Assignment 1: Planning a Group

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Counselling Psychology Review, Vol. 26, No. 3, September 2011 45 © The British Psychological Society – ISSN 0269-6975

COMMON PROBLEM in running groups in both primary and secondary care is that of recruiting a

sufficiently large cohort of patients with similar problems who are willing and able to attend group sessions to make the delivery of specific, targeted therapies financially and clinically viable. Within the Berkshire National Health Service (NHS) Foundation Trust’s psychology service, professional colleagues run groups focused on a variety of conditions including depression, anxiety, bipolar disorder and obsessive compulsive disorder. These groups have been demon- strated to produce favourable clinical outcomes, but these and other groups have sometimes failed to get off the ground due to a lack of suitable clients.

With ever increasing pressure from a growing waiting list and from our supervisors to run groups, the first author (SP) and a colleague decided to run a group where having a particular diagnosis or type of problem would not be a criterion for inclu- sion in the group. In true Solution Focused philosophy, and following on from LaFoun- tain and Garner (1996), we believed that we

could run a group where the primary focus would not be on the problem but rather on supporting members of the group to achieve their goals, notice exceptions and find solu- tions to their problems.

Solution Focused Group Therapy Solution Focused Therapy (SFT) is a future- focused, goal-directed approach to therapy that highlights the importance of searching for solutions rather than focusing on problems. Iverson (2002) has described SFT as an approach to psychotherapy which is based on solution-building rather than problem-solving. SFT explores the client’s current resources and future hopes rather than his/her present problems and the past causes of these problems. Typically, SFT involves only three to five sessions and has value as a preliminary and often sufficient intervention and can be used safely as an adjunct to other treatments.

SFT does not employ any formal theory of change but has key elements and tech- niques which when employed effectively in either individual or group psychotherapy can facilitate improvements in a relatively

Research Paper

Solution Focused Groups: The results look promising Simon Proudlock & Nigel Wellman

Aim: To explore whether Solution Focused Group Therapy could have a role to play in the treatment of adults with severe and enduring mental health difficulties. As demand for services increases, there is a growing pressure to offer treatments that deliver cost effective outcomes. Method: A total of eight people in two pilot groups were offered solution focused therapy as part of their treatment plans. All clients who wanted to make a change in their lives, independent of presenting problem, were welcome to attend. Pre- and post-measures were taken using the Mental Health Recovery Measure. Results: All participants were found to show some improvement on completion of the group. Conclusion: Although limited by small sample size, the results suggest that Solution Focused Group Therapy may potentially offer a cost effective way of treating adults with a variety of presenting problems within adult mental health services. Keywords: Solution Focused Therapy; groups; adult mental health services; crisis; group cohesion; resources.

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short period of time. Some of the key elements include the therapist taking a non- expert, not knowing stance, the emphasis on using the clients own language, the value of making changes slowly, a faith in people’s abilities and resources, and a recognition that the solutions which enable clients to achieve their goals do not necessarily directly relate directly to the problems they describe, (see Proudlock (2011) for a more in-depth explanation).

Pivotal techniques in SFT include the miracle question, focusing on exceptions, and scaling. In asking the miracle question the therapist asks the client to envisage a preferred future in which their problem(s) have dissipated, and hence elicit from them a description of what they might be doing if this miracle were to happen. Focusing on exceptions encourages the client to look at times when the problem could have happened but did not, or at the very least was less severe. SFT explores what is different at those times when the exceptions occurred and whether the client can do more of what works. Scaling asks the client to rate on a usually numerical scale where they are when describing a problem or achieving goal. It allows clients to channel their thoughts into seeing how they can move step by step into finding solutions.

Steve de Shazer and Insoo Kim Berg are credited with developing solution focused brief therapy together with their colleagues at the Brief Family Therapy Centre in Milwaukee, Wisconsin, in the 1980s. Devel- oped inductively rather than deductively, de Shazer and colleagues spent many hours observing a variety of therapy sessions to see what therapist activities were most useful to clients. As a result, SFT did not arise out of any particular theory of illness or problem creation but rather developed pragmatically.

