Solution Focused Therapy and Cognitive-Behavioural Therapy in the Mental Health Setting: A Comparison - Essay Example

SOLUTION FOCUSED THERAPY AND COGNITIVE-BEHAVIOURAL THERAPY IN THE MENTAL HEALTH SETTING: A COMPARISON 2007 Solution Focused Therapy and Cognitive-Behavioural Therapy in the Mental Health Setting: A Comparison Introduction Solution Focused Brief Therapy (SFBT) also referred to as Solution Focused Therapy (SFT) is a relatively new form of psychotherapeutic intervention that focuses on solution-building rather than on problem-solving (Iveson, 2002). The SFT approach is largely based on the philosophy of social constructivism. The core idea underlying this popular philosophic stance is that knowledge is socially and culturally mediated while learning is "...a self-regulated process of resolving inner cognitive conflicts that often become apparent through concrete experience, collaborative discourse, and reflection" (Fosnot, 1993: 7). Therefore, SFT explores current resources and future hopes of the patient instead of focusing on the problems experienced in the past and their causes. The initial version of SFT was developed in the Brief Family Therapy Centre, Milwaukee by a group of researchers whom focused on the inconsistencies typically observed in problem behaviour. Presence of such inconsistencies suggested the core idea underlying SFT, namely: regardless of the seriousness and chronic nature of the problem there are always inconsistencies or exceptions which contain the seeds of the patient's own solution (de Shazer et al, 1986). Consequently, the goal of therapist providing SFT is to facilitate the process of building the correct solution by helping patients identify the issues they would prefer change, attend to those issues, understand their strengths and resources, and construct a vision of the normal future. The focus on inconsistencies helps the therapist initiate minor changes in the patient's behaviour (e.g. repeat the successful behavioural patterns more often) and make the patient aware of these changes, which eventually results in more serious changes and puts the patient closer to the constructed vision of future (Iveson, 2002). The changes in behaviour which took place during the therapy are believed to be constant within the SFT approach. Cognitive-Behavioural Therapy (CBT) is also a relatively new method of psychotherapy: the fundamentals of CBT emerged in the late 1950s. As the therapy's name suggests, it includes the elements of both cognitive and behavioural therapeutic paradigms. The methodological principles of the theory have their roots in classical works of Russian physiologist Ivan Pavlov and one of the most influential American psychologists of the last century Burrhus Frederic Skinner. The spread of CBT as an effective treatment for a wide range of disorders began in the late 1960s - early 1970's primarily in the United States and Western Europe. The spread was associated with the classic works of American analysts Albert Ellis (1977; 1985) and Aaron Beck (1970; 1978; 1985). Initially cognitive and behavioural interventions were independent therapeutic methods. Behavioural therapists did not consider cognitive structure to be important in treatment interventions and focused primarily on the external behavioural reactions be observed and assessed. Cognitive therapists, in their turn, stressed the importance of human cognitions and emotions in the treatment process. Therefore, the goal of cognitive therapy was "... to reduce excessive emotional reactions and self-defeating behaviour by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions" (Beck et al. 1993: 21). This therapy focused on functional analysis of abnormal behaviour and identification of cognitions associated with it. In cognitive therapy, the therapist's approach to focusing on cognitions is based on leading the patient through a series of questions, and the treatment is believed to reduce or eliminate the abnormal behavioural patterns by changing the patient's way of thinking (Carroll, 1998). CBT represents a merger of these two approaches: it focuses on cognitive and behavioural experiences of the patient viewing them as the entwined aspects of human behaviour. CBT is a broader term than SFT: it is a common name for several different therapies that share common elements. Techniques and methods in SFT may differ substantially in each particular case, but the differences are not serious enough to produce a new kind of therapy. By contrast, CBT is an attempt to unite two rather different philosophies, and therefore the forms of CBT differ sufficiently to address them as separate therapies. Thus, the Rational Emotive Behavioral Therapy (REBT) (Ellis, 1975), the Cognitive Therapy (CT) (Beck, 1975), the Community Reinforcement Approach (Meyers & Smith 1995), the Relapse Prevention Therapy (Carroll, Rounsaville & Keller, 1991), the Dialectical Behaviour Therapy, Self-Instructional Training, Schema-Focused Therapy and many others are popular independent therapies, but each of them can be referred to as CBT despite the evident differences. Main Discussion Since its formal emergence as a recognised intervention strategy in the mid-1980s, SFT has been repeatedly reported to be an effective option across the variety of option, problems, and settings. The first series of studies to verify the effects of SFT was carried out by Steve de Shazer in the 1980. The studies employed the follow-up