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The Essence of Effective Psychotherapy: Reflections of a CAT Therapist learning Solution Focussed Brief Therapy

Nehmad, A., 1997. The Essence of Effective Psychotherapy: Reflections of a CAT Therapist learning Solution Focussed Brief Therapy. Reformulation, ACAT News Winter, p.x.

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The Essence of Effective Psychotherapy. Reflections of a CAT Therapist learning Solution Focussed Brief Therapy

Annie Nehmad

[I] gradually developed the notion that psychology is pretty much confined to the paradigms it employs and, while you can take off in a great many directions and travel a considerable distance in any of them [...] there is no harm in consorting with a strange paradigm now and then. Indeed the notion has occurred to me that psychology may best be regarded as a collection of paradigms wooed by ex-physicists, ex-physiologists, and ex-preachers, as well as a lot of other intellectual renegades. Even more recently it has struck me that this is the nature of man; he is an inveterate collector of paradigms.

George Kelly, Autobiography of a Theory 1

We know empirically that CAT works. But do we really know how it works, and why it is effective? Do the different psychotherapies (insofar as they are effective at helping people to feel better and function better) do different things, or the same thing by different means?

Tony Ryle's quest for a common language for the psychotherapies resulted in Cognitive Analytic Therapy - an integration of Object Relations, Behavioural, Cognitive, and Kellyan models. I continue the Rylian quest by considering another model: Solution Focussed Brief Therapy. I believe that its similarities to, and differences from, CAT shed interesting light on the essence of effective psychotherapy. I believe that we can borrow from Solution Focussed Brief Therapy, not only particular techniques but a different way of approaching our clients, which may enrich our perspectives, and make our therapies more effective.

Until November 1994, I was not aware of any form of psychotherapy which achieves results comparable to CAT, more quickly than CAT, and for a wider variety of problems. Then I attended a two day workshop by Steve de Shazer on Solution Focussed Brief Therapy. I went there rather sceptically, wondering whether I'd learn anything really new, since CAT itself is both brief, and focussed on Solutions (though we call them Aims or Exits). My skepticism was compounded by irritation at the rambliness of de Shazer's delivery. Then he showed videos of consultations, and I was hooked. This really was a new, different and powerful way of listening to clients, and talking to clients. Since then. I have continued to train in this approach, reading, attending workshops, and doing supervised casework. I have looked beyond de Shazer and

Berg's Solution-Focussed Brief Therapy to the broader and very rich movement known as "Brief Therapy. " 2

Solution Focussed Brief Therapy works very well for most clients. It achieves the same sorts of results as CAT, i.e. people stop engaging in maladaptive patterns, start living better and more interesting lives, develop better relationships, and become less impulsive, less emotionally labile, and more integrated. It does this for an even wider range of people and problems than CAT does.3

SFBT is less hard work than CAT - there is no homework for the therapist, though there is sometimes homework for the client. And it works faster. Steve de Shazer's team quote an audited average of three sessions; many clients only need one session; more than 80% remain well at six month follow-up. Brief Therapists dont work to a contract. Each session is treated as potentially the last. At the end of each session, the client is asked whether they feel they want to come again, and approximately when. When they decide to leave therapy, the door is always open for them to come back for more is they feel the need to do so.

I know this sounds difficult to believe. 4 But I have heard audiotapes and watched videotapes, and I have watched several live consultations through a video monitor. Most importantly, I have seed its effects in my own practice, which is not particularly skilled.

I'd like to first tell you a bit about Brief Therapy; secondly suggest that CAT therapists can learn from Brief Therapy. And finally, share some of my tentative thoughts on what constitutes the essence of all effective psychotherapy. These are tentative ideas, developed in a vacuum, as I have not yet been able to discuss these ideas with anyone who is trained in both CAT and SFBT.5

CAT and Solution Focused Brief Therapy:

What do they have in common?

