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Journal of Mental Health Research in Intellectual

Disabilities

ISSN: 1931-5864 (Print) 1931-5872 (Online) Journal homepage: http://www.tandfonline.com/loi/umid20

Solution-Focused Approaches in the Context of


People With Intellectual Disabilities: A Critical
Review

Hazel Carrick & Cathy Randle-Phillips

To cite this article: Hazel Carrick & Cathy Randle-Phillips (2018) Solution-Focused Approaches
in the Context of People With Intellectual Disabilities: A Critical Review, Journal of Mental Health
Research in Intellectual Disabilities, 11:1, 30-53, DOI: 10.1080/19315864.2017.1390711

To link to this article: https://doi.org/10.1080/19315864.2017.1390711

Published online: 31 Oct 2017.

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JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES
2018, VOL. 11, NO. 1, 30–53
https://doi.org/10.1080/19315864.2017.1390711

Solution-Focused Approaches in the Context of People


With Intellectual Disabilities: A Critical Review
Hazel Carrick and Cathy Randle-Phillips
Department of Psychology, University of Bath, Bath, UK

ABSTRACT KEYWORDS
Introduction: Solution-focused brief therapy (SFBT) has a growing Intellectual disabilities;
psychological interventions;
evidence base and several authors have recognized the advan- solution-focused
tages of applying this approach with people with intellectual dis-
abilities (ID). The purpose of this review is to summarize and
critique the literature that has used solution-focused (SF)
approaches in ID, and consider future directions. Methods: A litera-
ture review was carried out, identifying 12 studies; six with indivi-
duals, and six with staff and families. Results: There is preliminary
evidence for the effectiveness of SFBT for individuals with mild ID
and Solution-Focused Coaching or Consultation (SFC) for staff
working with individuals with moderate and severe ID. However,
the current evidence base consists primarily of case studies.
Recommended adaptations include shortened scales and more
concrete approaches to eliciting exception-seeking. Conclusions:
Solution-focused techniques should be modified to accommodate
the cognitive abilities of people with ID and carers should be
involved in sessions where possible. There is a need for further
controlled studies, with valid and reliable outcome measures, lar-
ger samples, and longitudinal data.

Introduction
Psychological Difficulties and People With Intellectual Disabilities
There is evidence to suggest that people with intellectual disabilities (IDs)
have an increased risk of mental health difficulties due to both genetic
vulnerability (Vereenooghe & Langdon, 2013) and increased risk of adverse
life events (Martorell et al., 2009; Vereenooghe & Langdon, 2013; Wigham,
Taylor, & Hatton, 2014). Prevalence rates of mental health difficulties in this
population range from 10–40.9% (Cooper, Smiley, Finlayson, Jackson, Allan,
Williamson, & Morrison, 2007; Cooper, Smiley, Morrison, Williamson, &
Allan, 2007; Emerson et al., 2012; Singleton, Bumpstead, O’Brien, Lee, &
Meltzer, 2001), with variation in estimates attributed to a lack of robust
methodologies and inconsistent definitions within existing studies (Cooper,
Smiley, Finlayson et al., 2007) Additionally, 10–15% of people with IDs are

CONTACT Cathy Randle-Phillips c.m.randle-phillips@bath.ac.uk Department of Psychology, University of


Bath, Bath, BA2 7AY, UK.
© 2017 Taylor & Francis
JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES 31

reported to have behavior that challenges (e.g., aggression toward others,


destruction, self-injury) (Cooper, Smiley, Allen et al., 2009; Cooper, Smiley,
Jackson et al., 2009; Emerson et al., 2012; Lowe et al., 2007). It is clear,
therefore, that the evidence-based treatment of mental health and behavioral
difficulties in people with ID represents a significant priority.
Recent meta-analyses have demonstrated that people with ID, mostly within the
mild range, can benefit from psychological therapy (Nicoll, Beail, & Saxon, 2013;
Prout & Nowak-Drabik, 2003; Vereenooghe & Langdon, 2013). This evidence base
is strongest for cognitive behavioral therapy (CBT) for anger and depression
(Nicoll et al., 2013; Vereenooghe & Langdon, 2013). In these studies, the protocols
that were originally developed for the general population were often modified to
accommodate the cognitive abilities of people with IDs, as per the guidance from
the Royal College of Psychiatrists (2004). The guidance also emphasizes that
therapists should be creative and flexible in tailoring techniques to individuals
with IDs (Royal College of Psychiatrists, 2004). Additionally, studies have high-
lighted the benefits of involving carers in sessions to aid communication and
outside of sessions to reinforce lessons learned in therapy (Willner, 2005). Whilst
protocol modifications such as these can benefit people with mild IDs, it is unclear
whether protocols can be sufficiently adapted for people with more significant
impairments in intellectual functioning (Campbell, Robertson, & Jahoda, 2014).
In comparison to the general population, there remains paucity in the
evidence base for psychological therapies for people with IDs (Bhaumik,
Gangadharan, Hiremath, & Russell, 2011; Hastings, 2013; Vereenooghe &
Langdon, 2013; Willner, 2005). Oliver et al. (2002) acknowledge that there are
a number of obstacles to conducting randomized control trials (RCTs) with
people with IDs: difficulties obtaining informed consent from individuals and,
when appropriate, their carers; having a smaller client base to recruit from; and
offering care As usual (CAU) being perceived as inappropriate.
However, whilst RCTs help to establish efficacy, they are not always the most
appropriate choice of design in psychological intervention studies. Recruitment
into RCTs may in itself result in a skewed population, and in providing
statistically significant sample sizes they may not provide the detail regarding
which patients will benefit from the treatment (Clay, 2010). Other studies can
therefore be valuable in providing information regarding “the translation of
evidence-base to everyday clinical practice” (Campbell et al., 2014).

Solution-Focused (SF) Approaches


Over the last twenty years, solution-focused brief therapy (SFBT) has gained
popularity as a psychological approach in the general population (Gingerich &
Peterson, 2012). It is a short-term (generally six sessions), goal-focused, and
client-directed approach, originally developed by de Shazer and colleagues
(1985, 1986, 2007). The central assumption of SFBT is that therapy should
32 H. CARRICK AND C. RANDLE-PHILLIPS

Table 1. Description of SF techniques.


