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Compare and contrast two examples of brief therapy. Solution focused therapy and gerard egan and the skilled helper model

It is now recognised that brief therapies provide a viable alternative to their longer, and hence more expensive, counterparts. While practitioners and researchers alike have wondered whether brief therapies can really provide the same degree of help to their patients, anecdotal evidence, as well as controlled studies, have started to show their benefits. Brief therapies are necessarily more limited in their focus, tending to concentrate more on the patients abilities rather than their deficits, on solving a particular problem or subset of problems, and patients tend to be more active and responsible for any improvements that occur. Since brief therapies are clearly useful for some patients in some situations, this essay compares and contrasts two particular forms of brief therapy, solution focussed brief therapy and the skilled helper model, largely developed by Gerard Egan.

Solution focussed brief therapy (SFBT) grew out of new therapeutic techniques developed at the Brief Family Therapy Center in Milwaukee, USA (de Shazer et al, 1986). This type of therapy is not so interested in analysing the problem a patient has, and more in the construction of a solution. Unlike some other forms of therapy, there is not much emphasis on traditional techniques such as talking about the problem itself, taking a history of the patient or diagnosing the patient's condition. The therapist concentrates mainly on helping the patient find a solution and how, through the use of available resources, this solution can be achieved.

These ideas have their root in the anecdotal finding that patients would often already manifest the small, almost unnoticeable, examples of the new behaviours they would need to escape their current behaviour. Despite having a problem behaviour of some kind, patients always had one small area which was an exception. It is this 'exception' that is the focus for the work of SFBT. The philosophy of this therapy is that patients are already trying to solve their problems and this comes from the assumption that patients have a desire to change and can visualise how this might be done (Gingerich & Eisengart, 2000). Early researchers in SFBT found that when patients articulated the end-goal of their therapy most clearly and solidly, they had the best outcomes and so this is a strong focus for the therapy.

SFBT, being a brief therapy, rarely takes more than eight sessions of around 45 minutes each. Iveson (2002) outlines the therapeutic process as involving four key tasks of the therapist: the goal the patient would like to achieve, the small details that would change as a result of achieving this goal, any steps the patient has already taken and what the effect would be of starting to change. In order to explore these ideas and start to achieve these goals, the therapist uses a number of techniques. The first is that of utilising simple scales for the client to indicate where they currently lie and where they would like to be along a score of one to ten. This allows both the therapist and the patient to have an understanding of the present position, the future goals, as well as the relative difficulty of different aspects of the problem.

Another important area in the SFBT is a focus on compliments and coping. According to Iveson (2002) the therapist should recognise when the patient is using their internal resources successfully, in whatever small way, and use that to compliment them. This helps the patient to recognise what resources they have available - ones they may have taken for granted.

To examine how effective this form of therapy is, it is useful to survey the literature on the outcome studies for SFBT - Gingerich & Eisengart (2000) provide a summary of both the early and more modern research. Early follow-up studies such as de Shazer (1985) reported that in following up 28 patients, there was 82% success rate. This and other early studies, however, were not controlled and used very subjective measures of patient improvement and so are not particularly strong evidence of the efficacy of SFBT.

Later research did use controlled studies and more confidence can be place in them. In assessing the more recent literature Gingerich & Eisengart (2000) split the studies into well-controlled, moderately-controlled and poorly-controlled of which only the first category is considered here. Zimmerman, Jacobsen, MacIntyre & Watson (1996) provide an example of a well-controlled study, they looked at the effects of SFBT on parenting skills by recruiting participants who were having problems with their children. The participants, after completing a variety of questionnaires to assess aspects of their parenting, were randomly split into two groups, experimental containing 30 people and the control containing 12. The experimental group were given six sessions of SFBT lasting 30 minutes each time. In the analysis they showed statistically significant improvements on some of the sub-scales of the Parenting Skills Inventory. Criticisms of the study include the small sample size and the fact that the improvements could have been a result of the non-specific effects of the treatment. In other words, merely attending some kind of therapy session and thinking about the problem may be helpful - no matter what type of therapy is provided.

