Applying a solution-focused approach in counselling

Sirkkaliisa Heimonen & John Brooker

Introduced by John Brooker

Lessons for Organisations

Practitioners use Solution Focus in different disciplines, including (but not limited to therapy, counselling, individual coaching, team coaching, organisational and supra organisational development. This article serves as a reminder that these disciplines often overlap and that it is important to keep cross-pollinating knowledge between them.

Sirkkaliisa Heimonen and her colleagues have been researching the impact on individuals with mild cognitive impairment and early-onset dementia while at work. Their work forms part of an international study into this issue, and they studied 11 people in total in Finland.

To receive a diagnosis of dementia is a challenge. For those of working age, it presents multiple extra challenges.

Recognising that the progressive nature of dementia can lead people to focus on the losses and limitations associated with the disease, Sirkkaliisa, an SFiO Reviewed Practitioner, chose to work with one individual using the SF approach. She intended to establish if SF could support an individual to find ways to enhance their well-being and meaningful daily living in a changed life situation.

As well as illustrating the approach she used and the help that SF gave to the lady she counselled, Sirkkaliisa also provides valuable lessons for people in organisations who may be working with a colleague who suffers from the disease.

She highlights the need to respect the individual, give support and ease stress. She encourages them in conversation to surface the individual’s strengths, make positive exceptions visible, and affirm their ability to cope in difficult situations so that the person can build self-confidence and esteem. She also suggests that leaders should consider the issue from multiple aspects, including how the work community, direct managers and counsellors may support the person. She highlights that leaders should have policies to support sufferers so that people feel safe to seek earlier support and that they should co-create solutions with the individual.

This is a valuable case study because it triggers thinking on a topic that perhaps those in organisations have yet to consider. However, it considers one person only, and it would be invaluable to have a broader base to strengthen the findings on the impact Solution Focus might have and what leaders might do to help.

With an ageing population and people working to a later age in many countries, this issue is likely to grow, and SF could play an important part in ensuring that those who succumb to this disease while at work can continue to work for as long as possible and leave with a positive outlook, greater self-respect and confidence. This leads me to suggest that this might be an interesting study for other SF practitioners to conduct to broaden the knowledge of the community.

Please find the pdf version of this article here.

ARTICLE

Summary

This article describes a case study reflecting how practitioners could apply a solution-focused approach in dementia counselling, particularly when people develop mild cognitive impairment (MCI) or young-onset dementia whilst still working. The work we report here was undertaken as part of an international multi-disciplinary project, ‘Dementia or mild cognitive impairment: @ Work in Progress’. It is also part of the Finnish project ‘Working Life and Memory Impairment – Mental Wellbeing, Legal Security and Occupational Capacity of People with Early Onset Dementia’ (WoLMI)’.

These projects aim to increase knowledge about situations when individuals develop MCI or young-onset dementia while still working, including finding ways to support and improve their mental well-being and legal security. Specifically, we seek to reach the appropriate working life practices, support services and ways to promote autonomy, occupational capacity, and agency of a person with MCI or young-onset dementia.

In our efforts, we implemented a solution-focused approach. According to the case study, a solution-focused approach is applicable in counselling, aiming to find individual solutions, strengths, and resources in a changed life situation. We adapted it to explore how it might help people with MCI or young-onset dementia process their situation and recognise their strengths and opportunities. In this frame, we conducted one coaching process with four meetings, audiotaped and transcribed for further analysis.

Co-authored by: Sirkkaliisa Heimonen, Mervi Issakainen, Ann-Charlotte Nedlund, Jennifer Boger, Arlene Astell, Anna Mäki-Petäjä-Leinonen, Louise Nygård

Background

Supporting the well-being of people living with dementia is a global challenge. The World Health Organisation expects the number of people diagnosed to increase in decades to come. Dementia and Mild Cognitive Impairment (MCI), which may lead to subsequent development of dementia, can affect people while they are still working. For those below retirement age, the onset of an incurable, progressive cognitive disorder such as dementia results in a significant life change. Numerous issues emerge relating to one’s identity and self-worth and decisions relating to work, finances, the future, family relationships, and social roles.

Dementia causes vulnerability through gradually deteriorating functional cognitive capacity, which leads to many changes in daily life and affects mental well-being and quality of life. The progressive nature of dementia often directs attention to the losses and limitations, which can overshadow the positive dimensions such as existing strengths, resources, and opportunities. People with dementia have strengths and resources that can help them face this challenging life situation.