Technique Description
Problem-Free Talk Exploration of interests, resources and strengths.
Pre-Treatment Change Helpful strategies used previously and examples of prior coping.
Exception Seeking Occasions when the problem was absent, reduced or manageable.
Scaling Rating and operationalizing problems and goals on a 10-point scale,
and exploring what would influence movement.
Goals Identifying specific, realistic, and observable personal goals.
Hypothetical Future Client’s description of a future when the problem is absent, reduced, or
manageable, e.g., de Shazer’s (1988) “Miracle Question”: “Suppose that
one night when you were asleep, there was a miracle, and this problem
was solved. The miracle occurs while you are sleeping, so you do not
immediately know that it has happened. When you wake up what are
the first things you will notice that will let you know there has been a
miracle?”
Task Intersession tasks, e.g. observing exceptions, doing more of what works
or trying something different.
Compliments Clinician’s observations of exceptions, strengths, resources and
motivation.
Competence Questions Client’s effective use of resources and strengths. Competence questions
can be considered indirect compliments as they helped the client to
identify his or her resources and success.
Eliciting, Amplifying, Reinforcing Clinician elicits, “what is better?” amplifies, “What exactly is better”;
and Start again then reinforces, “How did you manage to do that” and then starts
again, “What else is better.” Any disappointment is acknowledged.

support a client to reach his or her goals by constructing solutions rather than
analyzing problems (Beyebach, 2000; de Shazer et al., 1986, 2007; Gingerich &
Eisengart, 2000; Trepper et al., 2012). Other core assumptions include: there will
be exceptions when the problem is absent or reduced; clients have the strengths
and resources to change; and interactions between the clinician and client
should be collaborative. SFBT draws from a range of techniques, which are
outlined in Table 1 (Beyebach, 2000; de Shazer et al., 1986, 2007; Gingerich &
Eisengart, 2000; Trepper et al., 2012).
SFBT has an emerging evidence-base in the general population, across a
variety of settings: mental health care, social care, criminal delinquency,
occupational rehabilitation, and health management (Gingerich & Peterson,
2012; Kim, 2007). It has been used with adults, children, couples, families,
groups and organizations (Corcoran & Pillai, 2009; Gingerich & Peterson,
2012; Kim, 2007; Stams, Dekovic, Buist, & De Vries, 2006). Meta-analyses
have found SFBT to be an effective intervention for a range of presentations
including depression, anxiety, self-harm, obsessive-compulsive disorder,
posttraumatic stress disorder, and relationship conflict (Corcoran & Pillai,
2009; Gingerich & Peterson, 2012; Kim, 2007; Stams et al., 2006). A recent
meta-analysis found that in 32 of 43 controlled outcome studies there had
been a statistically significant benefit of SFBT and a further 10 indicated
positive trends (Gingerich & Peterson, 2012). The strongest evidence was for
adults with depression (Gingerich & Peterson, 2012). SFBT has also been
found to have larger effects when the problems are behavioral rather than
JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES 33

interpersonal or mental health related (Stams et al., 2006). Although there is


growing evidence to support SFBT, there are also important limitations and
critiques to consider. Primarily, it has been argued that focusing on solutions
may result in a lack of acknowledgement and exploration of wider difficulties
and context (Thomas, 2007), which in turn may create or perpetuate pro-
blems in the longer term. The focus on the unique experience of the
individual may also result in less acknowledgement of factors that may
connect individuals, such as race, ethnicity gender, and age. In addition,
the focus on change may result in either the client or therapist feeling rushed
to see this process and biased reporting of successful outcomes (Thomas,
2007). However, proponents of SFBT might argue that an awareness of this
in practice can support the approach being applied appropriately.

SF Approaches for People With ID


Several authors have recognized the possible benefits of SF approaches in the
context of ID (Bliss, 2005; Roeden, Bannink, Maaskant, & Curfs, 2009; Smith,
2005; Stoddart, McDonnell, Temple, & Mustata, 2001). Its focus on strengths,
competencies, and empowerment is advantageous, as people with ID may
commonly have the opposite experiences of deficiency and disempowerment
(Roeden et al., 2009). Additionally, SFBT has been effectively used for a range
of problems in the general population that people with ID also present with
(Gingerich & Peterson, 2012). In particular, indications that behavioral
problems respond well to SFBT is of interest to this population (Stams
et al., 2006).
In addition to individual SFBT, solution-focused coaching or consultation
(SFC) focuses on the staff’s goal for working with an individual with ID and
the competencies staff have to achieve their goals (Roeden, Maaskant,
Bannink, & Curfs, 2012). Thus, another advantage of an SF approach in ID
might be that people with lower functioning can benefit through the work of
their carers and family. In summary, over the last twenty years, SFBT
approaches have grown in popularity, and there are clear potential benefits
of SF approaches in ID. Whilst this approach may show promise with people
with ID, it is also recognized that adaptations are generally needed to any
therapeutic approach when applied to this population, particularly in relation
to simplifying language and process, augmenting techniques with more visual
methods, consideration of developmental level, being more directive, and
increased involvement of carers (Hurley, Tomasulo, & Pfadt, 1998). It is
therefore crucial to consider both the outcomes and the adaptations to SFBT
interventions within the context of people with ID. However, to the authors’
knowledge there is yet to be a review of the current evidence base in this
population.
34 H. CARRICK AND C. RANDLE-PHILLIPS

Aims
The aims of the current review are to:

● Summarize and critically review the literature that has applied SF


approaches in the context of ID.
● Provide an overview of the research quality of the identified studies and
consider the research implications.
● Outline how SF approaches were adapted and applied, and discuss
clinical implications.

Method
Search Strategy
A search was conducted incorporating research published between January
1990 and February 2016. The search terms are outlined in Table 2.

Inclusion/Exclusion Criteria
Studies were considered appropriate for inclusion based on the following:

● They were intervention studies that met the criteria for a solution-
focused approach by using one or more technique described in Table 1
● The population included in the study met the criteria for global sig-
nificant intellectual impairment required for an ID diagnosis (APA,
2013; WHO, 1992)

Studies were excluded if:

● The population included had a diagnosis of a specific learning difficulty


(e.g., dyslexia, dyspraxia, attention-deficit disorder)
● They weren’t original research articles (e.g., review articles)

Table 2. Search terms.


