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Prevention, solution-focused therapy, and the illusion of mental disorders
Applied & Preventive Psychology 5:37-40 (1996). Cambridge University Press. Printed in the USA.
Copyright © 1996 AAAPP 0962-1849/96 $9.00 + .00
Prevention, solution-focused therapy, and the illusion of mental disorders JEFFERSON M. FISH St. John's University
Abstract
Therapy theorists' criticism of the lack of specific mechanisms in the prevention of mental disorders is examined from the perspective of solution-focused therapy (SFI'), which argues that solutions can be unrelated to problems, and that it is not even necessary to know what a problem is in order to solve it. It is suggested that the shift of attention from problems to solutions in SFI" offers a conceptual framework within which the criticism is not relevant, and from which theorists of therapy and prevention can share a common outlook. This outlook involves a focus on encouraging productive, useful, positive behavior, with a corresponding deemphasis on and skepticism about current conceptualizations of mental disorders. Key words: Prevention of mental illness, Brief therapy, Solution-focused therapy, Response expectancy, Positive expectancy
An intellectual tension exists between theorists concerned with prevention and those concerned with service delivery. In part, there is a conflict of values (or in the relative arrangements of hierarchies of values) between the two groups. Prevention theorists are concerned with significantly reducing the overall level of suffering within a population, and theorists of therapy are concerned with alleviating the here-and-now suffering of particular individuals. These differences are evident in attitudes of the two groups toward both physical disease and abnormal behavior. In the case of abnormal behavior, however, there is another more subtle disparity between theorists of prevention and therapy. Interventions aimed at preventing physical illness are specific to the illness. For example, water purification eliminates specific water-borne bacteria that cause specific diseases. In contrast, public health measures, education, or parent training are seen as preventing psychological disturbance in a more general way. There is no program aimed at preventing schizophrenia in the targeted manner that water treatment prevents children from dying of diarrhea-related dehydration. This lack of specificity tends to make therapy theorists skeptical of prevention programs. "They sound well-intentioned, like advocating motherhood and apple pie, but come up short on mechanisms of change," is a typical comment. Therapy theorists, in contrast, are used to looking
for the specific effects of particular interventions on the behavior of clients. An example of the general way in which prevention measures affect psychological well-being can be seen in George Albee's description (1990) of a discussion he had with his fellow members of the Commission on the Prevention of Mental/Emotional Disabilities (1986). They attempted to decide which single prevention program they would put into place if they knew it would succeed. After several hours of discussion, The Commission agreed on an answer: We would opt for a program that would ensure that every baby born anywhere in the world would be a healthy, full-term infant weighing at least eight pounds and welcomed into the world by economically secure parents who wanted the child and had planned jointly for her or his conception and birth. (I would add the hope that the baby wourd be breast-fed by an adequately nourished mother who was not on drugs. I would also ask for good health care for expectant mother and child.) Such an arrival into the world would go a long way toward assuring later healthy relationships, reduced mother and child mortality, reduced retardation, and reduced later mental disorders. (Albee, 1990, p. 70) Rather than describing what forms of mental illness would be prevented by this program, and through what causal mechanisms the prevention would take place, the quotation places an emphasis on "later healthy relationships" and "reduced later mental disorders." This general
The author would like to thank Wandajune Bishop, Robert Ghiradella, and Irving Kirsch for their helpful comments. Address correspondenceand reprint requests to: Jefferson M. Fish, Department of Psychology,St. John's University, 8000 Utopia Parkway, Jamaica, NY 11439. 37
38
Fish
