What's Better This Week? is a weekly podcast focusing on balancing the practice of Solutions Focused Brief Therapy with the realities and the demands of a clinical environment in the USA.
What's Better This Week? is a weekly podcast focusing on balancing the practice of Solutions Focused Brief Therapy with the realities and the demands of a clinical environment in the USA.
Episode 7: Making Treatment Plans Solutions Focused
Welcome to What’s Better This Week? Episode 7: Making Treatment Plans Solutions FocusedWhen we last left off, we had collected some superfluous data and some pee, and now, here in our fourth appointment, we need to make a treatment plan that we’re going to refer back to regularly for a host of reasons. First, and foremost, at least in New York State, where we are mandated to by the Office of Mental Health: patients’ discharge planning is actually begun at their admission, or at least we have to check a box that says “discharge planning has begun.” Why? Because someone on the state or funding level has said that it is vitally critical that we make it apparent that we’re not trying to create patients for life, and that we are actively working on moving our patients along. For someone who is a Solutions Focused Brief Therapist, this is a no-brainer: the Brief, in SFBT means that we never keep a patient a micro-second longer than they want, to be in treatment. We don’t want patient’s for life, it means we’re n to doing our jobs. It is antithetical to our treatment model. However, part of proving that we’re being honest with the finances of insurance companies (who again, dominate this industry far more than they should) is that we indicate that we have already begun discharge planning by our fourth apartment (right after admitting our patient) and we continue this through the collaborative creation of a treatment plan.Additionally, the Treatment Plan ensures (or, in theory it works to try to ensure) for therapists and counselors who are not Solution Focused, that they are working with a goals/objective modality of therapy, rather than just talk therapy: those paying for therapy want to make sure that something more than a therapeutic relationship is happening…they want to make sure that patients are getting somewhere and that somewhere is “cured” and out the door. It is the Medical, not the Sociological model. Goal/Objective therapy removes “talk therapy” largely as an option, because a patient must consistently be doing something, to consistently be moving toward their goals…for my astute listeners, you will note that this is actually placing (or can have the trap of placing) many patients into some kind of pass/fail model of therapy, where they're “not making progress” quickly enough…and it’s largely nonsense; it also serves two interests: first the funders/insurance companies, and second, those clinicians who don’t take a step or two step down approach, but rather wish to seem superior to their patients who don’t “make enough” progress in their own eyes.So what do we do about this nonsense? And how on EARTH do we ethically and honestly connect Solution Focused Brief Therapy work into this insurance based, financially based, diagnostically riddled model? Actually, quite easily - but we have to be careful about it.First, our treatment plans follow a Problem -> Goal -> Objective -> Intervention model. This means that we have to share what our patient’s problem is, what their goal is, how they’re going to get to their goal, and what specific intervention is going to get them there. We call it a “PGOI” for short. Ergh.When working with patients, I will often explain - much like when I explain that all a diagnosis is, is a title heading that works to explain a combination of symptoms that go together, a treatment plan works like a journal, to log what we’ve been working on, and to make sure that I understand them correctly. I also - much like we have discussed to date - will then have to balance out the patient’s wants, needs, desires, and goals - my own, as an SFBT therapist - and the state’s, as our licensor, and of course the insurance company (as funder, and of course sometimes that’s the state).So first is working with the patient to explain to them all of the reas
Episode 6: How to Be Solutions Focused in a Crisis (Special COVID-19 Episode)
Welcome to What’s Better This Week? Episode 6: How to Be Solutions Focused in a Crisis (Special COVID-19 Episode).
With everything going on with COVID-19/the Novel Corona Virus, I figured a Special Episode might be helpful, whether for yourself, or as an intervention when working with patients and clients who may very well view this as a crisis well beyond their capacity to cope (especially if their traditional services are being interrupted, or you’re providing services over the phone). Unlike a “traditional” SFBT appointment, I have used the following very often in Crisis Appointments, both in person, and over the phone (and, to be honest, sometimes with myself!).
