The following excerpt is taken from a paper published by Lynn Segal in the "Handbook of Family Therapy." It describes how Brief Therapists conceptualize problems.
What Is A Problem
How one conceptualizes "problems" determines the therapeutic process--who is seen, what questions are asked, how the data are analyzed, what goals are set, what techniques are used, and how the outcome is evaluated.
The psychotherapy literature, however, uses the term "problem" freely, as if reader and author unanimously agree on its definition. But do they? When clinicians are asked, "What is a problem?", many are hard put to give a conceptual answer. Some clinicians describe a particular dimension of the term, " It has to do with suffering", or "It is something someone wants to change." Others offer examples of diagnostic categories from the DSM III: depression, chemical addiction, and anxiety.
Most therapists would probably agree that presently there are two general definitions that capture the meaning of the term "problem" in clinical work. Either the term refers to the patient's presenting complaint or something else that causes the complaint, in which case the complaint will be labeled the symptom. When the problem is viewed as the cause of the patient's complaint, it may be located inside an individual or between individuals, i.e., a family systems problem.
Most schools of therapy view human problems as the result of either psychopathology or a deficiency. In more simple terms, either something is broken or missing. Depending on how a therapist accounts for the patient's problem, attempts will be made to repair the damage or supply what is lacking.
To understand Brief Therapy, the reader must grasp how the brief therapist defines the term "problem" and how this definition impacts treatment. It should also be noted that the following definition is not offered as a true or proper way to define the term " problems". Rather, it is the definition the MRI Brief Therapy Group invented when they built their short term, generic model of problem solving.
The Definition of a Problem
We will use four criteria beginning with one or more clients, who, in essence say:
a. I am in pain or distress;
b. I attribute my pain to the behavior of others or myself;
c. I have been trying to change this behavior; and
d. I have been unsuccessful.
Therapeutic distinctions and implications related to this definition of a problem
First, to do treatment, someone other than the therapist must believe a problem exists. This is a non-normative definition of a problem.
Second, clients' problems are usually connected with someone else's behavior. Since many identified patients--teenagers, small children, psychotics and spouses-- are unmotivated for treatment, this definition supports the therapist working with other family members to change the identified patient's behavior.
Third, the complaint is the problem, not a symptom of an underlying disorder.
Fourth, problem behavior is inextricably tied to problem-solving behavior, a key point in understanding "how" problems persist.
Fifth, the definition transcends psychiatric contexts, applying to a wide variety of complaints.
Sixth, the definition shifts the therapist's focus from understanding the particulars of each diagnosis to developing skill in changing behavior, thoughts and feelings.
Seventh, the definition is non-normative. The client's distress defines the existence of a problem, not his behavior. Normative models define normal behavior and then attempt to account for deviance. To determine if the client has a problem, the normative therapist matches the client's with the model's norms. If he finds a problem but the client does not accept the diagnosis, the client is labeled resistant, which may then be used as further evidence to confirm the therapist's findings. In normative psychotherapy, either the therapist or the client can declare that a problem exists. Thus, in a non-normative model such as Brief Therapy, someone other than the therapist must "feel" or "own" the problem.Eighth, Brief Therapy's goal is to reduce or eliminate the client's distress. Either of two factors can bring this about a) the behavior has changed; or b) the client is no longer distressed by it. Usually, both conditions are met, but if the client's distress decreases although the behavior remains unchanged, this would also be considered a success.
This position on goal setting usually raises the question of limit setting. Clinicians will frequently ask, "Do the therapist's personal and professional values determine what the Brief Therapist will accept as the client's goal of treatment." The answer is a simple "yes". This author will not help a client achieve a goal that runs counter to his values and beliefs. For example, clients may ask the therapist to help them to engage in asocial behavior in the belief that to do so will reduce their distress, i.e. help me not feel nervous or remorse about stealing so I can support my drug habit or help me not feel guilty about abusing my child.
In the final analysis, the Brief Therapist always sets the goal of treatment. In most cases, the client and therapist's goals will overlap or be similar. The responsibility for setting goals, however, rests with the therapist not the model. The Brief Therapy Model is non-normative. It does not contain a list of what is the right or correct way for people to behave. Therefore, the Brief Therapist must take personal responsibility for what he or she believes to be useful or helpful to the client rather than claim to be a only spokesperson for some seemingly "objective" or scientific model of human behavior.
Ninth, Brief Therapy's definition of a problem does not require the therapist to interview the entire family when treating a family problem or interview both spouses when treating a marital problem. Given the client's permission, the Brief Therapist will work with anyone who is motivated to resolve the problem.
How Problems Arise And Persist
Problems develop and persist by the mishandling of normal life difficulties--predictable occurrences that arise in most everyone's life. These would include accidents, e.g., loss of work and transitions in the family life cycle - courtship to marriage, the birth of a child, children beginning school, children leaving home, and loss of a spouse due to death or divorce.
