Anne Bodmer Lutz, B.S.N., M.D.
The current epidemic of opioid use has been called the worst drug crisis in American history with associated overdose deaths building across the nation. It is affecting nearly every city and town in the United State and is the epidemic of the 21st Century. For this reason, we thought it is critical to address this in our first newsletter. I have found my work in treating those clients and family members coping with substance abuse an incredible privilege and immensely rewarding.
According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Survey on Drug Use and Health, 23.5 million persons aged 12 or older needed treatment for an illicit drug or alcohol abuse problem in 2009 (9.3 percent of persons aged 12 or older). Of these, only 2.6 million—11.2 percent of those who needed treatment—received it at
a specialty facility. Nearly nine in ten young people with addiction in the USA do not receive any treatment. (1) The growing number of adolescents presenting for treatment of substance use poses many challenges. Most adolescents do not voluntarily seek treatment, but are mandated by their parents, schools, criminal justice systems or child welfare agencies. Engaging youth and families remains challenging despite continuing advances in evidence-based treatment approaches.
SFBT for Adolescent Substance Abuse
Solution-Focused Brief Therapy (SFBT) is an evidenced-based approach, in accord with the positive psychology movement that focuses on solution building. Solution-Focused Brief Therapy (SFBT) is a short-term, brief therapy approach that builds on client’s strengths, enhances positive feelings, instills hope, and is highly congruent within positive psychology. SFBT is included in the Substance Abuse Mental Health Service Administration’s National Registry of Evidence-based Programs and Practices. SFBT is a very beneficial skill to incorporate when working with adolescents and families coping with substance use disorders. Many people dealing with substance use are challenging to engage in treatment, especially those who are adolescents. Often they are faced with a myriad of other problems including co-occurring disorders that make dual diagnosis the norm rather than the exception. They are frequently ambivalent about stopping their drug use, and those who are most important in their life are exhausted, frightened and tired. Both clients and their loved ones are in need of comfort, support and help.
Some Specific Solution-Focused Interventions
Building on Strengths: Commencing with strengths is especially important for clients coping with substance use disorders. It is these very strengths that will be conducive and critical to their recovery. Activating resources at the onset of the conversation is critical and the time taken to explore these details is crucial in helping build client engagement. It is time well spent! Exploring what clients are good at, what they enjoy and how they learned these skills are attributes they will need to use to help them overcome their addiction. Even when clients are unable to identify strengths outside their drug use, they often have many well-developed skills that are capitalized on when obtaining and sustaining their drug habit. Activating resources from the onset of the conversation by complimenting their skills, even if related to their drug use, accumulates indispensible conversational deposits. For example, one client responded that she is good at using, buying and selling drugs. Complimenting her entrepreneurial spirit, ability to make connections and courage were all skills that could be re-directed towards positive means. Especially when working with “mandated” “externally motivated patients” or challenging to engage clients, finding ways to provide genuine compliments is essential towards building engagement.
Complimenting: Adolescents frequently make threats when they are forced into treatment, from running away, to dropping out of school, or escalating their drug use. This generates desperation on the part of their parents, and concern their child may die. This necessitates acknowledgement of their fears and the arduousness of their plight by providing empathic emotional responses. Complimenting loved ones on their efforts to get their loved ones into treatment and how they accomplished this often uncovers tremendous resources on the part of the family and those who care about the adolescent. Complimenting the strength, perseverance and determination of patients and their VIPs to get themselves or their loved ones into treatment are critical to acknowledge and appreciate. Asking them where they get their strength and determination from can amplify these strengths. Compliments can impart much needed energy and stamina to both patients and their VIPS, enabling them to persevere when they are feeling exhausted and overwhelmed.
For You Statements: A language technique that can help to provide empathic responses quickly and easily to clients is to integrate the words “for you” within statements and questions. “For you” statements can be used in several different ways, helping to build emotional agreement within the conversation, while providing validation and acknowledgement of the client’s situation and feelings. Clients and families who are coping with substance use disorders often experience fear, anger, and sorrow, requiring a great deal of “for you” responses. Some examples of “For You” statements include how scary and frightening it must be “for you” to see your child struggling with substance use and be worried they may end up dead. For the adolescent, acknowledging how difficult it must be “for you” to be in a place you don’t want to be and how frustrating it must be “for you” to be forced into treatment you don’t think is needed. “For You” statements can help keep the clinician and parents out of the emotional argument. There is no arguing that it’s miserable “for them” that they are in rehab and can’t do the things they want. Adolescents are frequently surprised by these responses, as these statements are often very different than the typical feedback they receive. They are often accustomed to being asked “why” they did this, or told this is “why” they shouldn’t have done this. While all this may be true, these questions do little to validate their experience, often escalating conflict and disagreement. Reflecting and confirming their feelings with an inquisitive tone and tagging on the words “for you” takes the clinician and parents out of the emotional argument. Confirming the emotional aspects of behaviors from the client’s perspective helps them notice that their current way of doing things is either positively or negatively affecting what they want and need, and can help them move in directions that are more helpful for them. This can enhance their motivation to change and do things differently.