When a patient presents dysregulated and in crisis, it behoves us to take a Solution Focused approach with them (for all of the reasons that we are SFBT counselors). Also because SFBT is usually the most effective approach at providing an immediate experiment that our patients and clients can leave with to proactively work on whatever it was that brought them into our office in the first place. However, dysregulation usually requires a different approach than a traditional appointment, so while not necessarily Solution Focused, I find it helpful to start the session (in person or on the phone) by asking my patients to join me in taking three deep breathes (slowly in through the nose, and then slowly out through the mouth). Good….now again…and now one more, slowly. The reason is because many of my patients will often begin restricting their breathe when dysregulated, or anxious, or in a panic, and it’s important we work to decrease the physiological symptoms of flight, fight, or freeze (those times when we don’t have Behavioral Ownership).
In a crisis, I will adjust my opening question of “What’s better this week” to instead be: “have things gotten better, stayed the same, or gotten worse?” If this is a patient I have never met with, I will adjust the time frame. Maybe I’ll ask “since yesterday? Last week? Last month?” If I’m working with myself as my own patient (yes, you can use this with yourself) I will often ask “since you last had a moment to reflect?” Then it’s time to listen reflectively. If things have gotten better, we want to respond with a reflection, validate, and then ask them “how did you make that happen?” If things have stayed the same, again, we want to respond with a reflective statement, validate, and ask them “how have you managed to make sure that things have stayed balanced? That’s really hard work to do sometimes? How did you make it happen? What coping skills have you been using?” If our patient, client, or ourselves respond with “things have gotten worse! So much worse!” then we want to respond with a reflective statement, validation, and ask them how they’ve been coping with that. Almost universally the response I get when I ask a patient “how have you been coping with that” when they tell me that things have gotten worse is “but I haven’t been coping!” and generally I’ll reply with “Nonsense, you’re here! You made it to my office! I see that you’re largely in one piece! To my knowledge you didn’t assassinate an Arch Duke and start a World War, so, somehow, you’re coping, maybe we just have to figure out how…let’s think…maybe if you describe what you’ve been doing, we can figure out how you’ve been coping together…” Then validate, validate, validate.
After this, I will ask my usual scaling question of “on a scale from 1-10, where 1 is everything in the world is awful, like Zombies, and not even the cool ones, but the gross ones, and 10 is everything in the entire universe is amazing, like unicorns are just farting rainbows and glitter…where would you put yourself right now in this moment?” I will then work the scale with the pati
Episode 5: More Superfluous Data & Pee
Welcome to What’s Better This Week? Episode 5: More Superfluous Data & Pee
When we last left off, we covered what happens in the second assessment appointment, and we put our pinky toe in the water for how solutions focused counselors begin to address the concept of diagnosis with patients, while balancing out clinical requirements to New York State, the Office of Mental Health, the Office of Substance Alcohol and Substance Abuse Services, and payers like Medicare and Medicaid.
So what happens in our Third Assessment Appointment? During the third assessment appointment, we will again be gathering data that is less relevant for our work with our patient, and that benefits, on the whole, the Department of Health’s mission to gather statistics for the sake of gathering statistics: what is your Tuberculosis status? What is your Hepatitis Status? What is your HIV Status? If a patient really wants services they’re not necessarily going to be forthcoming with us, and they may not necessarily know, and even if we *give* them referral information they may take it and throw it in the trash which is why these screening questions are - at best - superfluous, and at worst a waste of time: I don’t want to say that this *isn’t* our job (I do believe in the “it takes a village” concept toward community health) but I do believe that we should be providing the services that patients have come to us for, not what we *think* they need. If a patient has come to me for counseling, it’s not to receive the Department of Health’s Statistical Questionnaire. We then provide our patients with printed information on all of the above without cause or concern for their ability to read and comprehend that information (more on that in a future episode, because we will be working with patients who have a variety of different cognitive abilities).
So it is VERY easy to see why our patients can think that we’re totally out of touch, and totally out to lunch…because here it is, week THREE, and we’re not doing counseling…we’re still asking them questions…and now we’re asking them healthcare questions…so it’s vital that we take a solutions focused approach to this: “I know that this information isn’t what you want to talk about today; and I apologize that we’re required to ask it. Let’s try and get through it efficiently so we can get to what’s really important: the reason why you’re here. I’ll absolutely work to save a good half an hour today so we can talk with one another.”