description of positive effects on the so-called functional disorders can be seen to contrast with suggestions of "reduced mother and child mortality" and "reduced retardation," which refer to the specific biological effects on mother and child of adequate prenatal care and nutrition. The criticism by theorists from a variety of therapeutic orientations, regarding the lack of prevention specificity, is based on a shared underlying assumption. That is, the helping process is assumed to require the therapist to define the problem (or make a diagnosis), figure out what caused it, and intervene to change it. If this view of the helping process should be mistaken, and its assumptions unjustified, then the specificity objection based on those assumptions would prove irrelevant. That is, if mental illnesses are not specific in the same way as physical illnesses, and if psychological interventions are not specific in the same way as medical interventions, then there is no reason to expect that psychological prevention would work with the specificity of public health prevention. There is a history of opposition to the view that abnormal behavior is organized into syndromes or disorders that are culturally invariant across time and space in the same manner as physical diseases. Beginning with "The Myth of Mental Illness" (Szasz, 1961), the behavior therapy movement (e.g., Ullmann & Krasner, 1969), and cross-cultural critiques (e.g., Sanua, 1980), opponents have argued not that abnormal behavior does not exist, but that the categories are arbitrary and not reflective of patterns of organization (e.g., diseases) found in nature. Thus, a nonbeliever in mental disorders is capable of observing a person giggling and speaking incoherently, accepting this behavior at face value, and dealing with it as such--rather than sacrificing its distinctive quality by labeling it and responding to it as an exemplar of the label. (After all, critics might ask, where have all the hebephrenics gone--or, for that matter, the neurasthenics? And how did homosexuality become normal? Many would argue that, as the culture changes, the kinds of abnormal behavior it produces, and even what it considers to be abnormal, change as well.) Over the same period of time, beginning with "Persuasion and Healing" (Frank, 1961), clinicians began emphasizing the central role of positive expectancies in overcoming psychological difficulties. Fish (1973) showed how therapy could be designed to maximize expectancy/placebo effects. Bandura (1977) stressed the importance of selfefficacy to behavior change, and Pentony (1981) discussed the expectancy model as one of three main models of influence in therapy. Kirsch (1990) developed the concept of response expectancy to emphasize the way in which expecting one's own involuntary behavior to change makes it more likely to do so, and presented a program of research supporting direct applications of response expectancy theory to therapy. A number of brief problem-focused therapies developed contemporaneously with skepticism about the existence of
mental disorders and interest in the role of positive expectancies in overcoming psychological problems. Although these treatments came from a variety of theoretical approaches, they had in common an interest in understanding the problem behavior in its current context and intervening to change it in the direction of explicit goals. These treatments include behavior therapy (Wolpe, 1958; Lazarus, 1971), multimodal behavior therapy (Lazarus, 1973), cognitive therapy (Ellis, 1962; Beck, 1963, 1964), and a variety of brief systemic therapies (Haley, 1963; Madanes, 1981; Minuchin, 1974; Palazzoli, Boscolo, Cecchin, & Prata, 1978; Watzlawick, Weakland, & Fisch, 1974). All of these approaches made use of positive expectancies, but did so largely to enhance the effects of problem-resolving interventions. To the extent that these approaches attend to client expectancies, past causes become less important, because positive expectancies deal with the future of behavior. In addition, given the probabilistic determinism of behavioral and systemic approaches (Fish, 1992, 1994), problems--or "symptoms"--tend to be viewed as acquired in a haphazard way, perhaps through accidental learning, especially at stressful times such as transitions in the family life cycle. That is, given external stress or systemic reorganization, the development of adequate or problematic behavior--and, if the latter, which problem--is seen as open to many influences and as largely unpredictable. The desultory acquisition of problem behavior contrasts with psychodynamic overdetermination, and raises doubts about both the possibility of knowing causes and the usefulness of such knowledge to the change process. Recently, solution-focused therapy has become a prominent force among brief therapy approaches (de Shazer, 1988, 1991, 1994; de Shazer et al., 1986; Walter & Peller, 1992). With intellectual roots in the systems movement and the philosophy of language, its emphases on parsimony and clear behavioral description make Solution-focused therapy compatible with the Zeitgeist of behavioral, cognitive, and brief systemic approaches. It differs from these other approaches in two surprising assertions, both of which can be seen as rigorous applications of Occam's Razor. These are that a solution can be unrelated to a problem, and that it isn't necessary to know what a problem is in order to solve it. Instead, solution-focused therapy emphasizes the clear
