Pain affects some 48% of the population, with low back pain being the most prevalent in affecting some 33% of the population and resulting in 2.6 million GP consultations per year. Pain can be classified as acute (less than 12 weeks) or chronic/persistent (if the pain extends beyond the 12 weeks). Persistent pain affects some 14% of the UK population and can be a consequence of a number of conditions such as Arthritis, Chronic Fatigue, Parkinson's Disease, Cancer, Irritable Bowel Syndrome. Due to the uncertain future that living with pain can bring, fear, distress and an increased sense of isolation can manifest. It can also impact everything from identity, to mobility, work and relationships. Unsurprisingly psychological challenges such as anxiety and depression tend to go hand in hand with sufferers of pain in particular those with long-term conditions.
Due to the increasing number of long-term pain sufferers, a more holistic or biopsychosocial approach has been increasingly explored. Cognitive Behavioural Therapy (CBT) has been the most common intervention up until now, but other interventions such as ‘Mindfulness’ and ‘Acceptance and Commitment Therapy’ have also gained traction in recent years. One of the most exciting additions to this list of therapeutic interventions is ‘Solution Focused Brief Therapy' (SFBT) approach. SFBT has been recognised by the National Institute for Health and Care Excellence (NICE) since 2009 as a therapeutic approach for a number of health conditions with pain management being one of them.
What is Solution Focused Therapy?
The SFBT approach is conversational in nature and seeks to help the patient/client reframe their life through questioning. Questions however are not used in the traditional sense in that the therapist is not seeking out information from the patient/client per se. Rather questions are used as a way of enabling the client to hear themselves and in so doing clarify what is working for them. Finding out ‘what works’ is one of the principles or assumptions that the SFBT is founded on. Some other principles include:
Change is happening all the time, it is, therefore, helpful to identify useful change
Change is not achieved through effort, it happens by invitation. The vocabulary should be one that shifts from doing to noticing.
Small changes can make a big difference
People can only change themselves
Problems are not there all the time they fluctuate
The client is doing the best they can all the time, believing anything else is fighting with reality
Everyone is unique, they have their own strengths and resources, both personal and within their social network
Everyone has the ability to find their own solutions
The patient/client is the expert, the therapist expertise is in facilitating the process
People's own solutions are likely to be more successful as it fits within their own circumstances, meaning it is more likely to be implemented and maintained
Problems that appear complex may not necessarily require a complex solution
Rapid change or resolution can happen when people hit on an idea that works
People are more likely to behave and/or think differently when you work with their preferred future.
Solution Focused Principles and Pain
The SFBT has been successfully applied to a wide range of circumstances. At its heart, it is about ‘empowering the individual’ to find their own unique future-oriented solutions. Below I will outline some of the solution-focused principles and how they can be best applied within a pain-related context.
The patient/client is the expert, the therapist expertise is in facilitating the process
When we consider the traditional medical model the relationship between the medical professional and the patient is one of ‘Expert’ and ‘Patient’. Within this context, the medical professional's role is seen as the person ‘to fix’ or ‘manage’ the problem. The patient is also viewed by the professional as a ‘diagnosis’ or as a ‘list of symptoms’. As you can see this relationship is heavily biased towards the professional and consequently disempowering to the patient. In its purest form, the SFBT turns this relationship completely on its head so to speak. This is because SFBT recognises the incontrovertible truth that there is only one true expert in an individual's life and that is the individual themselves. To not respect this fact guarantees long term failure.
So how can we square this circle in a medical context between the individual's expertise and the expertise of the professional? Although not purely SFBT in application, a more balanced approach that meets the needs of the patient at the same time utilising the medical professional's expertise can still be achieved. Firstly from a professional's point of view, they must acknowledge the expertise of the patient/client. They must recognise that it is impossible for them to truly understand the life of the individual and that they must therefore respect the expertise of the client/patient. It then requires a successful marriage of the expert knowledge of the client/patient of their own life with the knowledge and expertise of the health professional.
People are more likely to behave and/or think differently when you work with their preferred future.
In SFBT the initial conversation is all about establishing clarity on what a preferred future could look like. This is not about establishing a goal to work towards, but it is rather about describing in rich detail what an acceptable future looks like.
The description is important for a couple of reasons, firstly any description of the future is based on a past event or events in which you managed your condition in such a way that was acceptable to you. In this instance your past does and can equal your future in that they provide evidence of past success and a possible direction for future travel. Secondly, being more future focused within the therapeutic conversation helps the client/patient turn their attention towards a more growth orientated mindset (how can I maximise what I have?) as opposed towards an absence of something mindset. When in pain it can become all too easy to focus exclusively on symptom reduction at the expense of ‘learning to live at your best’ in spite of your circumstances.
Everyone is unique, they have their own strengths and resources, both personal and within their social network
As I have already discussed it is important to respect the expertise of the individual. Recognition of this can go a long way towards encouraging positive psychological and behavioural changes by empowering the individual. As an individual you are unique but also you operate within a unique set of social interactional circumstances. Your daily interactions with friends, family and society at large can all be utilised as possible solutions towards leading a life more inline with a preferred future. As these interactions and contexts are private, how best to utilise them to move the client/patient forwards can only come from that individual.
It is within this context that the detailed description can be built through the questioning. This process can often draw out solutions that initially appear unrelated to the problem and would never have been countenanced by anyone other than the individual themselves. An example of this could be a father unable to play football with his child due to knee pain, but meaningful interaction can still take place through another activity such as the building of a den or tree house. It would be highly unlikely that such a solution would not have been brought forwards by someone outside of that particular relationship i.e. the health professional.
The solution focused approach is also heavily biased on exploring instances of self resourcing and coping. Questions such as; How did you cope? How did you come up with that idea? Are designed to enable the individual to recognise their own individual strategies to overcoming difficulties in the past. In the midst of pain it is all too easy for people to disregard or not even be aware of past successes, the phrase you ‘can’t see the woods for the trees’, is very apt for many pain sufferers. The importance of this cannot be underestimated as having a greater sense of self-determination to mediate outcomes can act as an important platform from which one can live well.
Change is not achieved through effort, it happens by invitation. The vocabulary should be one that shifts from doing to noticing.
In a more traditional setting such as a medical setting prescriptions and advice are given to help support the individual to better manage or ameliorate symptoms. ‘To do something’, is an unspoken expectation between patient and professional. But in the act of ‘doing’ many useful lessons can be missed. What the SFBT does is it gets you to notice more through the simple act of providing a detailed description of your day-to-day living. What did you notice about yourself?, or How did you know that your partner knew that something had changed in you? Are all examples of how the solution-focused line of questioning can get the client to notice more and become more self-aware. The noticing of how the client/patient lives their life more successfully can provide evidence as to what they could do more in the future. Doing more of what works and doing less of what does not work appear obvious on the surface but sometimes it's a simple fact that can be lost to the patient/client in their day-to-day living of life.
Conclusion
As has been evidenced in a number of studies the SFBT can be a useful tool in the treatment and betterment of pain sufferers. It can work both as a stand-alone intervention or as one that sits alongside other treatment modalities as part of a multidisciplinary approach. SFBT helps individuals recognise successes in their lives and achieve preferred outcomes by discussing solutions, despite the patient's problems or difficulties. It increased hope and optimism, lowered associative depression, anxiety, and improved social and psychological adjustment.
By helping the client/patient see their situation from a new perspective they begin to draw more on their own strengths and coping skills thereby enhancing the individual's sense of control over their future. The process also allows the individual to look at their life from a wider perspective thereby encouraging them to look beyond their pain and more towards wider life goals.