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Hains, D., Kowalski, K., & Krogull, M. (2024). Beyond Technique: Maggie’s Story of Determination, Resilience and Growth Through SFBT and a Focus on the Therapeutic relationship. Journal of Solution Focused Practices, 8(2). https://doi.org/10.59874/001c.124265

Abstract

This paper provides insights and reflections on the use of Solution Focused Brief Therapy (SFBT) over 16 months to assist a client with both a complicated history and complex needs. However, this is not a typical case study. The purpose of this paper is not to provide details about SFBT or a detailed analysis of the conversation within the sessions, but rather to provide perspectives from each of the people involved: the client (Maggie), the clinician (David), and the mother (Kate). Each of these people have expertise in their own right, but Kate has a fourth and very unique perspective as one of the early team members of the Brief Family Therapy Centre of Milwaukee in the 1980’s.

In this paper, we will refer directly to sessions as well as emails and activities that occurred between sessions. Our aim is to show that SFBT is an approach that can be used in long-term therapy and in complex situations, emphasising that a flexible and tailored approach is required, and that the therapeutic relationship is an integral part of the therapy.

About the Authors

About David

DH: I am a Registered Nurse in Adelaide, Australia and started using the Solution Focused approach in 2014 when I was working in a Tertiary Hospital Emergency Department (see Durrant, 2016). After a two-day workshop with Michael Durrant I became hooked, and I am now one of many people in Australasia who are indebted to Michael for sharing his knowledge and enthusiasm. In the following years I started a SFBT Community of Practice in Adelaide, and then a small training business (www.leftturnsolutions.com.au). From 2018 to 2022 I had the privilege of being President of the Australasian Solution Focused Association (ASFA) as well as the Chair/Manager of the Journal of Solution Focused Practices. I currently work in a single session therapy (SST) clinic in a youth mental health organisation, so it is very unusual for me to see a client for more than 3 sessions.

About Kate

KK: I have a dual role in this project. First, as Maggie’s mother and a participant in her therapy sessions with David. Second, as a Solution Focused practitioner with a history with the approach dating back nearly 40 years.

In 1985-86, I participated in the year-long intensive training program offered by the team at the Brief Family Therapy Center (BFTC) in Milwaukee and was privileged to have Eve Lipchik as my supervisor and mentor. I am grateful for the life-changing connection with Eve, both professionally and personally, as we continue to share a deep friendship. Following training, I was honoured to be invited to join the BFTC staff. After visiting Australia in 1987, I made the decision to move to Sydney to join Michael Durrant’s therapy practice where I conducted Solution Focused therapy and training beginning in 1989. Upon returning to Milwaukee in 1991, I worked as a therapist at Family Health Plan, a health maintenance organisation, with the team led by two of the early collaborators in the development of SFBT: Don Norum and Marilyn La Court. My career eventually evolved, and I shifted my focus to administrative, programmatic, and education-focused roles in social services and higher education, retiring from the University of Wisconsin in 2019. Thirty-nine years after first training at BFTC I am again engaged with Solution Focused work, this time as a professional coach accredited by the International Coaching Federation (ICF) and the European Mentoring and Coaching Council (EMCC). As an early voice in SFBT and as someone who participated in the early dissemination of the approach in the U.S. and Australia, I feel like life has come full circle.

About Maggie

MK: I’m Maggie and I’m 29 years old. I’m autistic which means I see and experience the world differently than most people. One of my hobbies is reading, especially fan fiction. Growing up, my parents could always tell when I was reading fan fiction because of the look on my face. My mom called it my “look of delight” or “fan fiction face” that instantly told her that I was reading and not doing my homework. Reading fan fiction has helped me over the years to deal with my numerous health problems and chronic pain. I also love doing arts and crafts as well as baking because I like being creative and I like that the step-by-step process of it helps to calm and relax me. I also enjoy making people happy, and since the rule in our house is that anything I bake has to leave the house, I enjoy the process of choosing who gets what I bake.

I am happy to be part of this project. Talking with David has been very helpful and I’m glad we found him. I really appreciate that he was willing to take me on as his first long-term client. I’m thankful for how far I’ve been able to come with his help.

Maggie very much wants her story to be shared so that others, both clinicians and more importantly clients, might benefit from her experiences. As such, she has given permission to use her name, details about her life, and for us to directly quote from sessions and emails. Steve (Maggie’s father) has also given his consent.

Why we wanted to write this paper

DH: I have not only really enjoyed working with Maggie and her family, but I was also completely amazed by what she has been able to achieve. Reflecting on our sessions, I wanted to explore how it all happened. So, in true SFBT style, I wanted to know what was working so I could keep doing it.

Within Maggie’s story was a very unique aspect. Maggie had asked her parents Kate and Steve to sit in on every session which itself proved to be invaluable. But Kate was now seeing the approach being used to help her daughter. I was curious about Kate’s perspectives, both as a mother and as a clinician and previous member of the BFTC. I wanted to know what was happening in real life between the sessions. I wanted to know Kate’s thoughts on what was working, and why. I wanted to know more about the history of SFBT and the development of the approach. I also wanted to know what worked from Maggie’s perspective, because in SFBT literature the voice of the client is noticeably absent. I started to get an idea that this was a story that needed to be shared.

KK: I have seen many SFBT sessions over the years, starting at the BFTC watching Steve, Insoo, Eve, Elam, Wally and others, but this was the first time that I had encountered the approach with my own family. It proved to be a fascinating experience - not only to see David’s approach, but also to reflect on my perspective both as a mother and as a practitioner. The experience has opened up a new understanding of SFBT.

My main purpose in this project is to share how SFBT can be used to make a positive difference in the lives of people dealing with lifelong chronic health and developmental issues, and their families. This is a story that can add to the current literature on SFBT, showing how the approach can be beneficial with people living with complex and long-standing issues. Furthermore, SFBT is not to be seen only as a “brief therapy”, and we want to share how the approach can be used over a longer period of time and bring about continued results.

The initial referral and historical information

MK: From the time I was born, and even before, I have had a lot of health challenges. I was born 10 weeks premature due to pregnancy complications and I’ve been in pain almost every day of my life, at least as long as I can remember. When I was very little, I had a lot of stomach aches, ear infections, and headaches. When I was 10, my headaches became unbearable, and I was told I had migraines. My parents took me to a number of doctors, but nothing ever seemed to help. Over time, the migraines became chronic. I missed a lot of school because they were so bad. In my late teens I developed very bad pain in my joints that made it hard to be active. Before that, I loved riding my bike and playing outside. But the joint pain, combined with the migraines, made that difficult. I was eventually diagnosed with fibromyalgia, and it turns out that people who have migraines often have fibromyalgia, too.

The scariest health problem started when I was 22 and I found a lump on the side of my breast. Everything moved pretty fast after that. I had an ultrasound, a mammogram, a biopsy, and then a breast MRI. I was diagnosed with an aggressive form of cancer. Three weeks after being diagnosed I started chemotherapy, and I had six rounds of chemo before having a partial mastectomy. I had to have a second surgery since they didn’t get a wide enough margin after the first one. After recovering from surgery, I started 7 weeks of daily radiation treatments. When that was done, there was more chemotherapy to follow. The treatment lasted 18 months.

