Understanding Coaching: Problem-Focused vs Solution-Focused

I am not gonna lie. I didn’t coin the phrase solution-focused. If you dabble in the coaching or counseling scene you’d probably have heard of solution-focused coaching/brief coaching or solution-focused brief therapy. They are both founded on the same principles and I’ve slowly start to adopt them into my work with chronic pain clients.

Solution-focused coaching is also used in corporate and high performance settings. Given the versatility of the approach and my commitment to helping clients achieve their higher aspirations and goals, it makes perfect sense!

Problem-based approach to healthcare

Before we discuss the solution-focused principles, it’s a good idea to understand the problem-focused approach first.

The status quo in Singapore (perhaps around the world also) is to manage pain with a problem-based mindset.

There is an expectation from the patient that we have to find out exactly what the problem is before we can start treatment. Without being able to confirm a “root cause”, patients perceive treatments to be less specific and, by extension, of poorer value.

So this is really the “address the root cause” narrative.

With that, patients often request for a x-ray/MRI. The reasoning behind that is because they want to know what the problem is so we/they can fix it.

It should be quite clear by now how the problem-focused approach is at play.

Even without x-rays and MRI, we still see patients adopting a problem-focused mindset.

Chronic pain patients often get emotionally attached to the something they attribute their pain to. So this could anything from not stretching enough (lifestyle) to slipped disc or degeneration/osteoarthritis (unmodifiable-structural) to poor posture (modifiable-structural).

Because of these associations, their treatments will largely revolve around stretching, surgery or chiropractic adjustment to put the disc back in place, or posture-correction exercises.

The problem is that these treatments don’t work!

Alf Nachemson, the surgeon who pioneered spine surgery as a distinctive, separate specialty, and have published over 500 research papers said:

“I’ve been studying low back pain for the last 50 years of my life and if anyone says they know where low back pain comes from, they’re full of shit.”

That is not to say you cannot get recover from chronic pain.

The problem with being problem-focused

When we look at knee pain, we know from multiple studies that osteoarthritis or “wear and tear” in the knee joint is not the reason why people have pain. In fact, the “wear and tear” narrative has been condemned by world-class journal Rheumatology as being “archaic … pejorative and inaccurate.”

Let’s say you have chronic pain. You’ll likely be referred for a knee MRI. It’s also likely that you’ll see “degeneration” or some sort of less-than-textbook-perfect MRI findings on your scan.

The obvious next step then is to go for a arthroscopic knee surgery to “clean up” the knee joint.

That makes sense right?

You have pain. You found a “problem”. You get rid of the problem. Your pain goes away.

No.

Despite being the most performed orthopaedic surgery in the world, research has shown that the knee surgical procedure doesn’t work!

How do they know? They divided people with knee pain into real surgery (patients who actually had the knee arthroscopy) and sham surgery where a surgeon would cut their skin as per an arthroscopic procedure but WITHOUT actually performing it.

They found no difference in outcomes between groups. That’s crazy right?

With that in view, the current clinical recommendation for such knee pain patients is to exercise.

When we dig further into “knee problem” rabbit hole, we found that if we were to scan lots of people without knee pain or any form of knee symptoms, they actually also have less-than-perfect MRI findings!

When we dig further into the “wear and tear” narrative, we realise that some MRI findings reverse with marathon training i.e. they made people with “damaged” knees train for a marathon and the findings reversed!

Writing about all of these still gets me excited because what we wrongly understand as “damage” is actually less damaging than we imagine.

This means that more people like yourself can live without pain.

This also mean more people can benefit from less-risky treatments.

What we think of when it comes to surgery has to change. It’s not the ultimate solution. It’s possibly not a solution at all! (Depending on the condition of course.)

Problem-focused = worse treatment outcomes

When patients start to chase problem in knee pain, we see they often end up with unnecessary knee surgery.

With back pain, we are able to demonstrate tangible and worse treatment outcomes. Lower back pain patients who undergo MRI scans are more likely to spend more money on treatments, experience poorer recovery outcomes, and lower quality of life.

For the lack of a better way to put it, it’s a triple-whammy.

It really comes as no surprise because, again, research shows that 90% of low back pain comes without an identifiable cause. In the minority of the cases, the pain can be attributed to fractures, tumours, etc – these usually comes with dramatic symptoms like loss of bladder or bowel function, or sudden weight changes. They are rare.

We know it’s not intuitive and a lot to process so take a few deep breaths. Take your time to figure this out.

Here is the thing, we know this for a while already. Remember what Professor Nachemson said? We don’t know where pain is coming from.

Clinical guidelines and research commendations have been pushing for both healthcare providers and patients to move away from unhelpful problem-based narratives.

In 2018, the British Journal of Sports Medicine published a commentary on reframing musculoskeletal pain:

“The majority of persistent non-traumatic musculoskeletal pain do not have a pathoanatomical diagnosis that adequately explains the individual’s pain experience and disability.”

Being problem-focused doesn’t actually help you understand why or what is going on.

Again, I empathised it’s challenging to get our heads around this.

In a paper published in Scandinavian Journal of Pain just this year, their recommendation for musculoskeletal pain (joints, muscle pain or injury) is:

“The diagnosis of chronic primary pain should also shift the focus from finding or excluding a physical cause to identifying many possible contributors; physical, psychological, and social, thereby expanding the range of possible treatment opportunities for patients with chronic pain.”

In summary, let’s de-focus on trying to find the problem because it’s better for you. Not because I said so. But because that’s what the numbers are telling us.

Solution-Focused Coaching

Disclaimer: I am in the process of working to my solution-focused coaching accreditation. What I am presenting here is based on what I have come to learn of the methodology. Please do reach out to me if there are any inaccuracies that need correction.