People with dementia need support at all stages of the disease’s progress. When it comes to people with working-age dementia or MCI, counsellors must address specific considerations related to employment. One of the key questions is: does the person wish to continue working? If so, what kinds of solutions and adjustments would make this possible? What type of support does one need or have access to when making this decision? It is important to develop practices in a working environment that support the agency and individual decision making of a person with MCI or young-onset dementia. Finding the best solution with the person in question requires collaborative and attentive discussions. Applying a solution-focused approach to such discussions can be valuable with its key elements, techniques, and coaching skills. One can characterise the solution-focused approach as a way of interacting and thinking that orientates positive change and supports agency. In facing vulnerability and challenging life situations, this approach might be helpful to strengthen self-efficacy and make opportunities and resilience visible. The solution-focused approach might be beneficial to overcome the perceived stigma, decline in self-esteem and feelings of inability and bring out resources, competencies, and strengths.

People living with dementia need information about the condition and services available. They also need to develop an approach that helps create an overview of the situation and supports them to find ways to build a meaningful life that complements their situation. When living with symptoms or receiving a diagnosis, attention at first might focus on difficulties, limitations, and stigma caused by the disease. In this situation, it is vital to find ways to broaden their perspective on existing opportunities and restrictions, identify strengths and resources that balance limitations, and provide support to build a meaningful life. Supporters should do this in a way that respects the person’s values, experiences, and abilities, all of which can be dynamic in nature.

Highlighting the strengths of a person with dementia, making positive exceptions visible and affirming the ability to cope in situations is crucial to helping them overcome difficulties and solve everyday challenges. These qualities can broaden perspectives and help her/him/them to build self-confidence and self-esteem. Realistically, focusing on the best hopes for the future, opening positive views and highlighting existing opportunities are the basis for discussions on daily actions that can enhance their well-being.

Counselling and guidance are central forms of support for people with MCI or dementia. They can help one adapt to the situation, cope with the changes, strengthen life management, and support reorientation after the diagnosis. Counsellors should provide high-quality counselling with the principles of continuity and timely interventions determined on an individual basis to meet the person’s current needs. When applying a solution-focused approach in counselling, the counsellor values the person’s expertise on their own situation, points out positive perspectives and opportunities, focuses on resources and strengths, and reviews best hopes for a future in the changed life situation.

Coaching process path – Aim, steps, and findings

To examine the potential of counselling for people with MCI or working-age dementia, we applied a solution-focused approach to see if it could support an individual in finding ways to enhance one’s well-being and meaningful daily living in a changed life situation. As a part of our larger project, we conducted a one year qualitative follow up study with 11 Finnish persons living with mild cognitive impairment or early onset dementia. The researcher recruited the individual from among these interviewees, presenting her with the opportunity to participate in solution-focused coaching.

The coaching process began when the trained solution-focused coach spoke to the participant on the telephone and agreed on a time to start the pilot case. The coaching process occurred over ten months, with four meetings; two were face-to-face, and they conducted two telephone conversations due to the COVID-19 pandemic restrictions. The time between the first and second meeting was two and a half months, between the second and third was five months, and between the third and fourth was two and a half months. Each discussion lasted between 60 to 75 minutes.

In dialogue and collaboration with the participant, the coach adapted the focus of each meeting to her situation, according with the general principles of the solution-focused approach. They framed each meeting using the same format for the start and end. At the beginning of the session, the coach asked the participant if she had any news or stories she would like to share and agreed on what would be useful to talk about this time. The coach ended each session by asking the participant whether the meeting was helpful.

At the first meeting, the goal was to know the participant’s situation and the key issues she was dealing with right now. At the first meeting, the coach and participant reviewed the overall situation to gain a picture of the steps through which the participant had had to leave work and build herself new meanings for her daily life. This depiction of the situation was based on the participant’s descriptions, respecting her expertise in her own life, without other sources of information. The next three meetings focused on the participant’s current questions and troubling issues and looked at her coping strategies and resources in daily life. The final meeting reviewed the importance of having support and reflective discussions to foster renewed aspirations, activities, and purpose in life. Overall, this process brought up the participant’s worries and hopes and explored her experiences of restrictions and opportunities while supporting reflections of identity, self-worth, and meaningful activities in daily life.

The first meeting – Gaining a comprehensive picture of the situation

This discussion primarily focused on the participant’s experiences of the diagnostic phase of her illness, the pursuit of daily living, identifying some values and strengths of the participant, and her hopes for the future. Initially, the participant was on sick leave and tried to return to work, but this did not go well. In her own words, coping was simply challenging. She said that she could not learn anything new, and she made mistakes. The difficulties the participant experienced in trying to do her work resulted in her employer’s terminating her employment. She described leaving her job as a stressful and somewhat chaotic phase where she felt she was not treated respectfully and did not feel she had enough support and justifications for her termination. To the participant, everything happened suddenly and unexpectedly, even though she had recognised she was having some difficulties at work. She described how society highly values the ability to work and treats people who are not at work as second-class citizens; therefore, the sequence of events and the speed with which they happened negatively affected her sense of self-worth.

