By Coert Visser (2010)
Wallace Gingerich is Professor Emeritus of Social Work at the Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, Ohio. As a core member of the Brief Family Therapy Center in Milwaukee (BFTC), Wisconsin, in the 1980s, he has been an important contributor to the development of the solution-focused approach. In this interview, he looks back on how and why he joined BFCT and on how the solution-focused approach emerged in the next few years after he joined. Also, he talks about the BRIEFER project and about a soon to be published review of the research on the effectiveness of the solution-focused approach. Finally, he reflects on the ways the solution-focused approach may further develop.
Could you tell a bit about when and how you got involved with the Brief Family Therapy Center?
It was 1982. I had made tenure and I began thinking about what I wanted to do now that I had more independence and flexibility. Although I had been teaching social work practice courses at the University of Wisconsin-Milwaukee, I hadn’t been active in clinical work for more than 10 years, since leaving my job in California in to return to school for my PhD. I decided I wanted to get back into clinical work. I had always enjoyed it, and I felt I needed to be in practice myself to teach well and to have credibility with my students.
So I began to check out some options. I had heard through Elam Nunnally, a colleague of mine at the university, about an unconventional, forward-thinking, even radical, small group of therapists that had recently started a clinic – the Brief Family Therapy Center. They called what they were doing brief therapy. They were using a team approach with one-way mirrors, did lots of video-taping, and were beginning to publish some of their ideas in the journals. Of more interest to me was their 9-month training program which consisted of an afternoon seminar one day a week along with an evening of supervised clinical work. My skills were rusty, I lacked confidence, and I thought this would be a good way to get back into practice.
I made an appointment to go out and talk with Steve and Insoo – I remember the meeting quite vividly even today, nearly 30 years later! I was looking for a place to develop my clinical skills and the trainee program was perfect for that. I wasn’t crazy about whatever approach it was they were teaching – I just wanted the guided practice experience. Steve and Insoo were a little apprehensive. Why would a “researcher” from the university want to come out and be a trainee, after all? What does he have up his sleeve? I think they were afraid that I might be there to find out what they were doing and cause trouble. It soon became clear that they were interested in me if I would help them with their research. I, on the other hand, was interested in the clinical work. So we struck a bargain that afternoon – I would help out with research if they would teach me how to do clinical work. I didn’t know exactly what I would be learning, and neither they nor I really knew what research projects we would cook up over the years, but the adventure had begun!
From what I have heard and read, my understanding is that the BFTC team developed the core of the solution-focused approach roughly between 1979, when BFTC was founded, and somewhere around 1986. At what stage would you say that development was when you joined? Could you tell a bit about your memories of that time?
My first encounter with the BFTC group was in the fall of 1982 when I became a trainee in their 9-month program. The training consisted of weekly Tuesday afternoon seminars led by the BFTC team, principally Steve de Shazer, Insoo Kim Berg, Eve Lipchik, Marilyn Lacourt, and Alex Molnar. The content of the training had to do primarily with the BFTC version of brief, strategic therapy. There was a lot of emphasis on getting details about the pattern of the problem, what maintains the problem, and how could it be interrupted. The message from the team always almost included a homework task meant to help the client interrupt the pattern of the problem. I don’t recall using the miracle question or scaling question, or searching for exceptions during that year.
Although the approach in 1982-83 was problem focused, I suspect Steve and others were beginning to think about other ways of working with clients. The team was always open to new ideas, even if they were unconventional and even radical. There was not the feeling that the model had been developed – it was developing and new ideas were highly valued.
When I completed the training program in the spring of 1983, Steve invited Michele Weiner-Davis and me to form a “research team” with him that would meet weekly. We eagerly accepted. Initially we didn’t have a very organized or directed approach, so we looked at videos of cases, sometimes did sessions ourselves, or sat in on other team members’ sessions. We were clear that we wanted our work to be grounded in clinical practice, as opposed to being theory driven or building on existing clinical research of the time. We believed the BFTC approach was effective, but we wanted to learn more about what made it work and to develop more systematic evidence of its effectiveness. I have reflected many times since those days how important it was – essential, I would say – that our research meetings took place in the context of live clinical practice. That shaped the questions we were interested in, the words and concepts we used to formulate our questions. I firmly believe that had we met at the university to formulate our questions and design our studies, they would have been quite different and probably less useful.
The research team met regularly for several years. It was the group that conceived the study of interview transcripts that led to the discovery that what made the good sessions good was “change talk”, as opposed to talking about the problem. This study soon led us to drop the first interview (which at the time focused on detailed information about the pattern of the problem) and begin cases with talk of how they would like things to be different, has that happened before, etc. This also helped us see the topography of interviews where the early discussion focused on what was different (elicit), how did that happen (amplify), express surprise and amazement (reinforce), and then focus on what else needed to happen (initiate).
