Solution-Focused Brief Therapy shows goal attainment gains in people with mild learning disabilities

Documents published representing a ‘manualised’ cognitive behavioural therapy treatment for trained CBT therapists

Solution-Focused Brief Therapy (SFBT) focuses on evoking desired behaviour rather than on diminishing existing problem behaviour. It is goal directed and collaborative in its approach to helping people achieve behavioural change. The therapist works to help establish a vision of a desired future using a series of precisely worded questions. In SFBT, the goal of the therapy is defined by the client and the role of the therapist is to ask questions rather than to give advice, and to encourage the progression towards the agreed therapy goal in small, specific, behavioural steps.

Several authors have made a number of suggestions about modifications to the therapy process to enable people with learning disabilities to make of use of the approach, including the use of simple language, flexibility in questioning, giving more time to answer questions, and the use of visual aids such as emoticons and drawings.

Method

The researchers in this study in the Netherlands were interested in looking at the extent to which people with mild learning disabilities in receipt of SFBT reached their treatment goals and to compare these outcomes with a matched group who received ‘care as usual’.

They worked with 38 people who were in receipt of support from a provider of residential, day and home care services. Criteria for inclusion in the study were that participants had to be between 18 and 60, be in the IQ range 50-70 and have a clinically significant maladaptive behaviour as identified from a score on the Reiss Screening tool.

They excluded people with acute and severe psychiatric conditions, or issues that would need long-term multidisciplinary intervention. Everybody who took part lived semi-independently with between 2 to 14 hours support each week.

The researchers allocated 20 people to receive solution-focused sessions and 18 people to continue with care as usual (CAU). This allocation was not random, as they considered it unethical to withhold a potentially effective treatment from people, so those in the CAU group were put onto a waiting list for SFBT as vacancies in sessions became available. The two groups were comparable for age, IQ and adaptive functioning with no statistically significant differences found between these characteristics

The researchers describe what happened on a day to day in the care as usual group as quite different to those in the treatment group. The approach in the care as usual group was to coach people in ways that focused on a problem-solving model, helping to describe the problem and formulate client goals. In this model, the coaching plan and interventions were primarily performed by staff. It is described as a model in which staff suggest or prescribe solutions and act as experts to advise clients on the actions they need to take to alleviate their problems, which is in stark contrast to the approach advocated in SFBT Each of the therapy sessions were attended the person, a staff member and the therapist as a minimum (some were attended by more people).

There were six sessions for each focus person. The first was used to ‘get acquainted’. The second session was used as a goal setting meeting. The question used by the therapist here would invite the client to ‘Imagine a miracle that would (sufficiently) solve the problem,’ and then to consider ‘what would be different?’ From this, clients are encouraged to frame a goal as the presence of a solution rather than the absence of a problem.

Subsequent sessions use the ‘EARS question set’ – an acronym for Eliciting, Amplifying, Reinforcing and Start again as well as ‘Consolidation questions’ to increase the likelihood that the client will keep on working towards the desired goal.

Outcome measures

Data were collected at three points for both groups, pre-test, immediately post-test and then at follow up

Goal attainment was measured for the SFBT group

Goal attainment was measured for the SFBT group and differences with regard to quality of the life, maladaptive behaviour and resilience were measured for both groups.For goal attainment, they used the Scaling Question Progression (SQP) where the client indicates to what extent they have approached or reached the therapeutic treatment goal.They used the Intellectual Disability Quality of Life tool which looks at psychological functioning, social functioning and satisfaction about housing, where scores are an indication of the individual’s perceived quality of life.

They used the Reiss Screen for Maladaptive Behaviour (RSMB)to measure maladaptive behaviour, and this was completed by a. The RSMB measures the presence of psychological problems and was completed by a staff member who had knowledge of the person concerned.

Finally, they used the Positive Outcome Scale (POS), 10-item self-report instrument to look at autonomy and social optimism.

Two people withdrew from the sessions before completion, so 18 people completed the therapy sessions and the same number received care as usual.

Findings

Goal attainment was measured for the SFBT group, but not the care as usual group as no goals were set for this group. Some of the problems reported by people they wanted to work on were for example alcohol abuse, anger, bereavement, low self-esteem. Thirteen of the eighteen clients showed statistically significant progressions on the Scaling Question Progression directly after the sessions and 14 showed progression at follow-up.

At the start of the research, both groups had low satisfaction ratings on psychological and social functioning measures on the quality of life scales and average resilience scores were also low. Problems reported by both groups were within the clinically significant range on the scale. Directly after the therapy sessions, the SFBT group performed better on psychological functioning, maladaptive behaviour and autonomy.

Positive changes found but not all sustained at follow-up

Positive changes were found for 16 of 18 for psychological functioning, 11 of 18 for social functioning, All for reduced maladaptive behaviour, 11 of 14 for autonomy, 8 of 14 clients for social optimism.

Improvements in psychological functioning, reduced maladaptive behaviour and autonomy were sustained at follow up for the SFBT group.

Changes in social functioning measured directly after SFBT and at the follow-up point however were not found to reach statistical significance in the SFBT group and there were also no statistically significant changes in social functioning and social optimism in the care as usual group.

When looking at differences in performance between the two groups, the researchers found that the treatment group performed better than the care as usual group directly after SFBT with regard to psychological functioning, social functioning, maladaptive behaviour, autonomy and social optimism. Interestingly though, at follow-up, differences for autonomy and social optimism were no longer statistically significant, although gains were sustained in psychological functioning, social functioning and maladaptive behaviour.

Conclusion and comment

As an approach, the principles behind SFBT are entirely in line with current thinking about support to people with learning disabilities, in that it focuses on solutions rather than focusing on existing behaviours. It also sits very well with the notion of person centred supports, in that it is concerned with empowerment for the person and looks to help the person develop individual, unique strategies based on their understanding and skills. It recognises the expert status of the person and tries to build on a sense of self-efficacy in reaching solutions.

The findings of this small study show a number of statistically significant gains for people across a range of domains when compared to ‘care as usual’. The researchers themselves however point to the fact that although the treatment and control groups were matched on a range of characteristics, the allocation was not random or blind and this means that it is impossible to rule out confounding factors in findings relating to individual characteristics (enthusiasm for the therapy) or in the way the therapy was offered. The group sizes were also quite small, so again the findings need to be treated with some caution.

It also seemed to be the case that some of the gains were sustained at follow-up and indeed the follow-up period was quite short in this initial study, meaning that it is not possible to comment on long term sustainability.

However, the researchers point out that their findings were entirely consistent with recent SFBT research in the general population, which showed the therapy as more effective than ‘treatment as usual’ with medium effect sizes.

To deal with some of the limitations, they hope to run further studies in partnership with other providers, which would enable the recruitment of more participants in a shorter period of time which would allow random allocation.

There are some encouraging findings from this study which show that the therapy can be powerful in helping to focus on skills rather than deficits, and on what the researchers call ‘concrete’ and ‘immediate’ issues. Certainly the ‘getting acquainted’ session enables a joint agreement on the issue to be worked with, so encourages partnership and ownership. Despite these issues being immediate and relevant, they were also shown to be clinically significant and therefore finding solutions would be likely to have a positive impact on quality of life.

The authors suggest therefore that Solution Focused Brief Therapy can be a valuable therapy tool for people with learning disabilities, but that further research, involving larger sample size, randomisation and longer follow-up could add significantly to the evidence base.