Approaches to Drug Abuse Counseling U.S. Department of Health and Human Services, National Institutes of Health Scott D. Miller 1. OVERVIEW, DESCRIPTION, AND RATIONALE 1.1 General Description of Approach
The Solution-Focused Model is a brief therapy approach developed over the past 20 years at the Brief Family Therapy Center in Milwaukee, WI. The model continues to evolve and be applied to a variety of presenting problems and across a number of treatment settings. Research now continues at Problems to Solutions, Inc., a clinic that provides free services to the traditionally underserved population, specializing in the treatment of homeless, drug-abusing males. Primarily, the model is designed to help clients engage their own unique resources and strengths in solving the problems that bring them into treatment.
1.2 Goals and Objectives of Approach
Goals are the entire focus of the solution-focused brief therapy approach. The model uses a specialized interviewing procedure to negotiate treatment goals whose qualities facilitate efficient and effective treatment. The goals must be:
- Salient to the client rather than the therapist or treatment program.
- Small rather than large.
- Described in specific, concrete, and behavioral terms.
- Described in situational and contextual rather than global and psychological terms.
- Stated in interactional and interpersonal rather than individual and intrapsychic terms.
- Described as the start of something rather than the end of something.
- Described as the presence of something rather than the absence of something.
- Realistic and immediately achievable within the context of the client’s life.
After a goal is negotiated, the model specifies how to use a client’s own unique resources and strengths to accomplish the goal. Two such resources and strengths are known as exceptions and instances. Exceptions are periods of time when the client does not experience the problem or complaint for which he or she is seeking treatment. Instances, however, are periods of time when the client experiences his or her problems either in whole or in part. Interviewing methods are used to elicit information about the occurrence of exception and instance periods so that they may be repeated in the future.
1.3 Theoretical Rationale/Mechanism of Action
The approach proposes that the solution(s) to the problems that a client brings into treatment may have little or nothing to do with those problems. This is particularly true in the treatment of problem drinking, where any of a variety of life experiences or actions on the client’s part, which have little to do with his or her use of alcohol, may result in a resolution of the problem. While the number of potential solutions is limitless, one example is a problem drinker who stops using problematically when he or she:
- Obtains employment.
- Ends or begins a relationship.
- Makes new friends.
Treatment therefore need not make alcohol the primary focus to resolve the drinking problem. Rather, the focus returns to helping the client achieve the personal goals he or she sets.
1.4 Agent of Change
In the Solution-Focused Model, there is no one agent of change primarily responsible for positive treatment outcome. Indeed, in the solution-focused approach, the question as to the agent of change may be viewed as one that obscures rather than clarifies the nature of most successful treatment contacts. The solution-focused counselor assumes that change is constant and inevitable and would suggest that the successful counselor need only tap into and utilize that existing change rather than create or cause change.
1.5 Conception of Drug Abuse/Addiction, Causative Factors
Problems with alcohol and other drugs are seen as multidetermined, resulting most likely from a combination of factors both environmental and biological. There is no one alcoholism but many different alcoholisms. The sheer diversity of causative factors and problems resulting from alcohol and other drugs suggests that:
- No one treatment methodology can help all people.
- A diverse package of treatment strategies is needed.
- Treatment strategies should be developed and matched to meet the needs of the individual client.
2. CONTRAST TO OTHER COUNSELING APPROACHES 2.1 Most Similar Counseling Approaches
Some of the motivational enhancement therapy interviewing components by Hester and Miller (1989) are similar to this model (also see the chapter in this volume by William R. Miller), as are some interviewing procedures of the cognitive and cognitive-behavioral treatment programs.
2.2 Most Dissimilar Counseling Approaches
Although the various procedures of the Solution-Focused Model can be incorporated into most existing treatment approaches, the model is likely to be most different in terms of assumptions from the more traditional treatment approaches (e.g., 12-step, recovery-oriented approaches).
3. FORMAT 3.1 Modalities of Treatment
The solution-focused model was developed as a family therapy approach, but it is now being used in a variety of formats including individual, couple, family, and group. In each of these formats, the approach remains largely the same. The only major difference is that specialized interviewing techniques have been developed to encourage and incorporate the participation of multiple participants when the model is applied in couple, family, and group formats.
3.2 Ideal Treatment Setting
The solution-focused approach was first used in a private, nonprofit, outpatient treatment agency. It has since evolved into use in inpatient and residential settings. There seems to be no ideal setting for the model. However, it is unclear why the model would be applied in these latter settings as the expense is so much higher and the results, compared with outpatient settings, are largely similar.
3.3 Duration of Treatment
Being a “brief” treatment model, the average number of counselor-client contacts is 4.7, with a range of between 1 and 12 sessions. Typically, these treatment contacts occur in a 3- to 4-month period. The treatment is open ended, however, with clients being made aware that they may return in the future for any reason.
