SOLUTION-FOCUSED

JURNAL INTERVIEWING
PSIKOLOGI DAN KAUNSELING


Solution-Focused Interviewing for Suicidal Feeling Client:

A Case Study in Higher Institution
Farhana Sabri1, Mohd Yahya. Ariffin1, Mohd Khairul Anuar, R.1
1
Faculty of Leadershp and Management, USIM

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Abstract
This case study employs solution-focused interviewing to reduce the intensity of
suicidal ideation in a depressed client. Depression and suicidal tendency are frequent
comorbid symptoms in clients seeking for treatment. For some of these, being Malay
Muslims may further complicate treatment in a way it presents a barrier to clients
seeking help due to mental illness stigma attached to depression. The objective of this
paper is to illustrate the utilization of solution-focused interviewing in helping a
depressed client with suicidal feeling. Case study methodology was utilized to
illustrate what interventions the therapist used in the case. Following three sessions of
solution-focused interviewing spaced at 1-week interval, the findings indicated
reducing suicidal feeling in client and a reduction in the intensity of dark thoughts
that had previously plagued the client when triggered. The client¶s symptoms of
depression as measured by Beck Depression Inventory (BDI) reduced from severe to
normal range. In conclusion, solution-focused interviewing produced positive
outcomes in dealing with a suicidal feeling client.

Keywords; suicidal client; solution-focused interviewing

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INTRODUCTION
Solution-focused interviewing is originating from Solution-Focused Brief
Therapy (SFBT); developed by de Shazer and Insoo Kim Berg in 1981 (de Shazer,
1985). SFBT rooted in post-modernism philosophy of knowledge that believes in
multiple ³truth´ in explaining a situation. A client constructs his or her own problems
as well as solutions. Thus, there is no preconception notion in describing a client¶s
presenting concerns. SFBT focuses on a client¶s resources and resilience instead (de
Shazer, 1985). SFBT is also known as strength-based approach that stresses on
solution and future-oriented questions. Effective questioning is central to the solution-
focused approach as it¶s aim is to facilitate purposeful positive change. Questions that
are truly effective should have the effect of enhancing motivation and increasing
positive affect and self-efficacy for change. Psychological health develops when a
person devotes his or her time in creating solutions rather than analyzing the
problems. Focusing too much on the problems would create problem-saturated life
and lead further psychological problems. SFBT counselor argues that when a
counselor tries to find the root of the problem, it could even cause damage for the
client (Grant, 2012). Therefore, language to develop question is critical to highlight
solution and future orientation of counseling interaction. There are three main
interviewing questions that direct counseling interaction towards a client¶s vision of
solutions; exception questions, miracle questions, and scaling questions.

Exception questions are used to identify a client¶s coping strategies. Exception

is a situation where the problem should or could have happened, but it did not; either
with or without a client¶s intention. This is possible as the problem does not happen
all the time. That is, a client has tried strategies that worked and for unknown reasons
has stopped doing them. Miracle questions are used to articulate goals that require a
client to visualize what would be different if the problem solved. The miracle
questions could be phrased as such ³When you go to bed tonight, a miracle happens
and the problems that you prompted to me now is solved. But since that happen while
you are sleeping, you have no way of knowing that a miracle night just happened.
When you wake up in the morning, what would be the small changes telling you that

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your problems solved?´ The key in miracle questions is to elicit small changes for
goal development (Grant, 2012).

Scaling questions are used to assess a client¶s current situation and progress. To
set up a scale, a client is asked to mark any number on the scale that signifies his or
her current situation. Next, a counselor would explore the meaning of the number. A
counselor might say ³Last week you were at 4 on good communication scale, and this
week you feel like at 5. I was wondering what did you do differently? How do you
know that you are at 5? Let¶s suppose you increase one point on the scale, how would
you and your significant others discover this?´ This is important for the counselor to
probe why the number on the scale increased and not lowered as that would punctuate
new changes and focus on solutions (Grant, 2012).

Past studies indicated that SFBT has been used among clients with depression
and anxiety. Mental health issues that are presented with depression and anxiety
symptoms are the most important risk factor for suicide (Kondrat & Teater, 2012;
Rapaport, Clary, Fayyad, & Endicott, 2005). Kondrat and Teater (2012) reported that
solution-focused therapy was effective in an emergency room setting to increase hope
for patients presenting with suicidal ideation. Guterman (2006) asserted that an
effective therapy for depressed clients with suicidal ideation is one that provides
immediate hope and a vision of possibility of change. SFBT seeks to do just this by
encouraging clients to see that they already managing their problems.