Since then, I’ve lived with the fear of having a recurrence. The fear was so bad and I had so many scares that two years ago I decided to have a double mastectomy. I feel very good about the decision and don’t have any regrets. I also decided to have a hysterectomy late last year after developing very painful endometriosis about 18 months ago. There are other health challenges I could write about, like the severe bone pain I developed after receiving one of the Covid vaccines. I’m also constantly tired both because being in pain is exhausting and because a number of the medications I take cause fatigue.

KK: In late 2022 Maggie started thinking about seeing a therapist again. She had seen a number over the course of her life but was often left disheartened by some who didn’t seem to understand the extent to which her developmental challenges, multiple health issues, and chronic pain affect her life. Maggie particularly felt unheard about her lifelong health struggles, so it was extremely important to her that any future therapist truly appreciated these challenges.

I had long felt that Maggie would benefit from working with a Solution Focused therapist, but finding someone with that background was difficult - even in Wisconsin, the home of SFBT. But in this post-Covid period with virtual meetings having become commonplace, we were no longer constrained by geographic boundaries. I began considering the various Solution Focused practitioners around the world that I could potentially reach out to.

I was aware of David through his roles with the Journal of Solution Focused Practices and the Australasian Solution Focused Association. I had read his biography and watched a video in which he was interviewed about his work (Family Based Solutions, 2021). I was impressed by what I learned and particularly took note of David’s training and experience as a registered nurse who utilises a Solution Focused approach. So, with Maggie’s permission, I reached out and asked David if he would consider working with her.

DH: When the first email from Kate arrived, my first thought was “why have you gone past 10,000 perfectly good SF-practitioners and approached me?” I didn’t know who Kate was apart from being a mother, but I knew she had some knowledge of SFBT. It was only after the first session that I realised Kate’s history with the BFTC, and I wonder if I would have run the first session differently if I had known this.

The second email from Kate arrived on a Sunday morning (see appendix 1). In the first session I referred to this email as “the manifesto”. Kate acknowledged that the information she was providing would “be quite problem-saturated”, but that it was important to Maggie that I knew a lot of her history. Kate also included information about Maggie’s strengths and resilience, but I didn’t really take this into account as I was completely stumped by the long list of problems that had started in utero and built throughout her whole life. I spent the whole day contemplating this, and with a heavy heart and a buzzing head my only thought was: “What the heck can I do?” I carried this with me for the whole day.

I should note that in my other job I would typically pay little attention to the referral information. As a SFBT therapist, I was taught that you don’t need to know the problem in order to find a solution. I have previously found that a focus on referral information often distracts me from doing Single Session Therapy (SST). The more I focus on the complexity of a situation, the less confident that I am in assisting within a single-session framework and thus it impacts on the session delivery.

Somewhere between here and our first session I decided that there was nothing that I could do except stick to the model. Kate had suggested to Maggie that she try a Solution Focused therapist. What could I do, except give them a Solution Focused session and trust that the model works?

KK: With a background knowledge of SFBT, I assumed that David did not need to know much of Maggie’s history, but Maggie had other ideas. It was very important to her that David be aware of and appreciate the nature of the health challenges she has faced.

Writing the email proved to be more challenging than I anticipated. It wasn’t that I couldn’t remember the events or details, rather, it was more emotionally difficult than I expected to recall and explain her numerous experiences. Reflecting on it now, I realise that I only included Maggie’s health-related struggles but forgot to mention her developmental and educational challenges. By the time I finished the message and shared it with Maggie to review, I was emotionally drained. I found myself thinking that if this is how I feel writing about it, how must it feel for Maggie to be living it?

DH: I remember feeling drained when I first read “the manifesto”, but reading Kate’s words above (written almost a year after our first appointment) puts it into perspective - I was only reading it, but they were living it.

Setting up the first session, and a pre-session questionnaire

DH: Prior to the first session, I thought it was important to discuss the SST framework that I would be guided by. I explained that in my career I had only done brief therapy, and had never seen a client for more than three sessions. I would not necessarily put a limit on the sessions, but rather I would take a ‘one session at a time’ approach, and that Maggie could have as many sessions as she wanted as long as she was finding them helpful. I was aware that Maggie wanted her parents to attend the session, but I wanted to clarify if this was Maggie’s session with their support, or a family session. Finally, I asked Maggie if she would contemplate a few pre-session questions and bring some thoughts to the session:

1. What is the MAIN reason that you would like to talk to me? (a counsellor/therapist)

2. Is there a second reason that you would like to mention?

3. If talking to me was beneficial, what do you think would be different for you in the future as a result of this (i.e. as a result of meeting and working on these things, what would be different for you if we could get some or all of this under control)?

Pre-session change was an idea discussed in the early development of SFBT (Weiner-Davis et al., 1987) that proved to be useful both before our first session and several later sessions. At times, when Maggie emailed to set up the next appointment, I would ask her to consider what she wanted to talk about and how talking about this thing would be useful. These questions also helped to establish a starting point or ‘common project’ (Korman, 2017).

The last thing I asked prior to the session was if Maggie (and her family) would consider me taking a recording of the session. Given the complexities in Maggie’s life I thought that even if I couldn’t help Maggie, at the very least I may learn from the experience.

KK: I appreciated receiving David’s message with the clarifications and questions he posed. I wasn’t sure what to make of David mentioning that he typically sees clients on a short-term basis but was reassured by his comment about not putting a limit on the number of sessions. This was consistent with how I typically approached working with clients during my therapy career and now in my work as a coach.

When I checked in with Maggie, I was pleased to hear that she was already thinking about her responses to David’s questions and was going to write down her thoughts so she could be prepared for the first session. I left it at that as I was cautious not to interfere. I was happy to see during the session that Maggie had in fact written down her thoughts and was happy to share them with David.

DH: As a predominantly single session therapist I have a strong belief that for a lot of people one session is often enough, regardless of the apparent complexity of their issue. There are a few important assumptions within SST (Talmon, 1990):

  • It is impossible to guess which clients will benefit from a single session, and who won’t.

  • There is no correlation between the complexity of the problem(s) and the previous point, that is, you just can’t tell.

  • You cannot tell who is going to return for a second session and who won’t.

However, given that I had never seen a client with this level of complexity before, I was much more nervous and much less confident going into the session as I would normally be.

The First Session

DH: Generally speaking, I do have a ‘typical’ first (or single) session approach but a simple version could be summarised in just two questions:

  • What are your best hopes FOR THIS session?

  • What are your best hopes FROM THIS session?

There is only a one letter difference between these two sentences, but they are two completely different questions. The first establishes what the client wants to happen in the session, while the second and subsequent questions are about the preferred future.

