. Iran Journal of Nursing, 30(105), 3446. Bavelas, J. De Jong, P., Franklin, C., Froerer, A., Ginerich, W., Kim, J., Korman, H., Langer, S., Lee, M. Y., McCollum, E. E., Jordan, S. S., & Trepper, T. S. (2013). Solution focused therapy manual for working with individuals. Solution Focused Brief Therapy Association. Retrieved from https://irp-cdn.multiscreensite.com/f39d2222/files/uploaded/Treatment%20Manual%20Fi nal%2C%20Update%203-17-18.pdf on September 25, 2020. Carr, A., Hartnett, D. Brosnan, E., & Sharry, J. (2016). Parent plus systemic, solution-focused parent training programs: Description, review of the evidence-base and meta-analysis. Family Process, 56(3), 652-668. doi: 10.1111/famp.12225. Connie, E. E. & Froerer, A. S. (2023). The Solution focused brief therapy diamond: A new approach to SFBT that will empower both practitioner and client to achieve the best outcomes. New York: Hay House. De Shazer, S., Dolan, Y., Korman, H., Trepper, T., McCollum, E., & Berg, I. K., (2007). More than miracles: The state of the art of solution-focused brief therapy. Binghamton, NY: Haworth.

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Froerer, A. S. & Jordan, S. S., (2013). Identifying solution building formulations through microanalysis. Journal of Systemic Therapies, 32(3), 60-73. George, E., Iveson, C., & Ratner, H. (2017). BRIEFER: A solution focused practice manual. BRIEF. Gong, H., Hsu, W. S. (2015) A meta-analysis on the effectiveness of solution-focused brief therapy: Evidence from mainland China and Taiwan. Studies of Psychology and Behaviors, 13(6): 709-803. Gong, H. & Hsu, W. S. (2016) The effectiveness of solution-focused group therapy in ethnic Chinese school settings: A meta-analysis. International Journal of Group Psychotherapy, 383-309. DOI: 10.1080/00207284.2016.1240588. Hosseinpour, N., Jadidi, M., Mirzaian, B., & Hoseiny, H. (2015). The efficiency of solution-focused brief therapy on adjustment problems of female students in Amol, Iran. International Journal of School Health, 3(1), 1-5. Jonas, B., Leuschner, F., & Tossmann, P. (2016). Efficacy of an internet-based intervention for burnout: A randomized controlled trial in the German working population. Anxiety, Stress, & Coping, 30(2):133-144. Kim, D. I., Lee, H. E., & Park, E. (2017). The effect of solution-focused group counseling: Effect size analysis by multilevel meta-analysis. Research in Counseling 18(1):157-179. Kim, J.S. (2008). Examining the effectiveness of solution-focused brief therapy: A meta-analysis. Research on Social Work Practice 18:107-116.

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Kim, J. S., Franklin, C., Zhang, Y., Liu, X., Qu, Y., & Chen, H. (2015). Solution-focused brief therapy in China: A meta-analysis. Journal of Ethnic & Cultural Diversity in Social Work, 24(3):187- 201. Kim, J., Jordan, S. S., Franklin, C., and Froerer, A., (2019). Is solution-focused brief therapy evidence-based? An update 10 years later. Families in Society: The Journal of Contemporary Social Services, 100(2), 127-138. DOI:10.1177/1044389419841688. Maljanen, T., Knekt, P., Lindfors, O., Virtala, E., Tillman, P., Härkänen, T., & Helsinki Psychotherapy Study Group. (2015). The cost-effectiveness of short-term and long-term psychotherapy in the treatment of depressive and anxiety disorders during a 5-year follow-up. Journal of Affective Disorders,190, 254-263. doi:10.1016/j.jad.2015.09.065. McKergow, M. (2016). SFBT 2.0: The next generation of solution focused brief therapy has already arrived. Journal of Solution Focused Practices, 2(2), 1-17. Nedim, B. P., & Kaya, C. (2017). Sinif öğrencilerinin okul tükenmişliği ile baş etmede çözüm odakli grupla psikolojik danişmanin etkisi (The effect of solution focused group counseling program on dealing with school exhaustion of sixth grade students). Uluslararası Sosyal Araştırmalar Dergisi (The Journal of International Social Research), 51(10), 769-777. Neipp, M., Beyebach, M., Nuñez, R. N., & Martínez-González, M. (2016). The effect of solution-focused versus problem-focused questions: A replication. Journal of Marital and Family Therapy, 42(3), 525-535. doi: 10.1111/jmft.12140.

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Ngammoh, P., Inang, P., & Koolnaphadol, P. (2017). Theory of the short-term exit approach to self-sufficiency of undergraduate students in the faculty of education, Journal of Education Naresuan University,19(1), 90-102. O’Hanlon, B. (2003). A guide to inclusive therapy: 26 techniques for respectful, resistance dissolving therapy. New York, N.Y.: W. W. Norton. Park, J. I. (2014). Meta-analysis of the effect of the solution-focused group counseling program for elementary school students. Journal of the Korea Contents Association 14(11): 476-485. Pennapha, N. (2015) The consultant theory emphasizes short-term solution to reflect their inner thoughts of employees. Burapha University Journal Online, 25(3). Richmond, C. J., Jordan, S. S., Bischof, G. H., & Sauer, E. M. (2014). Effects of solution-focused versus problem-focused intake questions on pre-treatment change. Journal of Systemic Therapies, 33(1), 33-47. Schade, N., Torres, P. & Beyebach, M. (2011). Cost-efficiency of a brief family intervention for somatoform patients in primary care. Families, Systems, & Health, 29(3), 197-205. Smock, S. A., Trepper, T. S., Wetchler, J. L., McCollum, E. E., Ray, R., & Pierce, K. (2008). Solution-focused group therapy for level 1 substance abusers. Journal of Marital and Family Therapy 34(1):107–120. Stams, G. J. J., Dekovic, M., Buist, K., & de Vries, L. (2006). Effectiviteit van oplossingsgerichte korte therapie: een meta-analyse (Efficacy of solution focused brief therapy: a meta-analysis). Gedragstherapie 39(2):81-95.

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Suitt, K. G., Franklin, C., & Kim, J. (2016). Solution-focused brief therapy with Latinos: A systematic review. Journal of Ethnic & Cultural Diversity in Social Work 25(1), 50-67. Zhang, A., Franklin, C., Currin-McCulloch, J., Park, S., & Kim, J. (2017). The effectiveness of strength-based, solution-focused brief therapy in medical settings: A systematic review and meta-analysis of randomized controlled trials. Journal of Behavioral Medicine, 41(2), 139-151. DOI: 10.1007/s10865-017-9888-1.