December 1, 2019
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 appointment. Sure, maybe they sign a couple of forms and releases at the front desk (or online if they register through a portal), but as soon as they sit down, we start. Not so in a clinical environment. First, there’s a patient intake process, and confirming insurance (at my clinic patient’s do this in a little phone booth). Then there’s another intake process to get more information in the waiting room (which is done on a clipboard). Then we are required to complete an in person assessment process which takes (up to, and sometimes standardized to) three sessions, where we are required to ask a myriad of questions on an electronic form of which, as a solutions focused counselor, I find unhelpful, unnecessary, and generally useless (all of the information in this assessment will come out, if it’s relevant, during session). However, they’re mandatory…because someone (other than me) has determined that they’re mandatory (oftentimes the state agencies that license our clinics, and are what allow us to provide services to the most marginalized and in need in our communities).
What an incredible difference: In true SFBT practice, we begin our treatment of the patient from the word “go.” In clinical practice we don’t begin treatment until the fifth appointment. That’s because the first three appointments are assessment appointments (which, of course, benefits the clinician and the agency more than they benefit the patient). We also take a urine sample somewhere in there to establish a baseline measure so we can appease the DSM-V’s “rule out substances” clause, and then the fourth visit is when a collaborative treatment plan is made (more on that later, because it becomes incredibly important when we look at solutions focused work in a clinical environment…legally, ethically, and for billing purposes).
So…wow...that’s a month and a week of appointments before we get down to helping a patient help themselves figure out what to do for why they walked in our doors in the first place.
To be fair to my agency, we have been working diligently (across all modalities) to ensure that patients do receive some time in each assessment appointment to talk, or learn coping skills…but they are clearly not therapy sessions.
So besides the fact that this flies in the face of patient centered treatment; and the fact that it’s antithetical to solutions focused treatment, one of the bigger problems is that the statistical mode (the most common number of all sessions a patient or client will have in therapy) is one. This means that we spend a ton of time gathering information, and data (again, usually because a regulatory bureaucrat thinks that it's important) instead of helping patients in what may be their only interaction with a therapist ever.
So, why would I - or why would you, as a solutions focused person, ever want to get involved in this nonsense? It’s not because you want to get your C or your -R credential (editorial note: I’m heavily biased toward Social Work). It’s because it is absolutely vital that marginalized communities (of which these community mental health clinics serve) be given the opportunity to receive this same level of evidence based, person centered, empowering care, that otherwise only those who have extra, disposable income could afford. That’s why. And I’m going to encourage you to stick around with me, and to become experts on making it work…because we have to. Because people need this modality. And we have to be able to offer it to them.
So let’s dive in a bit further: There’s little I can do about the process (right now) before someone gets into my office. However, once someone is in my office, I have a great deal of control…it’s my space.
The first thing that I do when I sit down with a patient, after explaining confidentiality, is I ask them “What brings you in?” and then, after they let me know what brought them in, I ask “how can I be helpful?" (shout how to Denise Krause at the UB School of Social Work for teaching me that question, it’s one of my go to questions, especially when I get stuck. Then I genuinely listen. I don’t listen to respond. I just listen to listen.
Already, the tenor of a typical “assessment” appointment has changed. First, I’m not rapid firing questions at them, and I’m not talking about myself, my philosophy, my agency, or our process. There’s one person that’s important here. The patient (and their needs). Once they have expressed themselves enough to answer this question, I use a Solutions Focused Formulation to share back with them why they’re here.
I then share that I use collaborative documentation in order to take notes (we’ll come back to this - since I don’t use a pad or a computer during anything but the last five minutes of session after this process), and I ask for permission to begin the assessment process. I then wait to receive that permission. (it’s at this point I turn around, and unlock my computer screen). I then take everything that the patient and I have discussed, and - instead of asking it in the form of assessment questions all over again. Type what the patient has already shared with me into the corresponding boxes. I type while speaking out loud what it is that I’m typing, so if I make a mistake the patient can correct me (that’s part of the collaborative documentation part) . I will then ask for filler, or clarifying information as needed. In doing this, I show that I’ve listened to the patient. I then ask an assessment question, in a very solutions focused way.
Instead of asking the question that’s on the assessment (that was added to encourage clinicians to work with patients on some of their needs during the assessment process, which is “what is one thing we can work on today to make you feel hopeful about this and other sessions”), I ask the SFBT question of “so what’s your best hope for Today’s session, so when you leave here today, you’ll know that it wasn’t a waste of time, and that you really got something out of it?” I then make sure that we work on that.
This has, likely, used up around no more than 20 or so minutes of our time (all said and done). Assessment appointments (since they’re billed at a higher reimbursement rate, hence why there’s three of them, because three of them are allowed, and community health clinics are floundering financially as it is…) last an hour. This means that we have another forty minutes together. Within the first session there are certain tabs on our EMR’s intake assessment that must be completed. The biographical tab, the depression screen tab, the lethality tab, and then I always do the safety plan tab because, honestly, it does happen to be a great intervention. The depression tab has to be completed even if the patient has never, ever, ever, ever been depressed a day in their life. Totally antithetical to SFBT. That said, the questions don’t have to be. If a patient is “scoring” (as if it’s a sports match) low or high on the screen, we can still move it into SFBT languages (we cannot change the language of the screening tool…because then it will no longer be the evidenced based screening tool…).
So instead of saying “wow, you’re really depressed!” or “it seems that you’re very depressed!” we can say “wow, that all must be very difficult…how have you been coping?” or “wow, how have you managed, despite things being so difficult, to make sure that you’re mood’s been okay?” The same is true for questions on the lethality tab where we also do risk assessment, and have to ask about things such as past arrests (“That sounds very frightening, how did you get through that?”) or the safety/coping plan (“it seems that you have a lot of supports, and a lot of people who really care about you, how did you develop such a great support network?” or “that seems really difficult, not having many people to rely on, how are you coping right now?”).
So finally, we’ve made it through most of these tabs, and - if everything has gone right…there’s twenty or so minutes to go, where I can say “excellent, so we have twenty or so minutes remaining to talk, thank you so much for bearing through that process, let’s get you scheduled for your next appointment so we can finish out using the remaining time to brainstorm around what brought you in here, in the first place, when you mentioned what your best hopes for today’s session were, what I heard you say was…”
This seems as good a place as any to stop…since it’s where I have to stop with my patients during their first week of the assessment process. Next week, we’ll cover what happens after the patient leaves my office after their first session, as well as the second week of the assessment process. We’ll also go a little more in depth as we explore the notion of diagnosis, what it means to assess for past treatment history, trauma, schizophrenia, mood, eating disorders, gambling disorders, substance use disorders, and more as a solutions focused counselor, and what it looks like to prep the patient for their third assessment appointment.
Thank you for listening. Please tune in again next Sunday, as we continue forward together down our solutions focused path. I’m @TheMattSchwartz, and it’s time for some self care with my cat, Akiva, who is patiently waiting for cuddles while I record this.
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. One day, when I have enough subscribers, I may even purchase one of their pretty cool professional licenses licenses (you should check them out, NPR even uses them, they’re that snazzy). I’ll see you next Sunday with more; until then, make good choices.