The first session with Maggie was not my typical single-session approach as I spent a lot more time on rapport and relationship building, along with a good amount of validating, coping, teasing out some strengths, resources, and discussing what was already working. It also gave Maggie ample time to tell me what she wanted to talk about, but most importantly (as Maggie later explained) Maggie immediately started to feel like someone was listening to her. I didn’t realise until much later how important this was for her.

We were almost 30 minutes into the session before I asked specifically about the pre-session questions that I had sent, hoping to move the conversation towards Maggie’s “best hopes FROM THIS session”. Maggie took out a piece of paper and started reading out her responses:

M “Coping strategies for nausea, dizziness, vertigo, fatigue

M “How to function while in pain

M “Reach a goal of a better life

D “I like that one

M “Advice from someone who knows

D “Knows what?

M “Knows what being in pain means

D “I guess I know from a theoretical background, but I haven’t experienced it like you have

M “I want to be able to bake … [and] attend Culinary School … eventually … if possible … but that’s like a long term goal

D “So … which one should we start with today?

M “The balance between treatment and quality of life … being able to live your life … the quality of life thing is what I want to lift up … I’m not really expecting miracles, just a slow progress.

Within a session I am usually quick to note down words or phrases that my client uses so that I can use the exact words in subsequent questions. I try to identify words about strengths, coping, and preferred future rather than problem-orientated words. There were several words that stood out here:

  • Coping

  • Functioning

  • Better life

  • Balance (in regards to life, not vertigo)

  • Quality of life

  • Not expecting miracles

  • Wanting slow progress

I followed this up with some questions about what’s helped, and how Maggie has been coping so far. Maggie was again quick to reply with the following:

  • My family (we referred to Kate and Steve as “the elephants in the room”)

  • Find the silver linings … the good, the little things

  • Being able to help others

  • Baking

  • Making other people happy

  • Reading “almost 25/7”

At 43 minutes, I tried to get more specific about what the first few steps might look like:

D “If we could do some things, and maybe it’s about coping strategies, and something changes … and you start heading towards better quality of life, or something is a little bit better … what do you think would be the first thing or the first couple of things that you would notice that would let you know that you are heading in that direction? What would be different?

Maggie was quick to reply:

  • Not being in my room 24/7

  • Spending more time in the other parts of the house

  • Spend less time on the computer

  • Get out of the house more e.g. visit the Farmer’s Market or the pool

  • Taking steps along a path to a healthier lifestyle

Though I am not a family therapist, my boss has always emphasised the importance of using the family within therapy. So I turned to the two elephants in the room and asked them to share their thoughts about times when there have been glimpses of these things that have occurred in the past, or what might be the first sign within Maggie that would tell them that Maggie is heading towards a good place? They replied with:

  • Maggie is a positive, nurturing and caring person

  • She gets excited about seeing people and doing things

  • They can see “it” in her face

  • Doing purposeful activity rather than filling time

It was almost the end of the session and I was conscious that I hadn’t used a traditional SF-technique question. I thought a scaling question around confidence would fit well, but I didn’t get very far. Maggie was so quick to answer me before I had even set up the scale, so we didn’t actually scale in a traditional SFBT sense:

D "One more quick question, I want to ask you about your confidence in regards to how confident are you that you can move towards this better place … ?"

M (cutting me off before I even mention the scale) “I know I can do it … I just don’t always have the tools or the knowledge to know what the next step is.”

After failing the attempt at scaling, I thought it was time to wrap up:

D “Well I’ve got some good news and some bad news”

M “Yes”

D "The bad news, I don’t know what the next step is. [Maggie laughing] I don’t know how you can do it, and I’m not even going to say that I know any good strategies, I’ll be absolutely honest with you. But, the good news is that I’m happy to try and work it out with you.

M “Sounds good”

Finally, I reflected that Maggie is the expert having “walked the walk” whereas I have only read the story. However, I couldn’t help telling Maggie there was an “aura of positivity” around her, where she is always looking for “the silver lining” which she can’t help but share, and it makes people around her feel good.

After a short discussion about options for next appointments, Maggie and I shared our plans for the coming week, and we agreed that we would exchange photos of something nice that we do before we next meet (essentially this was both a homework task and a way of strengthening the relationship). Early Solution Focused literature referred to “tasks” (Durrant, 2024), and while more contemporary approaches discard the setting of tasks (as explained by McKergow, 2016), I still find this can be a powerful tool in the right context. It should be noted that the task was to notify me via email of something nice that she did before the next session, but I was otherwise not specific about what to do. I closed by saying that I was looking forward to hearing about the coming week, in an attempt to communicate a belief in Maggie’s competency and commitment.

After the first session

DH: I was a bit gobsmacked after the first session. I didn’t really think that anything I did was special at all; in fact, I was quite disappointed by my effort. Watching the video later didn’t actually change my mind on this, and I asked myself if anyone watching would even consider the session to be SFBT. I remember the sense of admiration that I had for Maggie. After reading Kate’s ‘manifesto’ I had been weighed down by a heavy heart, but now I was simply amazed by Maggie’s achievements, resilience and optimism.

In typical SST style I would usually let my client decide if they wanted another session. Maggie wanted to talk again in one week. SST would tell me to trust the process and be confident that a lot could happen in just one session, but I was still nervous about what would transpire.

Maggie followed up the session by sending me a link to her favourite TV show, Taskmaster, as well as the lyrics to a song that meant a lot to her. I followed this by sending Maggie a photo of some pizzas I had baked after our session.

KK: As a parent, both throughout the session and afterwards, I felt a sense of optimism and hope. It was quite emotional, actually, to experience the unconditional positive regard David conveyed to Maggie, and the acknowledgement he showed toward what our family has experienced over the course of Maggie’s life.

When Maggie said that it was important for her to talk with someone who “understood” her medical issues, what she meant was someone who, based on having at least some amount of medical training, would truly appreciate the implications of her multiple health issues. It was clear within a few minutes of talking with David that he did. About halfway through the session he referred back to the email I sent to him explaining Maggie’s history and shared how he felt reading it. He reflected on Maggie’s ability to have a positive outlook in spite of all she’s been through. He asked how she’s been able to remain positive given the significant challenges she’s faced. David’s comments and this question communicated a powerful validation of Maggie’s experience that she later commented on to Steve and I. It meant a great deal to her to receive this acknowledgement.

Immediately following the session, Steve, Maggie, and I gathered in the kitchen to reflect on how we thought it went. Maggie was smiling and remarked that she liked David very much. She said she felt that he understood her, and that she could trust him. It warmed my heart to hear this and made me feel hopeful. What did I feel hopeful about? Perhaps that Maggie’s experience of herself could begin to expand to include elements beyond being autistic, a cancer survivor, a person with lots of health problems, and a young woman who lives with chronic daily pain.

DH: I didn’t know this until much later, but straight after the session Maggie came out of her room and was having a conversation with her parents in the kitchen! Little did we know that this was a sign of things to come.

Feb 27 (email from Kate to David)

Hi David,

I hope I’m not overstepping by writing to you separate from Maggie. I just wanted to say how much I appreciated the way you structured the conversation today and how grateful I am for your willingness to work with Maggie. I loved your approach and was truly delighted and touched by Maggie’s responses. Your validation of her experience and focus on small steps was exactly what she needed.