Search term Variation
Intellectually Disability “Intellectual* disab*” OR “learning disab*” OR “mental* disab*” OR “cognitive*
disab*” OR “mental* retard*” OR “mental* handicap*” OR “mental* deficien*” OR
“cognitive* deficien*” OR “intellectual* development* disorder*” OR
“developmental* disab*” OR “developmental* difficult*” OR “intellectual* impair*”
OR “cognitive* impair*” OR “idiocy”
Solution-Focused “solution orientated” OR “solution focus*” OR “solution focus* therapy” OR
Approaches “solution focus* counsel*” OR “solution focus* coach*” OR “solution focus* brief
therapy” OR “solution focus* brief counsel*” OR “solution focus* brief coach*” OR
“solution focus* family therapy” OR “brief intervention” OR “brief counsel*” OR
“client directed” OR “person directed”
JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES 35

Review Process
The study search terms (Table 2) were entered into the PsychNET data-
base, yielding 163 results, and Web of Science database, with 42 results.
Two further articles were identified through manual searching of the
reference lists of the articles identified and Google Scholar searches of
other research that had cited the articles identified. In total, 26 duplicates
were removed.
A total of 181 results were screened. The titles and abstracts were read by
the first author and 157 results were excluded. Full texts were obtained for
the remaining 24 articles. They were reviewed thoroughly by the first author
and subsequently discussed with the second author to ensure they met the
review’s eligibility criteria, resulting in 12 being excluded. Reasons for exclu-
sion at this stage were that the study did not include one or more of the
techniques outlined in Table 1 (n = 3), was not published in English (n 3),
was not conducted with people with ID or insufficient information was
provided to determine the presence of an ID (n = 3), was not an original
research article (n = 2), or investigated questionnaire validity or methods of
evaluating SF (n = 1). A final number of 12 articles were included in the
review (see Figure 1).

Data Extraction and Analysis


Data was extracted from each of the articles, and then summarized.
Separate tables are used for SFBT for individuals with ID (see Table 3)
and SFC for staff and families (see Table 4). (Please note in studies by
Lloyd & Dallos (2006 and 2008), they describe SFBT for families. As this
did not predominantly involve direct work with individuals with IDs, it
has been included under SFC). A synthesis and critical appraisal of
research quality is provided in the text. The Centre for Evidence-Based
Management’s (Phillips et al., 2009) checklist for critical appraisal of cases
studies was used, as the majority of the literature in this area adopted a
case-study design. The checklist was used to assess descriptive quality and
transferability of the studies, as well as robustness of the methodology (i.e.,
design, method and analysis). Study quality was categorized as follows:
poor, acceptable, good, and very good.

Results
Description of Studies
Design
The most commonly used design was single-case design (n = 4; Bliss, 2005;
Murphy & Davis, 2005; Rhodes, 2000; Smith, 2005), followed by qualitative
36 H. CARRICK AND C. RANDLE-PHILLIPS

Records identified through

Identification
Additional records identified
database searching through other sources
(n = 205) (n = 2)

Records identified Duplicates


(n = 207) removed
Screening

(n = 26)

Records screened Records excluded


(n = 181) (n = 157)
Eligibility

Full-text articles Full-text articles


assessed for excluded (n = 12)
eligibility
(n = 24)
Included

Studies included in
synthesis
(n = 12)

Figure 1. PRISMA flow diagram outlines the four stages of the search strategy.

studies (n = 3; Lloyd & Dallos, 2006, 2008; Smith, 2011), case series (n = 2;
Roeden, Maaskant, Bannink, & Curfs, 2011; Roeden et al., 2012), controlled
studies (n = 2; Roeden, Maaskant, & Curfs, 2014a; Roeden et al., 2014b), and
lastly a descriptive service evaluation (n = 1; Stoddart et al., 2001). Sample
sizes were relatively low, as would be expected given the predominance of
single-case design, therefore limiting generalizability. Oliver et al. (2002)
acknowledge, however, that in ID service settings there is a restricted client
base to recruit from and this is a plausible reason for smaller numbers when
compared with similar research conducted by mainstream services.
Table 3. Information relating studies using SFBT.
Setting and Study Therapist
Article Recruitment Design and Samplesb Data collectionc Key findingsd quality Technique Adaptations experience
1. Stoddart Setting: Community Design: service Retrospective review of client Clinician ratings of therapy Good S, G, T, HF S- horizontal visual 3-point scales to Several
et al. (2001) ID services evaluation, records success were higher for those operationalize behavior & measure years of
Country: Canada comparing two Client satisfaction: Mean scores with higher functioning, fewer happiness/sadness. informal
ID screen: DSM-IV therapies on SEQ at 6-month post- presenting problems, who had HF- clients asked “what their wish for experience
Recruit: CR & SR Intervention group: therapy success: Average support from carers in and therapy was, what their wishes for using SF
Referral reasons: SFBT clinician 5-point Likert scale between sessions and who had their life were, or how they would
Social difficulties (n = Number of sessions: 8 ratings for the therapy success, self-referred. know therapy was finished”
8), Sample size: n = 16 at post. 6-months-post clients & carers T- homework termed “exercise or
Couples conflict (n = Drop out: n = 13 (not report higher satisfaction in the practice.”
6), included in analyses) SFBT group (mean = 26.35) than Format—Lead therapist with
Anger/aggression (n Age: min 23 the comparison group (mean = reflecting team behind a one-way
= 5), Gender: 6 Male: 10 24.89) mirror.
Depression/anxiety (n Female SFBT was delivered in shorter Support: family/carer support on
= 4), ID: Borderline ID (n = length of time (mean 118 days) intersession task completion.
Bereavement (n = 3), 4), Mild ID (n = 12) than comparison (mean 372 days)
Sexual issues (n = 2), Comparison group: *
Occupational long-term therapy
problems (n = 2), Other sample details
Low self-esteem (n = not reported
1),
Family difficulties (n
= 1),
Independence issues
(n = 1)
2.Bliss (2005) Setting: Community Design: Case study Care staff and therapist Reported observations of positive Acceptable PTC, ES, S, ES- additional structuring if client 4 years’
ID service Intervention: SFBT observations & comments benefits of SFBT for the client C, CQ unable to answer “how did you do experience
Country: UK Number of sessions: from support staff (e.g., tidying that?” she was given options. using SF
ID screen: SC 11 with client and 1 room, requesting to come to S- used visual 2-point scale.
Recruit: CR session with staff therapy, and reductions in C & CQ- client found it difficult to
Referral reasons: only challenging behavior). engage with concept of HF. Instead
Challenging behavior Sample size: n = 1 Reported therapist observations focus was placed on her current
(n = 1) Age: 45 (e.g. reduced anxiety attending strengths & coping.
Gender: Female sessions & requests to rearrange Support- carer support on inter-
ID: Mild/Moderate ID cancelled appointments). session task completion & 2 sessions
JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES

with staff to explore PTC, S & ES.


