Journal of Marital and Family Therapy

doi: 10.1111/jmft.12193
© 2016 American Association for Marriage and Family Therapy

SOLUTION FOCUSED BRIEF THERAPY: A SYSTEMATIC

REVIEW AND META-SUMMARY OF PROCESS
RESEARCH
Cynthia Franklin and Anao Zhang
University of Texas at Austin

Adam Froerer
Mercer University, Atlanta

Shannon Johnson
The Catholic University of America

This article presents a systematic review of the process research on solution-focused brief
therapy (SFBT). We searched published and unpublished studies in English across five data-
bases, five major journals, two book chapters, and four websites to locate studies that investi-
gate why and how SFBT works. Thirty-three studies that used various research methods
were located and included for further analysis using a meta-summary approach. The findings
supported the significance of the co-construction process within SFBT and the effects of
specific types of SFBT techniques. The most empirical support was found for the strength-
oriented techniques in comparison to the other techniques and for the co-construction of
meaning. Current studies require replications with larger samples and experimental designs
that study SFBT process in relationship to outcomes.

Process change studies on therapies use a pluralistic approach to research including quantita-
tive, qualitative, and mixed-methods designs, and are rich in perspectives for helping therapists to
identify, describe, explain, and predict the effects of the processes that bring about therapeutic
change, thus the “how and why” a therapy works (Elliott, 2010; Nock, 2007). Elliott (2010) identi-
fied four major approaches that are used to study therapy process (a) the Quantitative Process-
Outcome Design (QPOD), (b) the Qualitative Helpful Factors Design (QHFD), (c) the Microana-
lytic Sequential Process Design (MSPD), and (d) the Significant Events Approach (SEA). The
QPOD samples key processes from one or more therapy sessions and uses these to predict post-
therapy outcome. Researchers who use experimental designs consider QPOD to be the most rigor-
ous research method for studying mechanisms of change because this approach aims to establish a
causal relationship between specific therapeutic process(es) and therapeutic change (Kazdin, 2007;
Nock, 2007).
In contrast, the QHFD emerged over the past 20 years as a result of the popularization of
qualitative research often using interview methods to understand the client experiences during the
course of their therapy sessions. The MSPD also known as microanalysis focuses on the turn-to-
turn in-session interaction between client and therapist. Sequential process studies typically focus
on a small number of process variables, which means that they lend themselves to testing theories
about fundamental processes of influence in therapy session. In contrast, Change Process Research
(CPR) describes the entire course of therapy to understand the process of therapeutic change

Cynthia Franklin, PhD, Associate Dean for Doctoral Education and Stiernberg/Spencer Family Professor in
Mental Health, School of Social Work, The University of Texas at Austin. Anao Zhang, MSW, Doctoral Student,
School of Social Work, The University of Texas at Austin. Adam Froerer, PhD, Associate Professor, School of Med-
icine, Mercer University. Shannon Johnson, PhD, Assistant Professor, National Catholic School of Social Service,
The Catholic University of America.
Address correspondence to Cynthia Franklin, The University of Texas, School of Social Work, 1925 San
Jacinto Blvd D3500, Austin, Texas 78712-0358; E-mail: [email protected]

JOURNAL OF MARITAL AND FAMILY THERAPY 1

rather than creating a dichotomy between the process and the outcomes (Greenberg, 1986). The
SEA combines the basic (CPR) designs and qualitative and quantitative data collection, generally
within an interpretive, theory-building framework, and connects those events to postsession pro-
gress. SEA covers several different methods: (a) task analysis (e.g., Greenberg, 2007), (b) compre-
hensive process analysis (e.g., McVea, Gow, & Lowe, 2011), and (c) assimilation analysis (e.g.,
Stiles, 2005).

SOLUTION-FOCUSED BRIEF THERAPY

Solution-focused brief therapy (SFBT) change processes were originally grounded in the con-
structivist approaches to communication and social interactional theories (de Shazer, 1991) and
over time SFBT also became associated with social constructionism and the philosophical, post-
structural views of language such as Wittgenstein’s language games (Bavelas, De Jong, Jordan &
Korman; 2014; de Shazer, 1994). Researchers have noted that the specific questioning techniques
(e.g., miracle questions, scaling, etc.) are an important means of facilitating changes with clients
(e.g., Beyebach, 2014), and that increasing positive expectancies, and positive emotion, such as
hope and optimism, may be associated with positive outcomes within SFBT (e.g., Kim & Franklin,
2015; Kiser, Piercy, & Lipchik, 1993; Lipchik, 2002b).
A treatment manual on SFBT was first developed in 2008, and updated in 2013 (Bavelas et al.,
2013; Trepper et al., 2012) by the Solution-focused Brief Therapy Association (SFBTA). The
research committee identifies active ingredients and the core processes of conversations that are
important in SFBT. These ingredients include conversations that involve a therapeutic process of
co-constructing, by altering and/or creating new meanings with clients. Co-construction is a col-
laborative process in communication where speaker and listener collaborate to negotiate mean-
ings, and this jointly produced information in turn acts to shift meanings and social interactions
(Bavelas et al., 2013, p. 5). According to the SFBTA treatment manual, clients are specifically
asked to co-construct a vision of a preferred future and draw on their past successes, strengths,
and resources to make that vision a part of their everyday lives.