Thank you!

KK: Like Maggie, Steve and I both experienced a sense of validation. This occurred both within the first session, as well as afterwards with a task and some questions David asked us to discuss (appendix 2). This was especially meaningful for me as Maggie’s primary caregiver. Of course, I willingly care for Maggie out of deep love and gratitude for her presence in our lives. Still, it can be mentally and emotionally exhausting at times. Between scheduling and taking Maggie to appointments, helping to manage her medications, navigating our insurance, and trouble-shooting the frequent challenges that arise with all of it, I spend numerous hours each week tending to the many practical aspects of her care. I also spend time each day problem-solving with Maggie as she copes with whatever challenge she is facing that day. These aren’t the types of activities that are typically acknowledged or appreciated by professionals with whom we’ve consulted. So, to have David clearly “see” us and the impact Maggie’s challenges have had on our family was quite powerful. Another thing that made this recognition so profound was that we didn’t actually talk about any of this during the session. David just saw it. Just as Maggie had felt seen, heard, and acknowledged, Steve and I did as well.

So, what difference did this validation make? For one, it re-energized me to continue. It also helped to diminish the ongoing questions or guilt I carry about whether I’ve done enough or am doing enough to support Maggie. These questions weigh on me at times, so having some relief was very welcome.

DH: If I was a smarter SFBT & Family Therapist then perhaps I would have called my suggestion a “homework task” and then said that I had done this deliberately. Unfortunately, I am not that smart. While I was trying to validate their experiences and successes as a family, at the time I did not realise what profound impact this would have on the whole family.

The Second Session

DH: I’m not very good at second sessions, primarily because I don’t do very many of them.

It’s commonly said that you open the second session with something like: “What’s better since we last met?”. I am sure that my mentor Michael Durrant (Durrant, 2024) would have been pretty disappointed with my pathetic opening that went like this:

D “Well, I’ve had a good week, I don’t know about you guys, so what have you been doing Maggie?”

M “Umm, not much … just hanging out on my computer … I think, although I don’t remember most weeks.”

At the time I didn’t know that “Umm, not much” was a huge understatement, but the best information didn’t actually come out until after the second session was finished and I had stopped the recording. How different the second session might have been if I had started by asking Maggie a version of “What’s better?”, and then asking Kate and Steve what they had noticed?

After some initial awkwardness, I had asked Maggie about the homework task that we had agreed on, but Maggie said she couldn’t actually remember what it was. More awkwardness.

I had come to this session with my own agenda to do a second session of SFBT. Maggie had come to the session wanting to tell me about her “theories of pain”, yet I hadn’t asked her what she wanted to talk about. It was awkward for me to move away from what I had planned, but in retrospect it was actually giving Maggie what she wanted, that is, her best hopes FOR THIS session was to find meaning in her experience of pain. However, within this I was still able to note certain words and ideas on which to expand, and this led to her best hopes FROM THIS session:

  • To have stepping stones: "I have many little goals, and that’s easier than a big goal"

  • Being outside of her room more

  • Being out of her bed more, even if it was at her desk,

which would lead to:

  • Being happier, having a brighter mood

  • Spending more time with family

  • Travelling, reading, and learning.

Maggie also identified some medium and long term goals :

  • A two hour trip to Tulsa, Oklahoma

  • A six hour trip to St. Louis, Missouri

While I didn’t realise that Maggie had already started spending significantly more time outside of her room, nobody would have predicted that within 12 months Maggie would do three road-trips to Wisconsin, a 12 hour drive away.

KK: I continued to be impressed by David’s engaging conversational style. He comes across as genuinely interested which seems to make it easy for Maggie to respond to his questions. As a parent, one of the things that stood out to me in this session was again how relaxed and comfortable Maggie was with David. It was wonderful to see her being so open with sharing her experiences, hopes, and perspectives. I remember thinking that David’s approach and demeanour seemed to tap into a very reflective, strong, and resilient side of Maggie. This is a part of her we know exists, but is often hidden by the day-to-day challenges she faces. It was truly heart-warming.

I also recall feeling extremely grateful for David’s acceptance and appreciation of Maggie’s focus on small goals. For example, her goal to spend a few hours each day out of the safety and security of her bed. It would be easy for a therapist to undervalue or minimise the significance of this, but David recognised how meaningful this goal was for Maggie. As her mother, I was thrilled to hear Maggie say, “The point is to stop seeing my bed as my only safe space.” This was a huge revelation.

It was easy to see the value of David’s focus on small, manageable goals with Maggie, and how this clearly resonated with her. It seemed to help her see beyond the current situation and consider new possibilities. This approach is consistent with what Valusek (2021) describes in his Solution Focused work supporting people living with chronic pain. By focusing on taking small steps day by day, they make incremental progress toward a future worth living for, despite chronic pain.

David mentioned some awkwardness at the start of the session and I felt this as well. It’s often difficult for Maggie to remember what’s happened between sessions, particularly day-to-day differences in her activities or mood. As a result, she tends to respond to inquiries about how she’s doing from an in-the-moment perspective. This can create a disconnect. I recall feeling unsure about how to react since I knew the small, but meaningful changes (eg: interacting with our family outside of her room, talking about things other than her pain, etc.) that had occurred since she last saw David. But since this was Maggie’s session, and I was there as an observer, I decided to wait and see how the conversation evolved.

During this session, as well as others, I often found myself shifting my perspective between my role as Maggie’s mom and as a Solution Focused practitioner. It has been fascinating to move between these differing points of view, although the two are not totally disconnected. My SF training and practice took place prior to me having children, so there’s no doubt that SF ideas have influenced my parenting and continue to. Still, for our purposes here, I think it is helpful to separate the two perspectives.

There were a couple of times during the session when, wearing my SF practitioner hat, I would have asked different questions or responded differently to some of Maggie’s statements. For example, when Maggie talked about “stepping stones” and David asked:

D “Stepping stones to where?”

M “The other side of the river. … I have many little goals, and that’s easier than a big goal”

I might have asked, “What’s on the other side of the river?” to see if it might flesh out some of Maggie’s best hopes or elements of her preferred future. Having said that, David’s question, “Are you confident you can do it?” proved fruitful with Maggie responding, “I know I can do it, it’s just gonna take me a little bit.”

With that, I might have asked Maggie what she knows about herself that allows her to be so confident that she could do it. This might have opened space for her to talk about previous accomplishments or other potential exceptions or resources. Having said that, David’s follow up was productive, especially his question about what difference it would make to Maggie if she started spending time outside of her room.

D “So what’s the goal about getting out in the living room or in another space?”

M “Just not being in my bed is the goal … even if it’s out on my desk or something”

D "So what would you do [when you are] out in another room?"

M “I would do the exact same thing I always do on my computer. I wouldn’t change what I do, I would just change my location. The point is to stop seeing my bed as my only safe space.”

D “And what difference would that make to you Maggie if you started spreading out into other areas?”

