CME

Solution-focused therapy
Counseling model for busy family physicians
Gail Greenberg, MSW Keren Ganshorn, BPT, MD, CCFP Alanna Danilkewich, MD, CCFP, FCFP

ABSTRACT
OBJECTIVE To provide family doctors in busy office practices with a model for counseling compatible with
patient-centred medicine, including the techniques, strategies, and questions necessary for implementation.
QUALITY OF EVIDENCE The MEDLINE database was searched from 1984 to 1999 using the terms
psychotherapy in family practice, brief therapy in family practice, solution-focused therapy, and brief
psychotherapy. A total of 170 relevant articles were identified; 75 abstracts were retrieved and a similar
number of articles read. Additional resources included seminal books on solution-focused therapy (SFT),
bibliographies of salient articles, participation in workshops on SFT, and observation of SFT counseling
sessions taped by leaders in the field.
MAIN MESSAGE Solution-focused therapy’s concentration on collaborative identification and amplification
of patient strengths is the foundation upon which solutions to an array of problems are built. Solution-focused
therapy offers simplicity, practicality, and relative ease of application. From the perspective of a new learner,
MECSTAT provides a framework that facilitates development of skills.
CONCLUSION Solution-focused therapy recognizes that, even in the bleakest of circumstances, an emphasis
on individual strength is empowering. In recognizing patients as experts in self-care, family physicians
support and accentuate patient-driven change, and in so doing, are freed from the hopelessness and burnout
that can accompany misplaced feelings of responsibility.

RÉSUMÉ
OBJECTIF Offrir aux médecins de famille dont la pratique en cabinet privé est surchargée un modèle de
counseling compatible à la médecine centrée sur le patient, notamment des techniques, des stratégies et des
questions nécessaires à sa mise en œuvre.
QUALITÉ DES DONNÉES Une recension a été effectuée dans la base de données MEDLINE de 1984 à 1999 à
l’aide des mots clés « psychothérapie en pratique familiale, thérapie brève en pratique familiale, thérapie axée
sur la recherche de solutions et psychothérapie brève ». On a identifié 170 articles pertinents; 75 résumés
ont été cernés et un nombre à peu près égal d’articles ont été lus. Au nombre des sources d’information
additionnelles figuraient des ouvrages fondamentaux sur la thérapie axée sur la recherche de solutions
(TARS), les bibliographies des articles importants, la participation à des ateliers sur la TARS ainsi que
l’observation de séances de ce genre de counseling enregistrées par des experts dans ce domaine.
PRINCIPAL MESSAGE La concentration des thérapies axées sur la recherche de solutions portent sur
l’identification et l’amplification conjointes des forces du patient constitue le fondement sur lequel repose la
détermination de solutions à un éventail de problèmes. La thérapie axée sur la recherche de solutions est
simple, pratique et relativement facile à administrer. Du point de vue d’un néophyte, le MECSTAT offre les
paramètres qui facilitent le perfectionnement des compétences à cet égard.
CONCLUSION La thérapie axée sur la recherche de solutions reconnaît que, même dans les circonstances
les plus noires, l’insistance sur les forces du sujet se révèle habilitante. En reconnaissant les patients
comme des experts pour prendre soin d’eux-mêmes, les médecins de famille soutiennent et accentuent les
changements réalisés par le patient et, ce faisant, se libèrent de l’impuissance et de la fatigue professionnelle
qui accompagnent parfois des sentiments mal placés de responsabilité.

This article has been peer reviewed.

Cet article a fait l’objet d’une évaluation externe.
Can Fam Physician 2001;47:2289-2295.

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ounseling has been the subject of numer- Schilling state that the approach allows the medical