In a more satisfactory study, Cockburn, Thomas & Cockburn (1997) examined the rehabilitation of orthopaedic patients in which 48 patients were assigned to one of four conditions, involving a combination of SFBT and the standard rehabilitation treatment. Gingerich & Eisengart (2000) report that this study was better controlled as there was good patient screening, a randomised design and it used outcome measures that were standardised - return-to-work rates. It was found that the group that had both the standard rehabilitation combined with the SFBT had the highest return to work rate. Criticism of this study is based on the fact that there could still have been a beneficial effect for the extra attention on the therapy, no matter what type of therapy it was.

Lindforss & Magnusson (1997) addressed how effective SFBT was in reducing the rates of recidivism in a prison in Sweden. Treatment and control groups of 30 participants each were either given SFBT or the prison's standard treatment. After 12 months, rates of recidivism were at 53% in the SFBT group, compared to 76% in the control group. After 16 months the two figures had increased to 60% and 86% respectively. Apart from that it was also noted by the authors that the sentence length and level of seriousness of the committed crimes were both lower in those who had participated in SFBT. Gingerich & Eisengart (2000) criticise this study as it was unclear whether the treatment was standardised, in other words there is no mention of the manuals that were used by the therapists in providing the intervention. Despite this, it is clear that the intervention did have a significant beneficial effect.

In summarising these studies Gingerich & Eisengart (2000) make the point that, while there is evidence from the well-controlled studies for the efficacy of SFBT, there is no comparison to other forms of psychotherapy which limits the conclusions that can be drawn about SFBT's effectiveness. Further they claim that most of the studies were carried out by advocates of SFBT and there is no account taken of factors like therapist allegiance and expectancies - these would probably be unusually strong in this situation.

An alternative model for therapy is that elucidated by Egan (1990), called 'The Skilled Helper Model'. According to Egan (1990) this provides one way of examining a patient's problem to allow the creative production of alternative solutions. This model is not so much a specific method of carrying out therapy as an overall model of the helping process. What Egan (1990) provides is a framework within which a therapist or counsellor can work.

The model breaks down the helping process into three stages. The first stage involves the therapist orienting themselves within the patients world, to start finding out what is going on. Egan (1990) further breaks this down into three different stages. The first stage involves the therapist encouraging the patient to tell their story by using active listening and questioning to elicit all the relevant details. It is here at the first stage that a clear contrast can be seen with the SFBT which does not provide much focus on the exploration of the problem - Egan's model is keen to engage with the exact dimensions of the problem. The second part of the first stage involves identifying any blindspots or parts of the patients' story which have not been sufficiently investigated. As everyone has their own particular beliefs and assumptions about the world, the model's method encourages the  patient to explore themselves from a more objective viewpoint. According to Egan (1990) it will often be that there are many aspects of themselves that people are not aware of. To a certain extent, this will involve gentle challenging of the patient to help them arrive at a wider viewpoint. This provides a second contrast to SFBT which is not really concerned with challenging the patient's viewpoint, as its focus is more solution-orientated. The third part of the first stage is in focussing down onto which particular area the patient would like to concentrate on in their therapy. It may be that through making a change in one area of their life, beneficial effects will be seen in other areas as well. Egan (1990) talks of identifying those concerns, worries, or even opportunities, that will make a difference to the patient. This may involve deciding what would have the greatest knock-on effects, or what it is possible to achieve at the moment. Again this third part of the first stage provides a contrast to SFBT as it is still centred mostly on the different problems that the patient has.

The second stage in the skilled helper model, as explained by Egan (1990), is encouraging the patient to envision a better future for themselves. The aim of this process is to clarify goals and to provide motivation. Again, this stage is broken down into three parts. The first part is where the therapist encourages the patient to envision a solution state to their problem. The patient is helped to be creative in the way they solve their problem, not to be constrained by practicalities. The second part involves bringing in the practical aspects of the goal and trying to create something that can really be achieved. Egan (1990) also suggests that the goal should be in line with the patient's values, represent a good way of addressing the identified problem, be possible within a period of time and be realistic. The third part of this second stage involves the therapist in testing with the patient whether the motivation is there or not. And if it is not, then ways need to be examined for finding the motivation or making other changes to the goals.

