I stopped seeing my therapist because she kept stating that my Autism was a ‘problem’ or asking me what life would be like without it. It started to make me feel bad about myself.
Much like working with any diverse population, when working with clients with a physical, developmental, or intellectual disability, our language needs to be closely monitored and even sometimes altered. Disabilities can include, but are not limited to Parkinson’s, autism spectrum disorder (ASD), vision or hearing impairment, dementia, cerebral palsy, epilepsy, down syndrome, amputation, and spina bifida. Some disabilities can be diagnosed during someone’s birth, such as down syndrome or intellectual disability. Others, like dementia, may be diagnosed during the later years of someone’s life. Regardless of when the diagnosis was received, it is important to consider how we, as family therapists, are speaking about a client’s disability.
The quote above was stated by a client I worked with who was struggling with expressing his emotions and connecting with friends and family. When he discussed previous experiences in therapy, he mentioned leaving a therapist due to consistent questions about what “life would be like without my Autism.” For obvious reasons, the client felt misheard and disappointed in his treatment. Unfortunately, this client is not the first to report that certain phrases, therapeutic interventions, and questions asked by therapists are unhelpful, irrelevant, and unrealistic (i.e. Lloyd & Dallos, 2008; Turns et al., 2022).
Although it is out of this article’s scope to review every model and intervention that could be used when working with families with a disability, it is important to shed light on how family therapists can provide treatment in a sensitive, effective, and ethical manner. For the purpose of this article, Solution-Focused Brief Therapy is recommended and several considerations will be discussed in order to begin working with clients with disabilities. Many of the interventions within SFBT are suitable for clients with a disability, however, the Miracle Question (MQ) has been shown to be problematic (i.e., Lloyd & Dallos, 2008; Turns et al., 2022).
The Miracle Question
“Suppose that while you are sleeping tonight and the entire house is quiet, a miracle happens. The miracle is that the problem which brought you here is solved. However, because you are sleeping, you don’t know that the miracle has happened. So, when you wake up tomorrow morning, what will be different that will tell you that a miracle has happened and the problem which brought you here is solved?” (de Shazer, 1988, p.5)
The MQ is one of the most well-known interventions used by solution-focused brief therapists. After initial goals are discussed, the MQ is used to help clients identify what differences they would immediately see if their presenting problem were resolved (De Jong & Berg, 2013). The therapist helps the client identify small, realistic behavioral changes they would make in order to achieve their “Miracle Day.” The answer is frequently used in remaining sessions to identify previous times the client was able to achieve their miracle day, while also giving clients a range of potential solutions for reaching the preferred future (De Jong & Berg, 2013).
Previous research has identified that clients, specifically mothers raising a child with ASD, found the question to be unrealistic and painful to consider (Lloyd & Dallos, 2008; Turns et al., 2022. One mother reported, “I believe God can do miracles, but to me a miracle is . . . not real, and I don’t want to live where it’s not real” (Turns et al., 2022, p. 50). Another mother reported, “I’ve had [ideas of a miracle day] before and I’ve really trained myself not to. So, I’ve almost created a blank slate . . . I’ve closed that side so that I wouldn’t be hurt anymore, I wouldn’t have expectations of ideas that weren’t there (p. 50).
AAMFT Workshop: Families Living with ASD: Integrating MFT in Systems
Clients and family members caring for a loved one with a disability may be facing life-long, incurable disabilities that are drastically impacting their lives. Asking the MQ, without first addressing key aspects, may harm the therapeutic relationship or leave clients feeling confused or offended. In an effort to avoid this outcome, and maintain the integrity of the intervention, the following considerations are recommended:
1. Identifying the client’s preferred future
It is important when clearly identifying the client’s preferred future that you do not focus on or insinuate that the diagnosis or symptoms may disappear. Many clients will struggle with symptoms that are caused by their diagnoses and creating a preferred future focused on the absence of those symptoms can be challenging. For instance, I worked with a couple where the husband was diagnosed with Autism. The wife stated that she would like to work on his ability to make eye contact with her and engage in more physical touch, both of which were identified as symptoms from the husband’s autism diagnosis. Focusing on the removal of the symptoms would have left the husband feeling disengaged from therapy or feeling as though he needed to change something he cannot change. Instead, this couple was able to identify and create a preferred future in which the wife was able to receive love and affection in ways that were also comfortable for the husband. Additionally, the couple developed a code word for when the wife needed to ensure she had her husband’s attention even when he wasn’t able to provide eye contact to her.
Even though I asked what life may be like without the disability, the intention was to identify his preferred future and understand what the client was really longing for.