(Continued )
37
38

Table 3. (Continued).
Setting and Study Therapist
Article Recruitment Design and Samplesb Data collectionc Key findingsd quality Technique Adaptations experience
3. Smith (2005) Setting: Community Design: Case study Client self-reported incidence Pre SFBT the client had been Acceptable PFT, S, ES, Decision- focus on a few techniques Informal
ID service Intervention: SFBT of aggressive behavior at pre, involved in three physical fights HF, C as the client found it “confusing” to experience
Country: UK Number of sessions: 5 during and 9-month follow-up (within 6-month period), from first have too many techniques. using SF
ID screen: SC Sample size: n = 1 SFBT session and at 9-months ES- Using role-play helped to elicit
Recruit: SR Age: 45 post there had been no incidents coping & strengths.
Referral reasons: Gender: Male of physical aggression. Support- carer support on inter-
Aggression ID: Mild ID session task completion.
(n = 1)
4. Murphy and Setting: Residential Design: Case study Momentary time sampling (10- Expressive signing increased from Very good ES, CQ Integrated ES with self-modelling. Psychology
Davis (2005) school for students Intervention: Self- second intervals) measuring start (23.23%) to end (71.43%) of Video footage of client using desired trainee. No
with significant IDs modelling & client use of expressive signs therapy and was maintained at behavior (communicative signing) other
Country: US exception seeking during randomly selected 10- one-month follow-up (64.17%). was used to promote self-modelling details
ID screen: SC Number of sessions: 5 minute classroom recording. Informal positive feedback from and to amplify exceptions. Follow-up stated.
Recruit: CR Sample size: n = 1 Mean percentage calculated. client & teacher obtained. questions e.g., “how did you do that?
Referral reasons: Age: 9 what was different that time?”. Idea of
H. CARRICK AND C. RANDLE-PHILLIPS

Challenging behavior Gender: Male client being a movie star who was
(‘unacceptable’ ways ID: Moderate ID being interviewed about the movie
of expressing needs was used to introduce the technique.
e.g. pointing, hitting,
yelling) (n = 1)
5. Roeden et al. Setting: Day and Design: Case series Quality of life: Client completed Pre to post clients’ psychological Very good PFT, PTC, HF-Used “miracle question” or Not stated
(2011) residential service Intervention: SFBT IDQOL, at pre, post and 6-week functioning improved (7/10 G, HF, ES, alternatives e.g. “when you look
provider for adults (n = 10) follow-up. clients)* and was maintained at 6- S, C, CQ, forward and things have improved,
with IDs Number of sessions: 7 Maladaptive behavior: Staff week follow-up (6/10 clients)*. T, EARS what will you be doing differently?”
Country: Netherlands Sample size: n 10 completed RSMB, at pre, post Pre to post clients’ social Support: carers attended every
ID screen: WISC-III-NL Age: Mean 39 and 6-week follow-up. functioning improved (2/10 session and provided support on
for adults, WAIS-III-NL Gender: 3 Male: 7 Client reports of goal clients) and further improvements inter-session task completion.
for children & SRZ Female attainment: SQP, at pre, post were seen at 6-week follow-up (4/
Recruit: CR ID: Mild ID (n = 10) and 6-week follow-up. 10 clients).
Referral reasons: Staff reports of clients’ goal Pre to post there were clinically
Alcohol (n = 3), attainment: GAS, at pre, post relevant decreases in maladaptive
Anger (n = 2), and 6-week follow-up. behavior (8/10 clients) and these
Bereavement (n = 1), Client satisfaction with were maintained at 6-week
Depression (n = 1), treatment and therapeutic follow-up.
Sleep difficulties (n = relationship: Adapted SRS, There were progressions in goal
1), completed at every session. attainment reported by (7/10)
Low self-esteem (n 1) clients* and (7/10) staff*and these
Anxiety (n) were maintained at 6-week
follow-up for both clients* and
carers*.
Clients assessed treatment and
therapeutic relationship positively.
(Continued )
Table 3. (Continued).
Setting and Study Therapist
Article Recruitment Design and Samplesb Data collectionc Key findingsd quality Technique Adaptations experience
6. Roeden et al. Service and Design: Controlled Client (SFBT group only) report 2/10 clients terminated SFBT Very good PFT, PTC, Same as study 5. Roeden et al., 2011 Not stated
(2014a) recruitment details study of goal attainment: SQP, at pre, prematurely. G, HF, ES,
are the same as Overall Sample Size: post and 6-week follow-up. Pre to post, SFBT group showed S, C, CQ,
Roeden et al. (2011) n = 38 Quality of life: Client completed clinically relevant progression T, EARS
Referral reasons: Intervention group: IDQOL, at pre, post and 6-week toward treatment goals (13/18) *
Alcohol (n = 3), SFBT follow-up. and at follow-up (14/18)*.
Anger (n = 2), Number of sessions: 6 Maladaptive behavior: Staff Pre to post, SFBT group
Bereavement (n = 2), Sample size: n = 20 completed RSMB, at pre, post outperformed the CAU group.
Depression (n = 2), Drop out: n = 2 and 6-week follow-up. Partially maintained at 6-week
Sleep difficulties (n = Age: Mean 43.4 Resilience: Client completed follow-up
1), (range 18–60) POS, at pre, post and 6-week
Low self-esteem (n = Gender: not stated follow-up.
3), ID: Mild ID (n = 20)
Anxiety (n = 1), Comparison group:
Couples conflict (n = CAU
2), Sample size: n = 18
Self-help (n = 2), Age: Mean 41.5 (SD =
Social phobia/ 4.9)
relationship Gender: not stated
difficulties (n = 2) ID: Mild ID (n = 18)
Note. aSC = service criteria, CR = clinician referral, SR = self-referral, WISC-III-NL = Wechsler Intelligence Scale for Adults–III (Wechsler, 2005a), WAIS-III-NL = Wechsler Intelligence Scale for Children–III (Wechsler, 2005b), SRZ
= Dutch adaptive behavior scale (Kraijer & Kema, 1994); bCAU = Care as Usual; cSEQ = Service Evaluation Questionnaire (Nguyen, Attkisson, & Stegner, 1983), IDQOL = Intellectual Disability Quality of Life, including the
psychological & social functioning subscales (Hoekman, Douma, Kersten, Schurman, & Koopman, 2001), RSMB = Reiss Screen for Maladaptive Behavior (Reiss, Minnen, & Van Hoogduin, 1994), SQP = Scaling Question
Progression (Bannink, 2010), GAS = Goal Attainment Scaling (Schlosser, 2004), SRS = Session Rating Scale (Miller, Hubble, & Duncan, 1996), POS = Positive Outcome Scale, includes items relating to autonomy and
social optimism (Appelo, 2005); dStatistically significant = *; Adaptations: PFT = problem-free talk, PTC = pre-treatment change, G = goals, HF = hypothetical future, ES = exception seeking, S = scaling, C =
compliments, CQ = competence questions, T = tasks, EARS = eliciting, amplifying, reinforcing. and starting again.
JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES
39
Table 4. Information relating to studies using SFC.
Study Therapist
Article Setting & Recruitmenta Design & Samplesb Data collectionc Key findingsd quality Technique Adaptations experience
40

