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by Insoo Kim Berg
Making Ordinary Extra-Ordinary - "How Do You Cope?"
Many observers of my therapy sessions are surprised at how many times I use the word, "Wow" within a matter of an hour. One even counted and reported to me that I used the same word 25 times in a single session! I was amazed myself. Of course I was not aware of this until people began making a joke out of it, not that I felt offended.
When you listen to the client's account of how they came close to just "cover my head with a blanket and just stay in bed all day," but at the last minute, they somehow muster up their energy and decide to get out of bed, it is amazing. Imagine how difficult and daunting it must be to force oneself to get out of bed when there seems no reason whatsoever to do so. For most of us, it is something we do simply without much thoughts because we have always done it and there is no reason to stay in bed after getting a good night's rest. It is difficult to imagine for someone like myself - high energy, love to work, and thriving on the feeling of getting things done to stay in bed without being deadly sick.
The contrast is awesome and inspires us to imagine how difficult a life must be when one dreads to get up and face the day because it feels like you are doomed before you even being. It is easy to imagine to just give up and say, "Why bother!" But some mothers force themselves to get up and take care of their children because the children need them. Some people keep going even in the face of unimaginable tragedy, suffering, and hopeless situations.
We need to give credit to those who deserve to be given credit to, but it is more than that. By recognizing her extraordinary effort to take care of her children, this worn out, discouraged, depressed mother is making her best effort to do what is demanded of mothers, to give selflessly and it is indeed remarkable. And it is indeed not that difficult to blurt out, "Wow!" and mean it. What more can anybody ask of someone else to do more than this!
When we respond in these truly awestruck and amazed manner, they begin to see themselves in a new light, however small, perhaps their ordinary effort is indeed extraordinary. And it is not that difficult to blurt out "Wow!"
Believing is Seeing
I am often asked about my tenacity to "hang in there" when it seems absolutely hopeless about some of the clients we meet: Life-long patterns of substance use, multi-generation of physical violence, and other debilitating psychiatric problems and how to do you manage to hang in there with so much problems and hopelessness? It's easy.
Some people even compared my style as similar to "pit bull." Imagine that! But I'm quite proud of this comparison, not in viciousness but in not giving up on client and the tenacity to hang in there until I find some strengths, resources, and exceptions to build on, in most situations.
Many people believe that because the basic premise of SFBT is so simple, it should be easy to do. They are surprised to find that a therapist must work very hard just to hang in there and not give up on clients as hopeless. This is especially true if the therapist does not believe that client has the resources and ability to solve their problems on their own.
Where does my tenacity and ability to hang in there like a pit bull with a bone? It is because of the belief in people, that is, this absolute belief in people that if they have survived this far in their lives, they surely know how to go a little further. Most clients have abilities but they do not believe they do. Therefore, if you do not see it, it is easy to become discouraged.
In order to work with people, we all begin with certain assumptions and belief about what we believe about them. Unfortunately I believe many practitioners are not clear about their belief. But certain kinds of belief about people brought you to this field. Whether we admit it or not, these belief is spilled over in our interactions with clients in many subtle and not so subtle manner.
Of course when you begin with this conviction, you see it everywhere, and of course, then seeing it reinforces the belief even further, and so on.
Useful Language Use
Since language is the only tool we have in working with people, regardless of what kind of job we do in our daily work, it seems it is important that we have some simple, yet effective tools to keep in our pocket and pull them out easily when we need them. Aside from the usual Solution-Focused Therapy tools that it is known for, one of the most useful language tool is one that beings with:
"You must have a good reason to . . ."
For example, when you feel your own lecturing and urge to educate without being invited by the client welling up inside of you, even though they are all with good intentions, instead slow down and catch yourself before you utter the usual preachy word and begin with a sentence that starts with . . . "You must a good reason to . . ." (drink too much, lose your temper, slap your child, wanting to kill yourself) and listen carefully to the client's answers.
My experience is that some very bright and perceptive clients will catch on and immediately begin to either burst out laughing or say things like, "Not really, but I do drink a lot," and then explain what he or she must do to correct the situation. Of course this makes our job easy since we just need to follow up with . . . "What have you been thinking about doing, for a starter . . . ?"