definition of goals, increasing anything the client is doing to move toward them, and increasing anything else useful the client is doing. A distinctive difference between solution-focused therapy and other brief approaches is its emphasis on "exceptions," or what is going on when the problem is not occurring. The discussion of exceptions, movement toward the goal, and other positive behavior (even if unrelated to the problem) constitutes "solution talk." This is in contrast to the "problem talk" of other approaches, which" emphasizes understanding the problem and other negative aspects of the
Prevention and Solution-Focused Therapy
client's behavior. It can easily be seen that solution talk promotes positive expectancies regarding the client's behavior, while problem talk--however well intended-encourages negative expectancies. In this way, solution-focused therapy can be seen as promoting a radical figure-ground reversal for both therapists and clients. In other approaches, the problem (or symptom or DSM diagnosis) is the focus of attention, and little concern is shown for occasions when the problem does not occur or when the client does something positive but irrelevant to it. For example, if the client wants to stop being depressed, the therapist shows interest in understanding the depression--situations that bring the person down, his or her actions, thoughts, and feelings, the reactions of others, and so forth. Situations in which the client works or pursues a hobby or converses with friends--and is interested or amused or is less depressed or less upset by the negative m o o d - - f o r m part of the background. They are not what the client is seeking help for. Both therapist and client work on the client's not being depressed--like trying not to think of the word "hippopotamus." In contrast, in solution-focused therapy, the exceptions form the figure. The therapist wants to know how is it that the client is not depressed when involved with a hobby. What is the person doing differently that works for him or her? Could the client do more of i t - or if it is not clear what "it" is, how could the client find out? In this way, the depression--like the word "hippopotamus"--recedes into the background, and the exceptions become the figure. In other words, as the focus of therapy shifts from the problem to solutions, the problem recedes into the background and itself becomes an exception to the solutions, which now constitute the figure. As with any new idea, it is not difficult to find precursors of solution-focused therapy. Therapists from many orientations have recognized the utility of "building on strengths," and behavior therapists have known about the effects of the differential reinforcement of other (DRO) behavior (e.g., Conrin, Pennypacker, Johnston, & Rast, 1982; Goetz, Holmberg, & LeBlanc, 1975). Labeling theorists have understood that the same behavior may be regarded as normal or abnormal, moral or immoral, changeworthy or not, and that individuals may or may not seek help from friends, relatives, therapists, religious advisers, or others, depending on cultural circumstances. Furthermore, the consequences of labeling something as a Problem--including stigma, the possibility of changing it, the possibility of perpetuating it, and the possibility of making it worse--have also been recognized. Despite these antecedents (and the need for more process and outcome research), the figure-ground shift of solutions and problems offered by solution-focused therapy seems to many to be an important new insight. If people pick up problems haphazardly, and "syndromes" are illusions, then doing positive things--even when unrelated to target problems--will help to overcome them. It will also help to prevent them. Just as problems recede into the back-
39
ground when people are involved in more interesting and productive activities, they do not emerge from the background when the focus is on recognizing and making the most of whatever is going well. This emphasis on the positive is already familiar to theorists of prevention who deal with abnormal behavior on a larger scale. Consider two demographically similar cities with differing crime rates, or two comparable school districts with differing rates of achievement among children from single-parent families. One could look at the worse of each pair and try to figure out what caused the greater crime or lesser achievement, in an attempt to do something about the problem. A more reasonable strategy would be to look at the better of each pair to see what they are already doing right that the other might profit from. That is, the similarity within each