Previous Reviews of Process Studies on SFBT

Over the past decade, we found only one published review on the process change research and
that was McKeel’s (2012) narrative review that focused on the outcomes achieved using specific
SFBT therapeutic techniques. McKeel’s review showed therapeutic techniques, such as solution-
talk (e.g., “How have you all managed to keep things from getting worse?”), presuppositional
questions (e.g., “What changes have you noticed that have happened or started to happen since
you called to make the appointment for this session?”), and the engendering of hope and positive
expectations (e.g., using the miracle question by asking “. . . If a miracle happens and whatever that
brings you here gets solved, how would your life be different? How would you think, feel and
behave differently?”) in clients toward change increased positive results in client goals within SFBT
studies. McKeel (2012) also indicated that techniques, such as the scaling question and miracle
question, have also shown positive outcomes in therapy sessions. This review also pointed out sev-
eral negative outcomes and limitations in the process studies examined in comparison to the
growth and quality of the SFBT outcome studies. The Journal of Systemic Therapies recently fea-
tured two special sections (Smock-Jordan & Bavelas, 2013; Bavelas & Jordan, 2014) featuring
microanalysis studies. The special sections demonstrated important aspects of the co-construction
processes within the SFBT sessions. Studies showed, for example, that SFBT used more of the cli-
ent’s exact words, and used more positive language, than other therapies such as CBT and Motiva-
tional Interviewing (MI) (Jordan, Froerer, & Bavelas, 2013; Korman, Bavelas, & De Jong, 2013).
Additionally, we found several systematic reviews and meta-analyses of SFBT outcomes (e.g.,
Bond, Woods, Humphrey, Symes, & Green, 2013; Gingerich & Peterson, 2013; Kim, 2008; Kim
et al., 2015; Stams, Dekovic, Buist, & de Vries, 2006) supporting an increasing evidence-base for
SFBT; however, none of the systematic reviews examined mechanisms of change for SFBT (Frank-
lin & Montgomery 2013).

2 JOURNAL OF MARITAL AND FAMILY THERAPY

 AIMS OF STUDY

No systematic reviews have been completed on the SFBT process research. This article will
systematically review process studies in English that have been conducted on SFBT including those
that use the four major approaches to change processes research that have been identified by
Elliott (2010) and all other research designs that can be identified and are relevant to understand-
ing the change processes of SFBT. The purpose of this current review is to summarize the empirical
change process literature on SFBT and to review the use of practices and processes in SFBT as
reported by the literature.
We will examine studies that look at the active ingredients of therapy, for example, co-con-
struction of meaning and relationship factors, and therapeutic techniques, such as the miracle
question and other techniques. It is the intention of the authors to be inclusive of all the change
process research and to increase the rigor of this review by following a systematic approach to the
review resulting in a meta-summary (Sandelowski & Barroso, 2007) of the results for both quanti-
tative and qualitative process studies on SFBT.

METHOD

Selection Criteria
Our objective was to review (a) all available, (b) process studies of SFBT that were (c) deliv-
ered in clinical settings (direct client contact). We reviewed all studies in English, published or
unpublished, that purported to study the processes of SFBT. Unpublished studies, dissertations,
and conference reports, including published conference proceedings and conference presentations,
were reviewed just as published study (Higgins & Green, 2011).
In defining process studies, we started with a four-category conceptual framework based
on Elliott’s (2010) model: (a) the Quantitative Process-Outcome Design, (b) the Qualitative
Helpful Factors Design, (c) the Microanalytic Sequential Process Design, and (d) the Signifi-
cant Events Approach. Across each category, we assigned 11 analytical techniques extracted
from three methodology articles on change process research (Elliott, 2010; Greenberg, 1986;
Woolley, Butler, & Wampler, 2000) that fit a certain category. This conceptual framework
was important for this review because change process research is a broad concept that houses
a plurality of research designs. Our approach allowed this article to maximize the scope of
our search while keeping the focus on all analytical techniques and research designs that are
associated with process studies. During review of the abstracts of articles, we found one
research design that was not identified in Elliott’s review, recursive frame analysis, and we
added this term to our search criteria.