Although I recommend not focusing on the removal of the diagnosis or symptoms, some clients may focus on the removal of their disability without your prompting. It can be extremely normal for a client or a family member to wonder what life may be like without the disability. If a client discusses their goals including the removal of the disability, I have found that there is usually a deeper yearning they are seeking. For instance, a young man with cerebral palsy (CP) sought therapy for depression and discussed wanting his “CP to go away.” I responded to his comment, “I wonder how you might act or feel if the CP disappeared?” The client responded with, “feeling more confident at school, smiling more, and trying to make friends.” Even though I asked what life may be like without the disability, the intention was to identify his preferred future and understand what the client was really longing for.
2. Replacing the word ‘miracle’
After identifying the client’s preferred future, the MQ is commonly asked to identify small steps the client can begin making immediately. As discussed earlier, this term has previously been identified as ineffective. Since working with clients with disabilities in 2012, I have found that replacing the word “miracle” with a different term can have the same effect and keep the integrity of the intervention. I have previously used phrases such as “jolt (or shift) in the universe” and “transformation.” While conducting a research study on the effectiveness of SFBT for couples raising a child with ASD, one father recommended changing the MQ to, “If you were watching a film of yourself and everything was going the way you would like, what would you see? What are you doing?” (Turns et al., 2022, p. 20). Discontinuing the use of the term ‘miracle’ has allowed my clients to not get stuck on the thought of their life getting better if their disability or symptoms disappear.
3. Carefully searching for exceptions
A common question asked during SFBT is the exception question. This question can take several variations but encapsulates the idea that the problem wasn’t always occurring. For instance, “Can you tell me about a time in the past when the problem wasn’t occurring?” When asking an individual with a disability, this question can be responded to with, “Well, before I was diagnosed with ____” or “When I didn’t have ______.” Similar to the recommendations above, it is important for therapists to be specific in asking about the “problem” and ensuring that the conversation is focused on a problem or situation that can be altered.
While working with a gentleman with Parkinson’s, he discussed wanting to be able to “walk freely without having to pause so much.” Obviously, asking the exception question would lead the client to discuss life before his diagnosis. Instead, I asked the client how he would like to handle his thoughts and emotions during times when he cannot walk freely. The client took several minutes to process the question and stated that he would like to feel relaxation throughout his body and instead of judging himself, he would remind himself that, “God is carefully leading my steps.”
CDC Infographic: Disability Impacts All Of Us
Working with clients with a disability, and their family members, may feel intimidating to therapists. Due to the lack of education and exposure training therapists receive related to this population, many therapists do not feel qualified to help. Since more than 25% of the population currently has a disability (Centers for Disease Control and Prevention, 2023), it is crucial that therapists receive training in order to effectively treat them. This article highlights the use of one systemic model of therapy that has been recommended for families with a disability (i.e., Roeden et al., 2014; Smock Jordan & Turns, 2016) while considering how language must be altered in order to provide sensitive care.
Dr. Brie Turns-Coe, LMFT, ASDCS is an AAMFT Professional member holding the Clinical Fellow and Approved Supervisor designations. She is associate professor and Program Director of the Marriage and Family Therapy Program at Arizona Christian University. Her research and clinical specialization is families caring for a loved one with a disability. She has published numerous publications and presented at international and national conferences regarding families and ASD. Turns-Coe recently co-edited Systemically Treating Autism and wrote Parent the Child You Have, Not the Child You Were.
Dr. Turns runs and teaches the Certificate in Families and Disability offered online at Arizona Christian University. This certificate encompasses 3 eight-week long courses that will teach clinicians how to effectively and ethically treat individuals with a disability and their loved ones. For more information please email Dr. Turns-Coe at Brie.Turns@arizonachristian.edu or visit www.arizonachristian.edu/certificate-in-families-and-disability/
Centers for Disease Control and Prevention. (2023). Disability and health data system. http://dhds.cdc.gov
De Jong, P., & Berg, I. K. (2013). Interviewing for solutions (4th ed.). Cengage Learning.
de Shazer, S. (1988). Clues: Investigating solutions in brief therapy. Norton.
Lloyd, H., & Dallos, R. (2008). First session solution-focused brief therapy with families who have a child with severe intellectual disabilities: Mothers’ experiences and views. Journal of Family Therapy, 30(1), 5–28.
Roeden, J., Maaskant, M., & Curfs, L. (2014). Process and effects of solution-focused brief therapy in people with intellectual disabilities: A controlled study. Journal of Intellectual Disability Research, 58(4), 307-320.
Smock Jordan, S., & Turns, B. (2016). Utilizing solution-focused brief therapy with families living with autism spectrum disorder. Journal of Family Psychotherapy, 27(3), 155-170. doi:10.1080/08975353.2016.1199766
Turns, B., Olufowote, R., Jordan, S., & Chavez, M. (2022). A multiple case study examining the solution-focused brief therapy experiences of couples raising children with ASD. International Journal of Systemic Therapy, 33(1), 37-61.
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