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Psychological problems frequently occur in people with intellectual disabilities (ID). Compared with the general population, people with ID are reported to experience behaviour problems and/or psychiatric disorders twice as often (Cooper et al. 2007). Recent research and clinical practice experience reports have shown that clients with ID can benefit from individual, couple, family and group psychotherapy. For example, Beail et al. (2005) posited that psychotherapy is effective for people with ID, and demonstrated reduced psychological distress and interpersonal problems as well as increased self-esteem.
One approach used in psychotherapy, Solution-Focused Brief Therapy (SFBT; De Shazer 1985), has gained popularity over the past 25 years. SFBT is a short-term, goal-focused and client-directed therapeutic approach that helps clients focus on solutions rather than on problems. In SFBT, the client is considered an expert with regard to his or her own situation. One of the central premises is that the goal of the therapy is defined by the client and that he or she has the competences and resources to realise this goal. The therapist is an expert in asking solution-focused questions that stimulate the client to formulate his or her goal. The attitude of the therapist is one of ‘leading from one step behind’ and ‘not knowing’, meaning that the therapist asks questions and does not give advice. The therapist encourages the client to describe progression towards the therapy goal in small, specific, behavioural steps. The therapist also suggests tasks such as ‘continue with what is already working’ in order to stimulate or maintain changes. At the start, variations in the relationship with the client (i.e. whether it is a visitor, complainant or customer relationship) are identified. In a visitor relationship, the client is referred to the therapist by others, has not voluntarily sought help and is not experiencing emotional difficulties. In a complainant relationship, the client is experiencing emotional difficulties, but does not (yet) see him- or herself as part of the problem and/or the solution. In a customer relationship, the client does see him- or herself as part of the problem and/or solution and is motivated to change his or her behaviour. Each type of relationship requires different approaches by the solution-focused therapist towards the client. For example, in the visitor relationship the therapist may ask what the client thinks the person who referred would like to see changed in his or her behaviour and to what extent the client is prepared to co-operate. In the complainant relationship, the therapist acknowledges the client's difficulties and gives suggestions for observing the moments when the problem is or was present to a lesser extent. In the customer relationship, the client may be given a behaviour assignment (e.g. ‘continue with what is already working’). More information about SFBT is given in the treatment protocol in the Method section.
Two meta-analyses reports have reviewed SFBT outcomes in the general population across a wide range of studies. Stams et al. (2006) conducted a meta-analysis of 21 studies investigating the effects of SFBT, using Cohen's d to measure effect sizes. This meta-analysis found an overall small effect size for SFBT (Cohen's d = 0.37; 95% confidence interval: 0.19 < d < 0.55, P < 0.001). Studies that compared SFBT with ‘no treatment’ (n = 4) yielded a medium effect size of Cohen's d (d = 0.57; P < 0.01). Studies that compared SFBT with other treatments (n = 7) yielded a small effect size that was not statistically significant of Cohen's d (d = 0.16; not significant). Kim (2008) conducted a second meta-analysis examining the effectiveness of SFBT (22 comparison group studies) for different types of outcomes: externalising behaviour problems, internalising behaviour problems and family or relationship problems. This meta-analysis found small but positive treatment effects favouring the SFBT groups. However, only the overall weighted mean effect size for internalising problems, such as depression, anxiety, self-concept and self-esteem, was statistically significant at the P < 0.05 level, indicating that the treatment effect of the SFBT groups was better than that of the control groups. SFBT appeared to be less effective with externalising behaviour problems such as hyperactivity, conduct problems, aggression, and family and relationship problems. In a review of SFBT outcome research Gingerich et al. (2012) stated: ‘SFBT is as good or slightly better than other accepted treatments, but it is clearly better than no treatment at all’ (p. 106).
Solution-Focused Brief Therapy has a number of advantages that makes it attractive for use in people with ID. These include a focus on the person's empowerment and skills rather than on deficits, unique interventions for each person based on particular skills and needs, and recognition of the expert status of the individual resulting in a sense of self-efficacy within the therapeutic relationship (Roeden et al. 2009). In addition, MacDonald (2007) found no statistically significant differences in the effects of SFBT between socioeconomic groups. This is an important finding, as all other psychotherapies are more effective for clients from higher socioeconomic groups (Meyers & Auld 2006), whereas individuals with ID often belong to the lower socioeconomic segments of the community.
