Solution Focused Anxiety Management

A Treatment and Training Manual

Ellen K. Quick

• Publisher: Academic Press
• Year: 2013
• ISBN:
  9780123978134
• Topic: Psychologie
• Subtopic: Klinische Psychologie

Solution Focused Anxiety Management provides the clinician with evidence-based techniques to help clients manage anxiety. Cognitive behavioral and strategic tools, acceptance-based ideas, and mindfulness are introduced from a solution-focused perspective and tailored to client strengths and preferences.

The book presents the conceptual foundation, methods, and attitudes of a solution-focused approach. Case examples illustrate how to transform anxiety into the "Four Cs" (courage, coping, appropriate caution and choice). Readers learn how to utilize solution focused anxiety management in single-session, brief, and intermittent therapy as well as in a class setting.

The book additionally includes all materials needed for teaching solution focused anxiety management in a four-session psychoeducational class: complete instructor notes, learner readings, and companion online materials.

Special Features:

• Focuses on what works in anxiety management
• Presents evidenced based techniques from a solution-focused perspective
• Increases effectiveness by utilizing client strengths and preferences
• Describes applications in single session, brief, and intermittent therapy
• Supplies forms and worksheets for the therapist to use in practice
• Features clinically rich case examples
• Supplements text with online companion material
• Suitable for use as a treatment manual, reference, or course text

• Offers a solution-focused anxiety treatment
• Focuses on anxiety management, not "elimination"
• Translates the program to individual therapy
• Presents patient exercises and case examples
• Includes a guide for teaching/learning this therapeutic technique

Chapter 1

What Is Solution Focused Anxiety Management, and How Is It Different from Other Approaches?

Solution focused anxiety management is a class—and a philosophy. This chapter introduces the conceptual foundation, attitudes, and methods of both the class and the overall perspective. The class is a four-session psychoeducational program for adults. It blends psychoeducation about anxiety and other concepts, some acceptance-based, with solution-focused, strategic, and cognitive behavioral components. It also utilizes group process. The material is presented from a solution-focused perspective, with a style designed to invite members to tap into and utilize individual strengths and ways of learning. The therapist trusts that class members will use the material and the experience in ways that work for them. The content can also be used in individual therapy, a topic discussed in more detail in Chapter 7.

In this approach, the focus is on anxiety management. This is different from an anxiety elimination paradigm. The idea is that people do not have to wait to fully eliminate their anxiety to be able to experience it differently and to notice that it is not such a problem in their lives. People can discover that they do not have to wait for their anxiety to disappear to do both ordinary and extraordinary things.

The Solution-focused Perspective

Solution-focused therapy is a strength-based model, developed by Steve de Shazer, Insoo Kim Berg, and their colleagues at the Brief Family Therapy Center (BFTC) in the 1980s (de Shazer, 1985). Solution-focused therapy minimizes emphasis on past failings and problems. Instead, it focuses on clients’ strengths and previous successes. It works from the client’s understanding of the situation and what the client wants to be different. It also assumes that no problem happens all the time. There are exceptions: times when the problem could have happened but for some reason did not happen. The therapist attempts to discover what was different when the “exception” to the problem occurred. What was the difference that made a difference? Once that is known, the goal is to amplify those differences, creating more and more occasions when the problem is not a problem.

Methods in Solution-focused Therapy

Solution-focused therapy often uses future-focused conversation, inviting people to describe a future time when the desired changes are already happening. The “miracle question” is sometimes considered to be solution-focused therapy’s best-known method and “signature” technique.

However, solution-focused therapy is far more than miracle questions. In fact, a recent book is titled More Than Miracles: The State of the Art of Solution-focused Therapy (de Shazer & Dolan, 2007). Nonetheless, miracle question inquiry continues to be a valuable and versatile technique in solution-focused practice.

The basic miracle question says something like this: “Imagine that after you and I get done talking and you do whatever you’re going to do today, eventually you go home, and go to bed, and fall asleep. And while you’re sleeping, a miracle happens. And the miracle is that the problem you just told me about is resolved. It isn’t a problem any more. What will be the first thing that will be different, that lets you know: ‘This isn’t a problem any more’?”

After the therapist asks this question and hears the response, it is important to conduct detailed follow-up inquiry. This important component frequently includes two kinds of questions: difference questions and relationship questions. Difference questions ask things like this: “What will be different?” Building on the last change described, the therapist invites specific detail. “What else?” “And as a result of what you’ve just described, what else will be different?” “And when X happens, what will be different about how you respond?” “And how will that make a difference?”

Relationship questions ask questions similar to the following: “Who will notice your change (using the language of whatever the person has just described)?” “And how will he/she be different, as a result of your changes?” “And how will that make a difference?” “Who else will notice?” “What will he/she notice about you?” “Really! And how might he/she respond?” “How will that make a difference?”