7. Rhodes (2000) Setting: Residential care Design: Case study Average daily Reduction in challenging behavior Acceptable G, PTC, ES, ES- “Helpful Guidelines” for Not stated.
service for Severe ID Intervention: SFC (n = 1) frequency of pre (1.34) and post (0). T, HF, C, CQ staff outlining actions linked
Country: UK Number of sessions: 4 challenging behavior to reduction in the problem.
ID screen: SC ID client sample at pre and post. HF-“what arrangements
Recruit: CR Size: n = 1 would be ideal for [client]?”
Referral reasons: Age: 36
Challenging Behavior Gender: 1 Female
(food regurgitation) ID: Severe ID (n = 1)
(n = 1) Staff sample: n = 2.
Two key workers. No further
details reported.
8. Lloyd and Dallos Setting: Community ID Design: Qualitative case study Audio recording of SFBT highlighted parents’ Very good PFT, PTC, HF- The “miracle question” Training &
(2006) service Intervention: SFBT with initial sessions with competencies, goals and ES, HF, S, G, was used but alternatives supervision in
Country: UK families seven families achievements. Process emerged C, T yielded fuller replies e.g., ‘‘if SFBT.
ID screen: SC Number of sessions: 1 Analyzed using relating to empowerment and I drove past in 3 months
Recruit: RI to families on Family sample: thematic analysis integration of mothers’ goals into and saw things going really
waitlist for psychology Sample size: Families (n = 7) their life narrative. The ‘miracle well, what would I see,” “if
input. Parent attendance: 1 Father question’ prompted a shift from therapy is successful what
H. CARRICK AND C. RANDLE-PHILLIPS

Referral reasons: and 7 mothers wishful thinking to problem would you see?”
Oppositional problems Child age: Mean 8 (range solving.
(n = 3), 4–14) SFBT facilitated useful parent-
Depression/anxiety (n = Child gender: 6 Male: 1 professional partnership.
3), Female
Regurgitation & bowel Child ID: Moderate ID (n = 1),
management (n = 1), Severe ID (n = 4), Profound ID
Sexual issues (n = 1), (n = 2)
Anger/aggression (n = Family structure: two parents
1), (n = 3), one parent (n = 1),
Sleep difficulties (n = 1) blended (n = 2)
Mean number siblings: 1.4
(range 1–4)
9. Lloyd and Dallos Details are the same as Design: Qualitative interviews Interviews with seven Themes identified regarding SFBT: Very good PFT, PTC, HF- mothers reported Training &
(2008) Lloyd and Dallos (2006) Intervention: SFBT with mothers following it led to an idea of ‘making the ES, HF, S, G, finding the ‘miracle supervision in
families (n = 7) SFBT for families. best of it’, prompted examination C, T question’ irrelevant and SFBT
Number of sessions: 1 Interview schedule of wishful thinking & fostered self- authors suggested using a
Child & family demographics guided by the HAT efficacy and supported the different phrasing would be
same as Lloyd and Dallos Analyzed using therapeutic relationship. more helpful e.g., “what
(2006) Interpretive The miracle question was would a really good day
Interview sample Phenomenological perceived as the most “unhelpful” look like?”
Sample size: Mothers (n = 7) Analysis. aspect of therapy.
Mother age: mean 41 (range
31–54)
Mothers’ employment: FT
mother (n = 2), FT professional
(n = 1), PT professional (n = 2),
PT Skilled/manual (n = 2)
(Continued )
Table 4. (Continued).
Study Therapist
Article Setting & Recruitmenta Design & Samplesb Data collectionc Key findingsd quality Technique Adaptations experience
10. Smith (2011) Setting: Community ID Design: Qualitative interviews Interviews with social Social workers reported that post- Very good Specific Social workers reported that Social workers
social service Intervention: 2-day SFBT worker staff, 9- workshop their interaction techniques following the workshop in ID service
Country: UK workshop months post SFBT (communication, collaboration, delivered their interaction but no
ID screen: SC Staff sample workshop. feelings of control and self- not (communication, previous
Recruit: RI to 12 staff Size: n = 6 Interview schedule efficacy) with clients improved reported. collaboration, feelings of experience of
who attended a Drop-out = 12 consented to guided by the HAT They reported that they had control and self-efficacy) SF. Trainer
training workshop. All participate but for practical Analyzed using difficulty implementing the with clients improved post was a clinical
consented to reasons only 6 could attend. Thematic analysis. specific SF techniques. This was workshop but they had psychologist.
participate but six could Gender: 2 Male: 4 Female linked to limited opportunities for difficulty implementing the
not for practical Training: Social work practice, limited peer and specific SF techniques.
reasons. qualification (n = 2), Social organizational support and
Referral reasons: n/a work assistant (n = 4) perceived conflicts between SFBT
and professional role.
11. Roeden et al. Setting: Residential and Design: Case series Staff reports of team Post SFC, there were progressions Very good PFT, PTC, G, G-Before setting goal 2 SF
(2012) vocational service Intervention: SFC goal attainment: SQP, toward team goals (7/13)*, HF, ES, S, obtained a description on practitioners
provider for children Number of sessions: 3 at pre, post and 6- improved proactive thinking (5/ CQ, C, T, the problem. “What is the had master’s
and adults with Staff sample week follow-up. 10)* and improved staff-client EARS support problem with this degree in
Moderate & Severe ID Number of teams: 13 Proactive thinking: relationships (7/13)*. These were person?” and “what is the counselling &
Country: Netherlands Staff sample size: n = 42 SCIBI-PAT, at pre, all maintained at 6-week follow- problem for staff members?” training on SF.
ID screen: SC Age: mean 40.4 (SD = 11.1) post and 6-week up*. HF-Used “miracle question”
Recruit: SR from staff Gender: 0 Male: 42 Female follow-up. Staff mostly assessed procedures or alternatives e.g. “when
who experienced a Teams: 12 (with 2–4 staff per Quality of therapeutic and collaboration positively, you look forward and things
support problem with a team) relationship between except for one incident of lower have improved, what will
client. Mean years employed in ID: care staff and clients: scores (i.e., score below 9 out of you be doing differently?”
Referral reasons: 12.7 (range: 1–33; SD = 8.6) STRS, at pre, post and 0–10) relating to the procedure and “suppose we make a
Violent client behavior, Training: 95% professional 6-week follow-up. for handling aggression and video showing the most
Imbalanced training (nursing, social work, Satisfaction with needing a longer duration of SFC desirable support situation.
relationships, occupational training), 5% procedure and to address some problems. What do you see and hear
Communication high school degree collaboration: SRS, at on this video?”
problems, every session.
Lack of progress with
clients
JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES

(Continued )
41
42

Table 4. (Continued).
Study Therapist
Article Setting & Recruitmenta Design & Samplesb Data collectionc Key findingsd quality Technique Adaptations experience
12. Roeden et al. Details are the same as Design: Controlled study Staff reports of team Post SFC, there were progressions Very good PFT, PTC, G, As Roeden et al., 2012 Not stated
(2014b) Roeden et al., 2012 Total staff sample: goal attainment: SQP, toward team goals (10/18)*, which HF, ES, S, C,
Size: n = 118 at pre, post and was maintained at 15-week CQ, T, EARS
Teams: 44 (with approx.2–3 follow-up (i.e. 15- follow-up*.
staff per team) weeks after Pre to post, SFC group
Gender: 91% female commencement) outperformed the CAU group on
Staff intervention group: SFC Proactive thinking: pro-active thinking*, and quality
H. CARRICK AND C. RANDLE-PHILLIPS

Number of sessions: not SCIBI-PAT, at pre, of therapeutic relationships*. At


stated. post and follow-up follow-up these were maintained*.
Size: n = 59 (i.e., 15-weeks after
Age: Mean 40.2 (SD = 10.8) commencement)
Mean years of work Quality of therapeutic
experience: 12.5 (SD = 8.6) relationship between
Staff comparison group: Care care staff and clients:
as Usual SRS, at pre, post and
Size: n = 59 follow-up (i.e., 15-
Age: Mean 39.1 (SD = 10.8) weeks after
Mean years of work commencement)
experience: 11.7 (SD = 5.8)
Note. aSC = Service Criteria, CR = Clinician Referral, SR = Self-Referral, RI = Researcher Invitation; bCAU = Care as Usual, FT = Full time, PT = Part Time; cHAT = Helpful Aspects of Therapy Questionnaire (Llewelyn, 1988),
SQP = Scaling Question Progression (Bannink, 2010), SCIBI-PAT = Staff-Client Interactive Behavior Inventory subscale for proactive thinking (Willems, Embregts, Stams, & Moonen, 2010), STRS = Student Teacher
Relationship Scale (Koomen, Verschueren, & Pianta, 2007), SRS = Session Rating Scale (Miller et al., 1996); dStatistically significant = *
Adaptations: PFT = problem-free talk, PTC = re-treatment change, G = goals, HF = hypothetical future, ES = exception seeking, S = scaling, C = compliments, CQ = competence
questions, T = asks, EARS = eliciting, amplifying, reinforcing, and starting again.
JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES 43

Setting
Of the 12 studies identified, six were from the United Kingdom (UK), four from
the Netherlands, and one each from Canada and the United States (U.S.). (Please
note Lloyd & Dallos’s studies (2006, 2008) used the same set of families, and
hence setting and participant details are only reported once). Studies were
completed in community ID teams, offering psychological (n = 4) and
social services (n = 1) on an outpatient basis, in residential and day-care settings
(n = 5), and in a residential school (n = 1). Many ID services are multidisci-
plinary and clients in these studies are likely to have received other input, in
addition to SF approaches (McParland, 2015). However, only Stoddart et al.
(2001) stated that participants did not receive any other input.

ID Screening
Most SFBT studies reported the ID ranges of clients but did not specify how
this was determined. Studies were conducted with people in the borderline
range (n = 4), mild range (n = 4), mild/moderate range (n = 1), and moderate
range (n = 1). Stoddart et al. (2001) state that diagnosis is based on
Diagnostic and Statistical Manual of Mental Disorders (4th ed.) as a criterion
for accessing the service. Roeden et al. (2011, 2014a) reported instruments
used to determine ID diagnosis. Most SFC studies only stated general ID
ranges (moderate, severe, and profound) but not the screening procedures
used. The British Psychological Society (BPS) (2015) acknowledges that it is
not uncommon for ID services to make decisions regarding ID ranges based
on clients’ histories and their and their carers/families’ reports of function-
ing. However, it strongly recommends that standardized instruments also be
administered to assess IQ and adaptive functioning. Unfortunately, the gen-
eral lack of information regarding ID diagnoses in the identified studies
impacts external validity.

Demographics
Gender was generally reported in the SFBT studies, with both males (n = 11)
and females (n = 18) represented. Unfortunately, of the studies with the most
robust methodologies, two did not investigate the impact of gender on
outcomes (Roeden et al., 2011; Stoddart et al., 2001), and one did not report
gender breakdown (Roeden, Maaskant et al., 2014b). People with IDs across
the lifespan (9–60 years old) were included, suggesting potential utility across
age and life stages. However, only Murphy and Davis (2005) used SFBT with
a child (nine years old). While this case study had a reasonably strong design
(reliable measurements at pre, post, and follow-up), further studies are
required to determine effectiveness. In SFC studies, the gender and ages of
clients that care staff were working with was rarely reported. Care staff and
families receiving SF approaches were predominantly female. Across the
studies, reporting of ethnicity and socioeconomic status was variable, which
44 H. CARRICK AND C. RANDLE-PHILLIPS

unfortunately reduced generalizability and consideration of these factors


within the context of the intervention.
Studies used a range of measurement tools. Positive qualitative feedback
and descriptive outcomes were consistently reported in studies using single-
case designs (e.g., Bliss, 2005; Smith, 2005). The SF technique of scaling was
also utilized and could be considered an idiosyncratic self-report measure
(e.g., Rhodes, 2000). However, pre-post differences in scaling scores were
rarely reported and when they were reported it was not in a results section,
making it difficult for the reader to identify the information. The only studies
to use standardized measures were Roeden et al (2011, 2012, 2014a, 2014b)
and Stoddart et al. (2001), who included measures such as quality of life and
satisfaction with the intervention.