After asking these health questions, we will then ask some more questions about orientation, and identity, straight off the bat, with only two previous sessions of rapport built up, which can be terrifyingly forward for our patients (since we’re the one’s asking the questions, rather than eliciting information through a Solution Focused model) - but it’s there on an assessment form, and we have to provide a response: because if we don’t we’re not doing our duty to our agency, and we cannot simply respond with our own guess work, and we have to also respect the personal right of our patients to also choose to respond (or not) to their comfort levels to these assessment questions (and some are perfectly fine responding to any and all questions asked, having been socialized to do so).
After this, we’ll then ask intimate questions about their relationship with their partner or spouse or significant other, and then their relationship to their family as a whole.
Finally, we’ll ask them for information on their CPS connection, and then we’ll ask for legal information (criminal background, arrests, any criminal justice hearings pending, etc.).
Here’s the thing: in ANY Solution Focused Brief Therapy session…if ANY of this was at ALL relevant to the work that the patient wanted, or felt needed to be done…it
Episode 4: Welcome Back
Hello Everyone and welcome back! I apologize for the brief hiatus with no notice! Since the last episode two things happened at the exact same time: first I got very sick, and second (and more important) I bought and moved into my very own home. Personally, I hope it is my last move ever, because honestly it was a lot. Since then I’ve been recovering (and with a suppressed immune system and chronic illness, it’s taken longer than I’ve hoped for). This sadly hasn’t lent itself to working on a podcast…to say nothing of attempting to find my podcasting gear in all of the boxes that were set aside in my home office.
However, my home office is now setup, and I have found my podcasting gear, which means that as you are listening to this, I am recording this Sunday’s episode…uploading it, and setting it to auto publish! So please tune in this Sunday as we continue forward together down our solutions focused path. Thank you for bearing with me,
The music you’re listening to in the background today is Boston Landing on “Blue Dot Sessions" generously shared through a creative commons license. Please find more of their music at www.sessions.blue, that’s w-w-w- dot s-e-s-s-i-o-n-s- dot b-l-u-e. I’ll see you this Sunday with more; until then, make good choices.
Episode 3: What’s A Diagnosis Anyway?
Welcome to What’s Better This Week? Episode 3: What’s A Diagnosis Anyway?
Last week we covered what happens in an initial assessment session, the complications that assessment appointments bring when attempting to have a solutions focused practice in a clinical environment, and we finished with our hypothetical patient leaving their first (of three) assessment appointments.
So what happens after they leave my office? What do we do during their second assessment appointment? How do we prepare them for their third assessment appointment? All good questions. I’m glad you asked them.
After I’ve walked the patient back to the waiting room, there are certain things I have to go back and do that are not in line with solutions focused practice.
I have to add a mental status exam note (or MSE) to my documentation. This is a requirement in clinical practice. But just because something’s a requirement doesn’t mean that we can’t be solutions focused about it.
Generally speaking any standard MSE might read like:
Patient presented through Same Day Access, dressed appropriately, appeared alert and well-oriented. There was no evidence of disruption in speech flow or content, memory, or perception. Current mood observed as dysphoric with affect congruent to mood. Thoughts were organized and goal-directed. Judgment appeared good, and insight appeared moderate.
Patient presented with:
Stressors regarding housing
Stressors regarding living situation.
Symptoms of depression.
But what is we reframed the presenting symptoms to be not only more solutions focused, but more accurate to the patients truth, and more in line with our practice of taking a step down approach, and honestly more accurate to the patients presentation in general and instead the it read:
Desire to decrease stressors regarding housing
Desire to decrease stressors regarding living situation.
Hopes to increase mood, and desire to decrease feelings of depression.
Well, look at that. By reframing the “objective” (if there ever can be such a thing) MSE’s presenting “ problems to be solutions focused we reorient ourselves and our patient’s documentation away from the typical “patient is depressed,” “patient is angry” to where our patients are back in control, and are being proactive. My what a different way of thinking about our patients. What a different way of framing them to our colleagues. What a way of taking back control from the insurance companies where we must ethically, in a clinical fashion, report clinical symptoms each and every session (which means that everything we do to assist our patients, somehow, must also ethically link to these symptoms and further the patients goals of decreasing them or improving them!). It takes something that is antithetical to SFBT practice, and moves it in a way that most aligns to our core beliefs.