M “I’m hoping it would make me happier just being out and about with my family a bit more, and brighten my mood and just, I don’t know, I’m in my room kind of enough already”

As I write this, I am reminded of the numerous times I heard the team at BFTC make the point that part of the value of watching different therapists use the Solution Focused approach is seeing that there is no one right way to do Solution Focused therapy. Rather, it can look different and still be Solution Focused. Steve de Shazer comments on this in the introduction to his book, Clues: Investigating Solutions in Brief Therapy (1988) in relation to the members of the BFTC team at the time. “When first you look at interviews it is the differences that stand out. Each member of the BFTC team has a different style and a different way of implementing the model.” He then goes on to comment on the unique interviewing styles of Eve Lipchik, Insoo Kim Berg, Elam Nunnally, Wally Gingerich, Ron Kral, me, and himself. He ends with, “And yet, each member of the team will say that we are doing the same thing!

Sessions 3-17

There is no intention (or space) to summarise all of the 17 sessions, but rather we will consider some key themes.

For much of the time in sessions 3-17 the conversation naturally aligned with the acronym E.A.R.S. - Elicit, Amplify, and Reflect (Turnell & Hopwood, 1994). At times Maggie struggled with remembering what had happened between sessions, which made it difficult to elicit change. Kate and Steve however were quick to jump in (when invited) and share their perspectives. It was important to lead with presuppositional questions to ensure that the conversation elicited what was working rather than what wasn’t working. As soon as a change had been elicited, it was a simple process to clarify, amplify, and reflect.

The Elephants in the room - the role of family

DH: I will again say that I am not a family therapist and prefer to work 1:1 with a client without having family present. While the client always has the option to have a support person present, I will always clarify their role (e.g. observer, emotional support, participant etc.). These sessions highlighted the important role of family and how we can use their presence as a resource both within and between sessions. Maggie insisted on having her parents present, but all agreed it was primarily to provide help with communication i.e. Maggie stated that she sometimes can’t explain herself very well. I was to discover that Kate and Steve were valuable resources in reminding Maggie of what happened between sessions.

While it was handy having Kate in the sessions with her knowledge of SFBT, I am sure that Maggie’s natural ability to see positives can be attributed to the upbringing she had with a Solution Focused parent.

KK: I was impressed and pleased that in preparing for his work with Maggie, David clarified the role Maggie wanted Steve and I to play in the sessions. It was important for all of us to have a mutual understanding around whether we would function as full participants in the sessions or as observers who would occasionally be invited to comment. Maggie was clear that she wanted the sessions to be hers, but with Steve and I present, and David’s further exploration around the specifics conveyed his intention to respect and honour Maggie’s wishes. It was equally important for Steve and I to know what our role would and would not be.

I have to admit that it was sometimes challenging to be only an observer. There were times where, as a parent, I was tempted to jump in to expand on or clarify something Maggie had said. There were other times when, as an SFBT practitioner, I was tempted to jump in to ask Maggie a question. But mostly, it was fascinating and powerful to sit back and watch an experienced Solution Focused therapist at work and to bear witness to the positive impact it seemed to be having for Maggie. We heard her say things about herself related to her sense of competence, resilience, determination, and inner strength that we don’t often hear during the course of day-to-day life. It was at times both moving and heartwarming.

Dealing with big problems and even bigger setbacks

DH: Near the end of session four, Maggie spoke about her journey through breast cancer and that she had discussed this with a previous counsellor, but got the impression that the counsellor didn’t understand what she had been through. I had tried my hardest to not delve into problems but became worried that in doing so I may be invalidating her experiences. Maggie asked if we could spend the next session talking more about the cancer journey. In preparation for this, Maggie sent me a link to her page on the Caring Bridge website, an online journal with photos that documented her journey.

Session five was a lot about listening to Maggie’s cancer story, but it was what Maggie wanted FOR the session. I prefaced the session by exploring Maggie’s best hopes FROM the session. She was very clear that if she felt heard she would then be able to move on. I knew there needed to be a balance between listening to and acknowledging the bad, as well as highlighting the strengths and achievements.

Apr 17 email from Kate to David

Hi David,

Thanks to you for another helpful conversation. I checked in with Maggie about an hour after our session and she said she felt drained but good. I asked if there was anything particular she was hoping to take away from the conversations about her cancer journey and Maggie’s response was “closure”. … she just said it was helpful to talk about it and feel heard.

KK: I don’t recall exactly how I phrased it, but I mentioned to David the emotional fatigue we carry from knowing that Maggie’s future will likely continue to involve further health challenges and setbacks. My sense is that we all vacillate between worry, acceptance, frustration, resignation, and determination. We live day-to-day with the knowledge, and sometimes fear, of what additional challenges will emerge.

I also recall sharing with David an analogy I often think of during the times when Maggie gets discouraged. I imagine a boxer who during the course of a match gets knocked down multiple times. Each time, the boxer gets back up, initially quickly, but after a while and with more hits, it takes longer and longer. With each knockdown, the challenge becomes greater. This is what we have experienced with Maggie over the years.

DH: It was only a matter of days before the next setback. In session six I was told that Maggie had just had a biopsy of a cyst on her ovary, and there was concern that it could be a new cancer. Results were not due for two weeks. Again, it was another heavy session, but this time followed by a nervous wait.

10 days later I received an email that simply said “Cancer Free”, but that wasn’t the end of it.

KK: As a result of this scare along with significant pain from endometriosis, Maggie decided that she would have a hysterectomy so that there would be less chance of cancer developing in the future. It was a big decision and a tough time. Starting with the original breast cancer diagnosis in 2017, Maggie lost any sense of invincibility that so many young people have. For her, that sense was already tenuous because of the numerous other developmental and health challenges she had previously faced. The cancer diagnosis eliminated it.

So, while for most young women having ovarian cysts might be an uncomfortable nuisance, for Maggie it felt like a major crisis. Her mind, and ours, went immediately to wondering whether it could be a metastatic recurrence of breast cancer since the type of breast cancer Maggie had has a higher rate of recurrence than other types. Given this, it wasn’t an unrealistic fear.

DH: I was aware that Maggie had previously had an elective double mastectomy, so I was hopeful that I could focus on her achievement in getting through and using that experience to get her through the next surgery. However, there were some additional factors with a hysterectomy, including the resultant infertility that Maggie wanted to talk about. While our conversation felt like grieving, it developed a sense of clarity for Maggie. Her focus quickly shifted to getting herself fit and getting through the surgery. The following sessions were less about “what will be the first sign to you that you are getting prepared”, but rather they were predominately conversations about what Maggie had been doing since the last session. During this time I did not tell Maggie to do anything. Instead, Maggie was actually initiating goals and activity herself, including losing weight, exercising more, changing her diet, and stabilising her diabetes. Maggie was also becoming more natural in her ability to tell me what she had been doing (and why), rather than have me try to draw the information out of her. Maggie was both finding her voice and her autonomy. I can only wonder if she was consciously or unconsciously more aware of what questions that I would be asking.

Maggie’s surgery was a success, and she was home to celebrate Christmas with her family.