“For you” statements can also be used to acknowledge positive client experiences, such as how exciting it must “for them” to be making progress towards their goals, to see their relationships improving and “for them” to have accomplished a new skill. Positive “for you” statements reinforce with clients that what they are doing is working for them, and are another way to provide them with indirect compliments.
Punctuating Positive Differences: Listening for and discovering positive differences when clients are having some measure of success are crucial. These times may include when clients are able to have periods of abstinence, even if very brief, manage drug cravings, acknowledge and experience intense feelings without relapsing, get back on track after a relapse, stop and think through the consequences of their actions, attend an AA meeting, call and reach out to their supports or sponsors, do the next right thing, accomplish parts of their goals, and consider how their actions would affect their loved ones, to name a few. Amplifying these differences by exploring whether these differences are helpful, how they are helpful and how they accomplished these differences often uncovers additional resources.
Identify VIPS: Inviting a client to identify their VIPS (those who are most important in their life) and what they most appreciate about them is especially critical when counseling those with Substance Use Disorders. VIPS accrue vital relationship deposits for the client, while strengthening bonds that may have been damaged due to their substance use. One question particularly powerful for parents is asking them “What they know about their child that tells them they will succeed in life?” I have never had a parent not answer this question. Inviting adolescents to talk about what they most appreciate about their parents often leads to powerful positive emotions. Frequently they talk about how their parents are always there for them and don’t give up on them. Parents have often never heard these things and it is common for them to begin to cry.
Goal Negotiation: Rather than directly confronting a client’s denial, asking them their “good reasons” for using drugs and “how drugs are helpful for them”, respectfully explores their motivation to use drugs. These questions often open up conversations much better than asking “Why” they are using drugs. “Why” questions are often met with defensive and “I don’t know” responses. Often after pursuing all the details of how drugs are helpful and all their good reasons for using drugs, clients eventually acknowledge they are unhelpful. If they don’t acknowledge this, asking them whether their VIPs view drugs as helpful or unhelpful assists in amplifying their ambivalence. Scaling how helpful and unhelpful drugs are, from both the client’s and their VIP’s perspective can further magnify ambivalence.
Negotiating Goals: Negotiating Goals occurs by asking clients whether they are currently accomplishing their plans. For people coping with addiction, their plans are frequently coming to naught. Instead of trying to convince clients about their drug problem, inquiring with them whether it was in their plans to be in rehab, to be failing school, to be on probation, or to have lost their friends and families frequently meets with negative responses. These questions often stimulate clients to contemplate how their choices are effecting what they want or don’t want in their life, and what they want to do instead. Asking clients what their VIPs would notice them doing differently when they are succeeding with their plans spells out in greater detail their goals. A good sign people are working on their recovery is their plans are coming to fruition.
Best Hopes: Inviting patients to talk about their “best hopes” for treatment and how you can be most helpful for them so that meeting with them is worthwhile maintains the focus on what the client wants. Anything from desperately wanting help, to getting their probation officer or parents off their back, being able to go back home with their family, keeping their marriage together, regaining their driver’s license, getting a job, winning trust back or to improving relationships with their VIPs, to name a few. Asking clients what would it take for this to happen, and what else it would take are additional questions that can further develop their goals.
Scaling Questions: Scaling questions ask clients to rate their priorities, goals, satisfaction, problems, coping strategies, successes, motivation for change, safety, confidence, treatment progress and hope on a numerical scale from 1-10. They are used to scale solutions, different from many other scales which rate problems. Scaling questions help direct the treatment toward what the client wants and what is most important to them, increasing their motivation and confidence to change, and helping to facilitate agreement among client, clinician, and others participating in treatment Asking adolescents on a scale from 1-10 how much they “need” to get sober, how much they “want” to get sober, and how much their loved ones think they need to get sober assists in further detailing their goals. Scaling how satisfied they are with meeting their goals on a scale from 1-10 acquires their perspective on whether they are achieving their hopes and aspirations. Asking what keeps the number from being lower, whether this number is higher, lower or the same, what is a “good enough” number and what they would be doing when the number goes up by one point assists in amplifying their strengths and goals.
These are just some of the interventions we use when using Solution-Focused Brief Therapy to help engage adolescents and families coping with substance abuse. Solution-Focused Brief Therapy is an effective approach that has the benefit of being briefer in duration and less confrontational than traditional approaches. I invite any who are interested in learning more to join us for a one-day workshop.
Han, B., et al. “Receipt of services for behavioral health problems: results from the 2014 National Survey on Drug Use and Health.” Rockville (MD): Substance Abuse and Mental Health Services Administration (2015).