Some clients who have been hearing a great deal of "preaching" about what he or she ought to do, automatically begins to defend himself by listing all the "good reasons (or what others call them "excuses"). It is helpful to listen carefully to these and keep asking for more and more "good reasons." Most clients tick off 5 or 6 "good reasons" and then begin to repeat themselves. When you are patient, waiting for more "good reasons," then eventual arrive at the conclusion that you are not going to reprimand, cajole, or demand that he or she change. Many clients will say, "Actually, you know, I drink too much." Once the client has reached this point, then you can discuss what some ideas for solution might be the right approach to take.
The assumption behind this question, "you must have a good reason to . . . " is a stark departure from the usual attempt at problem solving that begins with finding out the nature of the problem. The message behind this question is: You seem like a reasonable person with good ability to sort things out, therefore, there must be some logical reason behind your behavior and I am curious to find out about these logical reasons that I might not have thought of. Not only this is a good posture of "not-knowing" stance to take, regardless what the problem might be, but having said this, the therapists must be congruent with the words and wait for a good answer.
Indeed, clients seem to rise to this challenge and begin to become more thoughtful and being to consider the questions in thoughtful manner. This is a good antidote to a burn-out and feeling frustrated with clients described as "in denial."
Case Example: Finding a Job:
I consulted with a program that encouraged adolescents to move into independence and self-sufficiency from such programs as foster care, group homes, halfway houses, and residential programs. When they reach the age of majority, usually a round 17 or so, these young people are encouraged to gain economic independence and ability to manage their money successfully. As most teenagers, they must master the skills of job finding and keeping them; usually an entry level jobs.
One staff member was very frustrated by a 17-year old, Travis, who kept promising he was going to apply for jobs and had lots of ideas of where to go to apply for jobs. The staff member was very encouraged at first and really supported Travis, each week expecting that Travis would report how many job applications he had managed to fill out. However, each weekly meeting with Travis included more and more stories of how he almost made it out the door, but never quite made it to the employment office or various fast food joints.
Travis had lots of reasons (excuses) about what got in his way. The social worker was getting pretty frustrated with Travis because it was quite clear that Travis has not even showed up to apply for a job. Travis knew how to read and write, he was always complaining about not having money to buy this or that CD; he loved to wear designer shoes and clothes; he liked to go to movies but always pouted about his lack of money.
I asked the social worker about what he thought Travis might reply when the worker asked him, "You must have some very good reasons for not applying for jobs, Travis. I would like to know what some of your good reasons are." The social worker replied that he had never thought about asking this question and he thought it would be a good idea to ask since he simply had run out of any more ideas on what to do with Travis.
I had forgotten about this exchange until the following meeting when the social worker reported with broad smile on his face. He wanted to update me and the group about Travis. Sure enough, the worker approached Travis during their next meeting and said to him, "Travis, I feel like I've been pretty tough on you about getting a job and it occurred to me that you must have some very good reason for not having looked for a job so far. I would like to hear about your good reasons because I never even bothered to ask you." As soon as these sentences escaped his lips, Travis immediately said, "Not really. I don't have any good reason for not getting a job, just lazy, I guess." The worker was shocked to hear this answer and wisely decided to drop the issue. Sure enough, two weeks later, Travis found a job flipping burgers.
Not allowing supervisees, staff members, client, or even one's own children or partners to lower themselves to a defensive position is the most respectful, empowering, and yet gently holding them accountable posture we can take. This approach works well with other problems that is annoying, repetitive, and non-productive exchanges of blaming and defending.
How do you apply the principles of SFBT to working with children?
I am often asked this question during training, consultation and supervision sessions. It is reasonable to raise doubts whether SFBT and working with children can mix together. SFBT relies heavily on the use of language, appreciates the subtleties of linguistic techniques as the primary tools to create changes. Yet, children do not have the language skills to respond in 'talking" alone because their limited ability to conceptualize and understand the language use.
Yet, we believe that SFBT and children can be in very good harmony because there are many similarities between how children think and make sense of the world around them and the assumptions and procedures of SFBT.