This proposition does not exclude the view that biochemical or neurological events may play a role in problematic behavior. Rather, the proposition suggests that despite what goes on inside a person, in the overwhelming majority of cases, the interpersonal events become the primary focus for diagnosis and intervention. Obviously, if one suspects an organic problem is causing the patient's acute pain, an internist or neurologist must check this. However, for the majority of everyday complaints presented to the working therapist, this view of problem formation provides a sufficient basis on which to proceed.
The original difficulty becomes a problem when mishandling leads clients to use more of the same "solution." A vicious cycle is set in motion, producing a problem whose severity and nature may have little similarity to the original difficulty.
People, including therapists, mishandle problems because they are making an error in problem solving. They use solutions that seem logical, necessary, or the "only thing to do." Usually, these solutions are consistent with their culture, their frame of reference, and their view of reality. In the Western Hemisphere, we believe in attacking problems head on. "If you don't succeed, try again;" "When the going gets tough, the tough get going." Thus, when someone has a problem they are like the proverbial man caught in the quicksand. The more he struggles, the more he sinks; the more he sinks, the more he struggles.
Attempted Solutions
Though people find many ingenious ways to "mishandle" problems, four patterns have been observed: (1) demanding that self or others be deliberately spontaneous; (2) seeking a non-risk method when some risk is inevitable; (3) attempting to reach accord through opposition; and (4) confirming the accuser's suspicions by defending oneself (Fisch et al, 1982.)
Attempting To Be Deliberately Spontaneous
Clients use this solution with sleep disorders, sexual difficulties, substance abuse, writing blocks, the inability to create and whenever a person tries to force himself or others to "feel" an emotion or to want something.
Most people will occasionally wrestle with uncomfortable feelings or have difficulty with a bodily function or performance. Viewed as normal life difficulties which will pass with time usually insures their spontaneous self-correction. Once a person begins to force their correction, however, they are caught in the trap of forcing spontaneous behavior, setting the stage for full- fledged problem.
Although one might expect clients to use this solution with themselves--self/self talk, it often occurs at the interpersonal level. One or more family members ask, demand or suggest that another family member be spontaneous, e.g., "Cheer up", or "You should want to go to school."
In the following example, a women describes how she and her husband deliberately tried to make her orgasmic.
PT: Before I married, I don't think I ever had an orgasm, but I never thought about it. You know, I tried sex, and it was fine. The trouble started just before I got married. I was with some girlfriends and we got to talking about sex. They told me that I had never had an orgasm.
TH: They told you?
PT: From our discussion, I realized that I'd never had one. Then it became a problem. And sex was no longer just enjoyable. I kept, you know, waiting for it to happen. Sex became work. There was no pleasure.
TH: In the first conversation what made you think that you were not orgasmic?
PT: What I felt when I made love didn't fit what they were describing. No firecrackers went off; there was no big release. And after it happened, you were supposed to feel, I don't know, a series of peeks. You would peak and then come down and your body would do something. And I knew that never happened to me. One time I was very close.
TH: After you found out that you didn't have orgasms, what did you try?
PT: First, we tried examining my body and figuring out where everything was. Then what to manipulate, the clitoris...And when that didn't work. I was so preoccupied with having an orgasm and what we were doing, step-by-step, that sex was just became a pain. I mean, there was no spontaneity. There was no fun in it at all. It was just a process we went through. The next thing we did was talk with friends, another couple we were close to. They told us about different positions, things like that.
The client enjoyed sex until her friends suggested something was missing. This lead to her understandable but misfortunate solution--trying to be orgasmic. She might have become orgasmic during the marriage if sex had not become deliberate and self- conscious.
Seeking a No-Risk Method Where Some Risk Is Inevitable
This solution is often found in problems which arose from life difficulties associated with work, dating or when one must make a major decision. The problem solver, attempting to avoid a mistake or the risk of failure, creates what they want to avoid, i.e., more doubt and indecision.
For example, consider a shy single male who wants to meet women but fears rejection. When approaching a lady, he anxiously seeks the perfect opening gambit only to find himself tongue-tied. These clients frequently complain that when they meet a women for the first time their minds go blank. People who try too hard to close a sale or get a job have similar complaints. The following transcript illustrates how one man tried to solve the problem of failing job interviews.
TH: What have you done immediately before, during and after the interview to maximize your chances of being hired?
PT: Ok. I have done something very few people ever do. I prepare a presentation about the company
TH: Based on knowledge of the company. It is about a 12-page presentation. I outline what my approach to managing information systems would be. In the report, I also analyze the company's weaknesses and strengths.
Attempting to increase his chances of landing the job, seek certainty, the client tries to impress the company. In this example, he prepares a 12 page report which explains what is wrong with the company, a solution which is likely to alienate the person who may hire him.
