Solution-focused therapy for clients who self-harm
This article outlines the development of a service using solution-focused therapy by a liaison psychiatry team for clients admitted to hospital following deliberate self-harm.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article found under “related files”
Chris Laydon, RMN, PGDip, FETC, is clinical lead nurse, Cherry Knowle Hospital, Sunderland; Sandra MacKenzie, RMN, Dip, is team manager; Sonia Jones, RGN, Dip RMHN, is senior nurse; Kirstie Wilson-Stonestreet, Dip RMHN, BHSc, is senior nurse; all at liaison psychiatry team, St Luke’s Hospital, Middlesbrough.
Laydon, C. et al (2008) Solution-focused therapy for clients who self-harm. This is an extended version of the article in Nursing Times; 104: 9, 30-31.
This article outlines the development of a service using solution-focused therapy by a liaison psychiatry team for clients admitted to hospital following deliberate self-harm. It summarises the early development of the service and the results of a study on the therapy’s effectiveness. It also reports on further developments made since the study was undertaken, including the use of follow-up sessions, feedback letters to service users and changes in clinical supervision. Future plans for the service are also described.
In 2002 the liaison psychiatry team in Middlesbrough formalised its commitment to a whole-team approach to care by adapting the solution-focused approach to interventions. The following year we completed a study exploring the effects of solution-focused brief therapy on reducing repeated deliberate self-harm (Wiseman, 2003). The study had an impact on our service delivery and a positive influence on the team dynamic. It allowed us to carry on and justified our dedication to change. This article outlines developments undertaken since then.
The liaison psychiatry team was established in 1996. Despite changes in staff, location, organisational structure and resources our shared vision has remained the same: to provide a timely, quality, physical, psychological and social assessment of patients presenting to the local acute general hospital with deliberate self-harm (DSH). The team also assess inpatients who have mental health needs in conjunction with a physical illness.
Referral protocols were developed when the service was established, and team members became committed to developing the necessary skills to assess risks for people referred following acts of self-harm. We had developed an assessment document that identified key factors (such as suicidal intent and repetition factors) which was based on contemporary practice. However, this still relied on a medical model that encouraged service users to highlight and discuss their problems. Therapeutic dialogue was limited, although risk factors were comprehensively documented.
As the service developed and the team’s assessment skills developed, the team manager became sensitive to staff requests to do more than simply assess clients. Appraisal conversations confirmed that the team felt the initial interface with service users (at such a critical time) could be used for more than just establishing the nature of their problems and assessing risks before referring on. We then began to review the literature and explore possibilities for making further improvements to the service.
The team manager had attended a workshop on solution-focused brief therapy and our regional liaison network meeting recognised the benefits of this approach. The possibility of integrating solution-focused perspectives into our practice was agreed and training was arranged for the whole team, consisting of nursing, medical and social work staff, to receive training. The initial aim was to introduce them to solution-focused concepts and to discuss the viability of a whole-team approach. In clinical supervision sessions after the workshop, we discussed the practicalities of using a whole-team intervention model. We arranged to ask for help from a practice development nurse from another trust who was trained in solution-focused therapy. The beginning of this process aimed to:
Familiarise the team with the concept – this involved training and encouraging staff to use the principles in a safe environment (workshops, group supervision sessions, directed conversations);
Involve the team through joint review of existing protocols;
Give individuals responsibility for redesigning relevant documents.
The team participated enthusiastically – their wish to do more for their clients and the need to ensure consistency were both met. Staff accessed training and regular solution-focused supervision was arranged.
We realised that staff had little time to spend with service users. The volume of referrals meant (and still does) there was no capacity for follow-up after discharge and therefore only a single assessment was possible. This meant our priority was to ensure we made the most of the one contact. We knew that any interaction with clients had the potential to be an intervention, and felt the outcome could be enhanced by taking a solution-focused approach.
Solution-focused brief therapy
Solution-focused brief therapy was developed in the US from the work of Steve de Shazer (1985) and his colleagues. It emphasises that individuals have unique resources and the potential to find their own solutions to problems. These researchers believed that focusing on problems often obscures the resources and solutions that clients often already have – they did not see therapists as the source of solutions (de Shazer, 1988).
The model’s philosophy is empowering. The individual client is acknowledged as the main activist in changing their situation. Within the sessions clients are helped to identify the future they want as well as the things they are doing which are helpful in getting there – the problem story is used to identify resources, achievements and survival strategies rather than criteria for diagnosis. Techniques familiar to many therapists are used within a new framework to focus on achievable goals. Accurate description of these goals is the cornerstone of solution work (Iveson, 2002).
