Solution-Oriented Therapy

Solution-oriented therapy grew out of strategic family therapy, especially the move away of the MRI model from theory, family history, and psychopathology. Even more than strategic therapy, solution-oriented therapy eschewed theory about the origins of problems and instead focused on goals, resources, and exceptions to problem behavior, rather than on problems themselves. Reflecting a radical approach to constructivism (the idea that reality is socially created rather than mainly objective), solution-oriented therapists aimed for therapeutic conversations that construct alternative realities that would lead to quick problem resolution through activating patients’ abilities. Leading figures were Steve de Shazer (1985), Insoo Berg, Eve Lipchick, and Michele Weiner-Davis (all connected with the Brief Therapy Center in Milwaukee), and Bill O’Hanlon of Omaha, who was trained by Milton Erickson (O’Hanlon & Weiner-Davis, 2003).

Solution-oriented therapy brought a number of innovative techniques into the field. In the miracle question, the therapist asks: “If you wake up one morning and a miracle has occurred and your problem is cured, how would you know it?” The patient is asked to elaborate the details—what would you and others in your family be doing differently if this miracle occurred. Then the therapist asks if there have there been any time recently when the miracle was present at least temporarily—for example, times when the patient was not drinking and was acting responsibly or the couple was getting along nicely. How would others in the patient’s world know the miracle happened, and how would they be acting differently? The goal is to stimulate the imagination about change and instill hope.

Another prominent solution-oriented technique is scaling questions. Here’s an example from Berg and Ruess (1998) in the substance abuse area. The therapist says to the patient: Let’s say you have reasonable control over your substance use. If the number 1 stands for the time you lost complete control, where would you say you are at between 1 and 10 right now? What did you do to get from 1 to where you are now? What would you have to do to move up one step? The patient is then encouraged to think about and enact a simple behavior that would move to the next level of control over the symptomatic behavior. Solution-oriented therapists challenged the first generation of family therapists by arguing that no theoretical work is needed beyond a basic model of how people can activate themselves to change. Like strategic therapy, solution-oriented family therapy now is rarely practiced in its pure form in contemporary family therapy, but it has added greatly to the body of clinical strategies in the field.

Narrative Therapy

Postmodernism hit family therapy in the 1980s in the form of narrative therapy (Doherty, 1999). Narrative therapy critiqued theory and expert knowledge in favor of a constructivist emphasis on narrative, story, and the cocreation of reality. The leading figures were Lynn Hoffman, Harry Goolishian, Harlene Anderson, Tom Andersen (Norway), and especially Michael White and David Epston (Australia and New Zealand). It was probably the cutting-edge movement in family therapy in the 1990s. We will focus on White and Epston’s version because it has been the most influential.

Although trained in family systems therapy, White and Epston (1990) came to embrace French philosopher Michel Foucault’s critique of expert knowledge as oppressive. Like individual psychotherapy theories and diagnostic systems, family systems theory was seen as a “totalizing” framework created by experts and imposed on ordinary people. Narrative therapists see people as developing “problem-saturated descriptions” of their lives, which clinicians frequently reinforce through traditional diagnosis and problem-oriented treatment. The goal of therapy is to free people from oppressive stories in their lives, stories derived from the dominant culture (including therapy), which they have learned to describe their problems. For example, a patient who has been told that she has chronic depression may internalize this diagnosis and view depression as a dominant character in the story of her life. The therapist’s job is to “deconstruct” this narrative and help the patient reclaim ownership of her life.

In this way of thinking, therapy becomes a form of conversation that involves “re-storying,” in which patients locate and generate alternative narratives that create an altered sense of self that is separate from the problem. The therapist does not diagnose and attempts to not use a substantive theory beyond assumptions about the role of narratives in people’s lives. Focusing on cultural scripts, White and Epston are explicitly multicultural, profeminist, progay, prolesbian, and opposed to social oppression in all its forms.

Narrative therapists de-emphasize technique but do have a number of common practices. The therapist maintains a positive, curious stance and is frequently impressed with what the patient offers up in therapy. The therapist speaks of the problem in a distanced way to help the patient “externalize” the problem. The problem is referred to as a separate entity existing outside the patient and family, which may have gotten control of the person or family. The problem is the problem, and the person is the person. Therapy is mostly a series of questions exploring the problem’s control of the family, how the family sometimes controls the problem (“exceptions” and “unique outcomes”). For example, the therapist might ask about situations in which the patient’s depression was not in charge and how the patient managed to make that happen. (Note the similarity to solution-oriented therapy, with the difference that the narrative therapist has a larger model of cultural influences on problems.) The goal is to liberate the family from their constraining constructions so that they can create alternative ones, or “re-author” their lives.

More than any other model of family therapy, narrative therapists have incorporated community perspectives into their clinical models by emphasizing how problems and problem-saturated language are often founded in mainstream cultural beliefs and maintained by the language and practices of professionals in the community (Madigan & Epston, 1995; White & Epston, 1990). Narrative therapists have experimented with ways to access the social networks of patients and to assist them in making stands against the culture and the mainstream treatment system (Madigan & Epston, 1995; Walgrave & Temasese, 1993).

Narrative therapy presented a major challenge to the first generation of family therapy models and continues to be a prominent force in the U.S. family therapy field, although not in the pure form of its originators. For one thing, it is difficult to do therapy in the United States without accommodating to the DSM diagnostic system. At a larger level, Nichols (2008) has argued that narrative therapists, in reacting against the rigidities of the first generation of family therapy, adopted rigidities of their own, rejecting the purity of systems theory for the purity of a postmodernist, social constructionist perspective that eschewed both biology and family dynamics. Narrative therapy continues to evolve in ways that transcend these limitations while staying true to its core focus on collaborative treatment of problems in their cultural context.