There were many open questions concerning her future, which caused her anxiety and uncertainty. The participant felt that health care professionals did not take her questions and concerns seriously and that she did not receive the answers she needed in this situation. During the study sessions, the participant worked with the coach, discussing meaningful occupations and activities in her daily life, her strengths and values, and the potential goals she could envision for the future.

The participant described these themes in her own words. With specific and insightful questions from the coach, they uncovered new perspectives, such as the participant speaking about the need to take care of oneself and find strategies to manage things in daily life. When evaluating this first meeting, the participant said that previously it had been difficult for her to recognise her strengths. Still, this discussion brought positive aspects and different, more empowering perspectives. She hoped that taking care of her well-being would result in feelings of happiness, calmness and serenity.

The second and third meeting - Identifying positive exceptions, strengths, and good things in life

In the second meeting, the participant started talking about the overall progress of her situation. She described that her plans seemed to have become clearer after the previous session, and she had felt pleased and happy. In her opinion, they had discussed the right things. She reported how things seemed to be somewhat brighter now she had found new meaningful activities, like the outdoors, music and investing more in self-care. However, she described mixed feelings in everyday life; everything should be fine in principle, but this was not the case in practice. Stress and anxiety were still present, especially when dealing with possible future work solutions. Viewing positive exceptions, e.g. when things have gone well, situations have been better, and feelings have been more positive, helped identify the participant’s strategies for dealing with these feelings. Reviewing how she coped when thoughts took an unfavourable course was possible.

Discussions in previous meetings recalled together the participant’s strengths and aims, the importance of concentrating on the good things in life, and practical ways to enhance well-being. The participant emphasised her need to find and maintain a positive attitude, to have the right to take care of herself, and to have the opportunity to give it time. When evaluating this second meeting, she said that it had been helpful in that it had helped her recognise her ways of thinking and allowed her to focus on more positive thoughts and self-care.

In the third meeting, they first discussed the effects and restrictions of the coronavirus pandemic. The participant reported how this new situation had caused extra stress and affected her general well-being. The central theme discussed in this meeting was how difficult she felt it was for her to get help and support from health care professionals. The participant described how she had been transferred from one professional to another, causing a feeling of not being heard. The participant seemed to have many questions, but clear and needs-based information was hard to find, causing many of her questions to remain unanswered.

In some cases, contradictory advice was offered, making it difficult for her to know what to do. These contradictions caused her to feel despair, that people did not believe her, that she was stuck in her situation. The coach directed discussions to the situations that went well and reflected on positive exceptions to strengthen a positive orientation. When evaluating this discussion, she felt she had been taken seriously and stated that this meeting helped her feel better and strengthened her self-efficacy.

The fourth meeting - Respecting the client’s expertise and crystallising recommendations

Originally they planned this coaching process to include three meetings, but the participant wished to have a fourth meeting as a follow-up to see how things had proceeded. At the time of the fourth meeting, the overall situation seemed to be okay, with the participant reporting that she had found daily routines and a more positive view of life. She was thinking more about possibilities, what she could do now, what aspects of life are worth putting effort into, and what she might aim for in the future. When looking at future perspectives, the participant analysed the difference between what she would like and what might be realistic. The participant had noticed positive changes in herself, specifically how she had learned to identify thinking and acting patterns that are detrimental to her well-being. The participant described how these discussions had been helpful in this process of change and its positive result.

Reflections and future directions

At the beginning of the solution-focused coaching process, the participant had raised her experiences in working life and the need for support in building new routines after leaving work. So, the coach elicited a change of perspective by asking the participant’s opinions and recommendations concerning support for people living in the same situation. Overall, the participant summed up that this coaching process had brought positive feelings and encouragement for her and pointed out three things:

Firstly, it is vital to listen to oneself thoroughly to determine what one can do. This might be valuable in mapping solutions for work and strengthening well-being and self-esteem. Secondly, people should focus on the importance of seeking advice and help. They may have many concerns and questions to discuss, and employers should discuss these with employees when there are problems at work. Being appropriately heard, being believed, and being treated respectfully both at work and by health care professionals is very important to feelings of identity, dignity, and self-worth. Thirdly, people should find pleasant and meaningful things in daily life; to concentrate on the best parts of life as it is now and what is working in one’s new situation.

Having mild cognitive impairment or young-onset dementia, having to leave work, and facing an uncertain future all add up to a challenging situation, which may strongly affect an individual’s self-esteem and mental well-being. This pilot case study exemplifies that continuous discussions and timely counselling are much needed and can benefit people positively.