In relation to group therapy, two promi- nent texts from Metcalf (1998) and Sharry (2007) have highlighted the benefits of using SFT in a group setting. Instead of having a single therapist seeking to identify the client’s resources, strengths and solu-

tions, the members of the group are mobilised to add to the work of the facilita- tors. Sharry (2007) has noted that solution- focused groupwork aims to establish collective and mutually beneficial goals in order to harness the group’s resources and strengths towards empowering its members to make realistic short-term steps towards their goals.

One of the most cited papers on the effectiveness of SFT in groups is LaFountain and Gardner (1996). This article reported promising results in the use of SFT in groups of children and adolescents in helping clients to obtain their goals. In this study at least 91 per cent of students demonstrated progress towards their goal and 81 per cent of the students achieved their goals at a moderate to very high level. The authors also reported a significant effect on reducing counsellor burnout rates when they utilised a solution focused approach.

Other research has reported positive effects of Solution Focused Group Therapy (SFGT). Lange (2001) used SFT in groups with incarcerated fathers and found that a solution focused approach provided the flex- ibility needed in such a setting to allow the group to define a unique set of therapeutic goals as well as incorporating an element of skills teaching.

Shin (2009) examined the effectiveness of solution-focused group treatment with Korean youth probationers with the aim of investigating interventional methods for helping Korean youth probationers reduce their aggressiveness and increase their social adjustment. As well as finding that the SFGT approach was especially favourable for dealing with involuntary populations, Shin found that this approach was effective in decreasing aggressiveness and in increasing social readjustment abilities in the experi- mental group. Group members were also able to enhance their participation motiva- tion and achievement motivation, allowing participants to successfully change their problematic behaviours.

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Counselling Psychology Review, Vol. 26, No. 3, September 2011 47

In another study, Froerer, Smock and Seedall (2009) looked at how SFGT can effectively aid those diagnosed with HIV/ AIDS to combat the obstacles they encounter. The authors reported that SFGT helped individuals to utilise existing compe- tences and resources and mobilise personal resources to cope more effectively with their illness.

Two studies have reported outcomes of solution focused group therapy with individ- uals on long-term sick leave and reported SFGT to be more effective than control conditions. Thorslund (2007) reported that the treatment group returned to work at a significantly higher rate than waiting list controls, worked more days and maintained their improved psychological health after completion of treatment. Similarly, Nystuen and Hagen (2006) reported on effects of treatment for employees on long-term sick leave due to mental health problems or musculoskeletal pain, finding that SFGT was superior to ‘treatment as usual’ in improving the psychological health of employees who attended at least 50 per cent of scheduled sessions.

The literature search also discovered two studies that used SFGT in a couples group. Zimmerman, Prest and Wetzel (1997) reported an empirical study that showed the couples in the SFT treatment group improved significantly with respect to overall affectional expression and satisfac- tion. Nelson and Kelly (2001) in a similar study showed improvements of at least 70 per cent in overall satisfaction scores with 80 per cent reporting progress towards their goals.

Linton, Bischof and McDonnell (2005) applied solution-orientated group therapy to individuals who have displayed assaultive behaviour reporting that the collaborative nature of solution orientated treatment had a very positive impact on treatment. Focusing on past exceptions and client strengths and resources in the early stages of group therapy helped group cohesiveness and increased participation in the group

process, allowing group members to take an active part in establishing treatment goals.

SFGT has also been reported to be effec- tive in the treatment of level 1 substance abusers in the US. Smock et al. (2008) compared SFGT with a traditional problem focused treatment for substance abuse and found those in the SFGT improved signifi- cantly on both the Beck depression inven- tory and the Outcome Questionnaire compared to controls receiving a standard psycho-educational intervention.

Aims Given that the literature review above suggests that SFGT may hold clinical promise in a number of areas, a pilot study was undertaken to explore its utility in a community mental health setting. The work reported below aimed to explore the accept- ability and potential utility of SFGT in the treatment of mixed groups of adults with severe and enduring mental health difficul- ties in standard clinical settings.