It was during this time that Michele came in one day excited about what had happened with one of her clients the previous week. The mother of an adolescent boy who had been referred by the school for absences and declining performance interrupted Michele during the initial interview (which was focused on the pattern of the problem) to ask if she wanted to know what she (the mother) had already tried with her son. Michele had the presence of mind to say “yes” and to follow up with whether the mother’s interventions were working. We found this an astonishing event, and a remarkable coincidence with some of the ideas we had been thinking based on our study of change talk. We recognized immediately that the mother’s talk about what she was doing differently, in the first session no less, was consistent with our growing interest in change talk rather than problem talk. It also suggested that we could begin our work with clients with “what was different?” rather than an extended discussion of the problem.
One other event during this period stands out in my mind. One day when we were training masters students to code interviews for the change talk study we came to a passage in an interview where Steve and I could not agree on whether the client was talking about change or not. After considerable analysis it dawned on us that the client was describing an actual change in her situation but she didn’t recognize it as such. It was “unrecognized” change, we decided! As we pondered this incident it became clear to us that the therapist needs to be on the lookout for change that the client may not recognize as such, and to bring it to the client’s attention. This event, and the one with Michele’s client, also suggested that change may already be happening and that it might be more useful to focus on that rather than the details of the problem.
So, to answer your question, I had the great good fortune of joining the BFTC team during the transitional period when it was moving from a focus on the problem to a focus on change – what we later began to call solution-focused. Looking back, I would say 1983-1984 was when the major shift occurred but, clearly, the foundation had been laid in the preceding years and the new approach would be elaborated and refined in subsequent years. It is difficult to describe the exhilaration we felt during that time about our “discoveries” and the anticipation we had for what would come next. We sensed we were in the midst of a revolutionary shift in how therapy was thought about and done, but also aware that the approach would be considered radical and even irresponsible or unethical by some. We knew we had our work cut out for us, but we felt up to the challenge.
The various publications by Steve and others showed that, in the next few years, the BFTC team did indeed make great progress. I am particularly curious about the BRIEFER projects which, I think, tried to formalize the therapy process and capture it in an expert system. I know you played an important role in BRIEFER. How do you look back on it? What would you say it was about and what did it amount to?
I had been interested in expert systems for some time, and Steve was also interested in computers, so we hit on this idea of developing an expert system that would serve the advising function of the team behind the mirror. The therapist would conduct the first part of the session, then come behind the mirror and ask the computer what kind of task to give the client. The computer would ask questions about what happened in the session and the therapist would answer. After about half a dozen interactions the computer would make its recommendation and the therapist would go back into the room and give the task. This is a simplified version, of course, but that was the idea.
This project evolved in the context at the time of us wanting to understand more about how skilled therapists did their work – how they thought about their cases and decided what intervention to use. We found that skilled therapists were not very adept at giving clear explanations of their reasoning that would enable another therapist to replicate their work. This is typical of experts in general, by the way; true experts tend to function in an intuitive and un-self-conscious way, knowing “in their bones” what to do. We were unsatisfied with this, however, because we wanted to understand better what made SFBT work, and to be able to describe it in such a way that it could be taught and learned more easily.
Expert system methodology at the time paid a lot of attention to the “knowledge mining” process – how the programmer could extract (or construct) the rule-based knowledge the expert used to arrive at her expert advice. We thought of this as another methodology with the potential to help us figure out what expert SFBT therapists did. We had the good fortune about that time of coming into contact with Hannah Goodman, a graduate student who was working on her masters degree in computer science and needed a project for her thesis. She was interested in expert systems and we talked her into doing her project with us. She would use methods she had learned in class to “mine” the knowledge Steve used to decide what intervention to give the client. We were thinking that, if successful, this would reveal more clearly what expert therapists did, that it could be used as teaching too, and that it could even potentially take the place of the team behind the mirror providing solo therapists the advantages of a team without actually having one. We knew this was a reach, but that was what we were thinking.
We met many times with Hannah asking questions to find out what Steve did, constructing rules that she thought embodied that knowledge, and then trying the rules on real cases to see if they led to the intervention the therapist had actually used. Although what came out had probably existed in Steve’s head somewhere, it often seemed like a revelation to us. The finished expert system consisted of about thirty IF-THEN rules and in most cases it did a pretty good job of replicating the intervention advice the actual therapist had given. We called the system BRIEFER, because we thought it should make the therapy process more efficient and consistent, and briefer, of course, which was one of the objectives of the solution-focused approach. BRIEFER also conveyed the idea that the computer would “brief” the therapist about her cases, and we liked that little play on words.
We never subjected BRIEFER to rigorous testing and did not release it outside the clinic because we were afraid people would actually use it if anything happened we could be held liable, so BRIEFER, the computer program, eventually passed into oblivion. We often used BRIEFER in training and presentations, however, and I remember fondly John Weakland’s half-serious comment at one conference that we had better not let it get out that SFBT consisted of only 32 rules – it could put us out of a job and would let the secret out that anyone could do it!