In Malaysia, the Ministry of Health Malaysia reported that mental disorders,

depression, emotional stress, relationship problems, anxiety, poverty, physical abuse,
alcoholism, drug abuse, unemployment, and financial problems are possible risk
factors for suicide in the Malaysian society (Kaur, 2006). Following this emergence,
the National Suicide Registry Malaysia (NSRM) was established in 2007 to monitor
suicide. Based on the registry, it was reported that financial problems and job
problems were among the factors that correlated high with suicide individuals
(NSRM, 2009). Furthermore, this report was concurred by a study conducted by
Hamidin and Maniam (2011), which reports that six most commonly reported life

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threatening events prior to a suicide attempt; personal illness, family illness,

interpersonal issues (i.e., serious problems with close friends, breaking off a steady
relationship, and a seperation due to marital difficulties), works issues, and other life
events issues.

Due to this alarming risky factor among the Malaysian society, researchers
were urged to investigate protective factors that could counteract with the risky
factors. This effort can be started as early as in adolescent population to indicate
prevention should be started off early in school. Ahmad, Cheong, Ibrahim, and
Rosman (2014) found that protective factors as in having close friends and married
parents were less likely for students to engage in suicidal ideation. Despite this effort,
suicidal behavior is also seen among university and college students in Malaysia. A
significant positive relationship was found between suicidal ideation and depression
among university students in Malaysia (Mustaffa, Aziz, Mahmood, & Shuib, 2014).
Suicidal behavior is becoming a worrisome polemic in Malaysia.

In response to this matter, this paper aims to illustrate the utilization of

solution-focused interviewing in helping a depressed client with suicidal feeling.
Solution-focused interviewing has been indicated to have a quicker reduction in
depressive symptoms and better results for patients with a comorbid personality
disorder (Knekt & Lindfors, 2004), significant improvement in depression and
symptom distress for depressed substance abusers (Smock, Trepper, Wetchler,
McCollum, Ray & Pierce, 2008), and to be superior to usual outpatient treatment for
problem drinkers (de Shazer & Isebaert, 2003). The findings of this paper would
contribute strengthening the discussion of strategies and techniques of solution-
focused interviewing in mental health services.

METHODOLOGY

Case study was utilized as a methodology to strengthen and refine the existing
theoretical construct of SFBT. Case study was selected because it allows the
researcher to identify which interventions and processes of SFBT were used to address
the suicidal case and depression. The researcher used information-oriented selection

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as a case selection strategy. The population consist of undergraduate counseling

students, who received counseling services at the Counseling Laboratory Centre,
Universiti Sains Islam Malaysia. Thus, the participant of this research was drawn from
a pool of cases at the centre. The specific case of this client was carefully chosen to
investigate because it was deemed critical, which can be exemplars for counselor to
work with this population. The protocol of the case selection was adhered throughout
the entire process. The participant was presented with informed consent and a detail
explanation about the study (i.e., the nature of the study, any risks involved in taking
part, and implications).

Case Introduction

Ms. B, a 21-year old woman who presented with appropriate clothing and was
cooperative throughout the session. She was referred by her course professor for
assessment for psychotherapy following severe stress-induced depression behavior in
the class. She was a second year student by the time this case study was conducted,
2017.

Presenting Complaints

During the initial interview, Ms. B maintained good eye contact and her affect
was in normal range and reactivity. This was evidenced by tears in response for topics
as would be expected for the situation shared in the session. There was no evidence of
psychotic phenomenon. She reported no history of major depression and suicide. Ms.
B expressed concern that she has been feeling ³overwhelmed´ since the past week.

Ms. B reported that she has not been able to fall asleep, stay asleep, and feel
restless after waking up. She reported feeling lethargic and loss of interest or pleasure
in daily activities. She said that she has difficulty getting out of bed and reported ³I
have nothing to look forward to´. Moreover, Ms. B reported feeling sad almost every
day for the past week, less appetite, loss concentration, low self-esteem, and crying for
unknown specific reasons. She stated having rapid heart beat at night and worrying
about ³something´. These symptoms have been going on for the past week.

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Ms. B is living with other housemates, whom also her course mates. She
reported feeling being ignored by her friends and stated ³I can¶t believe they did this
to me´. Ms. B reported she has absent few classes due to her depression. She has
informed her professor of her absence, and her professor is supportive of her seeking
treatment. However, she is worried that her many unexplained absences would result
to dropping off the course. She stated that she was ready to attend some counseling
sessions for help.