Search Strategy
We used two strategies to create the initial pool of potential studies for review. First, we con-
ducted five electronic databases searches including PsychINFO, Academic Search Complete, Med-
line, PUBMED, and Education Resource Information Center (ERIC). Within each database, we
used *Solution-Focused* or *Solution Focused* or *SFBT* or *Solution-Focused Brief Therapy*
AND four different types of Psychotherapy Change Process Research. For example, for type one
studies, search within PsychINFO, we used the key words: *Solution-Focused* or *Solution
Focused* or *SFBT* or *Solution-Focused Brief Therapy* AND *Mechanism of Change* or
*Mediator* or *Mediation*. As a result, we conducted four different sets of key word search
within each database and repeated five times for the period 1980 to January 2015.
Second, we conducted a comprehensive hand search including all possible sources of studies
like (a) major journal search with key words: *Solution-Focused* or *Solution Focused* or
*SFBT* or *Solution-Focused Brief Therapy*. We included: Journal of Systemic Therapy; Jour-
nal of Marital and Family Therapy; American Journal of Family Therapy; Journal of Family
Therapy; and “Family Process”, (b) all additional studies from McKeel’s (2012) book chapter ref-
erences, and (c) manually searched major Internet resources for additional candidate studies
including Solution-Focused Brief Therapy Association at http://www.sfbta.org/, European Brief

JOURNAL OF MARITAL AND FAMILY THERAPY 3

Therapy Association at http://ebta.eu/, Alasdair Macdonald’s website at http://www.solutions-
doc.co.uk/index.html, which included another McKeel’s Review and Lonnen’s process study, and
Bavelas’s list of studies at http://web.uvic.ca/psyc/bavelas/Publications.html. Finally, we contacted
experts in the field who had published process studies on SFBT to see if they could identify any
other studies. Our search resulted in an initial pool of 272 candidate studies.
Figure 1 shows the search process. We reviewed the title and abstract of the candidate studies
and discarded 172 that clearly did not meet one or more of the selection criteria. Finally, two
reviewers reviewed the full reports of the remaining studies and excluded those that did not meet
our search criteria. When there were questions about a particular study, the first and second
reviewer discussed the eligibility of the study until consensus was reached. If the first and second
coders were unable to resolve their different opinions, a third reviewer was consulted. Only two
articles were brought to a third reviewer and we excluded one of the two articles based on further
examination of the article in relationship to our selection criteria. Studies were excluded if they did
not use SFBT and did not focus on examining therapy process but on some other focus such as the
effectiveness of SFBT. During the review process, we were unable to obtain a copy of one

Records identified through Additional records identified through

database searching (n = 68) other sources (n = 272)

Records after duplicates removed

(n = 272)

Records screened based on title Records excluded based on title

(n = 272) (n = 172)

Records screened based on abstract Records excluded based on abstract

(n = 100) (n = 0)

Full-text articles assessed for eligibility Full-text articles excluded, with reason

(n = 100) (n = 67 + 1)

Full-text articles coded and reported

(n = 32 + 1)

Figure 1. Flow diagram showing the number of studies at each step in the selection process.

4 JOURNAL OF MARITAL AND FAMILY THERAPY

dissertation (Skidmore, 1993) and had to exclude the study for final analysis. As a result, 32 articles
were left for coding and analysis. During the analysis, one article (Richmond, Jordan, Bischof, &
Sauer, 2014) reported results of two separate studies within one article. After a detailed review of
this article, it was unanimously agreed that the two separate studies reported in this one article
were not interrelated in any way. Therefore, we decided to report this article as two separate stud-
ies in the result section, leaving 33 studies as our final sample.

Data Abstraction and Coding

We extracted data from each of the selected studies using a coding sheet (available as a supple-
mental file accessible with the article on the JMFT website). After the first five articles were coded
using the initial coding sheet, authors met again and revised the coding sheet based on the results
of the first five articles. All included studies (including the first five articles) were then coded in a
final version of the coding sheet by two coders. Both coders were experienced psychotherapists
with expertise in SFBT and research methods. Besides bibliographical information, the final cod-
ing sheet recorded the type of change process research design (e.g., process-outcome or microana-
lytic sequential), specific design of the study (e.g., quasi-experimental design or qualitative
interview), demographics of the study population (e.g., age, gender, race), problem addressed in
the study (e.g., family relationship, child behavior or anxiety disorders), nature of the intervention
(e.g., SFBT alone or SFBT versus CBT) including level of intervention (e.g., individual or family),
number(s) of session (e.g., single versus multiple sessions), duration of the session studied (e.g., full
session versus excerpt of a session), and providers’ experiences (e.g., graduate level intern or experi-
enced therapists).
The coding sheet also recorded information including SFBT skills (techniques or practices
identified), measures (if any), statistical outcome (if any), and qualitative (narrative) themes of the
studies (if any). In recording SFBT skills, we included both technique-oriented skills (e.g., miracle
question, exception questions) and linguistic (e.g., solution-talk, focus on co-construction) and
therapist relationship, and style-oriented skills (e.g. therapeutic alliance). Including this type of
information allowed us to capture the complex nature of most SFBT process studies.

