Selecting the "Focus" in Brief Psychotherapy
Robert L. Phillips, Ph.D.
The issue of clinical focus is a central concern of all forms of brief therapy. Flegenheimer(1993,p.5) sees the requirement of working within a focus as clearly distinguishing brief technique from other kinds of therapy. He defines focus as " a circumscribed symptom or area of difficulty the resolution of which wiill satisfy the present needs of the patient." Stern (1993) comments that the idea that treatment is more powerful when the focus is kept on the problems for which the client is seeking help is one of the great contributions of brief therapy relevant to all therapies. Messer and Warren (1995, p. 266) suggest that the inability to identify a focus during the assessment phase of therapy precludes optimal use of brief therapy.
While most brief therapists agree that the focus is the presenting problem, brief therapists differ considerably on what aspect of the presenting problem is the most important target of focus. Each practitioner has their own conceptual perspective on what aspect of the presenting problem needs to be the focus. Thus Malan (1976a) attempts to formulate a "minimal dynamic hypothesis" to guide the treatment,while Luborsky ( Luborsky & Crits-Cristoph, 1990,p.1) attempts to"capture the central pattern, script or schema that each person follows in conducting relationships" for this purpose. The Vanderbilt group (Strupp & Binder 1984) relies on " the concept of cyclical maladaptive patterns" and Horowitz (1991) has developed a "person, schemas theory" to shape the therapeutic focus. Solution oriented therapists (de Shazer,1988) look for sequences of behavior associated with non occurence of the problem in their search for problem solutions, while Ellis (Ellis & Dyden 1987) attempts to identify and challenge the irrational beliefs which are associated with the presenting problem.
While much has been written about how to conceptualise the presenting problem, there is little discussion in the literature on identifying what the presenting problem(s) is. It seems that it is assumed that the presenting problem is usually apparent and indeed, on the surface, identifying the presenting problem seems to be a simple task. It is obviously the problem (s) or the symptoms that clients say triggers their distress and leads them to seek counseling or psychotherapy. In practice, defining the problem(s) that needs to be the focus in treatment often turns out to be a more complicated affair. Initially the client's statement of the presenting problem is clear cut. They suffer from depression or anxiety, they abuse drugs or alcohol, they have marital or job problems etc. As we explore the context in which these presenting problems occur, the initial clarity frequently fades away. Often the presenting problem seems to change and we find ourselves asking the question "What really is the presenting problem?"
A case example will illustrate how what seems initially clear cut and obvious becomes more obscure as we explore a clients' presenting problems. A client seeks treatment because "I have a problem with anger". She says that she is angry with her mother, but she takes it out on her boy friend. She can understand why she is angry with mother. From her growing up years until the present, Mother has a tendency to unpredictably explode into a rage, becoming verbally and physically abusive. She is this way with all of the client's six siblings. A few years ago, she and her siblings agreed that they would all get together and confront mother. When they did so,mother flew into a rage and physically attacked several of the adult children. Father stayed away from the confrontation "because he knew this was not about him." The client blames mother for her low self esteem and lack of self confidence. She is also intimidated by father who she says is domineering and dogmatic, but she does not see her relationship to father as having any connection to her presenting problem.
The client is 29 yrs. old and has been involved with her boyfriend, who is 9 years her senior, for 3 years. Client gets angry with boy friend for "petty things"; e.g., he will begin eating before she sits down at the table. Boy friend generally is very kind and loving to her. There is a serious problem in the relationship however. Boy friend now works as a clerk in a retail store, but prior to this, he had never held a regular job. He has earned "spending money" buying and selling collectibles, has lived with his parents his entire life and has never had his own apartment. As the interview progresses, the client admits being gravely concerned about the boyfriend's lack of ability to earn a decent living. She is concerned that if she marries him, she will have to support him. She loves him but she is not "in love with him." Yet she doesn't want to leave him because he is the first boy friend who has ever treated her well. Client has had two other long term relationships. She reported that her first boyfriend was alcoholic and the second was addicted to cocaine (the client denied any involvement with drug or alcohol abuse). In both relationships, she was abused physically and/or emotionally. Towards the end of the interview, the client asks despairingly "What's wrong with me. Why can't I find somebody who is my peer."
So what shall we focus on in brief treatment with this client? Should we focus on her problem with anger towards mother, or should we deal with her ambivalence about continuing her relationship with current boyfriend? Should we deal with her seeming difficulty in choosing suitable boyfriends or do we need to address her issues around low self esteem? If our treatment is to be brief, we must select one or two issues for focus: we cannot deal with everything.
Whatever problem we decide to focus on should, in my opinion, meet three criteria. First, it should address the clients' initial complaint "I have a problem with anger." The client's concern about her anger led her to seek help. Therefore successful treatment must either reduce the amount of anger that she experiences and/or help her cope with anger in ways that make it less of a problem. Secondly, the problem(s) selected must be something that the client wants to work on. Since we expect the client to actively and vigorously participate in the change process, the focal issue selected must not only seem relevant to the client's ideas about her difficulties but also must generate a sense of hope that her emotional distress, which prompted the call for help, will be alleviated. Thirdly, the problem(s) that we select for focus needs to be something that resolves the client's presenting complaints as quickly and economically as possible. Parsimonious treatment not only meets the demands of managed care but it is congruent with our own sense of professional responsibility.
Malan (Malan, 1979; Chaps 17-22), in discussing the initial session, comments on the formidable set of clinical skills needed to accomplish the objectives of the session. In the initial session of focused treatment, as the therapist establishes an emotional connection to the client, he or she must frame and sensitively ask questions which define and clarifiy the presenting problem. Framing questions which are relevant to a particular presenting problem and which generate treatment strategies often requires a rapid scanning of several theorectical perspectives before one finds a viewpoint that is both problem relevant, meaningful to the client, and generative of a concrete change strategy.
One size does not fit all. There is no one perspective or technique that is useful in all clinical situations. The therapist, who can work effectively with a diverse group of clients, cannot be overly attached to one perspective but must acquire a certain degree of flexibility both at the cognitive and emotional levels of relating to the client. When one perspective doesn't generate questions which are meaningful to the client or yield feasible problem solutions, one has to quickly shift one's way of looking at the problem, generate different questions and problem solutions. Given the limits of any specific theoretical perspective, the therapist who is narrowly trained in only one perspective and set of techniques is likely to be effective with only a narrow range of presenting problems.
As this paper suggests, identifying a problem focus that is relevant to the initial complaints, that enlists the client's active cooperation and results in a parsimonious course of treatment is not a simple process. It often requires the integration of an awesome and complex mixture of personal qualities and clinical skills, a deep understanding of human nature as it is expressed in both intra and interpersonal process and a extensive exposure to diverse perspectives and techniques of facilitating human change.
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