To improve the applicability of SFBT for people with ID, several authors have suggested modifications to SFBT as originally described by De Shazer (1985). These recommendations include the use of simple language, flexibility in questioning, and allowing the person with ID enough time to answer questions, develop ideas and reflect on what transpires during the sessions. Also advantageous is using visual aids such as emoticons and drawings, involving carers and family, encouraging and explaining tasks, and adapting task assignments (Teall 2000; Stoddart et al. 2001; Corcoran 2002; Lentham 2002; Murphy & Davis 2005; Smith 2005, 2006; Westra & Bannink 2006a, 2006b; Roeden & Bannink 2007; Roeden et al. 2009).
Several process studies found that SFBT techniques increase clients' resilience, optimism and self-control (Beyebach et al. 1996; Shilts et al. 1997; Corcoran & Ivery 2004; Quick & Gizzo 2007). For example, Quick & Gizzo (2007) interviewed 108 clients who were receiving SFBT. The clients credited the therapy model with making them more optimistic and resilient. By the end of the last session, they felt statistically significantly more in control of the problems for which they had sought SFBT. Research literature on the effects of SFBT in people with ID is scarce, but the available literature reveals some promising positive treatment effects. Stoddart et al. (2001) reviewed 16 people with mild to borderline ID receiving SFBT. Clinicians rated the degree to which the outcomes as ascertained from client records were successful on a five-point Likert-style scale (1 = unsuccessful to 5 = very successful). Using this method, problems relating to poor self-esteem, family relationships and bereavement were most successfully treated with SFBT (success ratings 3.7–5.0), whereas depression and anxiety, couple conflict and independence issues showed the least improvement (success rating 2.0–3.3). Roeden et al. (2011) undertook 10 case studies of applications of SFBT in people with mild ID (MID). It was found that SFBT treatments contributed to improved psychological functioning and decreased maladaptive behaviour. In addition, goal attainment was reported by both people with MID and their carers. The positive changes evident shortly after SFBT proved sustainable during follow-up. Both studies, however, are subject to limitations because of the lack of control groups, which means it is possible that the treatment effects could have been reached without SFBT as well.
More research is clearly needed regarding the effects of SFBT in this population. Thus, we conducted a controlled pre- and post-test study with 20 people with MID receiving SFBT and 18 people with MID receiving care as usual (CAU). We expected that SFBT could help people with MID in (1) reaching treatment goals; (2) improving quality of life; (3) reducing maladaptive behaviour; and (4) increasing resilience. We therefore investigated differences in these variables in both groups (SFBT and CAU) at several points in time: before starting SFBT, directly after SFBT and 6 weeks after SFBT.
The key questions in this study were: ‘To what extent do clients in the SFBT group reach their treatment goals, and to what extent does the SFBT group outperform the CAU group with regard to improved quality of life, reduced maladaptive behaviour and increased resilience?’.
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A total of 20 clients received SFBT. Eighteen clients completed the therapy and two dropped out of treatment (see ‘Reasons for dropout’ below). These dropouts did not complete the measurements directly after SFBT or at follow-up. Eighteen clients received CAU. To rule out possible initial differences, the two groups were compared for age, IQ and adaptive functioning. No statistically significant differences were found between these characteristics (see Table 1). Moreover, no statistically significant differences were found between the SFBT (n = 18, excluding two dropouts) and the CAU group with regard to pre-treatment mean scores of relevant measurements: IDQOL-16 [SFBT: 57.7 (SD = 6.7) versus CAU: 61.4 (SD = 7.4); z = −1.6, P = 0.11], RSMB [SFBT: 11.6 (SD = 7.4) versus CAU: 9.6 (SD = 8.6), z = −1.1; P = 0.26] and POS [SFBT: 29.3 (SD = 3.7) versus CAU: 29.5 (SD = 3.3); z = −0.10, P = 0.93].