pair suggests the utility of transferring solutions that are already functional from one group to the other. Of course, cities are not always demographically similar, school districts may not be comparable, and the increasing cultural diversity of the United States raises questions about prevention strategies in distinctive populations with unique characteristics. Solution-focused therapy helps clients to become aware of and build upon strengths and exceptions that are already working for them. For this reason, an extension of its conceptual framework to prevention would not imply the imposition of one group's solutions on another (e.g., providing "disadvantaged" minorities with resources that prevent problems among the "advantaged" majority). Rather, it would imply working with the less functional populatiofi to highlight and increase strengths that already exist and times when problems are not occurring (or are occurring less frequently, or less intensely, or are dealt with more effectively). It is no coincidence that solution-focused therapy has gained prominence, along with other brief therapies, at a time of reduced mental health expenditures by individuals, employers, and insurance companies. Although cost cutters can stimulate the spread of more efficient forms of therapy, they can also use the excuse of efficiency as a pretext for saving money regardless of the actual effectiveness of the therapy offered. The history of deinstitutionalization provides a sobering example of cost-saving half measures leading to the transformation of warehoused behavioral deviants into homeless behavioral deviants. What if solution focused prevention paradigms--strengthening positive behavior already occurring among individuals, families, and communities--are put into practice? Perhaps they will prove more cost effective, practical, and culturally sensitive than those based on the introduction of prefabricated solutions from the outside. Perhaps they will simply be used as a pretext for providing less to communities at a time of government downsizing. In any event, it can be seen that extending solution focused thinking to the practice of preventiOn raises a number of social, political,
40
Fish
and economic considerations in addition to the theoretical issue to which this article is primarily addressed. In summary, the outlook of solution-focused therapy is one that seeks to attend to, understand, and increase enjoyable, productive, satisfying, useful, positive b e h a v i o r - abnormal behavior is the exception in the background. Unfortunately, theories of normal behavior have developed as extensions of theories of abnormal behavior; therapy has been the treating of disorders instead of the encouragement of preexisting strengths; and prevention has been
understood--at least by many therapists--as prevention of negative behavior rather than fostering the positive. The emphasis on fostering the positive in solutionfocused therapy offers a common conceptual framework from which theorists of therapy and of prevention can view behavior. In addition to overcoming therapy theorists' criticism of the lack of specificity of prevention, this perspective suggests that both groups might do well to rethink the usefulness of current conceptualizations of mental disorders.
REFERENCES
Albee, G. W. (1990). Suffer the little children. Journal of Primary Prevention, 11(1), 69-82. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191-215. Beck, A. T. (1963). Thinking and depression. I. Idiosyncratic content and cognitive distortions. Archives of General Psychiatry, 9, 324-333. Beck, A. T. (1964). Thinking and depression. II. Theory and therapy. Archives of General Psychiatry, 10, 561-571. Commission on the Prevention of Mental/Emotional Disabilities (1986). Report of the Commission. Alexandria, VA: National Mental Health Association. Connn, J., Pennypacker, H. S., Johnston, J., & Rast, J. (1982). Differential reinforcement of other behaviors to treat chronic rumination of mental retardates. Journal of Behavior Therapy and Experimental Psychiatry, 13, 325-329. de Shazer, S. (1988). Clues: Investigating solutions in brief therapy. New York: Norton. de Shazer, S. (1991). Putting difference to work. New York: Norton. de Shazer, S. (1994). Words were originally magic. New York: Norton. de Shazer, S., Berg, I. K., Lipchik, E., Nunnally, E., Molnar, A., Gingerich, W., & Weiner-Davis, M. (1986). Brief therapy: Focused solution development. Family Process, 25, 207-221. Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stewart. Fish, J. M. (1973). Placebo therapy: A practical guide to social influence in psychotherapy. San Francisco: Jossey-Bass. Fish, J. M. (1992). Discontinuous change. Behavior and Social Issues, 2, 59-70. Fish, J. M. (1994). Does Problem Behavior Just Happen? Does it Matter? Manuscript submitted for publication. Frank, J. D. (1961). Persuasion and healing: A comparative study of psychotherapy. Baltimore: Johns Hopkins. Goetz, E. M., Holmberg, M. C., & LeBlanc, J. M. (1975). Differ-