Data Analysis
This study used meta-summary, one of the mixed-method research synthesis approaches (San-
delowski & Barroso, 2007), to analyze data. Meta-summary has been suggested to be an appropri-
ate method for reviewing active ingredients of interventions (Heyvaert, Hannes, Maes, &
Onghena, 2013) and provides analytic methods for summarizing primary studies that include
quantitative, qualitative, and mixed-methods designs (Sandelowski, Voils, Leeman, & Crandell,
2012). Meta-summary follows the logic of meta-analysis and uses a comparability approach where
“the differences [between quantitative and qualitative results] are reconciled by converting the one
into the other” in order to provide an aggregate summary of primary studies (Sandelowski, Voils,
& Barroso, 2007, p. 239). For this study, both quantitative and qualitative results were retrieved
from primary studies and were aggregated using a data transformation approach. Using this
approach, we converted quantitative results into qualitative themes so that the results would be
comparable. Figure 2 summarizes the steps of the analysis.
In order to conduct a meta-summary, quantitative results and qualitative results were first sep-
arately retrieved from primary studies. Specifically, [STEP 1], we assigned results from primary
studies’ into either quantitative results based on the statistical data or qualitative results based on
the reported narrative results and themes. For mixed-method studies, quantitative and qualitative
results from the studies were separated and the results were assigned into quantitative or qualita-
tive categories. For quantitative results [STEP 2], we used a vote counting (Voils, Sandelowski,
Barroso, & Hasselblad, 2008) method and if p < 0.05, then a result was assigned as a positive
quantitative result. If p ≥ 0.05, then a result was assigned as a non-positive quantitative result. To
reiterate, the term “positive” was used when there was statistical support for the concept in pri-
mary studies, and the term “non-positive” was used when there was no statistical support for the
concept. For qualitative results, if a qualitative theme supported the research question, or if a qual-
itative theme emerged that was reported as a positive finding in the study, then the theme was
assigned as a positive qualitative result. If a qualitative theme did not support the research

JOURNAL OF MARITAL AND FAMILY THERAPY 5

 Quantitative results Mixed-method (quantitative and Qualitative results
qualitative) results

[STEP 1] QUANTITATIVE results QUALITATIVE results

If p < 0.05, then If p ≥ 0.05, then If a qualitative theme If a qualitative theme did not
supported research question, support research question, or, if
or, if a theme emerged, then a theme did not emerge, then

Positive Non-positive Positive Non-positive

[STEP 2] quantitative results quantitative results qualitative themes qualitative themes

If a result specified If a result described If a theme specified If a theme described

SFBT technique in process of SFBT in SFBT technique in process of SFBT in
relation to therapeutic comparison to other relation to therapeutic comparison to other
change, then therapies, then change, then therapies, then

Relational* Process Non-positive Relational Process Non-positive

[STEP 3]
positive positive quantitative positive positive qualitative
results results results themes themes themes

[STEP 4] Quantitative results were then transformed

into qualitative themes**

Relational Process Non-positive Comparable Relational Process Non-positive

positive positive qualitative positive positive qualitative
[STEP 5]
themes themes themes themes themes themes

All relational, positive All process, positive All non-positive

themes themes themes/statements

** The terminology of “relational result” in the context of this study is not about relationship of the client-therapist dyad. It specifically refers to those results that related the
techniques or practices of SFBT to therapeutic outcomes.
** For a relational, positive [quantitative] result, it was transformed into “SFBT techniques significantly improve therapeutic outcomes”. For a process, positive
[quantitative] result, it was transformed into “SFBT therapists used significantly more process (e.g., client’s own words) than other therapies (e.g., CBT)”. For non-
positive quantitative results, they were transformed into either “SFBT techniques did not significantly improve therapeutic outcomes” or “SFBT therapists did not use
more of clients’ words than CBT therapists”.

Figure 2. Steps of conducting a meta-summary analysis.

question, or if a hypothesized theme failed to emerged, then the theme was assigned as a non-posi-
tive qualitative theme. [STEP 3] If the reported positive [quantitative] results specified SFBT tech-
niques in relation to therapeutic change, then the result was assigned as a relational positive result
(e.g., “clients in the solution-talk group reported a significantly higher (p < 0.001) proportion of
treatment continuation” is a quantitative relational positive result). However, if the positive [quan-
titative] results described the process of SFBT in comparison to other therapies, then the result was
assigned as a process positive result (e.g., “positive utterance among SFBT therapists was signifi-
cantly higher that CBT therapists, p < 0.001” is a positive quantitative results that indicated pro-
cess differences between solution-talk and CBT). For clarity purpose, it should be emphasized that
the terminology of “relational result” in the context of this study is not about relationship of the
client–therapist dyad. It specifically refers to those results that related the techniques or practices