For example, I have never met a child who needs or wants to know what caused the problem she or he may be faced with. They certainly do not operate in a deductive manner or search for explanations of what caused the problem. What most children do is to experiment with variety of approaches and by and large solve problems by trial and error, very much like how SFBT was developed: in an inductive manner by finding out what works and does not work.
Therefore, working with children requires us to adopt the same assumptions and posture of "not-knowing" as working with adults do. A deep respect for the natural way a child functions, and to find solutions that fit with the way a child naturally operates. Playing is very natural to all children. Through playing, children learn to make sense of the world around them, and they certainly do not engage in long discussions about what went wrong or what makes things right. They just do it. Children's playing tells us what they are good at, what competencies they already have, and how they use their curiosity to arrive at a solution-building process. And children communicate through playing. Therefore, working with children requires us to be open to communicating with children through playing. It means intensely observing and listening for what they say they need to make their lives a little bit better.
Unlike traditional play therapy which uses children's playing, drawing pictures, story telling, games, to diagnose, uncover, and encourage regression as a treatment process, SFBT views joining with children's playing as a ways to communicate and to experiment to find out what works for them.
A colleague of mine, Therese Steiner, a child psychiatrist who lives near Zurich, Switzerland, tells the following case example:
A 7-year-old, Wilfred, was brought to see her and of course he was frightened about this new adventure of meeting a doctor. In fact, he was so afraid of the unknown that he started to cry and refused to step into her office. Of course mother's reassurance fell on deaf ears. Recognizing this, Therese picked up a red balloon and blew it up and handed it to Wilfred. Of course he was very surprised at this unexpected gesture and became very interested in the balloon.
Therese told the child that a fully blown balloon is the most afraid anybody can get about coming to visit a new doctor and not knowing what to expect. Then she asked Wilfred to slowly let the air out of the balloon until the size of balloon that showed that he can stay in the room and talk to the doctor, even though he was still afraid. Wilfred took the balloon and let the air out slowly until it became about half full and handed it back to the doctor, saying, "Now, I can talk." He looked around the room and proceeded with looking around the room and looking at all the toys that Therese had in her office. In no time, he almost forgot about his mother and was fully engaged with the therapist.
Of course the role parents play in treatment is significantly different from the traditional approach whereby parents are set aside and the most important relationship is between the therapist and the child. Contrary to this, we consider the parent as the most important relationship in a child's life, therefore, parents become a partner in treatment of the child. Therefore, parents are often invited to sit in the session, if not, then the summary of the session is often summarized for the parent.
Use of stories, picture books, painting, cartoon making, and so on, all generate from the strength perspective of the child, what the child is capable of doing and building on those abilities. Even so, we would say, working with children also requires special ability to network with other professionals, such as teachers, nurses, social workers, and other health care professionals who have profound influence on a child. As we do when working with adults, we also believe that the emphasis of the therapy should be on the real life of a child in his or her social environment, not on the intense relationship between the therapist and a child. Even though working with children takes longer than it does with adults, it still is very brief, compared with traditional therapy.
We think this is the most respectful way to work with the child is to encourage a sense of control over what happens to him or her, and to encourage making choices. An audiotape, titled Children's Solutions Work, is a conversation between Therese Steiner and Insoo Kim Berg about working with children. It is available through BFTC. Also their forthcoming book, under the same title, will be published in December, 2002, by Norton.
How does SFBT work with grief issues?
Many students and beginners express concern about how SFBT addresses the issue of grief. These kind of concerns are understandable for beginner's since SFBT emphasizes the shaping of the client's future instead of looking backward to what traumas clients have suffered. Many seem to think that we either ignore or are indifferent to the issue of grief when a client suffers from serious issues of loss of a loved one. A client's way of communicating to us about the profound sense of loss and grief takes many forms, as the following case illustrates. Learning to cope with grief can take many shapes, all of which are very individual and unique to each person's way of experiencing the pain emerging from the grief.
Perhaps the best way to discuss this grief issue can be through a case example.