Then, and this is of course where my scruff gets a little more ruffled. I have to provide some kind of diagnosis, because if I don’t, insurance won’t pay for the session. And if we, as an agency, don’t receive insurance payments we can’t continue to function as a clinic; and I, as a practitioner, deserve to receive compensation for my labor. I have to eat. I have to pay my bills. And so, I have to provide a diagnosis.
Here is another touchpoint.
We must remain ethical. We must remain truthful. We must remain solutions focused. We must balance each session and conversation in order to connect our patients conversation and scaling and best hopes to their mental health concerns which means we must, at times, also guide them in ways we might not have to in a pure SFBT environment. And so diagnosis becomes tricky, and important, because it will become relevant every single session
That said, how we approach the concept of diagnosis with regard to a computer scre
Episode 2: Starting From The Beginning
Welcome to What’s Better This Week? Episode 2: Starting From the Beginning.
So I’ve put a lot of thought into the best way to show the juxtaposition of Solutions Focused Work in a clinical setting, especially in a New York State, Office of Mental Health Licensed, Outpatient Community Mental Health Clinic.
What I’ve come up with (and we’ll see if it pans out, and if it doesn’t, we’ll change tracks) is to go through (at least for the very start of this program) what our patients experience when connecting to the process by going through the process itself, step by step; so I can show where the potential for clashes with the modality and clinical reality are, and how I address and account for them (where possible) in a solutions focused way, and how I make solutions focused work in all of this in general. Then, after that, each week, we’ll tackle general solutions focused stuff that comes up in the clinical world: advances, techniques, new evidenced based research, how we continue to make it all fit together, and more.
This Podcast probably isn’t the best for those entirely new to Solutions Focused work, though It will be beneficial for students who want to be SFBT clinicians in the field one day (especially in the states). So that said, I’m going to make one big assumption, and that assumption is that you’re already familiar with SFBT, and have a pretty decent handle on how to conduct a session (at least theoretically) or you’re already an SFBT practitioner.
If you don’t or aren't, that’s okay. I think of all of the modalities, SFBT is the modality where we most want to create new practitioners. My suggestion is that if you’re new to this branch of therapy or counseling or coaching (depending on what country you’re listening from) is to get super familiar with it really quick, by reading the works of Insoo Kim Berg, Steve De Shazer, and also watching and reading the works and videos of Scott D. Miller (and there are many more to choose from, and of course, YouTube…which is where I’ve learned everything from how to fix my cars headlights to how to pick a lock, all valuable skills as a former case manager).
That said, I’m going to jump right into the podcast. You are welcome back at any time, or you can stick around, and if you find that it’s not making sense maybe it’s time to hit the pause button, and do some light reading.
Let’s talk terms. In this podcast, I’m going to refer to clinical work to mean outpatient behavioral health care in an environment which requires the acceptance of insurance in order to treat clients or patients who otherwise could not afford mental health care, and I’m going to refer to SFBT or Solutions Focused to mean Solutions Focused Brief Therapy.
So, the first two issues that we run up against in the clinical vs. SFBT divide is that SFBT doesn’t rely on a diagnosis (in fact, we generally eschew diagnosing patients, and it isn’t necessary for the modality at all)…and, in SFBT we also begin work immediately in the first session, which just doesn’t happen in a clinical setting.
In the United States, and certainly in my practice in New York, I am required to provide a diagnosis at the end of the very first visit (despite the fact that we are trained, almost universally across the board of the helping professions) that diagnosing on the first visit or interaction is the worst practice and shouldn’t be done. Insurance requires it, so we make some ethical leaps and bounds, and et viola, we all do it, because otherwise no one would get care (and none of us have risen up en masse to put the insurance companies in their rightful place...yet).
The second, most noticeable difference is that in “pure SFBT” we begin the session with the patient or client immediately when they are in our office, at their first appointm