Solution-Focused Applications to Addiction Counseling: Assessment, Techniques and Interventions – Clinical Implications for Counselors

Assessment

Table of Contents:

When Solution-Focused counselors assess clients, they usually begin by discussing the clients reasons for entering treatment or what is referred to as the Presenting Complaint. The emphasis would be on what the client has been experiencing and why now? — that is, why has the client chosen this particular point in time to access treatment? The SFT counselor will also focus on what the client has tried in the past to manage or deal with the presenting complaint (including past attempts at counseling or treatment), with an emphasis on what worked as well as what didn't work. SFT counselors are interested in what internal resources the client possesses that can be brought to their current situation in a useful way. What’s noteworthy is what the SLF counselor will refrain from focusing on, such as past developmental history (e.g. childhood history, educational history, family history).They will also refrain from asking about co-occurring mental health or medical problems. Similarly, they will refrain from focusing on social history or social functioning. Some of these areas may be explored, but only to the extent that they’re relevant to the presenting problem. For example, if a client were to bring up that he or she will usually go on a binge after arguing with their boyfriend or girlfriend, then SFT counselors will explore the history of those relationships.

One of the main reasons for doing a thorough assessment of the problem is that it then allows the counselor and client to formulate treatment goals (see Boxed Item 7.2). Remember, SFTs are not interested in doing a more holistic Biopsychosocial Assessment. Rather SFT counselors are more interested in assessing the problem (or presenting complaint) that motivated the client to seek help. According to Berg (1992), well-formulated treatment goals would include the following:

Developing treatment goals from a SFT perspective has many of the qualities of good goal-setting (Perkinson, 2017) in that goals are described in simple, measurable, concrete terms rather than something vague like “Improving self-esteem.” An example of a simple, concrete goal would be something like “Client will develop positive social supports who support his/her recovery” or “Client will develop leisure activities that support his/her recovery.”

Treatment Techniques

There are three treatment techniques which are central to Solution-Focused Theory. The first technique we’ll examine is the Miracle Question. The rationale of the Miracle Question is that it encourages clients to explore what the future will look like once his or her alcohol or drug use is no longer posing problems or difficulties. It’s not unusual that when clients enter counseling they are looking for a miracle that will help bring about change, because they probably have tried

Boxed Item 7.2 Guidelines for Well-Formed Treatment Goals

(1) they are described in social interactional terms
(2) they have contextual or situational features
(3) they are described as including the presence of some behaviors as the start of something rather than the end of something.
(4) they are small rather than large
(5) they are salient (important) to the client and, through negotiation, salient to the therapist
(6) they are described in specific, concrete and behavioral terms
(7) they are described in terms of positive indicators of success rather than as an absence of problems
(8) they are both realistic and achievable
(9) they are perceived by the client as involving “hard work” on his or her part

Adapted from Berg (1992)

everything within their power to bring about change. Here’s how the Miracle Question would be posed to the client:

Suppose tonight, after you go to bed and fall asleep, while you are sleeping, a miracle happens. The miracle is that the problem or problems you are struggling with are solved! Just like that! Since you are sleeping however, you don’t know that the miracle has happened. You sleep right through the whole event. When you wake up tomorrow morning, what would be some of the first things that you would notice that would be different and that would tell you that the miracle has happened and that your problem is solved?

(Miller & Berg, 1995, p. 38)

As indicated above, the Miracle Question emphasizes what the future will look like when the problem or problems are no longer impacting on the client. The Miracle Question also asks the client to examine what their first indications would be that the miracle took place during the course of the night (i.e.“When you wake up tomorrow morning, what would be some of the first things that you would notice that would be different and that would tell you the miracle has happened ...”). In a videotaped session (Berg, 1990a), Insoo Kim Berg is counseling a woman who has been in recovery from her substance use disorder for several years but has been struggling with being able to lose weight. In the beginning of the session, the client tells Insoo Kim Berg how she was able to lose weight in the past but had regained weight because of the stress of working and going back to school to earn her degree. When Insoo poses the Miracle Question to the client, her whole demeanor changes. The client goes from being very serious and somewhat negative to smiling and laughing and becoming fully engaged as she explains how she

Solution-Focused Theory 131 would know the miracle took place during the course of the night. Interestingly, the client states she would know the miracle took place because she would wake up and feel like exercising.

Learning Opportunity 7.1 — The Miracle Question

Think about a problem or issue that you’re currently experiencing. Imagine someone were to pose the Miracle Question to you? Assuming a miracle occurs while you’re sleeping tonight, how would you know the miracle took place? What would be different? What would you be feeling? Discuss in small groups or in your chat room.

The next technique that is central to Solution-Focused Theory is Finding Exceptions. Exceptions are “those times when people do not experience their usual pattern of problem drinking (Miller & Berg, 1995, p. 79), which would include instances where the client’s drinking is greatly reduced and therefore becomes non-problematic, as well as periods of total abstinence and participation in treatment and/or 12-Step programs. Shining a light on exceptions helps to convey a sense of self-efficacy or self-confidence that positive change is possible. It’s important to note, however, that not all clients have experienced “exceptions” or instances where they have abstained or reduced their drinking or drug use. For some clients, they may have only experienced exceptions during times of residential treatment, incarceration or hospitalization. Once “exception” periods have been identified, the counselor may then ask:

What was different during those time when you weren’t drinking or using drugs? What are you doing differently during those times of exception? What would others say you are doing differently during those times? What happens shortly before or after those times?