3.4 Compatibility With Other Treatments
As indicated earlier, solution-focused techniques can be incorporated with most other treatment models. The idea is to help each client maximize his or her success by utilizing his or her unique resources and strengths within whatever treatment model is applied. One example of adapting the model to fit within traditional treatment settings can be found in the work of Campbell and Brashera (1994).
3.5 Role of Self-Help Programs
The Solution-Focused Model neither encourages nor discourages clients from attending existing self-help programs.
4. COUNSELOR CHARACTERISTICS AND TRAINING 4.1 Educational Requirements
As the model has been taught to largely professional audiences, the majority of people trained in this method have some type of graduate degree or professional certification (e.g., psychologists, social workers, alcohol and other drug counselors, certified employee assistance program coordinators). However, the model does not require a special educational background in the social sciences. Indeed, in one project with homeless clients, formerly homeless males who had alcohol and other drug problems have been taught the model and work as peer counselors. A number of these men now sit on the board of Problems to Solutions, Inc.
4.2 Training, Credentials, and Experience Required
People can receive training by participating in several different programs at Problems to Solutions, Inc., or they may receive training from other specialized centers. These week-long or month-long programs are divided into beginning, intermediate, and advanced levels. A certificate indicating completion of the program is offered at the end of the training. However, given that no certification process exists at this time, certificates from existing training programs do not guarantee proficiency in the model but only completion of the training program. Supervision is offered and encouraged.
4.3 Counselor’s Recovery Status
The status of the counselor’s former use/problems with alcohol or other drugs is seen as nonessential to practicing the solution-focused brief treatment model.
4.4 Ideal Personal Characteristics of Counselor
Certainly, the characteristics of a successful counselor would be seen as adding to the efficacy of solution-focused brief treatment. However, personal characteristics of the counselor are not viewed as central to the treatment process. If one characteristic does stand out, it would probably be flexibility.
4.5 Counselor’s Behaviors Prescribed
The majority of the solution-focused process consists of carefully crafted questions designed to elicit client strengths and resources and to help the client decide how to best use those strengths and resources to achieve the desired treatment objectives.
4.6 Counselor’s Behaviors Proscribed
It is difficult to say which if any specific behaviors on the part of the counselor are generally proscribed. Rather, there are certain behaviors that are used very infrequently by solution-focused counselors. These are, for example, advice giving, education about the effects of alcohol or other drugs, confrontation, indoctrination into a specific model or view of alcohol/other drug problems, labeling with psychiatric or other diagnoses (e.g., codependent), focusing on abstinence, and so forth.
4.7 Recommended Supervision
No formal network of solution-focused counselors exists for obtaining supervision in the method. At present, the majority of supervision is done on a one-to-one basis over the telephone with a recognized leader in the field. People being trained in the model are encouraged to seek supervision, however, since the approach appears easier to practice than is actually the case. Goals for supervision are determined in much the same way that goals are determined for therapy; that is, they are determined by the interests and concerns of the professional receiving the supervision.
5. CLIENT-COUNSELOR RELATIONSHIP 5.1 What Is the Counselor’s Role?
In the solution-focused approach, the counselor is seen as a collaborator/consultant hired by the client to achieve the client’s goals. This differs from the more traditional approach in two primary ways. First, in traditional treatment the counselor is viewed as the expert. Second, the goals and objectives of traditional treatment are frequently determined by the counselor or treatment model to which he or she adheres.
5.2 Who Talks More?
In the majority of cases, the client does the most talking. Furthermore, because of the collaborative nature of the relationship, what the client says is considered essential to the resolution of his or her complaints.
5.3 How Directive Is the Counselor?
In the majority of client-counselor contacts, the model is indirectly influencing the client through the use of specialized questions. However, the counselor would be more likely to be directive in the Solution-Focused Model if previous directive therapies had been helpful to the client or the client’s frame of reference about the helping relationship.
5.4 Therapeutic Alliance
The Solution-Focused Model was developed largely on a population that was mandated into treatment. To promote positive working relationships with this clientele, a classification system was developed to match interviewing techniques to the individual client’s level of motivation or willingness to work.
6. TARGET POPULATIONS
The approach was developed for low-income clients with serious alcohol or other drug problems. Many were African-American. The majority of clients served by Problems to Solutions, Inc., are unemployed and may be homeless at the time treatment is initiated. As the model has evolved, however, it has been applied across a variety of settings and treatment populations. The approach has also been used with clients who use a variety of drugs. Because the model stresses that the problem and solution are not necessarily related, the type of drug is not seen as a critical factor in determining differential treatment.
6.1 Clients Best Suited for?This?Counseling Approach
Available research suggests that the approach may be helpful across a broad range of drug-abusing clients.
6.2 Clients Poorly Suited for?This?Counseling Approach
Provisions are made in the model for dealing with difficult cases; in other words, those cases for which the model does not seem to work.
Standard forms for insurance and State certification requirements are completed by the client. These forms contain a list of complaints, client history in treatment, client history of alcohol and other drug problems, and so forth. In solution-focused therapy, no formal assessment is completed aside from the specialized interviewing questions that are the hallmark of the model. After completion of the State certifications and insurance forms, the treatment process begins. This is because all questions are considered interventions. It is, therefore, not possible to do an assessment without impacting the client.