Pilot study into the clinical utility of SFGT

Method This is an explanatory mixed methods evalu- ation study in which brief qualitative data is used to provide insights into quantitative outcome data (see Creswell & Plano Clark, 2007, for more on this type of design).

Participants and recruitment Clients for SFGT were under the care of a Crisis Resolution and Home Treatment Team (CRHTT) and SFGT was additional to standard care. The two groups ran for six consecutive weeks for two hours each week.

Potential group members were screened by clinical staff and asked a series of brief questions to determine if they could visualise a preferred future and identify features of their lives they would like to change. An assessment was also made to determine if they felt they would be comfortable working in a group situation. Referrals with active

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psychotic symptoms were excluded. Clinical diagnosis did not influence whether or not clients were accepted for the groups.

In total N=8 patients were recruited for the two pilot groups. There were N=5 partic- ipants in the first group and N=3 in the second. Unfortunately N=2 members of the second group did not attend the last session of that group when the end of treatment assessment was completed resulting in an incomplete data-set. Of the N=8 participants included, N=4 were male and N=4 female. Clinical diagnoses of participants included bipolar II disorder, major depression, gener- alised anxiety disorder, social phobia and borderline personality disorder.

Clinical instruments All group members were asked to complete the Mental Health Recovery Measure (MHRM) (Bullock & Young, 2003) at the start of the first session and then again six weeks later at the end of the last session. Group members were also asked to fill in a brief evaluation of the group at the last session. The MHRM is a behaviourally anchored self-report measure which focuses on the recovery process for individuals with serious mental illness. Recovery is assessed without relying on the measurement of symptoms. This measure was picked as it was felt it reflected more closely the ethos of SFT with its focus on recovery than traditional clinical instruments which measure symptom levels and distress.

As well as giving an overall score, the 30 item version of the MHRM also gives a measure on seven conceptual subscales: Overcoming Stuckness, Self Empowerment, Learning and Self-Redefinition, Basic Func- tioning, Overall Well-being, New Potentials and Advocacy/Enrichment. Total score on the measure was used to determine overall recovery for the purpose of this study. Addi- tional to this quantitative measure, the first author (SP) kept field notes on the progress of the groups and a record of qualitative feedback from group members

Facilitators Both groups were facilitated by the first author (SP), who is a counselling psychologist working in secondary care settings including the CRHTT. He is also a SFT trainer, practi- tioner and author of a book on SFT. There were two co-facilitators, the main co-facilitator was another counselling psychologist. This psychologist had limited experience of SFT but had completed his PhD thesis on group therapy and worked within the CRHTT. The second co-facilitator was a Community Mental Health Nurse and trained SFT practitioner who also worked in the CRHTT. The first author (SP) kept field notes on the progress of the groups and a record of qualitative feed- back from group members.

Group content Each group took place in an out-patient setting. The outline of the group was as follows:

Session 1: Questionnaires/Introductions/Ground Rules/What is SFT/Identify Group Goals. Homework: Notice times in next week when you don’t feel as bad as you have been feeling.

Session 2: Tuning in/Review Homework/How change happens/Introduction to Goal Setting/The miracle question. Homework: Continue looking at what’s been better with your week plus identify two goals you could aim for in the coming weeks.

Session 3: Tuning in and review homework/What’s working in the group/Individual Goal setting. Homework: Continue looking at what’s been better with your week plus what one thing can you do to move closer to obtaining your goal plus note down possible obstacles to achieving your goals.

Session 4: Review homework/Becoming What You Want. Homework: Continue looking at what’s been better with your week plus questions three and four on Becoming What You Want exercise.

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Counselling Psychology Review, Vol. 26, No. 3, September 2011 49

Session 5: Review homework/Introduce Scaling. Homework: Continue looking at what’s been better with your week plus finish off Becoming What You Want plus Solutions Scavenger Hunt.

Session 6: Review homework/Review progress towards indi- vidual and group goals/Review solutions found in the scavenger hunt/Questionnaire and evalua- tion/Endings.