(Berg, 1992)

There are also other questions that Miller and Berg (1995) recommend that counselors explore with clients as a means of helping to elucidate how periods of exceptions have come about:

How have you managed to overcome the urge or temptation to drink to the problem stage in the past? What did you actually do that helped you to overcome the urge to drink at that time? What would others say you did? What exactly did you do the last time you thought you deserved a drink but decided not to have one? What have you done in the past in order to stay out of situations in which the temptation to drink to excess might outweigh your resolve to stay sober? How have you managed to stop drinking to the point of its being a problem in the past? What did you actually do that finally helped you to stop? What would others day you did? How did you manageto get back on track the last time you experienced a setback in your efforts to solve your drinking problem? What was different about the last time you successfully managed to keep your drinking at an acceptable level to you and your loved ones? How did you do it? What would they say you did in order to be successful?

(Berg, 1992)

Learning Opportunity 7.2 — Exception Finding

What are some of the things that stand out in the Exception Finding questions that are listed above? Why do you think SFT counselors ask clients what his or her family or loved ones may have to say about periods of exception?

The next technique that SFT counselors may utilize with clients are Scaling Questions. Scaling questions are a means for clients to assess exceptions or times when drinking or drug use is not a problem. On a scale from 1 to 100, clients are asked to estimate the percentage of time that drinking or drug use is problematic. For example, if a client indicates that drinking is problematic 60% of the time, then the counselor would then explore with the client what is happening the other 40% of the time when drinking or drug use is non-problematic. SFT counselors also recommend that clients use graphs to chart the days of the week where exceptions are more likely or less likely to occur in order to help determine days or times of day which are more difficult for clients to enact change. Other Scaling Questions include the following:

On a scale from 1 to 10 with 10 meaning you are extremely confident that this problem can be solved and 1 meaning that you have no confidence at all, where would you put yourself? On the same scale, how realistic would you say this is? On the same scale, with 10 meaning you would do anything to solve this problem and 1 means you will probably wait and for something to happen before making changes, where would you say you are today? On the same scale how confident are you that you will be able to continue to make progress at the pace you have been at? On the same scale, with 10 meaning how you hope your life to be when you solve the problem and 1 represents how bad things were when you first called to make this appointment, where would you say you are today?

(Berg, 1992)

Another technique that SFT is something called the Solution Lottery. Here clients are first asked to make a list of activities or things he or she likes to do that are enjoyable or rewarding. Ideally, the activities on the list should not require a lot of preparation time or money to execute. Some of these activities might include going for a walk,

Solution-Focused Theory 133 listening to music, talking with a friend on the phone, going for a drive, or going shopping. Any activity can be considered reinforcing if the client is willing to engage in a less desirable behavior in order to reward themselves with the rewarding or desired behavior.The second step involves getting a paper bag or a small box and then taking several small strips of paper on which the client will write the following on each separate strip: No Reward, Immediate Reward, Reward in Four Hours, Reward in 12 Hours, Reward in 24 Hours. These strips of paper are then placed into the bag or box. The Lottery begins when the client is then asked to make a note of when exceptions occur. For example, a client notes that he did not go to the bar on his or her way home from work and had nothing to drink once he or she arrived home. The client first picks a rewarding activity from his or her list and then picks a strip of paper with the reward status. So if the strip of paper indicates No Reward, then the client does not engage in the activity. If the strip of paper indicates Immediate Reward, then the client engages in the rewarding activity immediately. You may be saying to yourself, “Why not just engage in the rewarding behavior immediately when exceptions are noted by the client?” However, the purpose of the Solution Lottery is not only to have the client engage in new behavior patterns but also to accept that rewards are not always immediate. Therefore, delaying gratification or reward can make the reward something the client can look forward to in the future, whether it be four, twelve or twenty-four hours from now (Miller & Berg, 1995).

Finally, SFT counselors also offer clients three Change Rules which are designed to help clients come up with new perspectives on change.

Rule 1: If it ain’t broken, don’t fix it. This rule pertains to instances where a slip or relapse takes place and the tendency of counselors to go back and pick apart the reasons for the lapse or failure. SFT counselors, on the other hand, refrain from “picking apart” the slip as it merely reinforces the clients “problem.”This is not say that there’s nothing to be gained by looking at antecedents to slips or relapses however, not at the expense of reinforcing the problem rather than the solution.

Rule 2: Once you know what works, DO MORE OF IT. Often there is a tendency to focus on past behaviors that didn’t work. A well-known colloquial saying that’s commonly heard in 12-Step meetings goes something like this,“Insanity is when you keep doing the same thing but expect a different result.” (This saying is attributed to Albert Einstein!) Often, in addictions, people keep repeating the same behaviors (e.g. getting high) but somehow expect that things will end up differently (e.g. “1 won’t get pulled over for drinking and driving this time” or “I won’t fight with my boyfriend or girlfriend this time”). Invariably, however, things turn out the same. Therefore, Rule 2 emphasizes the importance of continuing to do more of what works.

Rule 3: If it doesn’t work, don’t do it again. Do something different. SFT is often used with families and couples who are experiencing problems in their relationships with one another. When families enter counseling, it’s often because they continue to do the same thing over and over again, continue to have the same argument or continue the sameself-defeating behaviors but somehow are “expecting a different result.” The purpose of Rule 3 is to try to get clients to begin to do something different with regard to drinking and drug use. By doing so, the hope is, that he or she may be closer to moving towards a solution.