Changes to the service
We included solution-focused concepts in the original assessment tool adapted from the European Brief Therapy Association’s research definition. For example, ‘What would you like to happen?’ scaling questions, the ‘miracle question’ – which involves asking clients to imagine that while they slept a miracle occurred and their problems were solved, then to describe how they would go about discovering that this had happened – and specific feedback. We then scripted the questions in the relevant places of the tool (see www.ebta.nu/page2/page30/page30.html for more information).
In practice the responses to the new questions promoted a different type of narrative and concern. We had learnt to respond to the previous tool with, at best, sympathy, but most often with pragmatic referral outcomes. However, with the solution-focused questions we realised people could become more active in shaping their future. We were engaging with the person instead of the problem. Staff were becoming more enthused and there were fewer stories of despair in supervision.
In 2002 we conducted an open pilot study of single-session solution-focused brief therapy on people presenting to hospital services for the first time having deliberately harmed themselves (Wiseman, 2003). Our aim was to assess the feasibility of delivering the therapy to this group, and to inform the design of a future randomised trial. The results were positive – only 6.25% had repeated self-harm after one year compared with 13.2% of the control group (Fisher’s exact test p=0.3). It confirmed our belief that solution-focused therapy is a feasible and acceptable intervention for clients presenting with self-harm for the first time. The results reaffirmed that the initial contact with service users can have a more enduring impact if they are helped to consider more than just their problems.
Further service developments
New experiences bring new ideas; the assessment document is continually reviewed and revised as more up-to-date practice brings new ideas. For example, we are considering integrating a ‘preferred future’ topic rather than the ‘miracle question’, as the team felt the traditional miracle question approach was too wordy to use at a time when clients’ mental health problems are so acute. The team found that the question ‘What would be your idea of a preferred future?’ or ‘What are your best hopes…?’ was more grounded in reality and was more tangible for clients to work with. We are introducing feedback letters and considering offering follow-up sessions.
Feedback from staff is encouraging. They are the experts on what is needed in the sessions and are encouraged to develop a mutual process. The team manager’s role has involved ensuring staff were adequately trained and confident in applying their skills, and offering and arranging support as new challenges emerged. The consistency of approach, shared vision and ownership of the intervention model has helped our service develop the changes needed to take it forward.
Introducing follow-up sessions
We realised the first session is often the only opportunity to engage clients to move from recent past problems and identify more constructive hope for the future. The right kind of question can show them a way of relating to life that challenges their depressive view of the world. They can be helped to discover a way to move towards healthy change – to literally step out of their negative trance (Griffin and Tyrell, 2004). Solution-focused therapy helps to clarify these hopes.
Although the first session could be used to explore clients’ coping strategies – once the problem story has been given appropriate attention – in practice this did not happen. Several factors such as the environment (usually a medical ward); clients’ attitudes (regret, guilt, embarrassment and truculence); their physical state (pain, discomfort, hung-over); and staff’s need for risk assessment, efficiency and safety all tended to focus the session on identifying the problem, which reinforced the client’s reasons for being there. We noticed a shift occurred when the conversation moved to ‘What would you like to happen…?’
During our initial session with clients we felt some would respond to follow-up. They seemed to grasp the concept of the solution-focused approach and were interested in the idea of drawing on their own strengths in order to move on. However, the only way we could know that that session was useful was to offer some form of follow-up.
When clients accept a follow-up session, some fundamental changes occur. They are seen in a different environment, usually a clinic, which is more relaxed and conducive to proactive and therapeutic dialogue. They have been given responsibility to attend (giving them an active responsibility) and, depending on their mode of self-harm, they may no longer be feeling physical discomfort. Since the follow-up session may be 2–4 weeks after the initial assessment it is extremely likely clients will be in a better frame of mind. All these factors help separate the person from the problem and allow for autonomy: ‘…Working with and focusing on the person and steering them away from the problem’ (de Shazer, 1985).
Usually only one follow-up session is required, although we allow for up to four. We are currently auditing the effectiveness and drop-out rate of these sessions. We have devised a tool for second and subsequent sessions to help identify clients’ progress since their initial assessment.
Sample questions for follow-up sessions:
What has been better since we last met?
What things in your life have managed to stay okay, even through such a bad period?
What did you do/what have you been doing to prevent things getting any worse?
What are your best hopes for this session?
Revisit the miracle question.
On a scale of 0–10, how confident are you that you might be able to achieve what you set out to do in the first session?
What has prevented you from giving up even though things have been that bad?
What have others seen you doing that is useful?
What might be a sign that you are getting back on track again?
What has surprised you about yourself?
In situations where clients have encountered setbacks, it is especially important to acknowledge their achievements. We also use present- and future-orientated questions.
Introducing feedback letters
The inspiration to offer written feedback to service users came from two sources. The first, developed from a training workshop run by MindFields College, highlighted that clients would benefit from seeing their positive attributes written down. In addition, good practice protocols regarding offering clients a copy of their assessment letters were being discussed in our trust.