So, what worked? (part 1)

KK: David has a naturally relaxed manner that is very calming and reassuring. I was struck by the way he wove Solution Focused questions into the sessions in a manner that seemed quite authentic and genuine. On several occasions he prefaced his questions with statements that conveyed compassion for and amazement at what he was learning about Maggie. This made questions related to Maggie’s coping, her ability to remain positive, or her determination, even more powerful and meaningful.

One of the many things I appreciated about my time with BFTC was that when teaching the approach, the team clearly stated the underlying assumptions that served as the foundation for Solution Focused work. Eve Lipchik does this beautifully in her book Beyond Technique in Solution-Focused Therapy (2002) where she sets out a series of guiding assumptions. I noted that David employed many of these in his work with Maggie:

  • Every client is unique, and the therapist resists the temptation to think they know what the solution should be.

  • Clients have the inherent strength and resources to help themselves.

  • Nothing is all negative.

  • There is no such thing as resistance.

  • You cannot change clients; they can only change themselves.

  • Solution Focused Therapy goes slowly.

  • There is no cause and effect.

  • Solutions do not necessarily have anything to do with the problem.

  • Emotions are part of every problem and solution.

  • Change is constant and inevitable; a small change can lead to bigger changes.

One of the things that stood out to me in David’s interaction with Maggie was that it felt like a genuine conversation. It wasn’t simply David asking a series of SF questions or employing techniques with nothing in between. Rather, the questions David asked were surrounded by and embedded in a broader SF stance and mindset fitting with the assumptions articulated by Lipchik. To me, this is a sign of a skilled practitioner, one who is comfortable with the approach and is able to use it in an authentic manner.

What I’ve learned and am still learning is to take things at Maggie’s pace. Between her chronic pain and autism (which for Maggie involves numerous sensory challenges, memory issues, and delayed processing speed), her pacing is quite different from mine. In many ways, this is not unlike a therapist or coach’s work with clients, where pacing (ie: walking beside the client rather than leading or pushing) is such an important but often undervalued part of the process. David appeared to have a natural ability to work at Maggie’s pace, and yet I suspect what I was seeing was very different to his work in the ER or in single session therapy. In that respect, this was another example of tailoring the approach to what Maggie needed.

DH: With Maggie it was important for her to feel heard, especially given her previous experience with counselling in that she felt she hadn’t been heard. Trust, empathy, and validation all proved to be important to Maggie, as well as moving at the pace she felt comfortable with. So like Kate has identified, these conversations were less about ‘doing SFBT’, and more about having useful conversations based on the principles of SFBT. After 17 sessions we have only managed one full scaling question, and it hasn’t even crossed my mind to do anything resembling the miracle question.

So, what worked? (part 2): SFBT, Nursing Theory, and the Therapeutic Relationship

DH: I have always been interested in how a Solution Focused approach aligns with the core tenets of nursing (McAllister, 2007; Smith, 2021; Wand, 2010; Webster et al., 1995). The nurse-patient relationship is built on the foundations of mutual trust and respect, promoting clients’ self-efficacy and autonomy, a focus on strengths, and a pragmatic approach. Michael Durrant once told me that nurses are the most pragmatic professionals that he knows.

Hildegard Peplau was the first nurse to write about the therapeutic relationship in her Theory of Interpersonal Relations (Peplau, 1952), followed by others including Joyce Travelbee (1969). My first look at the therapeutic relationship started in 1993 during my first year of nursing training when I read a textbook by Arnold and Boggs (1989). This book not only highlights the importance of the therapeutic relationship, but I later discovered how the book aligns with a Solution Focused approach including:

  • The coming together of client and nurse brings about an opportunity for both to grow

  • The nurse brings a body of knowledge, a genuine desire to help, authenticity, and a view that the client is worthy of personalised attention and respect

  • The nurse does not need to hide behind titles but is free to interact with clients on an equal but compassionate level

  • The client brings a “rich reservoir of life experiences”

  • Focusing on negative history and outcomes can create a self-fulfilling prophecy as well as prevent a person from moving towards their goals

  • Once a problem has been identified, the focus can shift to the viable alternative options

  • Established goals will direct both the client and the therapeutic process

  • Finding a solution and deciding on an action helps the client to gain control of a situation

  • Breaking a problem down into simple steps that fall within the client’s capabilities will lead to a successful outcome

  • The client is allowed to generate new ideas or solutions without judgement, even if they don’t seem to make sense to the nurse. The more possibilities developed, the more likelihood that the solutions will have more meaning for the client

  • Nurses assist their clients in their struggle for health by entering the experience with their whole being. This “includes the act of giving freely and willingly of oneself to another through warmth, compassion, concern, and interest”

Durrant (2024) rightly identifies that the therapeutic relationship is an essential ingredient of successful therapeutic outcomes, but that Solution Focused literature has not emphasised the importance of this. A notable exception here is Eve Lipchik who is one of the few who has written extensively about the importance of the therapist/client relationship (Lipchik, 2002, 2017). Lipchik stated that the early Milwaukee team did not explicitly talk about the therapeutic relationship because, from an interactional/systemic perspective, they viewed it as obvious that the connection between the client and therapist was important. It was Lipchik herself who decided to write explicitly about the therapeutic relationship because she didn’t want SF therapists to think that it wasn’t important (personal communication with KK, 6 September 2024).

Recently the Australian Institute of Family Studies, with assistance from (SFBT practitioner) Will Dobud, has published a concise summary of the importance of the Therapeutic Relationship (MacDonald & Dobud, 2024).

Within the therapeutic process here, there was a great deal of time and emphasis placed on the relationship. Maggie has expressed that through this she:

  • Had a feeling that I understood her and the problems that she had

  • Was able to quickly develop trust in me

  • Felt heard

  • Felt like she had a voice, and could say things that she wouldn’t normally say

  • Felt that things were moving at the right pace.

Maggie identified that these things helped her develop a feeling that she was able to “push through” problems, and to move in the direction that she wanted (i.e. competency and capacity). But regardless of what I think about it, for Maggie a relationship built on trust and connection was one of the most important things for her.

KK: David’s focus on the therapeutic relationship has been especially relevant because Maggie indicated early on that it was important to her to feel heard and respected. From the start, she expressed that it was critical for her to feel that David “got” her, valued her perspective, took her seriously, and had an appreciation of her struggles. If David had simply asked a series of SF questions without building a relationship or conveying an appreciation of Maggie’s life experience, I’m sure the results would not have been as positive.