C ous family medicine journal articles, focus-

ing on a variety of issues. 1-9 All articles
share one precept: family physicians are
encounter to be effective, yet efficient, in terms of num-
ber and length of visits.12 It is consistent with a busy
practice where 15 minutes seems like a lot of time to
in the uniquely privileged position of working with have available for a counseling appointment.
patients who present with an array of physical and
mental health concerns and problems. Quality of evidence
As family physicians shift their delivery of patient The MEDLINE database was searched from 1984 to
care from a disease-centred to a patient-centred clini- 1999 using the terms psychotherapy in family practice,
cal method, the search for a compatible counseling brief therapy in family practice, solution-focused ther-
paradigm is timely. Solution-focused therapy (SFT) apy, and brief therapy. A total of 170 titles were identi-
emerged in the United States in the late 1970s and fied. We decided to obtain abstracts when authors
early 1980s under the umbrella of brief therapy. It were physicians or nurses, the article title referred to
was pioneered by family therapists who developed a a physical or mental health problem that presents in
model of counseling that clearly departed from the family medicine, the author was a recognized author-
psychotherapeutic theory and practice of the day.10 ity in SFT, or the title suggested an introductory or
The name of the new approach, SFT, captured its fun- research focus. This left us with approximately 75
damental shift from a focus on problems to a focus on texts (articles, book chapters, and books) published
solutions. Counseling concentrated on solutions and over 10 years that were relevant to family practice.
on causes of problems, and conversations recognized Research on SFT’s effectiveness as a brief coun-
clients as experts in solving their presenting problems. seling model, though minimal, is promising.16-20 It is
This idea, that “individuals have within them, or within important to state at the outset, however, that studies
their social systems, the resources to bring about the comparing short- to long-term therapies indicate neg-
changes they need to make,”11 is what makes SFT so ligible differences in outcome. In fact, de Shazer and
compatible with patient-centred clinical care.11 Kim Berg21 go so far as to suggest that “all therapy
The medical literature has begun to support SFT as models work” because, by and large, individuals ben-
a collaborative counseling model that fits within a busy efit from talking to a counselor.
patient-centred family practice.12-15 Family physician Outcome studies indicate that between 66% and
advocates suggest that SFT’s concentration on patient 80% of SFT clients improved during therapy. This indi-
strengths, abilities, and resources creates a counsel- cation supports 50 years of outcome studies22 compar-
ing atmosphere flavoured with hope and optimism. It ing psychotherapeutic approaches. Process studies
places responsibility for change in the hands of patients evaluating specific SFT techniques suggest effective-
by using empowering language and recognizing them ness, yet once again, the number of studies is small.
as skilled in matters of self-care. In this way it is deeply When scientific research on SFT is rigorous, results
respectful of patients as individuals and takes a more consistently demonstrate it to be effective in assisting
balanced approach to finding solutions. patients to accomplish their treatment goals.
Use of basic counseling skills, such as attending and
listening, genuineness, empathy, positive regard, and Assumptions of therapy
reflection, provide the foundation upon which SFT is The following core assumptions are at the root of SFT
practised. The model is applicable to the variety of men- and provide key ideas that drive the practice and tech-
tal and physical health problems in family medicine, niques of this counseling model.11,23,24
and contraindications are minimal.11-15 Giorlando and • Change is constant, inevitable, and contagious.
Solution-building conversations identify, elaborate,
Ms Greenberg is Medical Education Coordinator, and reinforce change behaviour.
Dr Ganshorn is an Assistant Professor, and • Patients are experts on their lives. Our job is to sup-
Dr Danilkewich is Residency Program Director and port and amplify this expertise.
an Associate Professor in the Department of Family • Presuppositional language emphasizes the presump-
Medicine at the University of Saskatchewan in Saskatoon. tion that change will occur, creating an atmosphere
Ms Greenberg is a non-physician member and of “when,” not “if.”
Drs Ganshorn and Danilkewich are physician mem- • Patients have strengths, resources, and coping skills
bers of the Section of Teachers of Family Medicine in the that drive change while generating optimism and
College of Family Physicians of Canada. hope.

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• Exceptions to the identified problem are often under-

valued. Because exceptions are part of solution Table 2. Miracle question: Variations on a theme
behaviour, solution-building conversations explore
Imagine that, while you are sleeping tonight, a miracle
them in considerable detail. happens. You wake up tomorrow, and you sense that you are
• Extensive information about a problem is rarely nec- on track toward making a decision. What will you be doing
essary to bring about change. differently that will tell you that you are on track?