After much debate, it was agreed that sending the usual assessment letter (the GP letter) may be detrimental to clients as its narrative structure may cause them to revive and possibly relive negative incidents contributing to their situation and prevent them moving forward. However, we agreed that constructive feedback may be helpful.
We explored the concept of a solution-focused therapy feedback letter, which would be sent to service users following completed assessments. We felt that by using headings we could maintain consistency and validate sessions with clients in a reflective rather than reactionary way. The letter would focus on the client’s skills, strengths, resources, qualities and coping strategies and offer evidence of what they believe they can achieve.
Possibly the first people to experiment with using letters as a therapeutic tool were Epston and White (1990). These Australian psychotherapists concluded through numerous informal surveys that such letters were ‘… tantamount to between three and 10 therapy sessions’ (Sori and Hecker, 2003).
The headings incorporated in the letters include: feedback on clients’ best hopes for the future (preferred future); their own perceptions of their strengths and abilities; and praise from staff about their resources:
Your best hopes for the future;
Ways in which you identified what you can do to achieve/work towards your preferred future;
The qualities you (and others) recognise in you;
What interests me about you.
The feedback is framed in clients’ language, quoting their statements on what they have done, are doing or plan to do that is helpful, positive or valuable.
Using this type of solution-focused questioning encouraged clients to reflect on their positive attributes and on actions they could take to improve their lives. The questions also served as positive affirmation and helped to ensure healthy coping strategies despite periods of low mood. It was a challenge for practitioners to support clients to identify as many qualities as possible. Each letter is unique and allows us to be creative and respectful to the individuals concerned and leave them a written acknowledgement of their strengths, such as ‘…despite that episode I still managed to…’
Anecdotal evidence of the potential benefit of follow-up can be seen in the following letter from one of our assessments:
‘Your letter arrived this morning. The first time I tried to read it I couldn’t for tears. I went back two hours later and read it 10 times.’
‘I will keep it with me and read it regularly I’m sure.’
‘You have no idea what you have done for me! You were a complete stranger that I was dreading meeting… the ‘miracle’ is the future.’
Our requirements of clinical supervision were quite specific. We needed it to:
Enable us to develop our knowledge base around solution-focused issues in liaison psychiatry;
Reinforce consistency and continuity of care;
Enable us to monitor the process and progress of the intervention;
Provide opportunities for learning and appraisal;
Formalise how we provide care and highlight what works;
Provide information and outcome studies;
Reinforce and improve minimum standards;
Ensure integrity of the approach during research projects (after 2002).
We agreed a supervision contract that included ground rules, statements of confidentiality, expectations, boundaries and agenda issues and was based on solution-focused values. We adopted Nicklin’s statement for supervision as we felt its reflective approach and forward movement towards goals fitted the project’s aims: ‘A facilitated process, during which the individual reflects on practice, analyses issues and problems, identifies goals, identifies strategies for goal attainment and establishes an appropriate plan of action’ (Nicklin, 1995).
As the supervision sessions developed, a noticeable change in their focus and content emerged. Initially the team searched for theoretical answers, for example, ‘How should I respond to their reply?’ As time went on, more philosophical questions were being posed, demonstrating a deeper understanding of their potential therapeutic impact. Currently clinical supervision takes place fortnightly. As well as reflecting on the process, practical issues are discussed, such as reframing questions on the assessment sheet, outcomes, information leaflets and discussions with ward teams.
The focus on strengths and solutions inherent in this model of service has enhanced team members’ therapeutic approach as a whole. The shift in philosophy towards individual clients as the experts on themselves recognises the advantages of respectful empowerment. We are planning to undertake a more in-depth follow-up of our original study (Wiseman, 2003) and plan to continue our progress with follow-up sessions and feedback letters. We will use the model’s perspective that we too are unique experts on ourselves, and our resources will help us move towards a solution to service demands.
de Shazer, S. (1985) Keys to Solution in Brief Therapy. New York, NY: Norton.
de Shazer, S. (1988) Clues: Investigating Solutions in Brief Therapy. New York, NY: Norton.
Epston, D., White, M. (1990) Narrative Means to Therapeutic Ends. New York, NY: Norton.
Griffin, J., Tyrell, I. (2004) How to Lift Depression… Fast (The Human Givens Approach). London: HG Publishing.
Iveson, C. (2002) Solution-focused brief therapy. Advances in Psychiatric Treatment; 8: 149–156.
Nicklin, P. (1995) Super supervision. Nursing Management; 2: 5, 24–25.
Sori, C.F., Hecker, l. (2003) The Therapist’s Notebook for Children and Adolescents: Homework, Handouts and Activities for Use in Psychotherapy. New York, NY: Haworth.
Wiseman, S. (2003) Brief intervention: reducing the repetition of deliberate self-harm. Nursing Times; 99: 35, 34–36.