Table 1. SFBT and CAU groups according to sample size (absolute numbers), dropouts, age, IQ, adaptive and maladaptive functioning (means and SDs)
|Characteristics||Study group|| |
|Sample size||n = 20||n = 18|| |
|Dropout||n = 2||–|| |
|Age||43.4 (SD = 16.4)||41.5 (SD = 12.6)||z = −0.1, P = 0.92|
|IQ||61.3 (SD = 6.4)||62.9 (SD = 4.9)||z = 0.8, P = 0.44|
|Adaptive functioning†||6.6 (SD = 0.8)||6.9 (SD = 0.8)||z = 1.1, P = 0.27|
Table 2. Within-group differences (SFBT and CAU) in psychological and social functioning (IDQOL), maladaptive behaviour (RSMB), autonomy and social optimism (POS) of the before, after and follow-up measurements and mean changes
|Measurement||n||Group||Before Mean Ratio*||After Mean|| |
Mean change before vs. after;
|n||Follow-up Mean Ratio*|| |
Mean change before vs. follow-up;
|18||SFBT|| ||19.9|| ||16|| || |
|18||CAU|| ||17.7|| ||16|| || |
| ||18||SFBT|| ||23.3|| ||16‡|| || |
|18||CAU|| ||23.3|| ||16|| || |
Cut-off score for maladaptive behaviour = 7
|18||SFBT|| ||5.9|| ||18|| || |
|18||CAU|| ||8.3|| ||18|| || |
Range for policlinic low-educated people: [15–23]
|14**||SFBT|| ||22.3|| ||14|| || |
|18||CAU|| ||20.1|| ||16|| || |
Range: Range for policlinic low-educated people: [7–11]
|14||SFBT|| ||10.5|| ||14|| || |
|18||CAU|| ||9.7|| ||16|| || |
Two clients dropped out of treatment for different reasons, which they indicated on the dropout list within 3 days of discharge. The first client reported the following two reasons for dropping out: (1) trust in the treatment was gone and (2) the treatment was stopped because of a disappointing working relationship with the therapist. The second client also gave two reasons: (1) the treatment was stopped as a result of pressure by the family or partner and (2) the treatment was not a personal choice. Both clients were asked, but chose not to fill in the IDQOL and POS questionnaires, leaving data from 18 SFBT clients for the statistical analyses.
Goal attainment (or progression towards the goal) was measured by using the SQP. No SQP data were available for the CAU group, as no goals were formulated in CAU. During the intakes, the following problems were reported by the participants and/or their staff in the SFBT group: alcohol abuse (three clients), anger (two clients), bereavement (two clients), depression/apathy (two clients), sleeplessness (one client), low self-esteem (three clients), avoidance/anxiety (one client), couples conflict (two clients) and self-help issues (two clients). The two dropouts reported problems with being in public places and being inactive in social relationships. During the first session, all clients formulated treatment goals, prompted by the solution-focused key question: ‘What do you want to see instead of the problem?’. This led to the following goals addressing the problems mentioned above: alcohol control (three clients), anger management (two clients), coping with bereavement (two clients), happiness/initiative (two clients), a good night's sleep (one client), self-confidence (three clients), courage (one client), a good relationship (two clients) and mastering self-help or aspects thereof (two clients).
Thirteen of 18 clients showed progressions of two points or more on the SQP after SFBT, as did 14 of 18 clients at follow-up. The differences in the scores of the 18 clients were statistically significantly higher after SFBT (mean progression +2.2 points; z = −3.8; P < 0.01) and at follow-up (mean progression +2.4 points; z = −3.7; P < 0.01). The remaining clients showed less improvements on the SQP (after SFBT, one client +0.5 point and four clients +1 point; at follow-up, one client zero points and three clients +1 point).
Differences within groups
The differences in scores for both the SFBT and CAU groups for all measurements are presented in Table 2. At the start of the study, both groups had average scores in the lowest quartiles of the quality of life measures, indicating low satisfaction ratings on psychological and social functioning. The initial average resilience scores of both groups also fell within the lower (‘poli-clinic’) ranges. Before SFBT, the problems reported in both the SFBT group and the CAU group fell within the clinically significant range (average scores for maladaptive behaviour 11.6 and 9.6 respectively, both higher than the cut-off score of 7).