History

Ms. B described an intense family home during her childhood, including her
mother being scolded excessively by her father when she was trying to protect the
children from her father¶s anger rage. The father had had anger problems where he
used cursing words towards Ms. B and her siblings. She has six siblings, which she
described ³detached relationship´ with their father. She reported no mental health
issues in her family.

Ms. B reported she was bullied in primary school and stated she did not have a
lot of friends. Reported ³I have to be someone else for me to feel accepted by the
peers´. She reported her mother had to consolidate her when she came home from
school. Ms. B has one older sister and five brothers. She stated that her father and her
older sister has an intense father/daughter relationship because of the sister¶s interest
to be a police officer. The father would like his children to be successful in Islamic
field. As a second child, she reported the pressure to be successful in academic fell on
her shoulder. When she was 15 years old, Ms. B shared an incident where she passed
out on the day she had to sit for her Penilaian Menengah Rendah (PMR) examination.
She said ³It was too much for me´.

When Ms. B 17-years old, her mother gave birth to her youngest brother,
whose now is four-years old. The mother gave birth when she was 41-years old and
the father was 52-years old. Ms. B reported growing up in a big family with ³detached
relationship´ with her father was a constant challenge for her. She reported her father
started to change when her youngest brother was born. He would come back home

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from work angry and project the feeling to his family by cursing and addressing them
with bad names. The father would not return home occasionally at night and if so, his
actions would full of rage towards her mother and her siblings. Ms. B reported
however, her father has never physically abused her. She reported ³I have been
emotionally abused´ by him. Ms. B. reported the mother would complain to her about
the financial problems of the family and other family-related issues.

Two years ago, she moved to a college to further her studies in Bachelor
degree. She lives with another three roommates who also students pursuing their
Bachelor degree in the same college. Ms. B reported feeling upsets thinking about her
mother at home. She would call her mother occasionally to check on her. Ms. B
reported feeling worried and guilty for not being able to be with her mother.

Assessment

During the initial interview, Ms. B reported having suicidal feeling. She was
assessed using self-report measure; Beck Depression Inventory (BDI). Ms. B meets
the criteria for Major Depressive Disorder, Single episode, Mild (F32.0) according to
Diagnostic and Statistical Manual of Mental Disorder (DSM-5; American Psychiatry
Association, 2016). She scored in the severe range for depression on the BDI. Among
the indicators that she scored highest were ³I feel sad almost all the time and I can¶t
snap out of it´, ³I feel the future is hopeless and that things cannot improve´, ³I cry all
the time´, and ³I have lost most of my interest in other people´. Ms. B reported having
no depression episodes in her life and stating that ³I¶ve never felt like so depressed in
my life´. From her presentation at interview and the items endorsed on BDI, Ms. B¶s
depression appears to be due to feeling worthlessness rather than lethargy or health
problems.

Given Ms. B¶s current situation suggesting lacking of social support, the
therapist felt that it was prudent to further conducting suicidal assessment to assess her
suicidal thoughts, plan, intent, means, and protective factors (PIMP). Ms. B reported
having suicidal feeling at the initial interview and the feeling has been lingering in her
mind for the past week. She reported suicidal feeling came two to three times per day

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and gotten worse at night. She reported having no specific plan for suicide, however
she stated ³How I wish I could be hit by a lorry or a train now´. Ms. B also reported
having thoughts to jump off an apartment where she lives now, however reported
having no intent to carry out the thoughts. She stated that ³Actually I don¶t want to
die, I just feel that I want to disappear for a while from this world´. Although Ms. B
current situation suggesting lacking of social support, she stated that she has a close
friend that she knew she would be a reliable friend for support (i.e., close distance and
accessible to reach our for help). Furthermore, it was prudent to provide Ms. B with a
card containing the number for the Crisis Counseling Services and encouraging her to
call if thoughts of suicide did occur. Based on the suicidal assessment, at the end of
the initial interview, the therapist concluded that Ms. B was safe not to be referred to
the hospital for suicidal case and believed that Ms. B had not specific plan and no
intention for suicide.