Data analysis The pre- and post-group scores on the MHRM were compared using the Wilcoxon Signed Ranks Test. The Qualitative data was analysed for complementary explanatory themes. These themes are presented infor- mally in the text below.

Ethical considerations The work reported here was undertaken as the service evaluation of a new clinical service development and advice was received from the chair of the local NHS Research Ethics Committee that NHS ethical review was not required for this project. The work adhered to the British Psychological Society’s Code of Ethics (BPS, 2006) and was further informed by their statement on researching human participants (BPS, 2004).

Results The pre- and post-group scores on the MHRM indicated progress towards recovery was being made and there was a significant increase in mean total MHRM score from pre-group to post-group Z=–2.24, p=.025. Increased scores were observed on all of the seven sub-scale scores, but as can be seen in Table 1, not all sub-scale scores reached statistical significance.

As was to be expected, due to the wide variation in presenting problems, there were individual marked differences in how much clients individually improved. Some showed large improvements whilst others only increased their scores by a couple of points. At least half of the clients increased their level of functioning from below average to above average.

For some clients, especially those with a personality disorder, self-report scores tended to be low despite anecdotal evidence from those around them that they had made significant improvements

All participants reported finding the groups to be helpful, with the main criticism being that it only went on for six sessions.

Qualitative feedback The facilitators did not seek to systematically explore the client’s experiences through structured interviews but did record client

Solution Focused Groups: The results look promising

Table 1: Sub-scale scores pre-test/post-test on the MHRM using Wilcoxon Ranks Text. Significant differences shown in bold.

Sub-scale Z score and significance (two-tailed)

Overcoming Stuckness Z=–.946, p=.344

Self-Empowerment Z=–2.178, p=.029

Learning and Self-Redefinition Z=–2.328, p=.020

Basic Functioning Z=–1.616, p=.106

Overall Well-being Z=–2.371, p=.018

New Potentials Z=–2.207, p=.027

Advocacy/Enrichment Z=–2.106, p=.035

50 Counselling Psychology Review, Vol. 26, No. 3, September 2011

feedback on group evaluation forms and in field notes. The most common feedback received by the facilitators with respect to client experiences in the groups was that clients felt as though all members of the group were experiencing similar difficulties, despite the fact that they had come to the group with a wide range of presenting problems. It seems group cohesiveness was derived not from prior shared experiences of problems and diagnosis but more by the desire to search for solutions, emphasise resources and strive towards having a different life.

The most striking theme evident from group members’ feedback was a shift towards a more positive outlook as evidence by the quotations below:

Client 1: I’m not looking for bad things anymore.’ Client 2: ‘If things go wrong I don’t beat myself up about it.’ Client 3: ‘I’ve learned to be more positive and to look towards the future and not the past.’

In general, feedback on the groups was very positive:

Client 4: ‘It has been the one thing worth getting out of bed for.’ Client 5: ‘It was very interesting and thought- provoking. I liked the way it focused on making good things better.’

Discussion Many clients find attending group therapy to be anxiety provoking; for this reason, in the first session the facilitators took the lead and encouraged participants to work in pairs to identify some positives that they might already be experiencing. In other exercises participants identified their favourite fictional characters, something they had learned in the past month, something they had enjoyed in the past month and some- thing positive someone had done for them recently. Encouraging participants to iden- tify their favourite fictional character and to discuss reasons why they picked that char- acter immediately reduced the ‘heaviness’ of the first session. SFT is still a relatively little

known therapy in the UK and so a major task undertaken in the first session was to intro- duce participants to the key concepts, methods and techniques of the solution focused approach and to think about how these approaches can help. Finally, group members were asked to get back into pairs and talk about what has brought them to the group. Although problem-focused, this allowed the facilitators to identify common- alties which were used in the formulation of group goals. The homework exercise was designed to get participants to identify exceptions, no matter how small, in order to begin the process of changing their focus away from problem saturation and moving towards an outlook containing opportuni- ties, hope and solutions.