Imagine 6 months into the future, after you have successfully

Over view of inter view solved the problem that brings you here today. What will be
The literature on SFT is abundant. We suggest the different in your life that will tell you the problem is solved?
acronym, MECSTAT, conceived by and borrowed
Pretend the problem is solved. What are you doing differently?
from Giorlando and Schilling,12 as a good place to
start for beginning practitioners of this model (we If I have a video camera and follow you around when you have
have slightly altered the acronym to reflect our own solved this problem, what will I see that will tell me this?
vision). The approach incorporates the fundamental
What will be the first sign that a piece of the miracle is
and essential components and language of SFT, its happening?
nuts and bolts, and molds them into a model that is
easy to both learn and use (Table 1). Although the • Who will be the first to notice this is happening?
literature on SFT is extensive, MECSTAT is the only • What will others notice about you that will tell them this is
documented model we found that clearly, succinctly, happening?
and sequentially walks counselors through the tech-
niques of SFT. Questions are asked using presuppositional language.
Inherent in any question is the presumption that change
Table 1. Solution-focused therapy using MECSTAT is inevitable and probably already happening. Use of
the word “suppose” implies that the patient knows the
M Miracle questions answer and, if not, encourages imagining an alternative.
E E xception questions
“When you are on track to solving the problem that
brought you in today,” elicits problem-solving skills and
C Coping questions suggests that the problem will be resolved. Additional
examples of presuppositional language include asking
S Scaling questions
“instead of ” questions (“What will you be doing instead of
T Time-out crying?”), “difference” questions that explore exceptions
and reinforce change (“What will your spouse notice
A Accolades
you are doing differently when you are coping better with
T Task the pain?”), and the use of tentative speech suggesting
change (“Could it be that you are already on track to
The model captures the essence of SFT. In any deal with the drinking problem?”).
given encounter with a patient, a physician can
combine the steps depending on time available, the Miracle questions
problem, the patient’s readiness to change, and the After meeting with patients and getting a brief descrip-
physician’s emerging skill level and comfort with tion of presenting problems, posing the miracle ques-
various techniques. Each visit ends with assigning tion signals the onset of solution talk.29 This question
a task that keeps patients focused on solution build- and all related amplification questions help patients iden-
ing. tify a goal, something that will be improved or different
Posing miracle, exception, coping, and scaling ques- to signal that treatment has been successful. Because
tions are central to solution-building conversations SFT is goal oriented, miracle and related questions facili-
(Table 2).25-28 By asking these questions, we remind tate description of a goal that indicates the presence of
patients of many things: change is constant; excep- something different, rather than an absence, something
tions to problems exist; coping indicates strength; that is concrete, in the present, in patients’ language and
goals that are important to and defined by patients control, and indicative of beginnings.
help drive and sustain change; and change, commit- Although there are variations of the miracle ques-
ment to change, and the confidence that change will tion, we suggest that a good place to begin is with
occur is measurable in increments. the following: “I am going to ask you a question that

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is different from those you might have heard before.

It is going to require that you do some pretending. Table 3. Exception questions
Suppose that tonight, after our meeting, you go home,
go to bed, and fall asleep. While you are sleeping, a Are there times now that a little piece of the miracle happens?
Tell me about these times. How do you get that to happen?
miracle happens, and the miracle is that the problem
that brought you here is solved. But, because you What will you do to make that happen again?
are asleep, you do not know that the miracle has hap-
pened. When you wake up tomorrow morning, what What will your husband (for example) say you need to do to
will be the first thing you notice that will tell you the increase the likelihood of that (exception) happening more
often?
miracle has happened?” (Table 2).
This question encourages patients to construct a What is different about the times when the problem does not
vision of the future. All related questions ser ve to happen, or when it is less severe or less frequent?
amplify the description, providing details of what the
“solution picture” will look like. Merely posing the Table 4. Coping questions
miracle question appears to act as a catalyst for people
on the cusp of making changes. As with all the other How did you manage to get yourself up this morning?
components of MECSTAT, asking the miracle ques- How are you preventing things from getting worse?
tion and then subsequent questions can be a stand-
alone intervention (also called a single-step strategy). That sounds nearly overwhelming. How do you manage to cope?
Because it elicits and amplifies patient goals, the mira- I understand how hard this is for you. How did you manage to
cle question is the place to begin. get to the office today?
Usually, we ask a presession change question
before the miracle question; often a small piece of accept patients’ perceptions of their situations, and
the miracle (the goal) happens between the time an then highlight how patients cope with and endure
individual books an appointment and then comes in difficulty 31-33 (Table 4). These kinds of questions
to the office. “Many times, in between the call for an uncover concrete acts taken by people coping with
appointment and the appointment, people notice that adversity and provide a foundation upon which to
already things seem different. What have you noticed build solutions.
about your situation?” This question focuses on differ-
ences and signals to patients an intention to draw on Scaling questions
strengths and resources. Scaling questions are useful for making vague patient
perceptions concrete and definable. They measure
Exception questions problem severity, progress toward a goal, confidence,
These questions are intended to uncover patients’ suc- and commitment to a goal.28 On a 10-point scale, the
cesses and strengths. Exception questions operate number 10 represents the most positive end of the
from the presumption that there are always times scale. Asking a patient to “scale” items transforms
when the identified problem is less intense or absent a description of something important into an acces-
and when pieces of the desired solution picture appear. sible and measurable entity. This then becomes a
Patients often paint a problem picture that is univer- starting point from which future progress can be
sally present, and exception questions short-circuit assessed (Table 5).
this presentation by eliciting exception behaviour,
instances when the desired outcome is happening, Table 5. Scaling questions
“even if only a little bit.” Once patients identify excep-
tions, physicians amplify their role in the solution pic- On a scale of 1 to 10, where 10 is the problem solved and 1 is
the worst it has ever been, where is the problem today?
ture30 (Table 3).
On a scale of 1 to 10, with 10 meaning you have every
Coping questions confidence this problem can be solved and 1 meaning no
confidence at all, where are you today?
Hopelessness is often expressed by patients in the
grip of crises or chronic problems, and it behooves If 10 means you are prepared to do anything to find a solution
physicians to rise above it. Coping questions enable and 0 means that you are prepared to do nothing, how would
you rate yourself today?
both patients and physicians, par ticularly in sit-
uations that seem over whelmingly hopeless, to What will you need to do to go from a (for example) 3 to a 3.5?