Maggie has seen David approximately once a month, but she is clearly thinking about their conversations between sessions. She has often communicated between sessions by sending David emails with photos or descriptions of activities she was engaged with, or even song lyrics she found meaningful. It is clear that Maggie feels a connection with and trust in David which seems to indicate a strong therapeutic relationship. Eve Lipchik wrote that the “underpinning for therapist-client relationships, regardless of orientation, is trust.” (2002, p. 25-26). Trust is especially important to Maggie, particularly in light of some of her prior unsatisfactory therapy experiences. If clinicians wonder whether it is possible, and important, to be concerned with the therapeutic relationship and still be Solution Focused, my answer would be a resounding “yes.”

de Shazer (1991) described the therapeutic relationship as a “negotiated, consensual, and cooperative endeavour” focused on identifying exceptions, goals, and solutions. He goes on to say that “all of these are negotiated and produced as therapists and clients misunderstand together, make sense of, and give meaning to otherwise ambiguous events, feelings, and relationships.” (1991, p. 74) While he doesn’t overtly address the issue of trust in the way Lipchik does, one could argue that what de Shazer described would require a level of trust on the part of the client for the therapy to be useful. More recently Burns (2024) states that empathy and trust are critical ingredients for any helping conversation: “In my experience working with marginalised groups and those who are rejected by society at large, empathy and building relationships … are vital ingredients. … empathy was the magical ingredient that broke down barriers, established trust, and opened up deep and sacred conversations.” (2024, p. 149)

Progress and Achievements

DH: This section was completed in a review meeting with Maggie, Kate, and Steve two months after our 17th session. I did not want to assume and describe achievements from my perspective in the same way as I do not want to prescribe hopes, directions, and instructions.

Maggie describes her biggest achievement as her making the decision to have an elective hysterectomy. This was obviously a well thought out decision where she weighed up her options, especially her dream of one day being a mother. Secondly Maggie is proud of her increased ability to deal with chronic pain in a way to minimise the impact it has on her life. This included a new understanding of what her limits are, an increased knowledge of the causes of pain, and experimenting with analgesia to better control the pain and limit side-effects such as sedation.

Maggie summed up her achievements by reflecting on ways that she has been able to “build my life back up”. In a practical and visible sense I have noted many things in respect to Maggie’s early goals of spending more time outside of her room, being more active, and travelling further away from home. Maggie has also taken up new hobbies and expanded her culinary skills.

Steve describes things on a deeper level, in effect dividing Maggie’s achievements into two separate but interconnected areas. While many of the behavioural changes are obvious, he notes changes on a deeper personal level. Maggie has an increased desire to understand a diagnosis, however this increased understanding actually brings less focus on the diagnosis, and more self-advocacy. She has a greater ability to think past the problem, and a stronger desire to move in the direction she wants to go. Steve also notes that Maggie has expanded her world in deliberate ways, for example, using skills and knowledge (such as baking) in order to expand her social world (meet people).

KK: Between sessions, Steve and I noticed a number of changes in Maggie. For one, she was gradually beginning to spend more time out of her room. For a long time Maggie had complained that she didn’t like our living room furniture because she found it uncomfortable to sit on given her body and joint pain. She asked if we would consider buying a chair specifically for her that she could pick out. We did, and it definitely made a difference in the amount of time Maggie spent out of her room.

Maggie was also more frequently asking to go out, sometimes to the grocery store, to a farmers’ market, the library, or to one of a number of thrift stores she and I enjoy exploring. She began baking again and started preparing various vegetable-based recipes she had been wanting to try.

During pleasant weather months, when it was warm enough to be outside, our family spent many evenings in the past year on our patio playing board games, listening to music, and talking. This was another sign of progress.

What was particularly nice about these developments, and others, is that they provided an opportunity to spend enjoyable time with Maggie as a person rather than as a patient. We talked about topics other than her health, and simply enjoyed being together. It wasn’t that Maggie was no longer in pain. Rather, she seemed to be deciding not to let the pain get in the way of her life. She even occasionally commented that she had decided to “suck it up” and do what she wanted to do.

The ultimate progress has been the three road trips to Wisconsin over the past year. We have many dear friends and family members there who are very important to us, especially our younger daughter. Maggie decided that she would do whatever it took to be able to manage the 12-hour car ride to see them. Travelling isn’t easy for Maggie, but she knows herself well and meticulously planned what she needed to do in order to make the trips as comfortable as possible. And she did it!

DH: In our 14th session I had asked Maggie to reflect on her progress and to consider what has been helpful over the past 11 months. Maggie said that it was really helpful having someone who understood her problems, especially all of the medical things, and that I was able to tell her what to do.

D: “I’m sorry to disappoint you Maggie, but I think I should be honest. I really don’t understand most of the things you have been talking about. I don’t understand cancer, I don’t understand chronic pain, I don’t understand gynae problems either. But the thing that I can understand, or at least try to understand, is how these things affect your life.”

M: “OK, but I don’t realise until I talk to you that I already have the answers, or pieces of the answer, and you help me see that.”

DH: Maggie’s progress was quite remarkable, and in many ways the following emails are enough to summarise the journey:

19 Feb, emails between Kate and David (relating to writing this paper):

Hi David,

Great to hear from you and thanks for the update … I appreciate you providing guidance and suggestions about the paper, so please keep them coming and I’ll keep plugging away. Finding chunks of time has been somewhat challenging lately. Maggie is doing better, which is obviously great, but it means she is wanting to spend more time out of the house or doing things together at home. On the one hand, I love it and am thrilled she’s wanting to be out of her room. On the other hand, it means I have less time to focus on my projects. Still, I feel hopeful about our mid-year time frame.

Have a good week!

Kate

So you’re a victim of Maggie’s success? Love it!

David

Yes…rather ironic, isn’t it?!

Kate

Conclusion

This case study shows an example of how SFBT has been used in 17 sessions over 16 months to assist a person with a complicated medical history and lifelong needs. The authors believe that SFBT should be built upon a foundation of trust and a strong therapeutic relationship. The approach must also be flexible and tailored to an individual’s needs and abilities (cognitive, language, and physical). The role of the family cannot be underestimated, and this case highlights ways in which family can be used to support the therapeutic process.

The authors would like to conclude by congratulating Maggie for both her effort and her achievements over the last 16 months, and we all look forward to seeing what happens next. We also thank Maggie for agreeing to share her story. Maggie, along with the authors, hope that her story can inspire other people who have similar, complicated situations and lifelong medical issues, to reach their goals no matter what trials befall them.


Conflicts of interest

The authors do not identify any conflict of interests.

Accepted: October 03, 2024 BST

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Appendices

Appendix 1 - The Manifesto

From Kate’s 25 February 2023 email to David, with Maggie cc’d:

Maggie is a delightful, kind, fun, and creative 28 year old (these are just a few of the many positive descriptors I could use to describe her). She lives at home with Steve (my husband and her dad) and me. In terms of Maggie’s history and some of the things she wants you to know…she was born 10 weeks premature with a genetic anomaly called Trisomy X (or 47XXX) which we learned about through an amniocentesis. Maggie had various health and development challenges as a child and was diagnosed with ADHD at age 8 and autism spectrum disorder at age 15. While during my therapy career I was not a fan of such diagnoses, Maggie and our family actually found them helpful in understanding some of the challenges she dealt with, and helpful for explaining to her teachers and others that she wasn’t lazy, unmotivated, unfocused, daydreaming, or any of the other negative descriptions that were given her. Rather, we were able to understand that Maggie is perfectly smart and creative, and that her brain just works differently than neuro-typical people.