6 JOURNAL OF MARITAL AND FAMILY THERAPY

of SFBT to therapeutic outcomes. The same procedure was applied for positive qualitative themes
(e.g., “clients reported one of the factors that was helpful to their treatment was the therapist
encouraged problem elaboration.” This is a qualitative theme that indicates a positive relationship
between problem elaboration and therapy outcomes; and “clients reported their perception of
solution-oriented questions are the ones that focus on exception, strengths and resources” is a posi-
tive theme that describes the process of asking solution-oriented questions). We did not separate
non-positive results/themes into relational or process category because only 14 (out of 116) results/
themes from primary studies were non-positive. By the end of [STEP 3], we had six groups of out-
comes including (a) relational positive [quantitative] results, (b) process positive [quantitative]
results, (c) non-positive quantitative results, (d) relational positive theme, (e) process positive
themes, and (f) non-positive qualitative theme. [STEP 4] Then, we transformed quantitative results
into qualitative themes based on the statistical data and descriptions of the findings within the pri-
mary studies. For any relational, positive [quantitative] results, for example, “clients in the excep-
tion question group reported significantly higher degree of change (p < 0.001)”, was transformed
into a relational, positive theme: exception question significantly improves clients’ perceived
change. For any process, positive [quantitative] results, such as “SFBT group reported significantly
higher proportion of preserving clients’ own words (p < 0.001)”, was transformed into a process
qualitative theme: SFBT group/therapist preserved a significantly higher proportion of client’s
own words. For any non-positive quantitative results, for example, a result was transformed into
either “exception questions did not improve clients’ perceived change significantly” or “SFBT
group/therapist did not preserve a higher proportion of clients’ own words”. At the end of [STEP
4], with all the quantitative results transformed into qualitative themes, we had two groups of rela-
tional positive themes, two groups of process positive themes, and two groups of non-positive
themes based on the quantitative and qualitative results that were retrieved from the primary stud-
ies. In [STEP 5], we combined the themes from the categories into (a) all relational positive themes,
(b) all process positive themes, and (c) all non-positive themes regardless if a theme came from
quantitative results or qualitative themes. Thus far, this procedure offered us a pool of aggregated
data that were composed of qualitative themes only.
Finally, in order to better understand the results of the aggregated data and to evaluate what
SFBT techniques and processes had the most empirical support (with positive quantitative and/or
qualitative results from primary studies) based on research findings, we grouped all the positive
relational themes, positive process themes, and non-positive themes into additional categories that
represented the types of therapeutic techniques and processes that were studied. This additional
coding of the findings from primary studies resulted in the aggregated data being categorized and
reconfigured into the follow groups of therapeutic techniques and processes. (a) Linguistic and col-
laborative language (e.g., therapist’s choice of positive language improves clients’ perceived change),
(b) Therapeutic relationship and therapists’ style (e.g., therapists who are flexible and do not force
clients to explore problems), (c) Strengths and resources techniques (presession change, formulation
first session task, scaling question, and exception question), (d) Future oriented techniques (mira-
cle question, goals, end of session homework), and (e) Multiple SFBT techniques and interviews.
Procedures for coding and making the transformations of the data included a first coder that trans-
formed all quantitative results into qualitative themes in a way that was previously described in
Figure 2, and the transformation were further examined as a confirmation check by the second
and third coder who were also familiar with all the original studies (Onwuegbuzie & Teddlie,
2003). In addition, one coder coded the aggregated data into types of therapeutic techniques and
processes resulting in the reconfiguration of the data into types of therapeutic techniques and pro-
cesses. A second coder further recoded the themes as a confirmation check and made sure that the
most accurate fit had been achieved in the way the data were configured.
Once aggregated and configured by therapeutic techniques and processes, the data were fur-
ther analyzed using descriptive statistics reporting the frequency of the positive and non-positive
themes across studies. This type of analysis is referred to in the mixed-method, research synthesis
literature as a frequency effect size (Sandelowski & Barroso, 2007). In this article, however, we will
use the term percentages because the numbers of themes across studies represent the cumulative
positive or non-positive support that we have for different SFBT therapeutic techniques and pro-
cesses as they were reported in the literature.

JOURNAL OF MARITAL AND FAMILY THERAPY 7

 RESULTS

We identified two studies (6%) published before 1991, eleven studies (34%) published between
1991 and 2000, and twenty studies (60%) published after 2001. Twenty-seven studies (81%) are
journal articles and the six are dissertations (19%). Regarding research designs used in the studies,
42.4% of the studies (n = 14) used MSPD and 39.4% of the studies (n = 13) used process-outcome
or mechanism of change method of analysis. Four articles (12.1%) used qualitative method of
analysis and only two articles (6.1%) used comprehensive or task analysis. Twenty-five studies
(75.8%) examined SFBT as an individual intervention, six studies (18.1%) examined SFBT for
couples and families, and two studies (6.1%) used SFBT as an intervention for both individuals
and family/couple.