ential reinforcement of other behavior and noncontingent reinforcement as control procedures during the modification of a preschooler's compliance. Journal of Applied Behavior Analysis, 8, 77-82. Haley, J. (1963). Strategies of psychotherapy. New York: Grune & Stratton. Kirsch, I. (1990). Changing expectations: A key to effective psychotherapy. Pacific Grove, CA: Brooks/Cole. Lazarus, A. A. (1971). Behavior therapy and beyond. New York: McGraw-Hill. Lazarus, A. A. (1973). Multimodal behavior therapy: Treating the "BASIC ID". Journal of Nervous and Mental Disease, 156, 404-411. Madanes, C. (1981). Strategic family therapy. San Francisco: Jossey-Bass. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Palazzoli, M. S., Boscolo, L., Cecchin, G. & Prata, G. (1978). Paradox and counter-paradox. New York: Jason Aronson. Pentony, P. (1981). Models of influence in psychotherapy. New York: Macmillan. Sanua, V. (1980). Familial and sociocultural antecedents of psychopathology. In H. Triandis & J. Draguns (Eds.), Handbook of cross-cultural psychology (pp. 175-236). Boston: Allyn & Bacon. Szasz, T. S. (1961). The myth of mental illness: Foundations of a theory of personal conduct. New York: Hoeber-Harper. Ullmann, L. P. & Krasner, L. (1969). A psychological approach to abnormal behavior, Englewood Cliffs, NJ: Prentice-Hall. Walter, J. L., & Peller, J. E. (1992). Becoming solution-focused in brief therapy. New York: Brunner/Mazel. Watzlawick, P., Weakland, J. H., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. New York: Norton. Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press.
Copyright © 1996 AAAPP 0962-1849/96 $9.00 + .00
Prevention, solution-focused therapy, and the illusion of mental disorders JEFFERSON M. FISH St. John's University
Abstract
Therapy theorists' criticism of the lack of specific mechanisms in the prevention of mental disorders is examined from the perspective of solution-focused therapy (SFI'), which argues that solutions can be unrelated to problems, and that it is not even necessary to know what a problem is in order to solve it. It is suggested that the shift of attention from problems to solutions in SFI" offers a conceptual framework within which the criticism is not relevant, and from which theorists of therapy and prevention can share a common outlook. This outlook involves a focus on encouraging productive, useful, positive behavior, with a corresponding deemphasis on and skepticism about current conceptualizations of mental disorders. Key words: Prevention of mental illness, Brief therapy, Solution-focused therapy, Response expectancy, Positive expectancy
An intellectual tension exists between theorists concerned with prevention and those concerned with service delivery. In part, there is a conflict of values (or in the relative arrangements of hierarchies of values) between the two groups. Prevention theorists are concerned with significantly reducing the overall level of suffering within a population, and theorists of therapy are concerned with alleviating the here-and-now suffering of particular individuals. These differences are evident in attitudes of the two groups toward both physical disease and abnormal behavior. In the case of abnormal behavior, however, there is another more subtle disparity between theorists of prevention and therapy. Interventions aimed at preventing physical illness are specific to the illness. For example, water purification eliminates specific water-borne bacteria that cause specific diseases. In contrast, public health measures, education, or parent training are seen as preventing psychological disturbance in a more general way. There is no program aimed at preventing schizophrenia in the targeted manner that water treatment prevents children from dying of diarrhea-related dehydration. This lack of specificity tends to make therapy theorists skeptical of prevention programs. "They sound well-intentioned, like advocating motherhood and apple pie, but come up short on mechanisms of change," is a typical comment. Therapy theorists, in contrast, are used to looking