It’s probably obvious by now that being solution-focused is putting your attention at finding ways to get the results you desire. In many sense, it’s very straightforward. It’s about what you want and how do you get there.

Having clarity in what you want

In reality, clarity of what we want doesn’t always come naturally.

If I were to ask you what you’d like to get from seeking treatment, your response will most likely be something along the lines of being pain-free.

What about the most important thing you are hoping to achieve from being pain-free? It’ll probably take you a lot more time to work through this question.

Clarity of what we want is important because it gives you a clear direction. It also keeps us anchored and accountable.

One of the clients I worked with was very intrigued by the numerous theories on why we experience pain and how exercise may work as a pain-relief mechanism. This is complex science and modern understanding of both subject matters is still incomplete.

As we worked through some of the questions, he thought more about it, and would have even more questions. Ultimately, it led to him being more confused!

By then, it was a challenging situation for him because nothing made sense.

This is when having clear goals helped. What he wanted was to be able to get back to exercising pain-free so he could get in shape for his wedding. So we focused on only that.

Within two sessions, everything made sense to him.

There is nothing wrong with all of his previous questions. However, knowing is not understanding, knowing is not doing, and knowing is certainly not half the battle won!

Being clear with what we are after can give us awareness of what is more important vs. what is good to know but ultimately irrelevant. It allows us to prioritise what we do so we can optimise our limited resources.

The Solution-Focused Framework

I don’t really want to go deep into what the framework is about partially because I am not yet qualified.

What I’d really want to highlight is solution talk vs. problem talk.

If you check out the videos conversations with my past clients, all of them attributed part of their recovery to a mindset shift.

Self-induced guilt tripping is very common with chronic pain patients. As a pain patient, you may tend to blame yourself for not stretching enough, not exercising enough, etc and that can very easily lead to problem talk.

• Why I didn’t stretch last time when I could have?
• Why I didn’t exercise more when I had a chance to?
• Why don’t I have more time?
• Why can’t I afford chiropractic treatments?

While there are answers to these questions, they are often not helpful in helping you attain your goal.

Very often, the better – arguably the only – question you need to ask is what can I do right now to bring myself one step closer to my goals?

It’s about being focus on tasks that are actionable with the presently available resources. It’s about making progress.

The Solutions Focus: Making Coaching and Change SIMPLE succinctly separates problem-focused vs. solution-focused:

• What’s wrong vs. what’s wanted?
• What needs fixing vs. what’s working?
• Blame vs. progress
• Control vs. influence
• Causes in the past vs. “counters” in the past
• Experts know best vs. collaboration
• Deficits and weaknesses vs. resources and strengths
• Complications vs. simplicity
• Definitions vs. actions

To a huge extend, it’s about reexamining your current situation and how we can reframe it so it works to your advantage.

Asking poor questions lead to poor outcomes

Over the circuit breaker period, there are a lot of social media posts about why people are socially irresponsible and not compliant with the compulsory wearing of mask.

The question is, “why are they so irresponsible?”

That is really a classic example problem-focused question.

For most parts, the disgruntlement against these people is not that they are socially irresponsible but that they are not wearing a mask in public.

The goal is obvious. We want the person to wear a mask in public. Questioning their social responsibility and morals actually doesn’t bring us closer to our goals.

Often this line of questioning puts us in a headspace that is consumed with anger, frustration, anxiety, or some form of negative mood.

What does this achieve? Is that our desirable outcome?

I’ll leave this with you for homework – what do you think is the better, solution-focused response?

Your state of mind follows your thoughts

There was a YouTube video that was touching on the same point.

It was late at night and there were this two kids running around and making a lot of noise. It was incredibly frustrating for this guy because he wanted some quiet to read his book.

Sitting next to him was this middle-aged man who was in an absolute peace of mind. He was sitting there calmly and not one bit affected by the commotion.

This went on for a while and that guy, at his peak of his frustration, couldn’t resist but decided to ask the zen man, “how do you seem so relaxed with these kids being all disruptive? Do you notice them there at all?”

The middle-aged man was startled by the question.

He replied to acknowledge that he had been distracted and that the kids were indeed noisy. He apologised for not noticing.

He explained he was their father and they just left the hospital after saying their final goodbyes to their mother.

Upon hearing what the man said, the speaker was filled with empathy and compassion for the man and his boys. In an instant, his frustration had completely dissipated.

While life may not be a direct case of I want to be happy therefore I am happy, whatever we think or assume does have an effect on our thoughts, emotions, and state of mind. In short, it directly impacts our sense of well-being.

(I’ve written about the neuroscience behind chronic pain and how mindfulness may help previously. I highly recommend that you give it a read if you are interested to learn more.)

With these examples, are you able to identify the areas in your life which are predominantly driven by problem-focused thought processes? Are you able to determine if these thoughts had an effect on your well-being?

Rome wasn’t built in a day, but they were laying bricks every hour.

When it comes to chronic pain management, the problem-based approach definitely doesn’t work.

With research and clinical guideline recommendations, we know that we can achieve good pain relief even without knowing or understanding the exact causal relationships behind a person’s pain experience.

In short, I don’t need to know for sure what are the “root causes” before I can help you.

In fact, because of the complex multifaceted relationships when it comes to a pain experience, science says that it’s impossible to determine a singular true root cause.

I could keep going and keep sharing more information but remember, knowing is not doing!

If you have been living with chronic pain and you are ready to take action towards your recovery goals, book in an appointment with me the discover the difference the right care can make.

Let us work together to co-construct you a long-term pain solution for you.