After SFBT the SFBT group performed better (Wilcoxon test: P ≤ 0.01), on psychological functioning (IDQOL-16), reduced maladaptive behaviour (RSMB) and autonomy (POS). After SFBT, positive changes were evident in 16 of the 18 clients for psychological functioning, in 11 of 18 clients for social functioning, in all clients for reduced maladaptive behaviour, in 11 of 14 clients for autonomy, and in 8 of 14 clients for social optimism (Sign test: P < 0.01 for all measures). In contrast to the CAU group, the mean maladaptive scores receiving SFBT dropped even below the threshold of seven points after SFBT and at follow-up. Albeit that at group level no statistical significant differences were seen in the CAU group (Wilcoxon test: P > 0.05), some clients in the CAU group showed positive changes in psychological functioning, social functioning, reduced maladaptive behaviour, autonomy and social optimism (after SFBT measurement), respectively, 8, 3, 10, 5, 3 (of 18 clients). The same was true for measurements at follow-up (improvement in respectively 9/16, 3/16, 8/18, 7/16, 2/16 clients).
At follow-up, the improvements in psychological functioning, reduced maladaptive behaviour, autonomy were sustained in the SFBT group (in 13 of 16, 16 of 18 and 10 of 14 clients respectively; Sign test: P < 0.01). The effect sizes were at least medium. The changes after SFBT for social optimism were positive in 8/14 clients and just reached statistical significance at group level (P = 0.01), but did not at follow-up (P = 0.07 at group level; at individual level, 9/14 clients showed positive changes).
Changes in social functioning after SFBT and at follow-up did not reach statistical significance in the SFBT group (P = 0.04), although there were medium effect sizes. There were no statistically significant changes in social functioning and social optimism in the CAU group (P > 0.05).
Differences between groups
The key issue in this study is whether or not the changes in scores between the measurements differ between the SFBT group and the CAU group. Table 3 shows the results of these analyses. Not all clients completed all questionnaires in full: the exact number of respondents is given in the relevant tables. For this reason, the pairs of observations differed to some extent within and between groups in Tables 2 and 3. The analyses revealed that the SFBT group performed better than the CAU group directly after SFBT with regard to all key variables: psychological functioning, social functioning, maladaptive behaviour, autonomy and social optimism (differences between groups for all variables P < 0.01). The effect sizes were large, medium, large, medium and large respectively. At follow-up, the differences were no longer statistically significant for autonomy and social optimism (P = 0.19 and P = 0.05 respectively). However, the results were sustained at follow-up for psychological functioning, social functioning and maladaptive behaviour (P < 0.01). The effect sizes for these three variables were medium, medium and large respectively.
Table 3. Between-group differences (SFBT versus CAU) in psychological and social functioning (IDQOL), maladaptive behaviour (RSMB), autonomy and social optimism (POS) of the before, after and follow-up; number of clients and mean changes
|Measurement||n||Group||Mean change after SFBT|| ||n||Mean change at follow-up|| |
|IDQOL||Psychological functioning||18||SFBT||+3.5|| ||16†||+3.7|| |
|Social functioning||18||SFBT||+1.4|| ||16||+2.4|| |
|RSMB||Maladaptive behaviour||18||SFBT||−5.7|| ||18||−4.9|| |
|POS||Autonomy||14†||SFBT||+2.5|| ||14||+2.3|| |
|Social optimism||14||SFBT||+1.0|| ||14||+1.1|| |
It may be concluded that SFBT offers improved results in the areas of psychological functioning, social functioning and maladaptive behaviour than CAU. The results for autonomy and social optimism (resilience) were not sufficiently sustained at follow-up.
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The results of this study indicate that SFBT can be considered as a valuable contribution to the support strategies offered to people with MID. Most clients in this study showed clinically relevant progressions (more than two points on a 1–10 scale) towards their treatment goals after SFBT (13 of 18 clients) and at follow-up (14 of 18 clients).
Directly after therapy, the SFBT group showed greater improvements than the CAU group on psychological functioning, social functioning, maladaptive behaviour, autonomy and social optimism. At follow-up, 6 weeks after therapy, the improvements on the first three measures mentioned were sustained. Overall, these results are similar to recent SFBT outcome research in the general population, showing that SFBT is more effective than ‘treatment as usual’ (MacDonald 2007; Gingerich et al. 2012) with medium effect sizes (Stams et al. 2006).