Quality of Studies
We assessed the studies on quality indicators that have been recommended in systematic
reviews including study designs, measures, sample and population, and intervention fidelity. The
study designs were diverse and only 12 studies (36.36%) used an experimental design that exam-
ined process along with outcomes. Eighteen studies examined processes only and did not link pro-
cesses to outcomes. One study (Lloyd & Dallos, 2008) used semistructured qualitative interview to
examine the relationship between SFBT components and self-efficacy and self-locus of control,
and two studies (Monro, 1998; Simon & Nelson, 2004) used qualitative interview on clients’ per-
ceived helpful factors of SFBT. Only nine studies compared SFBT against another intervention,
and eighteen studies did not compare the process of SFBT with another intervention. Six addi-
tional studies added SFBT component(s) to an existing treatment or intervention. There were no
studies that would meet the gold standard for mechanism of change research as described by Kaz-
din and Nock (2003), including (a) strong association, (b) specificity, (c) gradient, (d) experiment,
(e) temporal relation, (f) consistency, and (g) plausiblity and coherence. This is a criticism of the
quality of the studies in relationship to the overall confidence of the findings but it is additionally
noted that few psychotherapy process studies may meet this gold standard.
There were also strengths and limitations within measures used. Out of the sixteen studies that
included some types of measures, only seven studies used standardized rating scales, and five stud-
ies used either a therapeutic coding systems or client self-reported survey. The rest of the studies
used direct behavioral observations or observational measures, such as the Topic Initiation/Topic
Following coding scheme (Beyebach & Carranza, 1997a,b). Studies also used clinical data includ-
ing progress note (e.g., Franklin, 1996), transcribed videotapes (e.g., Gale & Newfield, 1992), and
audiotapes (e.g., Shields, Sprenkle, & Constantine, 1991).
Approximately half of the studies had small, clinical, convenience samples (n = 16) limiting
the overall generalizability of the findings. Of these studies, small sample sizes that used part or full
sessions of therapy were available and these studies lacked replications with larger samples. Most
of the studies (n = 25) reported 20 or less participants in the treatment condition. Only four studies
had more than 45 participants for the SFBT group, leaving the other four studies with a treatment
group sample size ranging from 21 to 40. Although smaller sample sizes are not uncommon in pro-
cess research, there were other characteristics of the samples that may limit the conclusions that
can be drawn from a synthesis of these studies. There was a lack of diverse populations and several
studies did not report about the client characteristics within the studies. Only 14 studies (42%)
reported clients’ racial background and they were predominantly Caucasian.
The experience of the therapists delivering the SFBT interventions also varied with 13 studies
using experienced therapists and 4 studies using intermediate therapists with at least 2 years of
experience. Five studies used both experienced and intermediate therapists and two studies used
both experienced therapists and master level interns, while an additional two studies used only the
interns. It should be noted that information regarding the therapists’ training, competencies and
experiences in using SFBT were generally not available in the primary studies. Limited information
could be drawn from the 13 studies that used experienced therapists. For a study’s therapist(s) to be
coded as experienced, he/she must meet the following criteria (a) well-known experts of SFBT like
Insoo Kim Berg, or (b) a doctoral level therapist with a marriage and family therapy background,

8 JOURNAL OF MARITAL AND FAMILY THERAPY

 Table 1
Descriptive statistics of techniques and practices of SFBT reported by the literature

Typesa No. of themes/studiesb Quant./Quali.c % out of all themesd

Positive relational themes

LCL 25/9 11/14 21.55%
TRTS 6/3 3/3 5.17%
SRT 14/6 8/6 12.07%
FOT 10/3 7/3 8.62%
MTI 13/6 5/8 11.21%
Total 68 themes 34/34 58.62%
Positive process themes
LCL 15/8 6/9 12.93%
TRTS 5/2 3/2 4.31%
SRT 8/2 0/8 6.90%
FOT 3/2 0/3 2.59%
MTI 3/2 0/3 2.59%
Total 34 themes 9/25 29.31%
Non-positive themes
LCL 4/2 2/2 3.45%
TRTS 2/1 2/0 1.72%
SRT 5/2 5/0 4.31%
FOT 0 0 0.00%
MTI 3/3 2/1 2.59%
Total 14 themes 11/3 12.07%
Total 116 themes 54/62 100%

Notes. aTypes of techniques and practices of SFBT that were examined in primary studies.
LCL = Linguistic and collaborative language, included co-construction and solution-talk;
TRTS = therapeutic relationship and therapist style, included positive, client-focused stance,
supportive and flexible approach; SRT = strengths and resources techniques, included pre-
session change, formulation first session task, scaling question, exception question;
FOT = future-oriented techniques, included miracle question, goal setting, and end of ses-
sion homework; MTI = multiple SFBT techniques and interviews. bNumber of themes
reported and by how many studies. cHow many themes were derived from quantitative data
and how many were from qualitative data in primary studies. dThe percentage of number of
themes out of all themes from primary studies.

or (c) a licensed clinician with several years of practice experience including SFBT. With this said,
however, except those who are well-known experts of SFBT, most studies were not clear about how
much actual training that an experienced therapist had in relationship to the practice of SFBT.

Study Findings
Descriptive statistics in Table 1 presented the frequency of the positive and non-positive
themes reported across studies. The qualitative themes are first grouped based on the nature of the
themes (positive relational themes, positive process themes, and non-positive themes). Then,
within each group, themes were further assigned into a configuration of the types of SFBT thera-
peutic techniques and processes that were examined in primary studies described previously.
Overall, 87.9% (n = 102) of the themes were positive themes from primary studies, meaning
87.9% of the results from primary studies retrieved either received statistical support or qualitative
support for the techniques and practices of SFBT. Out of the 102 themes, 68 themes (66.67%) were