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If a patient scales a problem at 1 or 2, you might take the form of cheerleading, they encourage patients
ask, “How will you know when you reach 2.5?” This to think aloud about personal accomplishments. “How
question requires the patient to identify the next step did you decide to do that?” or “How do you explain
and to begin solving the problem. If confidence is that?” reinforces and accentuates exception behaviour.
scaled at 1, asking, “How did you manage to come in In reality, once you get your head around the power
today?” encourages a patient to recognize that action behind the use of accolades, it becomes, for some
is possible even with low confidence. If confidence of us, the easiest and most supportive first step in
is scaled at 3, a question like, “What do you need solution talk. When we focus on small things patients
to do in order for your confidence to move to 3.5?” do to overcome adversity, we quickly begin to notice
will encourage thinking in concrete terms of strate- strengths and accomplishments. These become the
gies needed to sustain and increase confidence. When subject of compliments.
patients have trouble thinking in terms of forward
movement, a question like, “What do you need to do Task
to maintain the progress at 3?” frees up both patients Assessing patients’ change readiness in terms of the
and physicians to recognize that sometimes, treading cycle of change by Prochaska et al34 influences the
water is an accomplishment in and of itself. negotiated task. Webster summarizes it quite nicely:

Time-out Clients who are very unsure about what they want from
Because SFT is a counseling model used by a variety therapy are usually not given assignments. Those who have
of health care professionals, using time-out is prac- a defined complaint are given the task to observe when
tical for some and not for others. Time-out allows exceptions occur. Clients who are willing to change are
both clients and counselors to reflect on conversa- given “doing” tasks, which amplify existing exceptions and
tions they have just concluded. When a session has construct different kinds of interactions in their real life.35
been observed by colleagues behind a one-way mir-
ror, counselors use the time-out for consultation. At The homework task is discussed at the end of the
the onset of each session, counselors inform clients session, after the time-out. As physicians begin to
that a time-out will occur toward the end of their time learn to use this model, we suggest the following
together that day. This time-out prepares clients to as possible generic assignments to negotiate with
receive the accolades and task assignment that follow. patients: think about the times when an exception
Family physicians should limit time-outs to a min- occurs and note differences; obser ve for positive
ute or two, during which time physicians leave the changes; do more of the exceptions and pay attention
examining room to mentally list the accolades to to the consequences; pretend to do a small piece of
deliver moments later. Although time-outs are not the miracle picture; pretend you know what to do to
always feasible, the rationale for using them warrants start solving the problem and try it out; and finally,
reinforcement: the accolades we offer patients are think about what you are doing to prevent the situa-
part of solution talk, and taking a minute or two to tion from worsening.36
identify praise statements is important.
Benefits and caveats
Accolades Shifting from one’s favourite counseling approach to
Using accolades is a simple strategy that packs a pow- one that is new and unfamiliar is not without peril. We
erful punch. Integral to solution-building conversa- have experienced first-hand the dissonance from such
tions, its effect is multiple: it validates any progress an endeavour. The benefits of using this approach,
that patients make; it encourages patients by remind- however, far outweigh the discomfort of a counseling
ing them of personal power over their well-being; it situation when we are barely one step ahead of patients
emphasizes strengths and abilities; it sets up the expec- in our own knowledge and experience.
tation that past success is an excellent indicator of Solution-focused therapy is easily integrated into
future possibilities; it fosters confidence; and it facili- patient-centred clinical care. Its language is both hope-
tates relationship building and maintains rapport.29 ful and optimistic. Appreciating that change occurs
Accolades take many forms, including compliments in small increments means that goal behaviour is
and cheerleading. Simple statements are intended to readily accessible and attainable, thus creating a posi-
reflect back to patients positive observations about tive climate for both patients and physicians. Solution-
something they have said or done. When accolades focused therapy puts ownership of their health back