The therapist continues with this kind of inquiry, amplifying and inviting detail about multiple situations and relationships in the person’s life. “And that other problem you were telling me about, what will be different about that, as a result of those other changes?” As the inquiry continues, more and more specific detail will be elicited, and it becomes increasingly likely that the person is describing some things that are already happening.

Then the therapist asks what is sometimes called an exception question: “This scenario you are describing—are there any pieces of it that are already happening?” It is extremely likely by now that the answer is “Yes.” The therapist is then able to say, “Really? Tell me about it.” Again, specifics are invited and highlighted. It often becomes evident quite quickly that the person did not have to wait for the full “miracle” to be able to experience important parts of it.

When it is clear that pieces of the solution are already happening, it follows that the person can do these things again. This is evident even if the therapist does not directly suggest it. (And some solution-focused therapists would say that the therapist does not have to suggest anything. Simply as a result of having elaborated this detail, people recognize what they want to do again.) Often, however, the therapist will directly (or indirectly) invite continuing pieces of the solution that are already present. Or there may be an invitation to observe or be curious about where and when these pieces will happen next.

In solution-focused therapy, it is of critical importance to use this detailed follow-up to the miracle question (or to any of its variations, discussed in more detail later). This fact cannot be overemphasized. Therapists who ask the miracle question, just get an answer or two, and move on to something else are often the ones who say, “I tried that solution-focused stuff, and it didn’t work.” The follow-up inquiry may be the most important—and clinically elegant—method in solution-focused therapy.

Another solution-focused tool is the scaling question. Scaling questions are by no means unique to solution-focused practice. They may be seen as similar to SUDS [Subjective Units of Discomfort Scales] and other rating scales. Here is how solution-focused therapists tend to use scaling questions. They often ask, “On a zero to ten scale, where zero is when the problem was at its worst and ten is when it isn’t a problem any more, where are you now?” The next question might be, “How did you do get up to a three?” Then the therapist inquires, “And what will be different when you’re at a four?”

What happens when the client describes a miracle that is “impossible” (something that could never really happen)? Here is an example from Steve de Shazer in a session with a man who had been seriously depressed since an accident in which he lost his arm. de Shazer asked the miracle question, and the man said he would have his arm back. de Shazer nodded and said, “Sure”—and he waited. After a long silence, the man said, “I guess you mean something that could happen.” de Shazer nodded. The man then described how he would get up and make breakfast with his one arm. There was no further discussion about getting the arm back (de Shazer & Dolan, 2007, p. 40, as described in Quick, 2012, p. 105).

There are many different variations of the miracle question. It is absolutely not a requirement to use the word “miracle.” In fact, sometimes the word “miracle” is deliberately omitted, because inquiry is always tailored to individual client variables and preferences.

The following are some examples of variations on the miracle question: “What are your best hopes from coming here? What will let you know those hopes have been met?” (George et al., 2009). “If we’re having our next conversation and I’m asking you what’s better or different, and you’re telling me that you’re feeling really good about how you’re handling things, what might you be telling me?” “What will let you know you are on track to a solution?” “When you are going in the right direction, how will your email conversations (texts, tweets) be different?” “What will your Facebook friends notice about you?”

Variations used in the solution-focused Doing What Works Group (Quick & Gizzo, 2007; Quick, 2008) invite people to imagine “that this group helped you just as you hoped it would.” In other sessions, participants envision “writing the next act” in the drama of their lives and “looking through a crystal ball” to a better time. At another session, they imagine what they will be describing at a “one-year group reunion.” Some future-focused questions invite anticipation of “slips and recovery” (Quick, 2012).

One extremely important variation on the miracle question is often described as “the coping question.” If a person has just been through something horrendous, a miracle question that makes it sound as though the problem is “gone” can come across as disrespectful, as if the therapist didn’t “get it,” as if the magnitude of the pain or fear had not been heard or appreciated. Expert solution-focused therapists often use a different kind of future-focused inquiry. Their coping questions ask something like this: “Given what you’ve been through, how do you get through the day?” One of the most common responses is this: “I don’t know. I just do it.”

As Quick (2008) has pointed out, sometimes simple behaviors include strength and courage. The wording of the coping question communicates a coping choice, even in simple behaviors. “How did you manage to keep going?” implies that it was not just by chance that the person got through. Even if the coping behavior did not seem particularly remarkable at the time, the therapist is gently pointing out that the person did have a choice.

Sometimes the author asks class members if they know the answer to the following question: “When you’re depressed, what’s the reason to get up in the morning?” The answer is: “To go to the bathroom.” People laugh—and they understand: The person who got up to go to bathroom could have lain there and wet the bed. There was an active choice, a coping choice, reflected in that seemingly simple decision.