Maggie had many physical complaints, including stomach aches, as a child and we have since come to speculate that she may have been experiencing abdominal migraines. This came to us when she started to have significant and long-lasting headache migraines at the age of 10. She has continued to experience chronic, almost daily headaches since then. In her late teens, Maggie started to experience pervasive and significant muscle and joint pain and was diagnosed with fibromyalgia in her early 20’s.

At the age of 22, in May 2017, Maggie discovered a lump in her breast and was soon after diagnosed with an aggressive form of triple negative breast cancer. Luckily we lived in a university town (Madison, Wisconsin) with a well-regarded academic medical center and cancer center so Maggie received wonderful care. Still, she had a gruelling 18 months of treatment…two courses of multiple rounds of chemo, followed by two surgeries, radiation therapy, and more chemo. Maggie was declared cancer free in October 2018. While declared cancer-free, the fact that she had experienced this rare occurence of breast cancer at such a young age took an emotional toll and left Maggie with the constant fear of a recurrence. The fear led her to decide just over a year ago to have an elective double-mastectomy. Maggie says she feels good about this decision and has no regrets. The decision was hers and she feels strongly that it was the right one.

Maggie’s migraines subsided quite a lot during the cancer treatment, we suspect due to the steroids she was given. However, the migraines eventually came back with a vengeance. At that point, her neurologist felt she would be a candidate for an occipital nerve ablation. Maggie had two ablations in 2019, both of which kept the pain to a minimum for about 2 months each, but the migraines eventually came back once the nerves re-grew.

When Steve was offered a new job in Fayetteville, Arkansas, our family moved from Wisconsin to Arkansas in late 2019. We had high hopes for a new start, but more health issues soon emerged. The first was that Maggie got Epstein-Barr virus and then a year later she developed a significant fungal growth deep in her sinuses. Both took a long time to diagnose and involved numerous visits to doctors and the hospital emergency room. The fungal growth also involved a number of unpleasant exams and surgery to remove it.

Another recent challenge involved extensive dental work including numerous root canals and crowns. She previously had extensive dental surgery while we were still in Madison with the same procedures. The dental specialist speculates that Maggie’s prematurity caused her to have weak enamel and that the radiation therapy likely caused additional issues.

The final challenge I’ll mention has been going on since April of last year and that is that Maggie started having intense, deep, pervasive, and constant bone pain. Given her cancer history, we and her doctors were initially concerned about a recurrence, however that was ruled out. Maggie has seen numerous specialists, all of whom acknowledged that the pain is real, but none could figure out the cause. Her sed rate and CRP levels were quite high, but they couldn’t determine why. The only explanation anyone can think of is that the pain started soon after she got one of the Covid boosters. Maggie had a special blood test recently that showed that she has a genetic predisposition to inflammatory conditions so the thought is that maybe the booster stimulated an inflammatory response. Regardless of the cause, the pain has been tough for Maggie and none of the medications she was prescribed helped. However, Maggie recently qualified for medical marijuana which she started using in December and that has been the most helpful thing for her.

As you can see, Maggie has had more than her share of challenges in her life. In spite of it, she is determined to keep going and to find moments of happiness. She is a strong, brave, determined, and fierce young woman, that’s for sure. Still, sometimes the pain and worry gets to her. We’re looking for a therapist to help Maggie figure out how best to cope with the pain and other difficulties she faces. Given my past background with solution-focused work, I’m hopeful that this approach would be most helpful.

KK: Other issues I neglected to mention in the email to David include a complex ruptured appendix Maggie experienced at the age of 8 that required surgery and a weeklong hospital stay, and Type 2 diabetes that emerged during Maggie’s cancer treatment, likely as a result of the steroids she was given as part of her chemotherapy.

Appendix 2 - Kate and Steve’s Assignment

Feb 27 email from Kate to David

Hi David,

I hope I’m not overstepping by writing to you separate from Maggie. I just wanted to say how much I appreciated the way you structured the conversation today and how grateful I am for your willingness to work with Maggie. I loved your approach and was truly delighted and touched by Maggie’s responses. Your validation of her experience and focus on small steps was exactly what she needed.

Thank you!

Feb 27 return email from David to Kate

Hi [Kate]

I don’t think that is overstepping the mark. I appreciate the feedback, thank you. I hope Maggie finds it all useful.

I was truly amazed at what she said, and how she can remain so positive. I hope that in some way I can help this to continue and grow.

In regards to payment, I will have a think about this and get back to you after we chat next week.

KK: David replied again a couple of days later, and his message blew me away.

March 1 email from David to Kate

… what I would like you to do is go to Steve and ask for the money (for the payment). Then I want you to take the money and go to a shop or place or cafe or restaurant and buy something for yourself and Steve. That could be a meal, a pizza, a box of chocolates, a tub of ice cream, a bottle of wine, or whatever the two of you like. Then I want you to take a photo of whatever it is and send the photo to me. That could be a photo of you consuming the thing, or just of the thing itself.

Then I want you to think about everything you have been through for 28 years (but don’t dwell on it too much) and congratulate yourselves for all of the good work, and for getting through so many tough times.

I will also celebrate with you - you will have the blessing of having the nice ‘thing’ to enjoy, and I will get the blessing of giving it to you.

Only after you have sent me the photo, and after our next session, will I send you the details for payment for subsequent sessions (which will be cheaper and probably less fattening for you both).

I will look forward to seeing the photo.

Take care

David

March 2 return email from Kate to David

Hi David,

Well, I can honestly say that I’ve never before been brought to tears of gratitude and appreciation when navigating discussions of fees.

Steve and I are truly touched and humbled by your very kind gift. Thank you. We will gratefully accept it with the caveat that we pay your customary fee for future sessions. We value the time, expertise, and experience you bring and want to compensate you fairly.

Steve and I look forward to fulfilling the task you have given us. Stay tuned for photos!

Take good care and thank you!

Kate

March 6, email from Kate to David

Hi David,

Steve and I decided to do the assignment you gave us in two parts. The first was a very pleasant lunch yesterday at a Cuban restaurant we’ve been wanting to try called the Havana Tropical Grill. It was terrific! As you suggested, we talked about the struggles we’ve navigated over the years with an appreciation for how well we’ve worked together to help guide Maggie to become the warm, loving, strong, creative, and insightful person she is. Also as you suggested, we didn’t dwell on the challenges for too long, although it is helpful to acknowledge that there have been a lot, and instead focused on our present and future.

For the second part, we picked up a couple of bottles of South Australian wines (with a warm and friendly nod to you) and some Cadbury chocolates. Cadbury was my chocolate of choice during the time I lived in Sydney so it seemed fitting to have it again now. Steve and I will enjoy the wine and chocolate each evening over the coming week. Photos are attached.

Thank you for this wonderful gift. In saying this, I’m not just referring to the gift of the lunch, wine, and chocolate, although we really appreciate them. We are also grateful for the acknowledgement. Your validation of our experience is tremendously meaningful and impactful, and very much appreciated.

With heartfelt gratitude,

Kate and Steve