In the second session most participants were asked to identify a time in the last week when things had been a little better for them. Again, the session started off with the participants initially working in pairs and then sharing their exceptions with the larger group. For those who had struggled to find an exception, participants were encouraged to think about the possible exceptions they would have liked to have seen happen. A significant part of this session was spent looking at how change happens and how small changes/small improvements can incrementally become transformational. The near universal wish of everyone volun- tarily attending psychological therapy is to have something change in their life, but often relatively little time is spent on exam- ining just how change actually happens. Similarly with goal setting – most people are familiar with the concept of setting goals, but few are really aware of how to set goals which are realistic, timely and achievable. This unfortunately means that inappropriate goal-setting can reinforce clients’ experience of failure and ‘stuckness’. Finally, the miracle question was asked, with participants encour- aged to operationalise and describe how their lives would be different if the problems that had brought them to the group disap- peared.

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Part of the central philosophy of SFT is that if something is not working, then one should stop doing it and try something different instead (see Proudlock, 2011; De Jong & Berg, 2002). With this in mind, the third session opened with the facilitators asking participants for their views on what had been working in the groups thus far and what had not. Modelling this concept within the group helped to illustrate this essential SFT concept to the group. Most of the third session was focused on helping group members to set realistic and achievable goals for themselves. These goals were shared with the group which facilitated a huge flow of ideas between members on ways to achieve the goals. The homework encouraged partic- ipants to start taking action to meet the goals, together with thinking realistically about factors which might get in the way of achieving the goals. Although the core focus of SFT is away from problem-directed talk, this exercise focusing on potential difficulties was designed to assist group members use the next session to identify their coping mecha- nisms and brainstorm ways of overcoming these obstacles.

Session four centred around the ‘Becoming What You Want’ exercise. This exercise was adapted from Switek (2001) and is in itself highly adaptable depending on the needs of the clients. The exercise incor- porated most of the key elements of SFT – visualising a preferred future, identifying exceptions, setting goals and using scaling to measure progress. The exercise encouraged participants to imagine themselves as someone who copes with life’s difficulties and elicits past examples of coping, no matter how small these might seem. As part of the exercise participants were asked to rate on a scale of 0 to 10 how well they felt they were currently coping with life’s diffi- culties. Using an exercise adapted from Jackson (2005), participants learnt more about scaling and how a concept such as ‘coping’ can be represented on a scale rather in absolute, black or white terms. Participants shared with the group the

approaches they were using to maintain their current position on the scale, what it would be like to be a ‘0’ or a ‘10’, what they need to do to stop themselves slipping one point down the scale and the steps they need to take to move one point up their scale.

The fifth session was centred around a ‘Solutions Scavenger Hunt’ exercise adapted from Fiske and Zalter (2005), and simply asked participants to identify solutions in the world around them. Group members were asked to pay special attention to compli- ments, miracles, solutions in song, company’s offering ‘solutions’, and multiple kinds of evidence of strengths and resources.

The final session focused on the work the participants had done and the strengths and resources that had emerged. Group goals were revisited and progress charted against these goals. Participants were encouraged to focus on their next steps after the group had finished and how they can move further up their scale to achieve their goals and actu- alise their preferred future.

Group cohesion is a fundamental factor underlying the success of SFT groups. As Corey and Corey (2006) have highlighted, cohesion fosters action-orientated behav- iours such as self-disclosure, giving and receiving feedback and discussion of ‘here and now’ interactions. Similarly, Yalom (1995) has described the importance of group cohesion, noting that strong cohesion leads to positive group outcomes and better attendance.

Encouraging the group to focus on exceptions to their problems seemed to aid an improvement in individual members day- to-day functioning, which in turn helped members to see the possibility of a better future. This increased stability was noted by a colleague who was providing psychological therapy concurrently to one of the individ- uals in the pilot group. This increased stability provided the grounding the client needed allowing for exploratory individual therapy to take place.

The use of compliments is important in SFT. Although it was certainly therapeutic

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for the facilitators to give compliments and praise to individuals for strengths identified, goals formulated and progress made; compliments and praise from peers within the group have a unique authenticity and force and really magnify the work of the professional facilitators. For most partici- pants, the experience of having a group of their peers show real empathy and under- standing of their situation and receiving their support and encouragement to over- come obstacles and work towards the achievement of identified personal goals was probably the most empowering aspect of the group experience.