1. Brief - and proud of it ("less" can be "more")!

2. Collaborative

3. Goal-focussed

4. Researched and audited - shown to be a safe intervention which has a high success rate, and does no harm

5. Applicable to a very wide variety of clients and problems. Does not require clients to be "psychologically minded"

6. The repeated use of unsuccessful "solutions" locks difficulties into a self-reinforcing pattern

7. How we construe ourselves and others influences our lives and our interactions. Changing the way we perceive ourselves and others is likely to change our expectations, our behaviour, our mood, our thinking, and our interactions

8. Our behaviour is influenced by what others expect of us, and by how we are treated

9. "Insight", and/or changes in how we construe ourselves and others, need not precede changes in behaviour. The latter can happen first, and can influence our perceptions, mood, and thinking.

10. Clients decide what level they want to work on, what the problems are, and what changes they would like to make.

11. Use client's own words and expressions

12. Descriptive rather than interpretive

13. Therapeutic alliance usually achieved quickly. If it is not, the onus is on the therapist. Mistrust concepts like "Resistance"

14. Importance of Consciousness as a tool for introspection, self-knowledge and change

It is difficult to summarise Brief Therapy to a new audience, because it's evolving all the time, and even more importantly, because it doesnt have one key theoretician - there are several excellent people, each with their particular perspective, and some of them produce a book almost every year. There are differences between them, though they also have a lot in common. Some of them (such as Michael Hoyt) correctly consider themselves Integrative Brief Therapists. However, I will be discussing mainly the approach of de Shazer & Berg, because they are the most minimalist of all Brief Therapists, and hence the most challenging for us.

Features common to SFBT and CAT are summarised in the box above. In view of so many similarities, one might think a Brief Therapy session sounds much like a CAT Session. In fact they are completely different. So, what are the main differences between Brief Therapy and CAT? And how do Solution Focussed therapists manage to work so fast?

INFERENCES ABOUT A PROBLEM'S PURPOSE, FUNCTION, OR ORIGIN ARE UNNECESSARY. So it is not necessary to enquire about the past; or about details of the client's current life or family. There is no need for a psychiatric history, assessment, or diagnosis.

Everything the client says is taken seriously and respectfully - at face value. No inferences are made about what the client "really means", nor do Brief Therapists hypothesise on "why is he telling me this?"

THE RESOURCES THE CLIENT NEEDS IN ORDER TO SOLVE HIS PROBLEM LIE WITHIN HIM ALREADY. Of course usually the client doesnt know this (or he wouldnt be coming for therapy). In CAT we operate on the assumption that our clients will continue behaving maladaptively, unless they engage in effective psychotherapy. There is of course a large measure of truth in this, as so much that is maladaptive is in a self-reinforcing pattern. In CAT we not only accept the client's story of weakness, depressiveness, etc, we actually set it out in writing. For example, two ticks on the Psychotherapy File suggests to us, and to the client, that she ALWAYS either bottles feelings or explodes. The task of therapy then becomes for the client to notice, and understand, what she is doing, so that she can begin to stop doing it.

Brief Therapy, on the other hand, is predicated on the notion that even the most damaged people operate fairly normally sometimes.6 However, clients are often not aware that they already "know" how to be OK sometimes, and are almost always unaware of how they manage (inner resources, inner dialogue, etc.) to be OK sometimes.

When we assume that a problem is part of us, or that we are the problem, or that the family scapegoat is the problem, then any behaviour which doesnt conform to this assumption tends to be dismissed as "the exception which proves the rule".7

Brief therapists do not dwell on (and do not ask clients to monitor) problem behaviours or problem feelings, they dont need to know when they started, what triggers them, when they happen. What they do want to hear are examples of client's NOT behaving according to the problem complained of, NOT feeling depressed, etc.

Most of what a Solution Focussed Brief Therapist does is to ask questions - in order to bring out the client's healthy aspects, behaviours and hopes for the future. For example the therapist will enquire about Past and Present Solutions: instances of when the

person behaved as if the problem were smaller or non-existent ("Do you ever NOT binge and vomit?" "I never do it when the children are at home"; "Does

it ever seem as if your life isnt 'all screwed up'?"8

"When the baby smiles, I dont feel so bad")

The therapist's task is to help clients believe in their ability to change their lives in the desired directions, by noticing the Exceptions in the past, and in the present - exceptions which clients have often not noticed, or discounted. This is achieved mainly by the client beginning to say things he has never said before, because he has not been asked.