The second stage of the skilled helper model appears to come closer to SFBT as it is focussing on the solution. In particular, both therapies focus on having a vision of how things might be in the future. The skilled helper model, however, places more emphasis on the input of the therapist as a moderator for the patient, the therapist in a SFBT session will simply acknowledge the patient's choice, compliment it and move on to address it.

The third stage of the skilled helper model involves working out exactly how the client will get from the current situation to the goal that they have envisioned. Again, this stage is broken down into three parts. Firstly, the patient is asked to brainstorm for strategies - the emphasis at this stage being on thinking as widely and creatively as possible. Again, the second part involves narrowing these strategies down to choose the most appropriate. The choice of strategy may be limited by the patient's frame of reference and so the therapist is encouraged to help the patient get as close to their goal as possible. Finally in the third part, the patient is encouraged to turn the particular strategy that has been chosen into a concrete, step-by-step plan. Egan (1990) explains that this is done by breaking down the strategy into its component parts and then attaching a time-frame to each action.

With the emphasis in the third stage of the skilled helper model on the construction of a solution, this is perhaps the closest in spirit and method to SFBT. This third stage also emphasises the importance of allowing the patient to reach their own conclusions with the therapist simply guiding the way, a similar approach to that used in SFBT.

A search of the psychological databases for research on the evaluation of the skilled helper model reveals that little or no research specifically on this model has been carried out. This is probably because of the generality of the model, the difficulty of deciding on appropriate outcome measures and actually measuring any outcomes that are decided on. This then provides a further contrast between the two types of therapy, in that SFBT has some positive evidence in the peer-reviewed literature to support its use, while the skilled helper model - mostly because of its nature - has little.

Some other, more general contrasts can be drawn between the two types of therapy. In SFBT, the therapist is most interested in creating a vision for the future and believes that the seeds of this vision are contained in the patient's current behaviour. These can be brought out by concentrating on the behaviour and what the patient feels is required in order to reach their vision. In this way SFBT is extremely forward looking, with the therapist handing almost all the reins to the client. Crucially, the therapist tends to concentrate on bringing out the positive aspects that the patient is manifesting in any possible way. In contrast, the therapist in the skilled helper model looks backward as well as forward, and provides a much greater degree of guidance to the patient through the process. Egan (2002) is keen to point out that the skilled helper model is just one way of looking at the process and the stages of the therapy should be used flexibly and in this sense it is a higher level and less specific form of therapy than SFBT - it is perhaps better seen with the emphasis on 'model' rather than the more specific techniques that are contained within SFBT.


References

Cockburn, J. T., Thomas, F. N., Cockburn, O. J. (1997). Solution-focused therapy and psychosocial adjustment to orthopedic rehabilitation in a work hardening program. Journal of Occupational Rehabilitation, 7(2), 97-106.

de Shazer, S. (1985). Keys to Solutions in Brief Therapy. New York: Norton

de Shazer, S. (1988) Clues: Investigating Solutions in Brief Therapy. New
York: Norton.

Egan, G. (1990) The Skilled Helper: a Systematic Approach to Effective Helping, 4th edition, Monterey, CA, Brooks/Cole

Egan, G. (2002) The Skilled Helper: a problem-management and opportunity development approach to helping, 7th edition, Brooks/Cole: Pacific Grove, CA.

Gingerich, W. J. Eisengart, S. (2000) Solution-Focused Brief Therapy: A Review of the Outcome Research, Family Process, 39(4) 477

Iveson, C. (2002) Solution-focused brief therapy. Advances in Psychiatric Treatment vol. 8, pp. 149–157

Lindforss, L., Magnusson, D. (1997) Solution focussed therapy in prison. Contemporary Family Therapy 19, 89-103

Zimmerman, T. S., Jacobsen, R. B., MacIntyre, M., Watson, C. (1996). Solution focused parenting groups: An empirical study. Journal of Systemic Therapies, 15(4), 12-25.