Setting goals and finding solutions
Setting well-defined goals
A well-defined goal is:
- small enough for the patient to see it as clearly achievable
- focused on what the person will do, as opposed to what the person will not do (e.g., "I will limit my drinking to two drinks per day," rather than "I will not want to have a drink.")
- focused on actions rather than feeling
- as specific as possible in terms of time and place
- described in the patient's language
- in the patient's control.
Taking a solution-focused approach
A solution-focused approach involves gently shifting the focus of the therapeutic conversation away from the problem and toward potential solutions, with a goal of increasing possibilities for change.
The aim is to stimulate a shift in the way the patient is feeling or acting toward a behaviour that is more congruent with the patient's goals and desires.
Such an approach is often criticized as being superficial – not all situations and emotions are things to be "solved." Yet for many problems, once patients have indicated that they have been heard and their feelings have been acknowledged, discussing possible ways of going forward can be both liberating and therapeutic.
Done carelessly or hastily, a solution-focused approach often increases resistance to change and makes the patient feel that the health care provider is not listening.
This approach is most useful in situations where the patient wants to change and is not interested in further analysis or explanation.
Examples of situations that are generally not appropriate for a solution-focused approach include:
- acute grief reactions
- patients who have indicated a desire to understand and come to terms with their feelings and behaviour
- patients who simply want to "get something off their chest"
- long-standing issues of sexual or physical abuse.
Scaling questions give the patient and the health care provider a sense of how the patient is feeling about something. Most physicians are familiar with scaling a patient's experience of pain, but scaling questions can also be used to identify resources, brainstorm solutions, set goals and increase talk about change. It is important to ask the question very clearly, with understandable end points that the patient can gauge.
- "On a scale of 1 to 10, where 10 is the most important thing for you and 1 is the least important, how important is this for you right now?"
- "On a scale of 1 to 10, where 1 is the worst you have ever felt and 10 is the best, where would you put your mood, on average, over the past week?"
It is helpful to follow up by exploring the patient's response.
- "Why did you say 4 rather than 1 or 2?"
- "What would you need to do in order to get from a 4 to a 5?"
- "How would you know that it had moved from a 5 to a 6?"
Exception-finding questions: Looking back for solutions
The process of searching for exceptions to the problem introduces the idea that if the problem is not always occurring, there may be potential solutions that are not being noticed.
The following sorts of questions tend to elicit alternative views of the problem:
- "Have there been any times, even for just a moment, when the problem didn't happen?"
- "Can you think of any other times, either in the past or in recent weeks, that you didn't have the problem?"
- "What's different about the times when the problem doesn't occur?"
- "What would you say you are doing differently during those times?" (if the patient takes an active role in making the exception happen)
- "What would have to happen for that to occur more often?" (if the patient takes a more passive position)
Preferred future questions: Looking forward to solutions
This type of question takes patients out of the past and encourages them to think about the future. This is sometimes helpful when patients are mired in the problem and find it difficult to remember exceptions.
- "How would you know if the problem was a little bit better?"
- "What would you be doing?"
Often patients feel either that change is not possible or that it is beyond their control. In those situations, asking patients how they are coping or managing helps them to identify resources that they have perhaps ignored or forgotten.
- "With all that has been happening in your life lately, I'm wondering how you've managed to get through each day?"
- "How are you managing to cope with all this?"
- "It sounds as though you are a strong person. Would you agree?"
Alternative perspective questions
Some questions can help patients look at their problem through a fresh set of eyes and shift their point of view.
- "If I were to ask your best friends what they think you would be doing if the problem was a little better, what do you think they would say?"
- "What would your partner notice about you if you were feeling a little bit more confident about quitting smoking?"
Asking solution-focused questions
The way you ask the question is as important as the content. Depending on the tone, the same question can sound curious, patronizing or confusing.
Sometimes you have to ask several questions, in different ways, to generate a potential solution.
The goal is to try to elicit a clearly defined, observable behaviour that might form the basis of a possible solution. In other words, you are trying to encourage the patient to behave "as if" the problem was getting better (e.g., "You say that if the problem was better, you would be taking care of yourself. How would you start to do this?").