This allows the client to begin re-authoring his story, and himself, as strong, able to change, and already problem free some of the time.

ELICITING OF FUTURE SOLUTIONS: This involves the client imagining a preferred future (what life would be like without the problems). De Shazer & Berg found, when analysing audiotapes and videotapes of consultations, that clients perk up and become energised when talking about their achievements, their positive aspects, and plans and ideas for the future. They have developed a technique known as the Miracle Question, which involves imagining life tomorrow morning without the problem. This is a very powerful tool which I have now incorporated into almost all my CAT work including pre-therapy assessments. Even the most depressed clients usually perk up after a while. It's like imagework but without closing your eyes, and done purely verbally, by the therapist asking questions. It is often the first time the client has ever imagined what life could be like without the problem (as opposed to hoping the problem would go away).

Other brief therapists may do it differently - for example, "Imagine that two years from now we meet again, and you tell me that everything is just fine". What will be happening in your life? (encourage detailed description). What steps did you need to take for that to happen?

Brief Therapists look for the client's (genuine) strengths and achievements. Ask "How do you cope? How come things aren't even worse? etc"

VERBAL SCALES These are used a great deal in SFBT, to assess where the client is at, improvement, level of motivation, etc. (E.g. "On a scale of 1 to 10, where 10 is the Day after the Miracle - when all your problems have disappeared - and 1 is the worst you have ever felt [or, how you felt before you set up this appointment], where are you at right now?" Verbal scales also provide a bridge for talking about positive things ("So right now you are at 3. How come it's as high as that?" This will get the client to list positive aspects of himself, and his life, at the moment.)

These scales are also used as a bridge to imagining a better future, in realistic small steps. ("How will you know when you are at 4?")

VERY SMALL CHANGE IS ALL THAT IS REQUIRED IN ORDER TO SET THE BALL ROLLING. Aiming for big changes usually increases client's "resistance" and/or fear of failure. To quote Steve de Shazer: "the shorter you want therapy to be, the smaller the steps you take."

TRANSFERENCE/COUNTERTRANSFERENCE ARE NOT USED, OR EVEN ACKNOWLEDGED. I was more sceptical about this than about anything else in SFBT. What is astonishing is that it really doesnt seem to matter. Unhelpful roles dont seem to be enacted; negative transferences dont seem to happen. The patient is quickly recruited into a "Normal, helpful thoughtful" state, which sustains a therapeutic alliance, but also carries on functioning in the real world. This state is not only less prone to maladaptive behaviour, but also has a greater capacity for insight and reflection. (NB: Solution Focussed Brief Therapists do not talk about different states. This is just me using CAT terminology.)

There is no great meal made out of Termination of Therapy, Therapist absences, etc. If a client expresses anxiety about being OK now, but wondering how she will cope after therapy has ended, the aim of therapy becomes increasing her confidence about her ability to cope without therapy. No client leaves until they feel ready to do so.

CLARITY IS PROVIDED BY THE CLIENT. In CAT, the Therapist stance is that of Expert, with the client a valued and respected fellow researcher. We need the client's input (diary-keeping, monitoring of Problem Procedures, feedback), but it is we as therapists (with a variable degree of input by the client) who produce the Reformulations and Diagrams which "explain" their behaviour, unhappiness, etc. and which are apparently "necessary" for the patient to understand and hence get better. CAT therapists hypothesise about the source or reason for problem behaviours, or moods. Solution Focussed therapists never hypothesise (and if some of us - inevitably - do hypothesise sometimes, we do not use this in our comments or therapeutic interventions.) Links between past and present, or between different situations, are made (if at all) by the client.

Solution Focussed therapists never explain the client's behaviours, moods, shortcomings, or achievements. Instead, they ask questions and the client explains. The stance of the therapist is Confusion and Curiosity. This curiosity is conveyed to the client who in turn becomes curious about alternative readings or descriptions of their stories, and consequently can develop new ones. ("So how did you manage to stand up to your violent father and then work your way through college?" "I guess I must be a stronger person than I realised.")