Suppose a person develops MCI or young-onset dementia while still working. In that case, leaders in organisations must recognise that there are many different aspects to consider. These aspects include the work community, the work of the person’s managers, decision making, providing support to individuals, and the provision of counselling. However, in all these aspects, people in the organisation should strengthen an individual’s agency and dignity while reducing feelings of inability and worthlessness. Solutions concerning work should be made in co-operation, using a respectful dialogue that considers the views and wishes of the individual to provide personalised support and information. Leaders must respect the opinion of a person with MCI or young-onset dementia in matters concerning their own life; they are the experts of their own lived experience. This respect applies equally to work solutions and possible adjustments in the workplace.

There is a need for policies and service paths for working-aged people living with MCI or dementia. Leaders should provide timely information and counselling to individuals, with the principle of continuity, because things require processing and, as the situation progresses, people must resolve new issues. For working communities and managers, it means recommendations and mechanisms to take up the problems openly, plus paths to seek help early, such as access to occupational health.

The research that included the case study presented in this paper, demonstrates that the solution-focused approach applies to people in the early stages of MCI or dementia. This approach may have multiple benefits: it can help defeat the stigma, respects the experience and expertise of a person with MCI or dementia, supports their agency and dignity, and strengthens empowerment and hope. In applying a solution-focused approach, the participant should have the capacity to reflect on their situation and the willingness to describe their feelings and thoughts. Based on this coaching process, these elements are essential for building a good life in a changed situation. An important aspect is to open new perspectives and opportunities so that people with MCI or dementia can positively and confidently see the present and the future.

Counsellors and coaches can apply a solution-focused approach to many groups and situations. It can help provide and develop support, services, and adjustments for people with MCI still working or people with early stages of dementia or young-onset dementia. They can apply solution-focused interviewing skills, techniques, and questions to support decision-making, provide counselling and guidance, and help build solutions to everyday challenges. Training in the basics and skills of a solution-focused approach might be helpful for professionals in health care and other services for people with dementia. As a starting point, we recommend the following key elements and checklist for delivering solution-focused counselling for people living with MCI or young-onset dementia:

• Appreciative and open-minded listening • Positive and equal interaction • Focus on resilience, competence, and strengths • Point out resources and opportunities • Looking at aims, best hopes for the future and small steps • Open to different kinds of perspectives on one’s situation • Look at positive exceptions • Give empowering feedback • Strengthen hope

Conclusion

Living with MCI or young-onset dementia is not just a matter of identifying and adapting to the changes this involves. People must also determine the individual elements that build a meaningful everyday life and recognise one’s resources, strengths, and best hopes for the future. Using a solution-focused approach supports the person’s agency, identity and self-worth, strengthens coping skills and resilience to enable continuity in one’s life story, and helps to find ways to lead a meaningful everyday life. Individuals can learn the importance of these basic principles from this solution-focused coaching process.  

Authors

PhD (Psychology), Solution-focused coach, SFio Reviewed Practitioner, Sirkkaliisa Heimonen Age Institute, Helsinki FI Corresponding author. Email: sirkkaliisa.heimonen@ikainstituutti.fi

DSocSci Mervi Issakainen University of Eastern Finland, Department of Social Sciences, Kuopio, FI

Dr. Ann-Charlotte Nedlund Linköping University, Linköping, SE

Dr. Jennifer Boger University of Waterloo, Systems Design Engineering, Waterloo, CAN Research Institute for Aging, Waterloo, CAN

Prof. Arlene Astell KITE Research Institute, University Health Network, Toronto, CAN University of Toronto, Departments of Occupational Science & Occupational Therapy and Psychiatry, Toronto, CAN University of Reading, School of Psychology & Clinical Language Sciences, Reading, UK

Prof. Anna Mäki-Petäjä-Leinonen University of Eastern Finland, UEF Law School, Joensuu, FI

Prof. Louise Nygård Karolinska Institutet, Stockholm

Ethical standards

Ethical approval for this study was obtained from the University of Eastern Finland Committee on Research Ethics (19/2018, 20/2018). The first author conducted the coaching process, analysed the data, and drafted the manuscript. All authors reviewed and revised the manuscript.

Financial support

The research project “Dementia or mild cognitive impairment: @ Work in Progress” was supported by the Academy of Finland (grant 318848), Swedish Council for Health, Working Life and Welfare, FORTE (grant 2017-02303), and the Canadian Institute for Health Research (grant MYB155683) under the framework of the JPI MYBL, and the Ontario Shores Research Chair in Dementia Well-being as well as the research project “Working Life and Memory Impairment – Mental Wellbeing, Legal Security and Occupational Capacity of People with Early Onset Dementia” supported by the Academy of Finland (grant 314749).

Bibliography

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