JOURNAL OF MARITAL AND FAMILY THERAPY 9

positive relational themes and 34 (33.33%) themes were positive process themes. More specifically,
16 articles (including 51 themes) reported positive findings on SFBT techniques when combining
all the results across studies (strengths and resources techniques [SRT], future-oriented techniques
[FOT], and multiple SFBT techniques and interviews [MTI]) altogether (45%). When looking at
the SFBT techniques separately, eight studies (including 22 themes) examined strengths and
resources-oriented SFBT techniques (24%), and five studies (including 13 themes) examined
future-oriented SFBT techniques and reported positive findings (15%). Six articles (including 16
themes) examined multiple SFBT techniques and interviews combined and reported positive find-
ings (18%). The data also suggest that 13 studies (including 40 themes) examined linguistic and col-
laborative language and reported positive findings (39%). Additionally, six articles (including 11
themes) examined therapeutic relationship and therapists’ style and reported positive findings
(15%).
Concerning non-positive findings, two studies (including four themes) reported non-positive
findings of linguistic and collaborative language in relation to positive therapeutic change. One
study (including two themes) reported non-positive findings of therapeutic relationship and thera-
pist style in relationship to positive therapeutic change. One study (including five themes) reported
non-positive findings of SRT in relation to positive therapeutic change. Three studies (including
three themes) reported non-positive findings of multiple SFBT techniques and interviews in rela-
tion to positive therapeutic change. All non-positive themes were relational themes/results, and all
findings reported for FOT were positive.
A supplemental file accessible with the article online lists all 116 themes based on (row) the
nature of themes and (column) a configuration of the SFBT techniques and practices reviewed in
primary studies. Eight studies (including 16 themes) examined behavioral oriented outcomes, such
as treatment continuation (Beyebach & Carranza, 1997a,b), goal attainment (Lambert, Okiishi,
Finch, & Johnson, 1998), expressive communication (Shields, et al., 1991), and acceptance (of the
problems) (Lloyd & Dallos, 2008). Seven studies (including 15 themes) examined emotional-
oriented outcomes, such as optimism (Adams, Piercy, & Jurich, 1991; Johnson, Nelson, & All-
good, 1998), positive affect (Grant, 2012), hope (Bozeman, 1999), and distress (Richmond et al.,
2014). Two studies (including four themes) examined perceptual-oriented outcomes including goal
clarity (Adams et al., 1991), perceived problem improvement and outcome expectancy (Jordan &
Quinn, 1994). This supplemental file also underlined and italicized those themes that used stan-
dardized rating scales, behavioral observations and different coding schemes.

DISCUSSION

The findings from this study have important implications for clinical practice/supervision,
education, and future research. The results of this current review suggests that both SFBT tech-
niques and linguistic/style-oriented methods show positive support and that both may be co-func-
tioning in the change processes of SFBT. Even though, SFBT techniques and linguistic processes
are presumed to interact together to create change, the studies on techniques are different than the
studies that focus on linguistic processes resulting in the two being discussed separately within this
review. Only a few studies, for example, discussed the use of techniques in relationship to linguistic
change (e.g., Strong & Pyle, 2009; Strong, Pyle, & Sutherland, 2009). Future researchers may want
to pay more attention to how both linguistic processes and techniques co-function together in the
change process because a more thorough sequential or systemic analysis would be useful for educa-
tion and supervision.
Overall findings from this review add to the scientific foundation for SFBT practice and pro-
vide support for the active ingredients that have been identified in the SFBTA treatment manual
and in other training and clinical literature on SFBT (Berg & De Jong, 1996; Trepper et al., 2012;
Bavelas et al., 2013; Taylor & Simon, 2014). This review indicated that the strongest overall find-
ings based on the most positive themes for effectiveness (0.45%) were for all the SFBT techniques
combined (strength and resources, future-oriented, and multiple techniques. In comparison to
other techniques, the strengths and resources techniques received most positive findings from pri-
mary studies (i.e., eight studies support the use of these techniques). These findings support the
continued need for clinicians to be thoughtful and purposefully integrate the specific strength/