design and used clients' assessment of their own progress to report the average success rate of 70%-80% (de Shazer, 1985; 1986). The most recent study published by de Shazer and Isebaert in 2003 presents the results of another follow-up study of male alcoholics conducted in an adult inpatient unit in Belgium. The researchers surveyed 118 patients who had been treated in the program at 4 years post-discharge via telephone, and found out that 84% of the respondents demonstrated significant improvements with 50% of this group reporting abstinence and 34% controlled drinking. The self-reported findings were confirmed by the answers of family members and relatives where possible (de Shazer & Isebaert, 2003). Later studies report, for most part, similar outcomes though some variance in effectiveness rates is observed. Jane Lethem, a clinical psychologist working with children, adolescents and their families, provides evidences that SFT is effective in addressing such problems as home violence and traumatic childhood experiences (sexual abuse) in clinical setting (Lethem, 1994). Robert McNeilly (2000) describes several hundred instructive case studies illustrating the effectiveness of SFT techniques in dealing with such problems as depression, anxiety, eating disorders, insomnia, stress, and other common behavioural disorders. One of the latest studies reports data collected from 277 cases involving 140 male and 137 female patients. The data analysed with references to such variables the number of sessions and the degree of problem resolution demonstrate that such factors as the number of presenting problems, number of stressors, and availability of simultaneous pharmacological treatment determine the number of sessions the patient should attend to achieve positive outcomes. Patients suffering from non-affective disorders tend to show the impressive 76% of positive outcomes after only 2.3 sessions while patients with affective problems have more difficulties in coping with their problems through SFT: almost 61% of positive outcomes after 4.14 sessions (Reimer, & Chatwin, 2006). This very solid research generally confirms the high percentage of positive outcomes reported by previous studies, and reinforces the reputation of SFT as a brief but effective therapy: the average number of sessions attended by the patients is relatively low as compared with other therapies (e.g. psychoanalysis or cognitive-behavioural). Eakes (1997) reports effectiveness of family-centred SFT in treatment of chronic schizophrenia. The study employs a comparison design involving three groups (experimental, control, and reflecting) 5 patients and families each, and demonstrates significant improvement in the members of experimental group on such parameters as inexpressiveness, active-recreational orientation and incongruence. In another credible randomized trial of the effect of short-term psychodynamic psychotherapy and SFT during a one-year follow-up, Knekt and Lindfors (2004) report higher effectiveness of SFT for personality disorder. However, while the existing case and follow-up studies largely highlight the effectiveness of SFT in addressing a number of mental problems some scholars observe serious methodological gaps in the SFT related research. Methodological vulnerability is probably the most important among them. For example, this problem is emphasized in one of the first reviews of the result research publication on SFT carried out by Gingerich and Eisengart (2000). The authors managed to find only 15 controlled outcome studies and only 5 out of these 15 were found methodologically sound. Although the whole batch of studies included in the review shows similar results in terms of SFT effectiveness the quality and number of the existing literature does not provide sufficient evidence for the authors to make any conclusions other than the studies under review "do provide preliminary support for the idea that SFBT may be beneficial to clients" (p. 495). Therefore, while effectiveness of SFT is regularly demonstrated in the literature the lack of methodologically sound efforts such as credible randomized control studies is needed to determine the level of SFT effectiveness in treatment of various mental problems. Despite the growing body of publication sin the field the existing studies do not provide data sufficient to question the conclusion made by Gingerich and Eisengart. By contrast, CBT is probably the most intensively studied psychological intervention in modern psychotherapeutic research. Such status of CBT is largely due to relatively long history of use and very broad scope of application: the variety of therapies known under the umbrella term CBT can be used to treat almost every mental disorder though with varying effectiveness, as the existing literature suggests. The evidence base that verifies effectiveness of CBT in reducing or eliminating symptoms of psychiatric and even medical disorders is versatile and huge: for example, the number of clinical studies that found various versions of CBT effective for many problems in children and adolescents exceeds 4 hundred. Credibility of the findings reported by these studies is confirmed by the National Institute for Health and Clinical Excellence which officially recommends CBT as the preferable treatment option for such problems as major depression, post-traumatic stress disorder, Obsessive-compulsive disorder, eating disorders (bulimia and