Case Conceptualization

It is clear that Ms. B¶s depression is around feeling of worthlessness and

overwhelmed by suppressed feelings of her father action of rage towards her and her
mother and hatred towards her father. The overwhelmed feelings were triggered by
her current situation (i.e., living apart from her mother, studying stress, and feel being
rejected by her peers) and poor coping skills. Given Ms. B history of bullying and a
great deal of sadness in Ms. B¶s history in a ³detached relationship´ with her father
from childhood throughout the early adulthood years, it is reasonable to use a milder
structured interventions to avoid stressing the sadness and opening old wounds.
Therefore, solution-focused interviewing questions in SFBT adopting a curious,
nonjudgmental stance, and taking optimistic an optimistic view may help Ms. B to
find her own healthier solutions to increase her coping skills and manage her moods.

Solution-Focused Interviewing and Assessment of Progress

The main goal of initial interview is to reduce suicidal feeling in her. During
the suicidal assessment, Ms. B rated her suicidal feeling at number seven on the scale
of one (1 = less likely to feel suicide) through ten (10 = more likely to feel suicide).

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Ms. B agreed to the safety contract where she and the therapist developed at the initial
interview session. She was aware that the safety contract was the plan consisted of
steps that she should be taking if suicidal feeling increased on the scale.

According to SFBT, the notion of change is that a person is already doing

something that is working for him or her in coping with struggles. It is derived from
the basis that problems do not happen all the time and there is exception in
individuals¶ life (de Shazer, 1991). In this case, the therapist evaluated that Ms. B
rated her suicidal feeling at seven although it could have been at ten (worsen) on the
scale. This lead to the belief that Ms. B has practiced some sort of coping strategies
that work for her, even though without her realization. To assess Ms. B¶s coping
strategy, the therapist began by acknowledging how difficult that must have been and
inquired what resources had assisted her through those times. In response to the
exception questions, Ms. B has tended to remind herself of sacrifices her mother has
done for the family and keeping her spirits as she copes with challenges. However,
reminding herself of her mother¶s spirits was not always possible, for example at
evening when she was trying to working on her school work or at night when she was
trying to sleep. This lead into a discussion of kinds of thoughts or other potential
strategies and where they could be used.

The therapist complimented her on her achievements and encouraged her to see
whether she could make more of this technique or discover a better solution to discuss
in the next session.

The therapist begun each session with the question ³what has been better since we last
met?´ rather than the usual ³how are you doing today?´. The earlier encourage the
client to see her issues differently whereby the later will increase the likelihood of the
client to been trapped in problem-saturated discussion. Ms. B had three sessions of
SFBT. Ms. B was asked to pay more attention to small changes and details that
occurred between the sessions. Each session used this same format that begins with
Ms. B¶s hope for the future, looks for times when the depression was absent, explores

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coping strategies and solutions, and uses scaling to track her achievements and
compliments her.

The session outcomes were assessed by using pre to post-treatment changes on

BDI, suicidal intensity, client¶s self-reported on session satisfaction, and the therapist
judgment regarding her progress. Ms. B rated her suicidal feeling at one on the scale
of 1 through 10, which indicated having no suicidal feeling at all. Pre and post-
treatment changes on BDI are presented in Table 1.

Table 1. Pre- and Post-scores on BDI

BDI Score Depression Severity
Pretreatment 33 Severe
Posttreatment 13 Minimal

Note: BDI = Beck Depression Inventory

DISCUSSION

Ms. B brought a number of assets to session and responded well to solution-

focused interviewing question that were asked throughout the session. Once she was
told that this session would not going to dwell on her past experience, she was able to
engage well and work on her goals. She responded well to being complimented on her
achievements and appeared to be pleased with her progress.

Overall, the results of the present study indicate that SFBT was successful in
helping a depressed client with suicidal feeling. Specifically, Ms. B reported a
decrease in depressive symptoms (from severely depressed to minimal as measured by
the BDI) as well as reducing suicidal feeling and the intensity of dark thoughts. An
important aspect of Ms. B¶s treatment was the therapist¶s reinforcement of the need to
focus on small changes and emphasis on the present during the psychotherapy session.

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CONCLUSION

Ms. B¶s case represents a successful example of solution-focused interviewing in

helping a depressed client with a suicidal feeling. However, Ms. B¶s outcome may not
generalize to all depressed clients and clients with substance abuse problems. Ms. B¶s
improvement was probably enhanced by her determination to look for solution and
motivation for change. Furthermore, use of a non-confrontational and future-oriented
approach in solution-focused interviewing may increase engagement of the client.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research,
authorship, and /or publication of this article.

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