SOLUTIONS ARE PROVIDED BY THE CLIENT. Clients are not given specific behavioural homework such as "try smiling when you meet new people". Nor are they encouraged to "be assertive", or count to 10 before hitting out. Instead, a homework task might be, "Today you are at 4 on the Scale from 1 to 10. One day this week, pretend to be at 5."

UTILISATION This concept comes from the work of Milton Erickson. It involves utilising the client's attributes, even the "problematic" ones, to enhance the therapeutic work.

ALL THE CREDIT FOR IMPROVEMENT IS MEANT TO BE TAKEN BY THE CLIENT This leads me to think that SFBT would be worth trying with narcissistic clients who find it difficult to acknowledge our therapeutic input, and who make CAT therapists cross and hurt by not acknowledging our worth (or, more subtly, that of the Reformulations and SDRs we produce).9

If a client leaves therapy feeling better, but thinking she probably didnt need to come in the first. place, this is considered a particularly elegant piece of therapy ("invisible therapy") by the therapist and his colleagues.

MEET THE CLIENT AT HER MODEL OF THE WORLD Solution Focussed therapists never confront the client's views or beliefs, as this is considered unproductive and unnecessary. If, for example, a client says, "The problem is that my wife nags all the time", the aim of the therapy will be to help the client help his wife to nag less (he will be asked about Exceptions, i.e. the times when she doesnt nag, or nags less than usual. Gradually it may dawn on him that her nagging is not unrelated to what else is happening, including his behaviour. However, this is not made explicit by the therapist).

This aspect of SFBT allows work with psychotic patients, on problems which are distressing them, without having to look at whether their delusions are

"real").10

THERE ARE MANY POTENTIAL "TRUTHS", SOME OF WHICH INHIBIT CHANGE, AND OTHERS WHICH PROMOTE IT. Rather than accept client's story of failure/weakness/badness, co-author a new story. In terms of the meanings that can be attributed to events, no absolute reality exists, only constructs or "mental maps" through which people make sense of their experiences, and which govern their responses to those experiences. 11

IMPORTANCE OF DEFRAMING AND REFRAMING: new or alternative frame or meaning to a situation (e.g. Survivor of Sexual Abuse: "I'm not normal"; Therapist: "You are a normal person trying to deal with an abnormal experience". For Bill O'Hanlon, Deframing and Refraining is the most basic and necessary operation in the process of change. Everything else is subordinate, and either aids or impedes this process.

IMPORTANCE OF BREAKING THE PATTERN/DOING SOMETHING DIFFERENT "Problems are the same damn thing, over and over again". Anything which breaks an unhelpful pattern is helpful.

This brings me to what I think might be the essence of all effective psychotherapy.

There are two sorts of differences between CAT and SFBT: some are simply non-CAT, others are anti-CAT. By Non-CAT I mean certain aspects or techniques which we can import into our CAT work, such as the Miracle Question. By anti-CAT 1 mean those aspects which contradict CAT theory and/or practice. How can Brief Therapy and CAT both achieve positive change, when the theory and the practice of each contradicts the other? Is there a "final common pathway" to all effective therapies? After all, even psychoanalysis sometimes works, and much of its theory and practice contradicts what goes on in CAT. Similarly with the creative therapies, Davanloo, transpersonal psychotherapy, etc. etc..

There are two other sets of related questions:

Why do all forms of therapy sometimes fail, even in skilled hands? Why do some of our CAT patients fail to change, in spite of excellent reformulations and diagrams? And by the way why do some CAT patients improve greatly, even though they were given fuzzy TPP's, a long biographical reforniulation containing no procedures, and an inadequate SDR, or even none at all?

Much has been written about the fact that the differences between particular methods of therapy matter less than the relationship with the particular therapist. Much has been written too about nonspecific factors in therapy - empathy, acceptance, and so on. Yet these non-specific factors while they make almost everyone feel better, do not always lead to change.

So what does happen in all successful psychotherapies (CAT, SFBT, or any other), and doesnt happen in failed therapies (CAT, SFBT, or any other)?