Outcome is assessed via scaling questions during the treatment process and after treatment in followup interviews conducted at 6, 12, and 18?months.
8. SESSION FORMAT AND CONTENT 8.1 Format for a Typical Session
First sessions are considered the most important interview in the treatment process. These generally begin with questions that are designed to negotiate treatment goals and orient the client toward the strengths and resources that will be used to accomplish those goals. This is followed by a team break, when the counselor meets with fellow professionals who have observed the session from behind a one-way mirror. Team members are usually made up of trainees and staff at the treatment center. Together, the team and the counselor construct a summary message and homework task that match the goals and motivational level of the client. There are three general types of homework tasks.
- Those that help the client change actions.
- Those that help the client change personal views or thinking.
- Those that encourage the client to return for subsequent sessions.
Second and subsequent interviews use interview questions to elicit, amplify, and reinforce the changes the client is making or to renegotiate goals if progress is not forthcoming. These sessions also utilize the team break and message components of the first session. Cases may or may not be seen with a team during subsequent sessions depending on the availability of other team members and the status of the case.
8.2 Several Typical Session Topics or Themes
Typical themes in solution-focused therapy include:
- The outcome that the client desires from the treatment process.
- Strengths and resources of the client that can be used to achieve the desired outcome.
- Discussion of previous successes of the client.
- Discussion of exception and instance periods.
- Discussion of changes in the client’s life from session to session.
- Exploration of what the client does to achieve those changes.
Session themes are believed to result from the interaction between the client and the counselor.
8.3 Session Structure
The session content is largely structured by the client. However, as noted in section 8.2, there is a loose structure inherent in the model and in the series of interviewing techniques that guide the individual interview.
8.4 Strategies for Dealing With Common Clinical Problems
All client behaviors are interpreted as efforts to aid the counselor in learning the best way to help each individual client. Therefore, the counselor must decide how to best incorporate and utilize whatever behavior is exhibited by the client. This attitude fosters a cooperation between the counselor and client that is not likely to occur when client behaviors are viewed as problems that must be dealt with to ensure the integrity of the treatment process. A common-sense attitude prevails. For example, if a client is chronically late to a session, this would be interpreted as a message to the counselor that too many appointments are being scheduled. After communicating this to the client, a suggestion might be made that the client call on the day that he or she would like an appointment. If an appointment is available, then the client would be seen. If, however, no appointment were available, the client would be instructed to call on another day. The same attitude prevails with regard to other common clinical problems.
8.5 Strategies for Dealing With Denial, Resistance, or Poor Motivation
In the Solution-Focused Model, all of these terms are seen as evidence of the counselor’s difficulty (failure) in cooperating with the client’s frame of reference or level of motivation. For example, the word “poor” in reference to the client’s level of motivation is an indication that the counselor has made a judgment that the client is not at the level that the counselor would like. Therefore, in this model, there are no poorly motivated clients, only counselors who poorly match their client’s frame of reference or level of motivation.
8.6 Strategies for Dealing With Crises
A variety of specialized interviewing techniques are utilized in the Solution-Focused Model that help the client quickly reorient to strengths and resources when experiencing a crisis. One example of these interviewing techniques is known as the coping sequence. When a client calls in a crisis, questions are used that focus attention on how the client is or how to cope with the situation rather than on what is causing the crisis or how bad the client feels.
8.7 Counselor’s Response to Slips and Relapses
As change is inevitable and constant, there can technically be no relapses back to a previous level but only to different, new experiences. Therefore, in the Solution-Focused Model, such occurrences are considered new experiences and challenges and even signs of success. After all, a client cannot have a slip or relapse without first having been successful. In these instances, the choice of the solution-focused counselor is to focus on exactly what the client was doing when he or she was feeling more successful and to encourage the client to begin doing more of that again. This is a perfect example of the resource, competency-based perspective of the model.
9. ROLE OF SIGNIFICANT OTHERS IN TREATMENT
The Solution-Focused Model, as indicated earlier, began as a family therapy approach. Over time, it has been discovered that the model can affect family systems?and the individuals within that system?when only a few members of the system come to treatment. Sometimes this means that the identified client may not even come to the treatment sessions but will still be helped by the process. Therefore, when any potential client calls for an appointment, he or she is told to bring anyone that might be useful in solving this problem. If a certain member?even the identified client?is not willing to come to treatment, the willing members are instructed to come.
Campbell, T.C., and Brashera, B. The pause that refreshes. J Strat Syst Ther (13)2:65-73, 1994.Hester, R., and Miller, W.R., eds. Handbook of Alcoholism Treatment Approaches. New York: Plenum Press, 1989.
Scott D. Miller, Ph.D.Institute for the Study of Therapeutic ChangeP.O. Box 578264Chicago, IL 60657