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into the hands of patients, and in so doing reminds

them of the control, authority, and responsibility they Editor’s key points
have over their lives. This feels good to patients and • Solution-focused therapy is a practical method of
doctors alike. It relieves physicians of the silent bur- counseling for busy family physicians that is both
den of having to come up with the right answers, while efficient and effective.
providing tools to find answers. • Solution-focused therapy is based on assumptions
Ample literature supports using SFT with patients that change is inevitable, that patients are experts
on their own lives, that patients have strengths
in a variety of situations: psychiatric disorders, sexual
and resources, and that they can be supported to
abuse, grief, palliative care, family dysfunction, weight
find their own solutions.
loss, addictions, and physical disability, to name a • Solution-focused therapy is patient-centred and
few.26,28-33 It is important to clarify, however, that SFT expresses optimism that problems can be solved.
is different from long-term, traditional counseling
approaches in its assumption that patients are capa-
ble of moving forward and growing in spite of incom- Points de repère du rédacteur
• La thérapie axée sur la recherche de solutions
plete understanding, insight, or resolution of deep,
représente un mode pratique de counseling pour
underlying problems. Although these problems are
les médecins de famille affairés, qui est à la fois
not denied, patients determine the pace of discovery efficiente et efficace.
and relevance to the current solution. • Cette thérapie se fonde sur l’hypothèse que le
Contraindications are minimal, and can generally changement est inévitable, que les patients sont
be described as any situation where counseling in les experts quant il s’agit de leur propre vie, qu’ils
family physicians’ offices is contraindicated: emergen- ont des forces et des ressources, et qu’ils peuvent
cies, life-threatening situations, threats of suicide, or être appuyés dans la recherche de leurs propres
psychotic episodes. Time restraints of family practice solutions.
often mean that physicians learning to use the model • La thérapie axée sur la recherche de solutions est
take a “single step” approach. We encourage learners centrée sur le patient et est empreinte d’optimisme
quant à la résolution des problèmes.
to select bits and pieces of the acronym MECSTAT,
become familiar with its language and method of ask-
ing questions, and then gradually build on as comfort
with the model grows. Quite often, scaling is a good Conclusion
place for new learners to get their feet wet (for exam- Solution-focused therapy is a brief counseling model
ple, scaling “coping” and “hope” in a patient with that seems uniquely adaptable to patient-centred care.
depression). On the 10-point scale, scaled information The MECSTAT acronym offers a ready-to-use tool
provides a small goal to work on between appoint- that captures the essence of the model and provides
ments (patients could choose to maintain hopefulness a step-by-step guide for new learners. Best of all, phy-
at a particular number as a week’s goal, or perhaps sicians who have used SFT describe its optimism and
pay attention to coping behaviour). hopefulness with patients whose lives sometimes seem
The biggest hurdle in implementing the model bleak. This counseling model offers both patients and
lies in initially tr ying to do too much, given time physicians a new way to discuss the intricacies of life
and knowledge constraints, which can be ver y frus- that is refreshing, effective, and filled with promise
trating. Solution-focused therapy as a conceptual and change.
model is user-friendly, and steps can be taken one
at a time. We like keeping visual reminders in the Competing interests
room with us during practice sessions, reminding None declared
us what to do when clinical encounters begin to
sound like problem talk instead of solution talk. We Correspondence to: Ms Gail Greenberg, Regina General Hospital,
encourage new learners to read SFT material (the 1440—14th Ave, Regina, SK S4P 0W5; fax (306) 766-4041;
reading will help address various dilemmas, such e-mail ggreenberg@shin.sk.ca
as when patients present the solution in terms of
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