for the specific effects of particular interventions on the behavior of clients. An example of the general way in which prevention measures affect psychological well-being can be seen in George Albee's description (1990) of a discussion he had with his fellow members of the Commission on the Prevention of Mental/Emotional Disabilities (1986). They attempted to decide which single prevention program they would put into place if they knew it would succeed. After several hours of discussion, The Commission agreed on an answer: We would opt for a program that would ensure that every baby born anywhere in the world would be a healthy, full-term infant weighing at least eight pounds and welcomed into the world by economically secure parents who wanted the child and had planned jointly for her or his conception and birth. (I would add the hope that the baby wourd be breast-fed by an adequately nourished mother who was not on drugs. I would also ask for good health care for expectant mother and child.) Such an arrival into the world would go a long way toward assuring later healthy relationships, reduced mother and child mortality, reduced retardation, and reduced later mental disorders. (Albee, 1990, p. 70) Rather than describing what forms of mental illness would be prevented by this program, and through what causal mechanisms the prevention would take place, the quotation places an emphasis on "later healthy relationships" and "reduced later mental disorders." This general
The author would like to thank Wandajune Bishop, Robert Ghiradella, and Irving Kirsch for their helpful comments. Address correspondenceand reprint requests to: Jefferson M. Fish, Department of Psychology,St. John's University, 8000 Utopia Parkway, Jamaica, NY 11439. 37
38
Fish
description of positive effects on the so-called functional disorders can be seen to contrast with suggestions of "reduced mother and child mortality" and "reduced retardation," which refer to the specific biological effects on mother and child of adequate prenatal care and nutrition. The criticism by theorists from a variety of therapeutic orientations, regarding the lack of prevention specificity, is based on a shared underlying assumption. That is, the helping process is assumed to require the therapist to define the problem (or make a diagnosis), figure out what caused it, and intervene to change it. If this view of the helping process should be mistaken, and its assumptions unjustified, then the specificity objection based on those assumptions would prove irrelevant. That is, if mental illnesses are not specific in the same way as physical illnesses, and if psychological interventions are not specific in the same way as medical interventions, then there is no reason to expect that psychological prevention would work with the specificity of public health prevention. There is a history of opposition to the view that abnormal behavior is organized into syndromes or disorders that are culturally invariant across time and space in the same manner as physical diseases. Beginning with "The Myth of Mental Illness" (Szasz, 1961), the behavior therapy movement (e.g., Ullmann & Krasner, 1969), and cross-cultural critiques (e.g., Sanua, 1980), opponents have argued not that abnormal behavior does not exist, but that the categories are arbitrary and not reflective of patterns of organization (e.g., diseases) found in nature. Thus, a nonbeliever in mental disorders is capable of observing a person giggling and speaking incoherently, accepting this behavior at face value, and dealing with it as such--rather than sacrificing its distinctive quality by labeling it and responding to it as an exemplar of the label. (After all, critics might ask, where have all the hebephrenics gone--or, for that matter, the neurasthenics? And how did homosexuality become normal? Many would argue that, as the culture changes, the kinds of abnormal behavior it produces, and even what it considers to be abnormal, change as well.) Over the same period of time, beginning with "Persuasion and Healing" (Frank, 1961), clinicians began emphasizing the central role of positive expectancies in overcoming psychological difficulties. Fish (1973) showed how therapy could be designed to maximize expectancy/placebo effects. Bandura (1977) stressed the importance of selfefficacy to behavior change, and Pentony (1981) discussed the expectancy model as one of three main models of influence in therapy. Kirsch (1990) developed the concept of response expectancy to emphasize the way in which expecting one's own involuntary behavior to change makes it more likely to do so, and presented a program of research supporting direct applications of response expectancy theory to therapy. A number of brief problem-focused therapies developed contemporaneously with skepticism about the existence of