Main Findings
SFBT Delivery
SFBT was only provided to clients with mild and moderate ID and studies
consistently found it was effective in addressing a range of problems for this
client group. In particular, Roeden et al.’s (2011, 2014a) studies, which had
the strongest methodologies (with standardized screening measures; valid
and reliable measures; and a pre, post and follow-up design) found SFBT
was effective in reducing problems in alcohol use, sleep, depression, anxiety,
self-esteem, and relationship difficulties. In addition, Stoddart et al. (2001)
found that participants with IDs who self-referred, had fewer presenting
problems, and whose problems were around poor self-esteem, family rela-
tionships, and bereavement performed better on clinician ratings of success
post-SFBT. Those with depression, anxiety, couples conflict, and indepen-
dence issues were the least successful, but in other studies SFBT was con-
sidered helpful in addressing these problems. None of the studies offered
SFBT to individuals requiring psychological input for severe mental health
problems (e.g., schizophrenia, bipolar disorder), risk to self and others, and
abuse or trauma work.
In SFBT, clients received between five to eleven sessions. Whilst a chief
characteristic of SFBT is that it is “brief” (normally six sessions), some studies
(Bliss, 2005; Roeden et al., 2011; Stoddart et al., 2001) suggested that indivi-
duals with ID benefit from additional sessions. Similar recommendations for
other psychological approaches for people with ID have been made in the
literature (Campbell et al., 2014).
The average number of techniques used per study was six (range: 2–10).
Few studies used specific SFBT treatment protocols. The exceptions were
Roeden et al. (2012, 2014a), who stated that they used a consistent format for
each session that primarily adhered to the standard SFBT protocol developed
by de Shazer et al. (2007). Smith (2005) found that using fewer techniques
JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES 45

was less “confusing” for clients with IDs. In addition, Murphy and Davis
(2005) exclusively used video feedback as means of exploring exceptions and
self-modeling desired behavior. This stands out as a resourceful method to
engage a client with moderate ID and limited expressive language. The most
commonly used techniques were: scaling (n = 5); exception seeking (n = 5);
compliments (n = 4); competency questions (n = 4); and hypothetical future
(n = 4). There is a degree of overlap between the different techniques and for
this reason it is possible that some studies used other techniques but did not
explicitly state this. As would be expected, additional adaptations were made
for individuals with ID that were not made for care staff and families in SFC;
for the most part these were consistent with regular recommendations for
adapting psychological therapies for people with IDs (Royal College of
Psychiatrists, 2004).
First, clients with ID were supported by a carer or family member during
and in-between sessions (Bliss, 2005; Roeden et al., 2011, 2014a; Smith, 2005;
Stoddart et al., 2001). Carers and family members could remind clients about
intersession tasks and aid completion, and help clients to understand and
respond to questions asked by the therapists. Stoddart et al. (2001) found that
clients who were supported by carers in and between sessions had signifi-
cantly better outcomes (clinician ratings of therapy success). Second, scales
were adapted: using shorter scales (two or three points); using pictorial
scales; having scales on a vertical axis rather than horizontal axis; using
concrete examples (thermometer); and basing scales on specific behaviors
(Bliss, 2005; Stoddart et al., 2001). Third, adaptations to exception seeking
were suggested. These included using role-play, video-talk, and actual videos
to make exception seeking more concrete for clients (e.g., Murphy & Davis,
2005; Smith, 2005). Fourth, the importance of helping clients to structure
responses to competency questions was emphasized. Bliss (2005) described
how additional structuring to questions by giving several options aided
responses. Last, the most common technique requiring adaptation was the
“miracle question,” regardless of whether it was for clients with IDs, their
family, or their carers. This technique involves posing a scenario to the client
whereby a miracle happens when they are asleep one night and the “pro-
blem” they are experiencing is solved. They are then asked what they will
notice when they wake up to indicate that the problem has gone (de Shazer,
1988). In Stoddart et al.’s study (2001), individuals with ID clients were asked
“what their wish for therapy was, what their wishes for their life were, or how
they would know therapy was finished” and in Roeden et al. (2014a; 2014b),
they asked carers to consider “when you look forward and things have
improved, what will you be doing differently?” Interestingly, there was an
exception to this; Lloyd and Dallos (2006) observed that in sessions with
mothers of children with IDs, the “miracle question” prompted a shift from
wishful thinking to problem solving. However, in a follow-up study the
46 H. CARRICK AND C. RANDLE-PHILLIPS

mothers reported that the “miracle question” was the least helpful aspect of
therapy (Lloyd & Dallos, 2008). Hence, Lloyd & Dallos subsequently recom-
mended that the question be reworded.
Dropout was generally low, implying that the intervention is well received
and accepted by clients with mild-to-moderate IDs. However, in Stoddart
et al.’s (2001) study, 29 clients were initially referred to SFBT. Of these, 13
did not complete therapy: five withdrew their request for therapy, five were
redirected to long-term therapy, two dropped out after one to two sessions,
and one had not yet completed therapy. Two of those who did not complete
therapy were the only clients with moderate ID in this study. Two people
dropped out of Roeden et al.’s (2014a) study for the following reasons: lack of
trust in the treatment, dissatisfaction with the therapeutic relationship, pres-
sures from family or others to withdraw, and treatment was not a personal
choice. Furthermore, in one SFC study, a child with ID and autism attending
the family session was reported to struggle with SF concepts due to poor
understanding of the future, difficulties differentiating between fantasy and
realities, and difficulties focusing on the whole rather than details (Lloyd &
Dallos, 2006). These examples raise questions regarding the appropriateness
of directly using SF approaches for some individuals with ID.

SFC Delivery
When SFC was provided, it was always for care staff working with clients
with moderate, severe, and profound ID. In the identified studies, care staff
received between three and four sessions. In comparison to SFBT, in SFC a
larger number of techniques were used (range: 7–10), which is consistent
with standard SFBT protocol developed for the general population (de Shazer
et al., 2007) and, as noted above, adaptations to the techniques used were not
required for staff. Care staff self-referred to SFC if they had support-related
problems and families were either clinician- or self-referred for a variety of
reasons. The most common referral reason was related to challenging beha-
vior, with studies consistently reporting that SFC was helpful in addressing
these issues. For example, Roeden et al. (2014b) found that SFC was superior
to CAU at post-treatment and at follow-up.
Smith (2011) was the only SFC study to highlight difficulties applying the
solution-focused approach in the context of ID. Social-work staff were
provided with a two-day workshop on use of SF approaches with individuals
with ID. Unlike the other studies using SFC, this meant there was not a focus
on a particular client, and this perhaps contributed to their reported diffi-
culty implementing the techniques. In comparison, care staff and families
from the other studies assessed the SF approach and techniques favorably
(Rhodes, 2000; Roeden et al., 2012; 2014b).
Rhodes (2000) highlighted another advantage of SFC, that it was a good
starting point that could then be integrated with other approaches. This is
JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES 47

important, given that most ID services are multidisciplinary and clients will
likely receive different inputs, aside from SFC (McParland, 2015). However,
because of this it is not clear whether SFC alone is a sufficient intervention for
care staff experiencing difficulties providing support or whether additional
approaches (e.g., behavioral) will be required. For example, Lloyd & Dallos
(2006, 2008) reported only their initial SFC session. The authors state that
some families went on to have further SF input or other input; the details of
what this entailed were not reported.