Sharry (2007) has highlighted three factors which really impact on group func- tioning. These factors are whether the client feels supported and understood within the group, whether they feel involved and able to participate, and whether they feel the goals, content and tasks of the group are helpful to them. The structure and content of the SFT group was designed to maximise these three areas. As Froerer (2009) has reported, group work within an SFT frame- work can create a synergistic effect where the benefits of group work are merged with the most effective elements of SFT.

Looking back on the groups, in the initial stages the facilitators probably tried too hard to find solutions, minimise problem-related talk and keep the atmosphere of groups as positive as possible. It was clear after two sessions that this approach was unhelpful and in keeping with the central philosophy of SFT, this approach was dropped and a new approach adopted. In subsequent sessions the facilitators aimed to achieve about 80 per cent solution talk and 20 per cent problem talk and this mix seemed to be more comfortable for all group members. In the first few sessions problem talk was clearly unifying for the group, increasing cohesive- ness and working alliance. However, as the group evolved, clients became more focused on looking at the positives and less inclined to focus on the problem. Formulating group goals and discussing what had brought

members to the group also aided in achieving the right mix of problem/solution talk. Searching for solutions, strengths and resources with clients can be a refreshing change for practitioners who are faced with an environment bursting with problems. Similar to the findings of LaFountain and Garner (1996), all the facilitators in the groups found it invigorating and uplifting to change their focus away from problems and distress and focus their skills on helping clients recognise their strengths and identify solutions to the issues facing them.

Future groups Since the initial pilots described in this paper, SFGT has become part of the treat- ment offered by other local crisis resolution and home treatment teams within Berkshire NHS Foundation Trust. In one area, slightly lower group numbers, which permit more focus on each individual member of the group, has allowed the duration of group sessions to be reduced from two hours down to 90 minutes. Outcomes have been similar to those described above, with all partici- pants showing overall improvement on the MHRM. Groups are now run by two facilita- tors, generally one being a lead psychologist and the other a clinician being trained in SFBT. In true solution focused style, we are continually searching for what is working in these groups and doing more of it, whilst maintaining one of the core philosophical tenets of counselling psychology by struc- turing treatment interventions based upon the lived experiences of our clients.

Due to the positive results from these initial two groups, referrals are now being welcomed from anywhere within the Community Mental Health Team. Some clients who have already completed courses of psychological therapies have attended and reported finding the groups to be valuable in helping them move on with their recovery. It is hoped that the use of SFGT can be expanded and used to manage waiting lists and as an adjunct to help people with complex needs to stabilise their intense

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Counselling Psychology Review, Vol. 26, No. 3, September 2011 53

emotions. The first author’s (SP) experience of using SFT with individuals with Border- line Personality Disorder suggests that these techniques are often well received and successful, with those clients joining the SFT groups appearing to benefit from the group.

Although this research reports a positive benefit for the majority of those that attended the groups, the small sample size is a clear limitation to the current research but hopefully provides a strong basis to develop further research in this area. Future research should also look at whether the benefits of attending such groups are maintained over time. Although the current political agenda seems firmly committed to Cognitive Behav- ioural Therapy through the Department of Health’s Increasing Access to Psychological Therapies initiative, early evidence suggests that solution focused approaches may also be a valuable and potentially highly cost- effective addition to the therapeutic arsenal.

About the Authors Simon Proudlock, Highly Specialist Coun- selling Psychologist, Berkshire NHS Founda- tion Trust and Independent Practice. Nigel Wellman, Independent Research & Training Consultant.

Correspondence Simon Proudlock Email: [email protected]. Nigel Wellman Email: [email protected].

Solution Focused Groups: The results look promising

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Proudlock, S.M. (2011). The Solution Focused Way: Incorporating solution focused tools and techniques into your everyday work. Milton Keynes: Speech- mark.

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Simon Proudlock & Nigel Wellman

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