mental disorders and interest in the role of positive expectancies in overcoming psychological problems. Although these treatments came from a variety of theoretical approaches, they had in common an interest in understanding the problem behavior in its current context and intervening to change it in the direction of explicit goals. These treatments include behavior therapy (Wolpe, 1958; Lazarus, 1971), multimodal behavior therapy (Lazarus, 1973), cognitive therapy (Ellis, 1962; Beck, 1963, 1964), and a variety of brief systemic therapies (Haley, 1963; Madanes, 1981; Minuchin, 1974; Palazzoli, Boscolo, Cecchin, & Prata, 1978; Watzlawick, Weakland, & Fisch, 1974). All of these approaches made use of positive expectancies, but did so largely to enhance the effects of problem-resolving interventions. To the extent that these approaches attend to client expectancies, past causes become less important, because positive expectancies deal with the future of behavior. In addition, given the probabilistic determinism of behavioral and systemic approaches (Fish, 1992, 1994), problems--or "symptoms"--tend to be viewed as acquired in a haphazard way, perhaps through accidental learning, especially at stressful times such as transitions in the family life cycle. That is, given external stress or systemic reorganization, the development of adequate or problematic behavior--and, if the latter, which problem--is seen as open to many influences and as largely unpredictable. The desultory acquisition of problem behavior contrasts with psychodynamic overdetermination, and raises doubts about both the possibility of knowing causes and the usefulness of such knowledge to the change process. Recently, solution-focused therapy has become a prominent force among brief therapy approaches (de Shazer, 1988, 1991, 1994; de Shazer et al., 1986; Walter & Peller, 1992). With intellectual roots in the systems movement and the philosophy of language, its emphases on parsimony and clear behavioral description make Solution-focused therapy compatible with the Zeitgeist of behavioral, cognitive, and brief systemic approaches. It differs from these other approaches in two surprising assertions, both of which can be seen as rigorous applications of Occam's Razor. These are that a solution can be unrelated to a problem, and that it isn't necessary to know what a problem is in order to solve it. Instead, solution-focused therapy emphasizes the clear
definition of goals, increasing anything the client is doing to move toward them, and increasing anything else useful the client is doing. A distinctive difference between solution-focused therapy and other brief approaches is its emphasis on "exceptions," or what is going on when the problem is not occurring. The discussion of exceptions, movement toward the goal, and other positive behavior (even if unrelated to the problem) constitutes "solution talk." This is in contrast to the "problem talk" of other approaches, which" emphasizes understanding the problem and other negative aspects of the
Prevention and Solution-Focused Therapy
client's behavior. It can easily be seen that solution talk promotes positive expectancies regarding the client's behavior, while problem talk--however well intended-encourages negative expectancies. In this way, solution-focused therapy can be seen as promoting a radical figure-ground reversal for both therapists and clients. In other approaches, the problem (or symptom or DSM diagnosis) is the focus of attention, and little concern is shown for occasions when the problem does not occur or when the client does something positive but irrelevant to it. For example, if the client wants to stop being depressed, the therapist shows interest in understanding the depression--situations that bring the person down, his or her actions, thoughts, and feelings, the reactions of others, and so forth. Situations in which the client works or pursues a hobby or converses with friends--and is interested or amused or is less depressed or less upset by the negative m o o d - - f o r m part of the background. They are not what the client is seeking help for. Both therapist and client work on the client's not being depressed--like trying not to think of the word "hippopotamus." In contrast, in solution-focused therapy, the exceptions form the figure. The therapist wants to know how is it that the client is not depressed when involved with a hobby. What is the person doing differently that works for him or her? Could the client do more of i t - or if it is not clear what "it" is, how could the client find out? In this way, the depression--like the word "hippopotamus"--recedes into the background, and the exceptions become the figure. In other words, as the focus of therapy shifts from the problem to solutions, the problem recedes into the background and itself becomes an exception to the solutions, which now constitute the figure. As with any new idea, it is not difficult to find precursors of solution-focused therapy. Therapists from many orientations have recognized the utility of "building on strengths," and behavior therapists have known about the effects of the differential reinforcement of other (DRO) behavior (e.g., Conrin, Pennypacker, Johnston, & Rast, 1982; Goetz, Holmberg, & LeBlanc, 1975). Labeling theorists have understood that the same behavior may be regarded as normal or abnormal, moral or immoral, changeworthy or not, and that individuals may or may not seek help from friends, relatives, therapists, religious advisers, or others, depending on cultural circumstances. Furthermore, the consequences of labeling something as a Problem--including stigma, the possibility of changing it, the possibility of perpetuating it, and the possibility of making it worse--have also been recognized. Despite these antecedents (and the need for more process and outcome research), the figure-ground shift of solutions and problems offered by solution-focused therapy seems to many to be an important new insight. If people pick up problems haphazardly, and "syndromes" are illusions, then doing positive things--even when unrelated to target problems--will help to overcome them. It will also help to prevent them. Just as problems recede into the back-