Here are my - still tentative - thoughts:

The client begins to feel that a different story is possible, that it isnt necessary to remain stuck in a place they dont want to be.

The healthier parts of the client come to the fore and start to grow and take control, so that healthy and adaptive behaviours are learned, or re-learned, and these become habitual rather than exceptional.

The therapist, by treating the client in a new way, and by responding to him in a new way, Breaks the Pattern. And hopefully starts a better pattern.

Deframing/Reframing is simply new descriptions or explanations or accounts of client's life and difficulties. The account need not be accurate, as long as it breaks the impasse, the rut, the feeling that one is condemned to it forever.

The client can begin to imagine, or play with, a vision or an experience of a different future. In particular, the client can begin to consider that he can affect his own life through his behaviour and his interactions. From learned helplessness or inability/unwillingness to change, to beginning to ask herself what small steps she could take, for the future to be different.

If, as a result of our endeavours - whatever therapeutic approach we are using - a client can begin to imagine a future that is different to, and better than, the past and the present, as a result of his own actions, and can begin to experiment, then therapy will, broadly speaking, be successful.

This would also account for why people continue to improve after therapy has ended - a phenomenon we are well aware of in CAT.

It would also account for another phenomenon, not usually acknowledged in CAT, but key to SFBT - the improvement which clients make even before the first session (re-authoring by the client starts as soon as they have named the problem and decided they need therapy).

It also accounts for why many clients improve despite a "bad CAT". It may well account for why even good CAT in skilled hands, sometimes doesnt work. Many of us find narcissists difficult to work with, "unrewarding", because they "cant collaborate". 12 My guess is that we are not offering these people more helpful re-authorings, nor the possibility to work at the level they choose to. Perhaps SFBT is a better treatment for narcissists. For a start, Brief Therapists do not label people in this way, so they do not start therapy with the negative expectations which many CAT and psychodynamic therapists will have.

Let me pose a rather extreme question - to which I do not yet have an answer: Could it be that the greater speed of Brief Therapy over CAT is due to its DIFFERENCES from CAT? In other words, could it be that some of what we are doing is actually slowing our work?

Cognitive Therapy and CAT have the advantage over psychodynamic therapies in that the assumption is that through relatively straightforward explanation and socialisation, clients can change. The past does not have to determine the future.

The added advantage of SFBT is that, rather than having to build a better future in spite of the client's past, it can recruit part of the client's past in order to build the preferred future. (Part of the preferred future is already contained in the present and past. The therapist's task is help the client figure this out).

Could we improve our efficiency by talking about solutions and preferred futures from the start, rather than dwelling on problems as much as we seem to need to? Should we present the Reformulation as being "true"? (This question was asked at the ACAT conference in 1993 by Louise Elwell, in a thoughtful presentation which had a huge impact upon me 13). Should we accept clients' accounts of themselves as "Doormats", or even as "Either Doormats or Bulldozers?" Should we always concentrate on our clients' problem procedures, or should we make a point of also eliciting their healthy procedures? If you actually ask about instances when your client

DOESNT placate, you may well be pleasantly surprised by the list of Exceptions. Yet this should not surprise CAT therapists in 1996, since Problem Procedures are now understood to mostly belong to particular Self-States, rather than to the person as a whole. However, are we using this new

understanding to our best advantage?

There are many other such questions, which I feel we - as integrative therapists - should keep asking, so I make no apology for ending on a series of questions. I will end with another quote from George Kelly's The Autobiography of a Theory:

If I had to end my life on some final note I think I would like it to be a question, preferably a basic one, well posed and challenging, and beckoning me on to where only others after me may go, rather than a terminal conclusion - no matter how well documented.

Annie Nehmad

This article is based on a talk at the ACAT Conference, March 1996

Suggested Reading and Listening

Three excellent audiotapes of Insoo Kim Berg, produced by the Brief Family Therapy Center, Milwaukee: "It's her Fault" (a man who is violent to his wife); Dying Well (a woman prepare for death from AIDS); and another, whose name escapes me (a survivor of childhood sexual abuse).