This study has some limitations concerning the choice and type of outcomes, the length of the follow-up period, and the research design. The first issue to consider is that any choice of standardised instruments automatically implies restrictions. During SFBT, each individual formulated his or her own goal. It is possible that the chosen goal did not sufficiently match the measuring pretention of the instruments used. This does not apply to the SQP, because this measurement adjusts itself to the individual's goal. However, it does hold true for the IDQOL and the POS, as the quality of life domains and the resilience domains within these instruments were broad and could differ from what people with MID considered to be relevant outcomes. The fact that SFBT had minimal effect on, for example, social optimism, may confirm this thought. Second, it is difficult to conclude from this study whether the improvements attributed to SFBT can hold over time. Although gains were made through the interventions, it remains uncertain whether these improvements will last over time (e.g. longer than 1 year). Another consideration is that the choice and allocation of participants may be subject to discussion. All SFBT clients were referred by staff and not randomly allocated to both conditions. It is possible that the selected clients tended to be more co-operative in therapy and the outcomes could be more favourable to SFBT compared with a random selection. In future research, the intent will be to recruit more potential participants in a relatively shorter period of time (e.g. by collaboration with other service providers). This would enable researchers the ability to random allocation of participants to the SFBT or CAU group. Change process research can identify how clients can benefit from any particular intervention (McKeel 2012). For example in SFBT, goal setting is an important issue. In future research, it may be of interest to study to what extent this goal setting accounts for the effects, rather than really working on the goals. Additionally, measurements (in both the SBT and the CAU condition) were also administered directly by the therapists/researchers. This meant that the participants and therapists/researchers were not blinded to the treatment condition or the treatment results. Biases due to the non-random allocation of groups and non-blind assessors may have influenced the results and cannot be ruled out.
Despite these limitations, we conclude that SFBT has several strengths and advantages that makes it a useful additional approach for use with people with ID. First, SFBT focuses on skills rather than on deficits, and it recognises the expert status of people with MID. This is in line with the present view of ID that focuses on elements such as the importance of empowerment. Second, our findings support Stoddart et al.'s (2001) discussion of the strengths of using SFBT in people with ID: ‘SFBT is a highly structured, active and directive approach. It focuses on concrete and immediate issues. The approach partialises problems by setting limited and clearly defined goals, and it fosters an early and positive relationship between clients and therapists’ (p. 36). As stated in the introduction, people with ID are reported to experience behaviour problems and/or psychiatric disorders twice as often as the general population (Cooper et al. 2007). SFBT can support them in overcoming or at least reducing such problems in a structured and focused manner, emphasising the individual's unique contribution. In this study, we focused on clients with clinically significant problems. However, SFBT can also be used for less severe problems, such as housekeeping issues (see Roeden et al. 2009 for the use of SFBT with a less severe problem). Third, SFBT encourages the involvement of staff in the therapeutic process. This may help staff to develop more positive views of people with MID and to become more aware of their resilience, resources and competences, and in particular their ability to come up with solutions themselves (Lloyd & Dallos 2006, 2008). Indeed, solution-focused principles and techniques developed in a therapeutic context can easily be adapted to a staff context. This also implies possibility of using SFBT as tool for non-therapeutic coaching. As in SFBT, staff actually can develop a strengths-based mindset: focusing on solutions rather than problems, on strengths rather than weaknesses, and asking more than telling.
Solution-focused therapists can be seen as specialists who can be employed on a temporary basis to assist clients with MID in achieving their therapy objectives. These temporary contributions become more sustainable if staff works in a solution-focused manner in their everyday practice. This entails adopting a solution-focused attitude by staff and making use of solution-focused conversation skills in supporting clients. Finally, unlike other therapies, there is empirical evidence that SFBT is equally effective for all socioeconomic groups (MacDonald 2007). People with MID are often economically disadvantaged and usually belong to lower social groups; the finding that they too can benefit from SFBT is certainly encouraging.
We therefore conclude that SFBT can be regarded as a valuable therapy tool. Nevertheless, further research in this area is needed, and should involve randomisation, larger sample sizes, standardised measures, prolonged follow-up measurements and comparisons with other established therapies.