Case Example: Unwelcome Visits from a Son
Marilee, in her early 50's, is an African-American woman with a cane in her right hand, with a rigid posture as if walking from the waiting area to the office was the most difficult task she had to undertake. She lowered her body into a chair as if it was a very heavy burden. When I shook her hand to introduce myself, I could feel her calloused hand, indicating her hard working life. She looked older than her age, particularly her rigid posture and no expression on her face, and no eye contact, all combined to make her look older than her age. When I sat across from her, she revealed no expression of any sort, including a curiosity about meeting me for the first time. Marilee agreed to talk to me at the suggestion of her therapist who had seen her about four sessions, each time the client reporting "no change." The therapist requested a consultation with me because he also agreed with Marilee that nothing has changed and her complaints about her dead son's visit remained the same.
I explained to her that I really didn't know much about her situation and asked her to be patient with my questions because mostly likely I would ask questions that she might think I should have know. She softly nodded her agreement.
So I asked her how helpful her coming to these sessions had been and she replied, "nothing is different." "How long have you been coming?" "Since around thanksgiving time and still nothing is different." Then she lowered her head and didn't say anything. So I asked her, "I understand that you son has been visiting you." She explained in a halting, barely audible voice that she wanted to go away but he visited her and she was scared. So, what do you do when he visits you? I turn up the TV, stereo, so that I don't have to listen to his talking. What does he say? I don't know because I am scared. I urged her to drinker her coffee while its still warm but she didn't move, or reply, she only stared into the space.
Every time Marilee talked about her son, her tears flowed and I had to hand her tissues to wipe her tears and blow her nose. She answered in short sentences, in a very soft voice that I could not hear her well. As the session went on, I had to pull my chair closer and closer to her so that by the end of the session, our knees almost touched each other. She did not move away, which I thought was a good sign. When I asked about the pattern of his coming and goings, Marilee answered that her son "comes and goes at all hours, sometimes hangs around the house all day," and "comes to the end of my bed and stands there talking about something" that she could not make out. The flow of her tears increased as we talked more and more about her son, punctuated by her saying that she was scared of his visits and that she wanted him to go away.
So, I told her that I was sure that he had gone to heaven and the reason he wanted to come back to her must be because he was worried about his mother. Obviously he was have a tough time leaving his mother. Marilee responded with lots of tears to this and added, "we close" a couple of times. L asked her whether she lived alone: Marilee replied that her only other child, a daughter in high school, lived with her. I asked whether his son, Dante, visited his sister also and she replied, no, he used to visit his girl friend but Marilee was not in touch her anymore.
When I asked her whether she left Dante's room the way he had it when he lived with her, she replied yes, adding that she never touched his room, and she left his room as he had when he went away and now nobody is using the room. She volunteered that he was killed in California in a car accident and that he was studying engineering in college at the time he was killed. She started to sob again and tears streamed down her face and she kept blowing her nose and wiping her tears as I was telling her he must have been a very bright young man. She volunteered that his bedroom is right across the hall from hers and he talked to her for a long time some days. In the midst of sobs and tears, she further volunteered that she never got to say good-by to him and that she had lots of things she wanted to tell him.
I asked her whether she belonged to a church. She answered that she used to go to a Baptist church but now had no contact with anyone from the church and softly added that she should go back to church. I wondered aloud whether she had been wrong about her son's visits, that "maybe it's not to scare you but that he's worried about you." For the firs time in our interview, she wondered out loud whether there was something someone can do with something like that and looked at me directly. I told her, "Maybe there is something that could be done about his visits." She perked up and asked again whether something could be done to stop his visits; I indicated to her that I was there was something that could be done about this. I told her that I would take a thinking break and talk to my team and would be back in 5 minutes.
When I returned from the consultation break, she was drinking her by now lukewarm coffee and she was more composed. I held her hand in my hand and admired her beautiful nails in this and that way, and asked who did her nails. She replied that her cousin did it for her. I was a bit reassured that she had family who seem to be looking after her. We talked a minute or two about how to keep such beautiful nails. I saw it as a good sign that she allowed me to hold her had in mine for several minutes. The following is the message I gave her on behalf of the team.