* Solution Talk : Hosting Therapeutic Conversations - Ben Furman & Tapani Ahola, New York: WW Norton, 1992

* A Brief Guide to Brief Therapy, B. Cade & W. O'Hanlon, New York, WW Norton, 1993

* Problem to Solution - Brief Therapy with Individuals and Families - Evan George, Chris Iveson and Harvey Ratner, London BT Press

A Field Guide to PossibilityLand - Bill O'Hanlon and Sandy Beadle, London BT Press 1996

Clues - Investigating Solutions in Brief Therapy, Steve de Shazer, New York, WW Norton, 1988

Narrative Means to Therapeutic Ends - Michael White and David Epston, New York, WWNorton, 1990

Words Were Originally Magic, Steve de Shazer, New York, WWNorton, 1994

Those with an asterisk are particularly suitable for beginners.

1 In B. Maher (ed), Clinical Psychology and Personality: selected papers of George Kelly. New York. Wiley, 1969

2 The name "Brief Therapy" is rather annoying; as it seems to imply that all therapies outside of itself are long. However, that is what its practitioners call it. It should be distinguished from brief therapy (without capital letters) which includes CAT, as well as many other forms of brief psychotherapy.

3 For example, SFBT is used with clients who are actively psychotic, and with clients who are currently abusing alcohol and/or drugs.

4 I fear that some CAT therapists might dismiss SFBT as superficial and "not real therapy", and the change in clients as "not real change" - which is what many psychoanalysts think about CAT.

5 One of the reasons for doing this presentation at the ACAT Conference, and publishing it in this Newsletter, is to help me find such people. If you are out there, please get in touch!

6 In CAT terms: everybody sometimes operates outside their habitual TPP's; everybody operates sometimes in a relatively well-integrated manner. Even those prone to severe depression are sometimes not depressed, or less depressed. Even those prone to violence are sometimes not violent, even when faced with a habitual trigger for it. And so on.

7 In Cognitive Therapy terms, information which contradicts core beliefs, or assumptions about oneself or other people, is altered in order to he assimilated into them. This process of altering, discounting, or invalidating positive information about the self and others is less clear and explicit in the CAT model.

8 As in CAT, the client's expressions are used as much as possible. SFBT therapists are very careful, however, to emphasise through their own use of language the fact that the client's negative descriptions are not shared by the therapist, and not even always felt by the client. (e.g. "So sometimes, it can feel to you as if your life is `all screwed up'...") The therapist's tone of voice is natural - there is no need for the words in bold to be given verbal emphasis for her words to call into question and begin to undermine the client's negative self-perceptions.

9 Unfortunately, I have not yet treated a difficult narcissist with SFBT, so at the moment this is only speculation on my part.

10 This lack of confrontation could appear to be collusion. In fact it isquite different. For a very powerful and moving example of non-collusive therapy which does not need to confront the client's views, listen to "It's her fault", an audiotape of Insoo Kim Berg with a man who is regularly violent to his wife, and does not see it as his problem. An extraordinary amount of change happens after two sessions, in both his behaviour and his insight, though she has never explicitly confronted his world view.

11 Some Brief Therapists go further, arguing that there is no "out there" reality, but only that which is in the "most immediate and concrete sense" constructed by the observer. For a lucid discussion on levels of reality see The Reality of "Reality" (or the "Reality" of Reality): "What is really Happening? " in A Brief Guide to Brief Therapy, Brian Cade and William O'Hanlon, W. W. Norton, pp 30-41. Cade and O'Hanlon invite Watzlawick (who has argued this position) "to elaborate [it] further whilst standing in front of an irate polar bear".

12 On the difficulties of CAT therapists working with narcissists, see the articles by John Marzillier, Cynthia Pollard and Annie Nehmad in this issue of the ACAT Newsletter.

13 It later appeared in ACAT Newletter N° 3

Annie Nehmad

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Nehmad, A., 1997. The Essence of Effective Psychotherapy: Reflections of a CAT Therapist learning Solution Focussed Brief Therapy. Reformulation, ACAT News Winter, p.x.

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