Attempting To Reach Interpersonal Accord Through Opposition
This solution arises from the belief that talking can solve all problems. Frequently used with marital and parent-child conflicts, this solution often degenerates into criticism and nagging. The transcript below illustrates how family members use this solution to deal with the father's depression following two strokes.
Son1: You got to work harder if you want to improve your physical well being, and I think that...
Son2: Only in improving your physical well-being are you going to improve your mental well being, and I think you can do it. I don't know what it's like to feel what you have in your hands and in your leg.
Son1: I realize that I don't have the physical limitations that you do you, but you look at television and you see people who are painting with the paintbrush held in their teeth. You may not be able to do work in your shop anymore, but I think that if you really wanted to, you could do a heck of a lot of things right now. I think its a matter of saying, " Damn it, I'm going to do this for myself because I want to."
F: Well, it started out--the question of me and the trouble that I was having with everybody and everything. I still think there is a hell of a lot wrong with me physically that none of you give me credit for.
W: You're looking at me.
H: I mean you
W: Well
H: It seems to me that everybody--the way I walk. I don't walk and drag my leg because it feels good. It feels like hell to drag that fucking leg, and that's no good. I try [crying].
W: Well, when I tell you to lift your leg and stop dragging your foot, hon, I'm only telling you for your own good. I think that if you concentrate on lifting your leg, you will be able to do it. You only started dragging it during the last three weeks, and I don't think its physical; I think it's a little bit of laziness.
H: It is not. It happens. That leg will not lift.
W: Well, it will lift if you try to lift it.
H: Then you walk around behind me and lift the damn thing.
Confirming the Accuser's Suspicions by Defending Oneself
Many problems associated with paranoia arise from this solution ( See Fraser, 1980, Journal of Marital and Family Therapy). It begins when person A defines person B's comment or directive as insidious or intrusive. Person A then becomes defensive or withdraws. Person B, then takes a greater interest in person A, and the cycle escalates.
This solution is frequently used with parent--teenage problems. The typical teenager wants to spend less times with their parents and siblings, desiring to be with the friends or spend time alone. Sometimes, the parent, fearing something is wrong or feeling shunned makes a greater effort to talk with their teenager or encourage them to join family activities. The teen experiences the parent as intrusive and becomes more reclusive or stays away from home, escalating the cycle. Given the increase of teenage suicide and the media amplifying parent's fears with the threat of copycat suicide, one can expect a significant increase in this pattern of interaction.
The following example illustrates two patterns: a) too much discussion; and b) drawing attention to oneself by attempting to be left alone. The client describes how he dealt with his ex- wife's request to accompany him on his vacation to France.
PT: She asks how come I'm going to France. I said," What do you mean, how come? She replied, "I want to go with you!" I told her, "You can buy your own ticket, but you also have to validate your passport," But she kept on insisting. Finally, I said,"You cannot go with me!" But she kept on insisting. Does this make sense? I couldn't reason with her, so I hung up.TH: She called you to ask if you would take her to France?
PT: Uh huh
TH: You didn't want her to go with you?
PT: I was going alone. I had made up my mind.
TH: You gave her all the reasons why she could go alone.
PT: Yes. She had the money! She could do the same thing.
TH: What stopped you from saying, "Look Mary, I don't want you to go with me."
PT: I did. I told her, "You know, I'm not stopping you from going, but you're not going with me."
TH: Your not going with me, that's what you told her?
PT: That's what I told her.
TH: Did you tell her why?
PT: No I didn't. ....It's not only why, I did not want to have any association with her. I'm finished.
TH: Did you tell her that?
PT: Many times.
TH: This is a crucial point. It has to do with your wording. How did you tell her you didn't want her to go to France with you?
PT: I didn't stop her. I didn't tell she couldn't go.
TH: I don't follow.
PT: I told her that I had my ticket and she could not go with me. I told her she could get another flight.
TH: Did you ever tell her that even if you could change your plans and arrange your schedule to fit with hers, you wouldn't want to go with her.
PT: No. I did not want to express any resentment. I was afraid it would only make matters worse. I never express anger or resentment to her.
The more the client attempted to be left alone by hiding his true feelings--his resentment and anger, the more his wife pursued him. He might have been better off telling her; "I don't want you to join me on my vacation. I can't stop you from going to France. That's up to you, but I do not want to be with you."
In summary, the theory and technique of Brief Therapy rests on two assumptions: "regardless of their origins and etiology - if, indeed, that can ever be reliably determined - the problems people bring to psychotherapists persist only if they are maintained by ongoing current behavior of the client and others with whom he interacts. Correspondingly, if such problem- maintaining behavior is appropriately changed or eliminated, the problem will be resolved or vanish, regardless of its nature, or origin, or duration" (Weakland, Fisch, Watzlawick & Bodin, 1974, p.144). This also applies to the problems therapist's have with their clients and the solutions therapists use to solve them.