What does solution-focused therapy do at the end of a session? Generally, solution-focused therapists give input to their clients. Sometimes they call it homework; often they talk about it as an experiment or a project. It might include noticing pieces of the miracle or doing more of what works, or it might invite doing something different. It might be noticing examples of coping, such as “how you do it when you have discomfort and get through it,” or “when you slip, noticing how you get back on track.” One tool, called the first session formula task, invites people to notice things in their life or family that they want to continue to have happen. The best solution-focused suggestions often include the client’s own language and metaphors.

It might be noted that it is usually hard to predict at the beginning of a session of solution-focused therapy what suggestion will be given at the end, because that task is likely to be co-constructed, growing from shared language during the session. One of the interesting differences between homework in solution-focused therapy and homework in positive psychology/positive psychotherapy is the following: Positive psychotherapy (Seligman, Rashid, & Parks, 2006) more frequently suggests standard tasks, such as “List five things you’re grateful for,” whereas solution-focused therapy might not necessarily talk with a client about a concept such as gratitude unless it was already part of the client’s language.

The same is true for how solution-focused therapists approach asking people to use journaling, writing, and record keeping. The therapist checks out whether writing is a useful tool for this person. If writing is useful, or if the person is interested in experimenting with it, it can become part of the therapy. If writing is experienced as a burden, irrelevant, or simply not helpful, it will not be required. This is part of a solution-focused attitude: The therapist assumes that people know the modalities that work best for them.

Solution-focused therapists use language in specific ways. As Trepper et al. (2010) pointed out,

[T]he signature questions used in solution-focused interviews are intended to set up a therapeutic process wherein practitioners listen for and absorb clients’ words and meanings (regarding what is important to clients, what they want, and related successes), then formulate and ask the next question by connecting to clients’ key words and phrases. Therapists then continue to listen and absorb as clients again answer from their frames of reference, and once again formulate and ask the next question by similarly connecting to the client’s responses. It is through this continuing process of listening, absorbing, connecting, and client responding that practitioners and clients together co-construct new and altered meanings that build toward solutions.

Some fascinating process research on microanalysis of solution-focused therapy sessions has recently indicated that solution-focused conversations do differ from conversations in other kinds of therapy. When they are compared with conversations in sessions of cognitive behavioral therapy, motivational interviewing, and client centered therapy, the following differences emerge. Solution-focused therapists tend to ask more questions, with less of a “teaching” or psychoeducational component. They tend to make more positive utterances. When they paraphrase or repeat client language, they tend to preserve positive language or coping statements rather than pain or pathology (De Jong & Bavelas, 2010).

Attitudes in Solution-focused Therapy

Solution-focused practice involves much more than applying a set of methods. Being solution-focused is also an attitude (Quick, 2012). That attitude includes multiple components. There is an absolute refusal to pathologize people for their complaints. There is little discussion of pathology or formal psychiatric diagnosis. In some situations, there may be a sense that diagnostic labeling has the potential to make things worse. That is the case even when there appears to be a biological component and when medicine is part of the solution. At the same time, there is an important exception: When the client (or someone else who is in the client’s world) thinks that those things are important, the therapist is ready to actively address them. The attitudinal components of “speaking the client’s language” and respecting what the client thinks is important take priority over the attitudinal components that focus away from discussion of diagnosis or symptoms!

The same thing is true for the past and the history. The therapist does not need to understand every detail about the history or even the problem to be able to facilitate solution-building now. However, if it is important to the client for the therapist to hear something about the problem or the past, the therapist listens attentively. What the cli...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Preface
• Acknowledgments
• Chapter 1. What Is Solution Focused Anxiety Management, and How Is It Different from Other Approaches?
• Chapter 2. Conducting a Solution Focused Anxiety Management Class: “The Nuts and the Bolts”
• Chapter 3. Instructor Notes for Topic One: Physical Reactions and Coping Techniques
• Chapter 4. Instructor Notes for Topic Two: Behavioral Techniques
• Chapter 5. Instructor Notes for Topic Three: Thinking Techniques
• Chapter 6. Instructor Notes for Topic Four: Life Issues and Anxiety
• Chapter 7. Solution Focused Anxiety Management and Individual Therapy
• Chapter 8. Appropriate Caution as an Ingredient of the Solution
• Chapter 9. Perspectives from the Solution-focused Community
• Chapter 10. Concluding Questions: What Creates Change in Solution Focused Anxiety Management, and How Can We Do More of It?
• Appendix A. Learner Readings for Topic One: Physical Reactions and Coping Techniques
• Appendix B. Learner Readings for Topic Two: Behavioral Techniques
• Appendix C. Learner Readings for Topic Three: Thinking Techniques
• Appendix D. Learner Readings for Topic Four: Life Issues and Anxiety
• References
• Subject Index