Even though we did not use BRIEFER as an expert system, we felt the project was a success because it helped us describe with considerably more clarity the solution-focused therapy process. It made crystal clear just what information the therapist needed to gather in the initial interview, and how to put it together to figure out what direction to take with a case and what kind of intervention to give. This resulted, among other things, in the flow chart that appeared in the Family Process article which I use to this day in my teaching. That flow chart also helped me stay on track when I interviewed clients in those days, as I did not have the same level of expertise as Steve and found the chart a useful rubric. In effect, BRIEFER helped me interview and decide what intervention to give, even though I wasn’t using the computer version of the program, only the flow chart.
I don’t think the BRIEFER project significantly changed how solution-focused therapy was done at the clinic; it made clearer and more systematic what we were already doing. On the other hand, Steve might say that describing the process in a new language and structure did actually change it. That would be an interesting conversation to have…
Well, I can surely imagine BRIEFER helped to get more clarity about what the solution-focused approach is. Another thing that seems important to me is your research work on the efficacy of the approach. In 2000 and 2001, you and Sheri Eisengart did a review of the outcome research and, if I am well informed, Lance Peterson and you are currently updating the review. Could you share some thoughts on what you think the research has shown about the efficacy of the approach?
Yes, Lance Peterson and I are nearing completion of an update of the 2000 qualitative review of SFBT outcomes, and it looks like we will have around 40 studies that will meet our more rigorous criteria for controlled outcome studies. We are reviewing only studies that utilized comparison groups with random assignment or some form of matching. The studies consistently show positive pre-post benefit from SFBT, and results that are comparable to other established treatments. The increase in number and quality of studies between 2000 and now is impressive, and the evidence base for SFBT is steadily growing. In fact, I would say SFBT now approaches or meets contemporary standards of evidence-based practice, particularly in the fields of mental health and child behavior problems, the populations with which most of the outcome research studies have been conducted.
Two meta-analytic reviews published recently by Stams, et al, in the Netherlands, and Johnny Kim here in the U.S. Those two reviews found SFBT effect sizes to be consistently positive, but lower than those for other well-established interventions. This may be due in part to the wide range of studies included in the meta-analyses, both in terms of study methodology (poor control) and type of outcome studied. Clearly, however, there is room for improvement in the quality of research designs used to study SFBT outcomes, particularly in the areas of treatment integrity and treatment fidelity.
Over time I think we will find that SFBT is equivalent to other established therapies. Wampold’s analysis of the psychotherapy research suggests that all approaches when done well produce equivalent outcomes. The findings of the Helsinki Psychotherapy Study, a very large and well-designed study, confirm this; SFBT produced outcomes comparable to both short-term and long-term psychotherapy, but in much less time and significantly fewer sessions. Thus, I think we’ll see increasing attention to issues such as the efficiency and cost of psychotherapy, as well as consumer preference.
So, overall, I’d say the evidence is accumulating that SFBT is effective – as effective as other approaches – and is probably less expensive and more time efficient.
This seems to fit well with my experience, which is that the solution-focused approach is as effective as other approaches but often faster and more broadly applicable. In addition to this, my experience is that both clients and practitioners tend to be more satisfied with the solution-focused way of working. Clients, because they are approached so respectfully and taken so seriously and practitioners because they experience so much that what they do really makes a difference for their clients. My last question is about the further development of the solution-focused approach. Insoo Kim Berg once said to me she did not think of the solution-focused approach as a finished approach. She said: “For any model to stay alive it will need to constantly keep developing and renewing itself.” What are your ideas about its development? How do you expect it to develop, and how would like to see it develop?
Insoo and Steve were both very clear that the approach should continue to develop – this came more from a belief that nothing is ever final or perfect, rather than an idea that there was something unfinished or wrong with the approach. Most of the fundamental changes in thinking and working occurred in the 1980s, whereas the 90’s and 00’s saw refinements. One of the major ways the approach developed beyond the BFTC group was moving into the area of organizational consulting and other types of interpersonal change in addition to traditional psychotherapy.
The world today is quite different from the developmental days of SFBT. Then there was little thought about the cost of therapy, and “evidence base” was not a big factor in choice of treatment approach. Now cost (length of therapy) is a big factor, as is evidence of effectiveness. Wampold’s work on common factors suggests that all approaches, when done well, are effective and have essentially equal outcomes. I think he makes a strong case for that, backed up by his meta-analysis of the outcome research across many approaches.
A consistent theme in the studies comparing SFBT to other therapies shows SFBT is almost always briefer, more cost-effective. I think that is because the approach does a better job of addressing some of the common factors Wampold talks about – creating the expectation in the client that change will happen, doing things in the session that show change is already happening, and constructing a working alliance that emphasizes client strengths rather than limitations, which makes the approach more attractive to clients. I expect as time goes on we will see less emphasis on distinctions between SFBT and other approaches and, hopefully, more collaboration with other approaches that also focus on strengths and positive change. Collaboration and intellectual exchange can strengthen SFBT and keep it responsive to the needs of clients and the world they live in.