10 JOURNAL OF MARITAL AND FAMILY THERAPY

resource techniques into their work with clients. In addition, supervisors should work to provide
feedback to emerging clinicians regarding the appropriate use and timing of all SFBT techniques
and in particular, ways to support the strengths and resources of the client. Additionally, educators
may want to provide instruction on the strengths and resources techniques as a part of their train-
ing in the co-construction process because this review also indicates that education and supervision
on SFBT should focus attention on teaching the language skills needed to meaningfully co-con-
struct conversations with clients. Evidence from this review indicated, for example, the significance
of the co-construction process within counseling. Of the 33 studies reviewed, 13 studies supported
the linguistic techniques and the collaborative language approaches as being important to the pro-
cess of change for SFBT. This represents the second strongest overall findings based on the most
positive themes for effectiveness (0.39%). Only two studies did not show a positive result for the
linguistic techniques that were studied.
Findings from this review specifically showed that SFBT applies the purposeful use of lan-
guage in the form of the co-construction of meaning in a unique way that is different from some
other therapies (e.g., client-centered, MI, CBT) and co-construction of meaning is a specific
method that is used for building solutions with clients (e.g. Berg & De Jong, 1996; De Jong & Berg,
2013; Tomori & Bavelas, 2007; Korman et al., 2013; Jordan et al., 2013; Froerer & Jordan, 2013).
Not only did a large portion of the studies show the use and effectiveness of the co-construction
processes within SFBT, but also six of the studies in this review examined co-construction of mean-
ing also made use of microanalysis of communication as a research method. The cumulative micro-
analysis studies add to our understanding of the change theory and core processes of SFBT.
According to Elliott (2010), microanalysis is a potentially useful and rigorous research design for
studying theory and sequential analysis within therapy sessions and has not regularly been used in
psychotherapy process research; however, this review indicates that it has been frequently used in
SFBT process research. We identified no microanalysis studies, however, that showed that the
co-constructive processes in SFBT are directly linked to how problems are solved, in other words,
how the process is linked to outcome. Additional research is needed to study the co-construction
process in relationship to client outcomes.
The fact that studies in this review show the significance of the co-construction of meaning
to the SFBT process but do not study these processes in relationship to client outcomes has
implications for clinical practice. In the absence of empirical evidence, practitioners using
SFBT are encouraged to routinely evaluate how they are using the SFBT language to co-con-
struct meaningful conversations with clients and to also examine the progress of their clients
in therapy. SFBT educators and supervisors should also clearly understand the way SFBT uses
the co-construction process, how to facilitate this process, and how to evaluate if therapists
are learning this process in order to increase the clinical competence with SFBT. The results of
this study also suggest that a measure of competence in the linguistic and co-construction pro-
cess may be necessary for determining fidelity in SFBT research studies because the co-con-
struction process is an active ingredient of SFBT. Outcome studies have not assessed fidelity in
this manner but instead identify the use of SFBT techniques as an indicator of fidelity (e.g.
Gingerich & Eisengart, 2000; Kim, 2008).
The therapeutic relationship and therapists’ style were other change processes that were
examined in this study but there were only five primary studies that found positive results for
these processes within SFBT sessions and these showed only a small percentage of the themes
that are associated with change processes within SFBT (15%). One additional study also found
that therapeutic alliance was not associated with a positive outcome (Wettersten, Lichtenberg,
& Mallinckrodt, 2005). The lack of research on therapeutic relationship may be partly due to
early statements by Steve de Shazer about not needing to focus on the therapeutic relationship;
however, these views were modified in later literature (De Jong & Berg, 2008; Lipchik, 2002b).
The findings contrast with the therapeutic literature that shows the significance of the thera-
peutic relationship as a common factor for therapeutic change and to the clinical literature on
SFBT which discusses the importance of the collaborative, empowering, cooperative, and flexi-
ble relationship style of the therapist, as being important to success with clients (Lipchik,
2002a; Lipchik, 2011; Beyebach, Morejon, Palenzuela, & Rodriguez-Arias, 1996). This lack of
research on therapeutic alliance may also be due to a misunderstanding about what may

JOURNAL OF MARITAL AND FAMILY THERAPY 11

contribute to a positive alliance. Froerer and Connie (2016) recently advocated for an alterna-
tive view of the therapeutic relationship—this view being consistent with the postmodern, con-
structivist approach in which a collaborative, client-lead, language is synonymous to a
therapeutic relationship and can lead to the client feeling understood and cared for. More
attention in SFBT process research needs to be completed that studies the impact of a mean-
ingful and cooperative therapeutic relationship, and how the language process may contribute
to this meaningful relationship.

Limitations
First, there is always a possibility that we did not find all the process studies within the
proposed timeframe, although, we followed a rigorous search criteria and process making use
of methods that have been recommended for systematic reviews. This study is also limited to
studies in English and no doubt a broader search in different languages may enhance or even
possibly change the findings of this study. The mixed-method research approach, meta-sum-
mary that was used to aggregate primary studies while adding strengths to this study by allow-
ing a summarization of findings from diverse study designs also has limitations in that some
of the information from different studies may be lost in the recoding and analysis. The config-
uration of study variables is also based on an analytical qualitative technique, and it may not
represent all the quantitative findings within each study or the thick descriptions of the sum-
maries within the qualitative studies. Even with these limitations, we believe that this study
provides a contribution to literature by providing a systematic review and analysis of the cur-
rent process studies on SFBT in English.

CONCLUSION

This review show that SFBT techniques have considerable support across the process studies
and that the techniques directed toward the strengths and resources of the clients show the most
positive results. The linguistic and collaborative language approaches also have relatively strong
support in the SFBT and this finding adds to the empirical support for the co-construction of
meaning. The current findings have limitations in their evidence due to the quality and numbers of
the current studies. The next steps for SFBT process research will be to replicate current findings
and improve upon research designs regardless of what methods are used. One way to improve the
studies is to design prospective studies that can show that the co-constructive processes in SFBT
are directly linked to client outcomes. It may be useful to study outcomes that have been found to
be significant in effectiveness studies because a normal progression for evidence based practice is to
first show a therapy works and then proceed to study how and why it works. Two areas that have
shown promise for example, are with internalizing disorders such as depression, (Gingerich &
Peterson, 2013) and with problems that occur in children and families (Bond et al., 2013). Samples
would need to be large enough to meet the recommended standards for the research designs being
used. In particular, the development of larger randomized controlled trials that study both process
and outcomes are indicated.

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