In each therapeutic encounter, regardless of professional domain, the human connection between two people-the clinician and the patient-is an essential ingredient. Thus, the conversations in which we engage with our patients are pivotal in facilitating successful treatment.
Conversations with patients who are facing a chronic condition are challenging on several levels: enabling patients to work through acute episodes, helping patients to stay hopeful about re-establishing their lives, and equipping patients with the emotional confidence to independently problem-solve on their own without immediate treatment support.
It can be stressful figuring out how to talk with clients when they present with difficult emotions and difficult living situations. In counseling, what I hear most often from patients about their encounters with health care providers concerns conversations that don't go well-feeling misunderstood, questions not being answered, anxieties not being listened to.
Bridging the chasm between disability and ability is a difficult one for both patient and practitioner. This article will review solution-focused conversation techniques to integrate into counseling sessions. The following strategies offer alternative ways to talk with patients when they may feel emotionally stuck. Please be aware that Solution Focused Therapy, founded by therapists and researchers Kim Berg and their team at the Brief Family Therapy Center (see Resources, p. 45), is a specialized treatment approach within the mental health field. Practitioners in this model seek extensive training in this method. Although the strategies described in this article can be characterized as solution-focused techniques, this article is not a blueprint for doing solution-focused therapy.
The following strategies are suggestions to stimulate personal evaluation of your therapeutic conversational styles. However, if a patient has specific complications such as personality/cognitive deficits or co-morbid conditions, it is important to consult with a mental health professional, as this approach may not be appropriate for certain patients.
Conversations as Tools
Most often when we are working with patients seeking rehabilitation, we are entering their lives at turning-point moments: moments where they are feeling vulnerable, undergoing change and having to contend with significant adaptations in their lives. Our conversations with our patients are the first tools in helping them face the enormity of what they are experiencing.
It is important to remember that words evoke emotion, stimulate thinking and validate feelings. Thus, our choice of words and the meaning we are trying to convey have an impact. I would recommend role playing therapeutic conversations in team meetings with other OT professionals.
Judith Goldberg, Director of Initiative for Women with Disabilities at NYU Hospital for Joint Diseases, is a rehabilitation counselor, administrator and individual with a disability. She has ontogenesis imperfecta (brittle bone disorder). She shared her own memory of a facilitating conversation:
"When I was a teenager I remember my physical therapist said to me, ?You are the consumer and your body is your product; it's OK to ask questions.' I remember this conversation and it has stayed with me. I was scared of medical people. She taught me not to be afraid of medical professionals and not to be afraid to ask questions."
Problem Free Talk
A beginning principle of solution focused counseling is to balance the focus of talking about problems with a focus on "problem-free talk." Translated, this refers to learning more about the patient's -functioning in the world outside the scope of the disability or acute condition. The goal is to make note of strengths, competencies and untapped sensibilities that can be built upon in treatment planning.
- What activities brought your pleasure before this problem existed?
- What activities do you always wish you had explored?
- What are your interests, hobbies?
- What part of the day or week do you look forward to?
The Miracle Question
Another core technique of solution-focused therapy is the strategy of the "miracle question." This technique helps patients explore the possibilites of what they want for themselves and/or explore ways to re-establish hidden needs or hopes.
The following is the classic version of the miracle question: "If you woke up tomorrow, and a miracle happened so that you no longer would feel overhwlemed by your condition, what would you see differently? What would the first signs be that the miracle occurred? What else are you going to notice?... What else?"
For chronically disabled people, obviously the disabilty will not change or resolve, but the purpose of this question is to stimulate ideas about how the patient's life can be re-envisioned or renewed, despite the obstacles he or she faces with a disablity.
For example, Lisa, a 28-year-old woman with MS, responded to the miracle question with the following answer, "I would not be as exhausted, and I would be more productive."
Once we were able to pinpoint what would be different for her, we immediately were able to implement behavioral strategies (see "Integrating Behavioral Skills," March 31), along with stress management strategies (see "Stress Management," April 28) to improve her functioning. This in turn restored her sense of self. When patients are emotionally overwhelmed, it may be hard for them to articulate their goals or needs. A technique such as the miracle question is a great tool for learning what goals would help patients feel more empowered.
Exception Seeking Questions
Another principal of solution-focused counseling is the belief that every individual patient has moments when the "problem" (in the case of rehabilitation patients, the handicapping condition) is less taxing or consuming. The goal of this strategy is to explore details of situations in which the patient may have felt less stress or felt calmer, or to explore what the patient did differently to improve functioning.
Jane, age 51, struggles with chronic pain caused by fibromyalgia; she shared how she notes the "exception moments" to her chronic pain:
"I can't change my condition, but I am a very social person and can easily make friends. When I meet someone new, I feel energized. I still feel the pain in my body, but the feelings of energy from meeting a new person alleviates the stress I feel. I started to make it a point to have lunch dates weekly, so I can look forward to this and reduce my stress."
The goal of implementing exception-seeking questions is to explore such strategies and consciously integrate them into the patient's life. The emotional demands of managing a chronic condition have o endpoint, and so it is easy for patients to feel overwhelmed, consumed and hopeless. Exception questions can stimulate hope and open patients up to tangible ideas to implement within their day or week.
Goals/Preferred Future Questions
In solution-focused counseling, open-ended, exploratory questions help patients imagine futures in a constructive way. These types of questions can prove to be powerful, as patients can take a mental break from the stressors of their current situations and brainstorm about preferred goals, hopes and expectations for the future. Such questions emphasize what is realistically achievable versus what is not.
Preferred future questsions are "W" questions-what, when, where and how. Also, asking for detail is key for this technique.
- Can you tell me about situations where you feel your condition is less troubling. When or what times of the day do you have this feeling?
- What is different when you feel you cope better with your condition?
- What makes it easier?
- Can you give me an example of what worked for you in the past, even if it was temporary?
- What else?
- Tell me more about that.
Conversations are memorable, leave impressions and can remain a constant source of emotional fuel. Our hope is that the conversations we engage in with our patients will guide them in testing the boundaries of disability and ability.
Dr. Reji Mathew is a psychotherapist/clinical instructor at New York University. Her clinical expertise is in integrative psychotherapy, particularly cognitive behavioral skills training. Reach her via email at firstname.lastname@example.org.
The following are primarily mental health references. SFBTA offers links to videos and study material for this approach.
Solution Focused Brief Therapy Association (SFBTA)
Beyond Technique in Solution Focused Therapy
Solution Focused Therapy
Richard Niolon, PhD
Resource Page for Solution Focused Therapy