Fidelity
The level of experience of SF practitioners in the studies varied; some had
informal experience and some had formal training. Almost all studies actively
sought to encompass the core assumptions and techniques of SF, suggesting
there were attempts to ensure treatment fidelity, although no formal evalua-
tion of this was reported.

Summary of Methodological Limitations


A number of recurring limitations were noted within the articles reviewed
here. The reliance on single-case designs and small-scale research resulted in
a lack of baseline and follow-up measurement, control groups, and rando-
mization, which limits the generalizability and reliability of results (Bhaumik
et al., 2011; Hastings, 2013; Vereenooghe & Langdon, 2013; Willner, 2005).
In addition, seven out of the twelve studies did not use standardized outcome
measures.
Limited demographic detail was provided, particularly in relation to estab-
lishing level of ID, and demographic variables such as gender and age were
not considered as part of the analysis.
No study compared to another active treatment; therefore, it is possible
that the successful outcomes reported in the identified studies could be
attributed to nonspecific therapy factors (the client-therapist relationship)
rather than specific factors (SF approach and techniques). It should also be
noted that due to publication bias it is unlikely that studies in this review,
especially those with a single-case design, would have been published had
they not obtained positive outcomes. Thus, there is a possibility that effec-
tiveness of SF approaches for people with IDs has been overestimated.

Discussion
This review has aimed to provide an overview of the evidence base for
solution-focused approaches within the context of working therapeutically
with people with ID. Studies provide preliminary support for the benefits of
both individual and staff/family-based SF approaches in the context of ID.
48 H. CARRICK AND C. RANDLE-PHILLIPS

Findings were strongest for individuals in the borderline or mild ID ranges.


In addition, the evidence for SFC with care staff experiencing problems in
their work with clients in the moderate, severe, and profound ID ranges was
promising.
The identified studies illustrate the benefits of using a SF approach that
emphasizes clients’ and carers’ strengths, competencies, and empowerment
(Roeden et al., 2009). This approach might be especially appropriate within
the context of working therapeutically with people with ID, where experi-
ences of deficiency and disempowerment are often a strong narrative for
clients and staff (Bliss, 2005; Roeden et al., 2012). In addition, several studies
note that SFBT benefits from a structured and concrete approach, which may
also be of benefit to many people with ID (Roeden et al., 2011; Stoddart et al.,
2001). From a service perspective, SF approaches may offer health-care
professionals working with people with ID an attractive and economical
intervention that allows more timely outcomes.
Studies in this review found SFBT to be effective across a variety of
presenting difficulties, including substance misuse, depression, anxiety, and
relationship difficulties. SFC was also found to be effective, mostly within the
context of addressing behavioral difficulties. These findings warrant further
investigation, particularly given that behavioral difficulties alone have been
found to account for a significant proportion of mental health difficulties in
people with ID (Cooper, Smiley, Finlayson et al., 2007).
Although positive outcomes were found within the studies reviewed, they
also indicated that standard SFBT may require modification in order to prove
a successful intervention for people with ID. Adaptations such as involvement
of carers or family members, and use of fewer techniques and adaptions to
techniques, including simplified language, using concrete examples, and using
smaller, two-point scales and pictorial scales were all recommended. These are
consistent with general guidance on adapting psychological techniques to
accommodate for the cognitive abilities of people with IDs (Roeden et al.,
2009; Royal College of Psychiatrists, 2004). In addition, it was recommended
that the wording of the “miracle question” regarding a hypothetical future be
rephrased. The idea of a “miracle” may have been considered unhelpful
because it seemed irrelevant in the context of ID or primed participants toward
“wishful thinking” around the ID being absent or removed (Lloyd & Dallos,
2008). This poses the danger of locating problems within the individual and
the disability, rather than seeing the potential for realistic change. However,
there were some responses to the question that were considered positive, such
as prompting discussion regarding greater understanding and acceptance. It
was generally suggested that the question be rephrased so that it was more
concrete and more focused on coping, strengths, and competencies.
Most of the limitations of SFBT and SFC for this client group can
currently be attributed to the limited evidence base. In comparison to the
JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES 49

general population, there remains paucity in the evidence base for psycholo-
gical therapies for people with IDs (Bhaumik et al., 2011; Hastings, 2013;
Vereenooghe & Langdon, 2013; Willner, 2005), and it is acknowledged that
there are a number of obstacles to conducting randomized control trials
(RCTs) with people with IDs, such as difficulties obtaining informed consent
from individuals, and when appropriate from their carers; having a smaller
client base to recruit from; and offering care As usual (CAU) being perceived
as inappropriate (Oliver et al., 2002). In addition, whilst RCTs help to
establish efficacy, they are not always the most appropriate choice of design
in psychological intervention studies. Recruitment into RCTs may in itself
result in a skewed population, and in providing statistically significant
sample sizes they may not provide the detail regarding which patients will
benefit from the treatment (Clay, 2010). Other studies can therefore be
valuable in providing information regarding “the translation of evidence-
base to everyday clinical practice” (Campbell et al., 2014).
Nevertheless, the reliance on case studies and the lack of robust metho-
dology within the current review limits the conclusions that can be drawn
regarding the efficacy of solution-focused approaches. There remains a need
for further controlled studies, with larger samples and longer follow-ups. To
establish efficacy, RCTs with full randomization to SF interventions with
specific treatment protocols (e.g., Roeden et al., 2011, 2014b), and CAU or
another active intervention are warranted. Studies should also use several
different measures (descriptive, idiosyncratic, and standardized) simulta-
neously, allowing for assessment of changes in client-centered goals, as well
as broader evaluation of psychological outcomes across the evidence base
(McParland, 2015). Generalizability of findings would be improved if further
information regarding the assessment of ID ranges and other demographics
was reported, and efforts should be made to provide background information
about service settings, including any input provided alongside SF interven-
tions. The SF clinicians in these studies varied in terms of their level of
experience and training, and further guidance is required to enable clinicians
to make decisions regarding whether they have the competencies required to
offer SF interventions. Finally, although diverse referral reasons suggest
broad applicability, future research should prioritize samples with more
defined populations, allowing for better identification of problem-specific
outcomes.

Conclusions
This review has examined the evidence for SF approaches in the context of
IDs. Thus far, the findings suggest that SF approaches show promise across a
range of presenting difficulties. They illustrate a number of potential benefits
of an SF approach that focuses on creating solutions rather than analyzing
50 H. CARRICK AND C. RANDLE-PHILLIPS

problems, and builds on the strengths and competencies of individuals with


IDs, their families, and their carers. However, the research base remains in its
infancy and limits the conclusions that can be drawn about the effectiveness
of SF approaches for this population. Further robust research is imminently
needed if we want commissioners, service managers, and clinicians to inte-
grate SF approaches into their services.

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