anorexia), and others (Reinecke, 2003). CBT is also successfully used in adult treatment for such serious conditions as anxiety disorders and psychotic disorders. One of the latest reviews carried out by Durham et al (2005) explores the long-term outcomes of participants in clinical trials of CBT for anxiety disorders (one generalised anxiety disorder, four with panic disorder and one with post-traumatic stress disorder) and schizophrenia. The review included 10 randomised, controlled, clinical trials of CBT conducted from 1985 and 2001 in Scotland. The authors report that the long-term positive outcomes of CBT interventions for anxiety disorders largely depend on the complexity of the presenting problems and the therapist's ability to strictly follow the formal treatment strategy. At the same time, short term effectiveness of CBT is confirmed by almost every study included in the review (Durham et al, 2005). The effectiveness of CBT in many other psychotic and health disorders in adults population has been demonstrated by an impressive number of randomized controlled trials and several meta-analyses (Beck, 1997; Christophersen & Mortweet, 2001; Shaddish et al, 2000; Mitte, 2005). Despite availability of a very solid evidence base confirming efficacy of CBT the research in this field still continues with high degree of intensity. However, the focus of contemporary studies tends to be more specific than in the traditional trials in order to investigate the efficacy of specific CBT version for treatment of specific disorders. Evidently, such research will benefit the existing CBT practices by improving its outcomes in some highly specific cases that have not been covered by the previous studies. Conclusion Although both SFT and CBT are commonly addressed as evidence-based approaches, the existing bodies of credible evidences to support efficacy of each approach can hardly be compared. Evidently, SFT is a 'younger' form of psychotherapy than CBT, and this is one of the reasons for the insufficient amount of credible efficacy studies. However, this seems to be only one contributing factors while other have nothing to do with the history of research. One of the most essential drawbacks associated with SFT is lack of rigorous and clear specification of this treatment strategy. Although many studies state that SFT was delivered as a treatment, "...it is often difficult to know exactly what was done in session and how comparable the therapy is across studies" (Trepper et al, 2006: 134). Given the prevalence of comparative studies in SFT efficacy research, it is clear that this problem should be addressed as soon as possible by designing a clear specification for this intervention strategy. The attempts to adequately define SFT have been recently undertaken in Europe and America which suggests the researchers are fully aware of the critical importance of this step for obtaining really credible evidences of SFT efficacy. By contrast, CBT researchers do not have to cope with this problem because despite numerous variations within this therapeutic approach each of them has clearly defined techniques effectiveness of which can be verified with relative ease. Development of easily measurable goals has traditionally been one of the core features of CBT research (Beck, 1975). This represents a serious advantage as compared with the lack of rigorous SFT framework which undermines measurability of the SFT outcomes and thus limits the options for improvement. Consequently, the evidence base of CBT and SFT efficacy can hardly be compared either qualitatively or quantitatively: the amount of methodologically sound randomised control studies of CBT efficacy is much larger than the overall body of SFT efficacy research. However, while lack of the formal definition and clearly identified measurable goals are normally perceived as the drawback of SFT, in some cases this may be considered as a strong point which provides the therapist with more flexibility in terms of treatment. One often cited weakness of CBT efficacy studies must be mentioned in this regard too. The problem is that absolute majority of evidences in support of CBT efficacy comes from the trials involve patients with only one mental or general condition. Evidently, such approach facilitates the process of research, but unfortunately such purity of condition is a rare case in modern clinical practice (Carroll, 1998). Despite the lack of methodologically sound, well-controlled clinical trials in the field of SFT efficacy, the existing literature allows for at least two important conclusions: SFT does demonstrate positive outcomes, though difficult to measure, in treatment of numerous mental conditions. Specific nature of SFT, coupled with its great flexibility and short continuance makes this option the best alternative in some cases where other therapies are likely to be less effective At the same time, the need for better quality clinical-trial research measuring the efficacy of SFT in treatment of specific disorders is required to validate the existing findings. Furthermore, serious comparative studies are also needed in order to understand the key differences/drawbacks/advantages of SFT as compared with CBT and other popular interventions. Yet one of the major advantages of SFT over CBT is evident even now: it is less costly and requires less treatment sessions to achieve positive results. 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