39
ground when people are involved in more interesting and productive activities, they do not emerge from the background when the focus is on recognizing and making the most of whatever is going well. This emphasis on the positive is already familiar to theorists of prevention who deal with abnormal behavior on a larger scale. Consider two demographically similar cities with differing crime rates, or two comparable school districts with differing rates of achievement among children from single-parent families. One could look at the worse of each pair and try to figure out what caused the greater crime or lesser achievement, in an attempt to do something about the problem. A more reasonable strategy would be to look at the better of each pair to see what they are already doing right that the other might profit from. That is, the similarity within each pair suggests the utility of transferring solutions that are already functional from one group to the other. Of course, cities are not always demographically similar, school districts may not be comparable, and the increasing cultural diversity of the United States raises questions about prevention strategies in distinctive populations with unique characteristics. Solution-focused therapy helps clients to become aware of and build upon strengths and exceptions that are already working for them. For this reason, an extension of its conceptual framework to prevention would not imply the imposition of one group's solutions on another (e.g., providing "disadvantaged" minorities with resources that prevent problems among the "advantaged" majority). Rather, it would imply working with the less functional populatiofi to highlight and increase strengths that already exist and times when problems are not occurring (or are occurring less frequently, or less intensely, or are dealt with more effectively). It is no coincidence that solution-focused therapy has gained prominence, along with other brief therapies, at a time of reduced mental health expenditures by individuals, employers, and insurance companies. Although cost cutters can stimulate the spread of more efficient forms of therapy, they can also use the excuse of efficiency as a pretext for saving money regardless of the actual effectiveness of the therapy offered. The history of deinstitutionalization provides a sobering example of cost-saving half measures leading to the transformation of warehoused behavioral deviants into homeless behavioral deviants. What if solution focused prevention paradigms--strengthening positive behavior already occurring among individuals, families, and communities--are put into practice? Perhaps they will prove more cost effective, practical, and culturally sensitive than those based on the introduction of prefabricated solutions from the outside. Perhaps they will simply be used as a pretext for providing less to communities at a time of government downsizing. In any event, it can be seen that extending solution focused thinking to the practice of preventiOn raises a number of social, political,
40
Fish
and economic considerations in addition to the theoretical issue to which this article is primarily addressed. In summary, the outlook of solution-focused therapy is one that seeks to attend to, understand, and increase enjoyable, productive, satisfying, useful, positive b e h a v i o r - abnormal behavior is the exception in the background. Unfortunately, theories of normal behavior have developed as extensions of theories of abnormal behavior; therapy has been the treating of disorders instead of the encouragement of preexisting strengths; and prevention has been
understood--at least by many therapists--as prevention of negative behavior rather than fostering the positive. The emphasis on fostering the positive in solutionfocused therapy offers a common conceptual framework from which theorists of therapy and of prevention can view behavior. In addition to overcoming therapy theorists' criticism of the lack of specificity of prevention, this perspective suggests that both groups might do well to rethink the usefulness of current conceptualizations of mental disorders.
REFERENCES
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