Message: "Marilee, I have the impression that maybe you've been misunderstanding your son; It seems that Dante was a very nice and lovely young man. I'm sure he went to heaven but I can also see that he never go to say good-bye to you either, and I'm wondering if you've been misunderstanding his visits because I can imagine, he is very worried about you, too, being how you two were. So there is something you can do to reassure him. Whenever Dante visits you, you go into his bedroom and ask him to follow you to his bedroom. You can only talk to him in his bedroom and when you get there, tell him what you wanted to say to him but didn't get to tell him, like saying good-bye to him, and many other things like how much you miss him (she sobs again) and maybe you need to listen to what he wants to say to you, too. When you finished telling him what you wanted to say, you can tell him that he does not need to come and visit you anymore and that he does not need to worry about you. He may have to visit you many more times yet but each he visits you, I want you to talk to him only in his bedroom and you need to stay there until goes back to heaven." She stopped her sobbing and with drier eyes agreed she would do it.
When I asked her when wanted to return for another session and she replied in a firm voice, "In two weeks."
Discussion: One can easily imagine that most traditional therapists would have diagnosed as having much more serious problems, with visual and auditory hallucinations. Once we begin to think from this perspective, then the expert-driven diagnosis and treatment process would begin, and fairly soon, the client's own ideas about problems and solutions would take a back seat, disregarding her concerns and realities. Once she believes that nobody understands how real his visits are, the more she is likely to stay isolated from those around her, thus aggravating her symptoms further. Suppose she was medicated (as she was indeed, as we learned later), it is not difficult to understand that her will to follow the doctor's prescription for any kind of treatment, including medication, would diminish. Any effort to convince her that her son's visit was her imagination would have no credibility with her.
For SFBT, however, in many ways this session was not very different from sessions in which the presenting complaint maybe something other than loss of a loved one: The content of the complaint changes but the process of how to listen to the client remains the same. We listen very carefully for clues about the client's "frame of reference" and how she or he views the problems and respect what he or he may want the outcome to be. In Marilee's situation, her fear of her son's presence was real and therefore, this is accepted as such and we worked with this thinking.
Follow up sessions. Marilee showed up again in two weeks, right on time, still looking the same, and no visible or reported changes, for three more times. She did not follow my suggestion to only talk to her son in his old bedroom because she was too scared. So, I realized that it was not a good suggestion and decided to focus on changing the meaning of her son's visit. So, we continued the same theme of what her son might want to tell her through these visits - that he also wants to say good-bye to his mother, that he wants her to be happy with her life, that he also misses her. Each time Dante's name was mentioned, Marilee wept profusely, adding bits and pieces of information about what their relationship was like. She added that he was a loving child, her favorite, and she had lots of hope for his future and how much she wished that she could have said good-bye to him. Her conversation has never changed from her two or three words sentence, and there was no adjectives she added, just factual information only.
During the second session, it occurred to me that it might be helpful to talk to her family; so I asked her who drove her to the appointments. My thought was that it was possible that someone dropped her off and came to pick her up at the end of the hour. When I asked her how she got to the office for appointments, she replied, "I drive." I nearly fell over! With her rigid posture, could barely walk with a cane, and she drove a car in traffic! This was beyond my imagination and also added more information about her abilities.
During the second session I asked her a scaling question: "10 stands for how you are able to live with Dante's visits and 1 stands for you cannot stand it, where are you at between 1 and 10 today?" Her answer was 4. At what number would you say, you would be able to live with how things are? 6, she replied. So, our aim was to reach for 6, not 10. Even though we never discussed it, Marilee was quite realistic that Dante's visits may not stop. She just wanted not to be afraid of his visits. She continued with her tears each time her son was mentioned. My primary work was trying to put words into her son's mouth, attributing positive motives for his visit, to say good-by, to reassure her that he missed her also, and to make sure that his mother took care of herself and live a good life. She continued to sob and tears flowed each time I gave voice to son's visits.
Marilee came a total of 4 more sessions and announced that she did not need to come anymore and we ended the contact, saying that she reached 6.
Discussion: Even though Marilee never verbalized her grief and sorrow, her behavior spoke louder than her words. We believe, like any other problems, there is no right way to grieve, but many different ways, and unless one asked more balanced picture of her, it would have been difficult to understand client's competencies. Even though she could have easily been diagnosed as "psychotic," she functioned rather well, considering her physical disabilities. She was raising her teenage daughter whom she reported doing well in school. Clients do not have emote and use many words to "work through" their griefs, there are many ways to accept and adjust to this life changing events in our lives.