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Section 17
Solution-Focused Counseling for Controlled Drinking

Question 17 | Test | Table of Contents

Solution-focused counseling (SFC) and motivational interviewing (MI) have gained recognition over the past 2 decades. A review of the features of these counseling approaches is provided, as well as an examination of the similarities and differences on several dimensions of counseling. Attention is given to empirical research, and it is proposed that SFC and MI be considered concurrently, which appears consistent with calls in the literature for theoretical integration. A case study is included. SFC is an evolving counseling approach conceived and developed by de Shazer and colleagues (de Shazer, 1985, 1988, 1991; de Shazer et al., 1986; Molnar & de Shazer, 1987; Walter & Peller, 1992) in the early 1980s at the Brief Family Therapy Center (BFTC) in Milwaukee, Wisconsin. It is often referred to as solution-focused brief therapy (i.e., a form of brief or short-term psychotherapy) in light of its emergence from the brief strategic therapy movement (Watzlawick, Weakland, & Fisch, 1974).

The solution-focused approach to counseling is considered an alternative to the problem-focused approaches that have prevailed in mental health clinical practice. Although its roots are in the work of hypnotherapist Milton Erickson and family systems theory, as well as in poststructural/ postmodern or constructivist ideology (de Shazer, 1991, 1994; de Shazer & Berg, 1992), solution-focused counseling began taking shape as a reaction to the problem-resolving model espoused by therapists at the Mental Research Institute (MRI) in Palo Alto, California (Shoham, Rohrbaugh, & Patterson, 1995). Its impetus, therefore, was disenchantment with what was viewed as an interest in understanding how and why problems persist. A nonpathological, salutary, strengths- or competency-based approach to helping people was more attractive and appealing, one that Prochaska and Norcross (1999) regarded as "refreshing" (p. 440).

The foundation of SFC is the counselor's confidence in the client's ability to make positive changes in his or her life by accessing and using inner resources and strengths. The client is not provided with a blanket prescription for problem resolution nor, for that matter, told by the counselor that he or she needs to change (I. K. Berg, personal communication, November 30, 1995). Rather, the client often directs the therapeutic process (Berg & Miller, 1992) by voicing his or her preferences (Walter & Peller, 2000) and by determining the goals and outcome of therapy (de Shazer, 1990). In this regard, SFC has been characterized as "client-determined" (Berg & Miller, 1992, p. 7). Solutions are constructed by identifying and capitalizing on nonproblem occasions or "exceptions" to the presenting problem (de Shazer, 1988), rather than exploring and dissecting the problem. The client's strengths and competencies are fostered and then funneled toward the implementation of realistic and achievable behavioral objectives.

G. Miller (2001) regarded solution-focused brief therapy as "a radically new institutional discourse because it is based on different assumptions about social reality, new practical concerns about the therapy process, and new strategies for changing clients' lives" (p. 75). Primary assumptions include the notion that solutions are constructed rather than that problems are solved (Berg, 1995; De Jong & Berg, 1998; Gingerich & Eisengart, 2000; G. Miller, 1997), implying, in part, that knowing a lot about the problem may not be necessary to formulating a solution (de Shazer, 1988). Indeed, G. Miller and de Shazer (1998) stated that problems may be "unconnected" and even "irrelevant to the change process" (p. 370). In addition, a small change in one area can lead to greater or more expansive changes in other areas (referred to as the "ripple effect"; see Berg & Miller, 1992), often made possible by identifying "problem irregularit[ies]" (S. D. Miller, 1992, p. 2), or occasions when the problem is not a problem (past or present) or times when the client has taken, or can envision taking, a break or vacation from the problem. The "miracle question" is a primary method used for capturing these exception times, wherein the client is encouraged to imagine a time in the future when the current difficulty does not exist. Finally, counselor-client cooperation is key to the practice of counseling (Berg & Miller, 1992), with the counselor assuming the role of student and the client viewed as the teacher, a "notion that challenges the prevailing idea that the therapist dispenses wisdom and brings about cures" (McGarty, 1985, p. 149). SFC, therefore, reflects a humanistic, respectful, egalitarian approach to working with clients who are encouraged to make use of available resources and are trusted to know and make decisions about what is best for them.

Research on SFC
SFC has been criticized for its lack of an empirical research base (Eckert, 1993; Fish, 1995, 1997; S. D. Miller, 1994; Shoham et al., 1995; Stalker et al., 1999) despite its more than 20 years of practice. Most of the studies reporting the effectiveness of SFC have been promulgated by its founders, clinicians at the BFTC in Milwaukee, Wisconsin, and students of the BFTC training center. These reports are "substantiated solely by reference to 'subjective clinical experience'" (S. D. Miller, 1994, p. 21) and are often presented in anecdotal form. Two studies reporting favorable outcomes (viz., length of treatment, and achievement and maintenance of client goals) of solution-focused brief therapy (SFBT) have frequently been cited in the SFBT literature (see Kiser & Nunnally, 1990). These studies, however, were conducted at the BFTC by Center staff, were based on "poorly designed" methodology, and have not been published (D. Kiser, personal communication, January 11, 1996). Claims of its utility and efficacy, therefore, are purely theoretical and have not been subjected to sound empirical testing (Fish, 1997; Shoham et al., 1995). Although existing outcome research is less than adequate and must be interpreted cautiously (Fish, 1997; McKeel, 1996), Gingerich and Eisengart (2000) reviewed 15 outcome studies of SFBT, five of which were determined to have met established standards for empirically supported psychological treatments. Two of these studies reported significant outcomes favoring a solution-focused approach: return to work for patients with orthopedic injuries, in comparison to a standard rehab program (Cockburn, Thomas, & Cockburn, 1997); and less recidivism for prisoners involved in an SFBT treatment group, compared with a control group, up to 16 months after release (Lindforss & Magnusson, 1997). Efforts are underway, therefore, to demonstrate efficacious outcomes of a solution-focused approach, addressing what has been acknowledged as a "shortcoming" of SFC (Lewis & Carlson, 2000b). These efforts, however, do not compare with, and trail far behind, the consistent rigorous investigations of the effects of a MI approach.

Style Integration
With both SFC and MI advocating for the consideration of multiple perspectives, with SFC being promoted as adaptable to (or compatible with) other approaches (Guterman, 1996), and furthermore, with MI itself informed and guided by a transtheoretical theory of counseling and psychotherapy (see Prochaska, 1999), a consideration of the coexistence and confluence of both counseling styles appears appropriate and consistent with themes inherent in both approaches. What follows represents our preliminary attempt to understand and articulate SFC and MI from an integrative and a both/and perspective in the hope of promoting the strengths of a synergistic emergence.

Honoring Client Stories: What is paramount to us in the confluence of SFC and MI is a respectful and humanistic therapeutic posture that values and, indeed, honors (even relishes in) the unique stories and experiences of clients. Counselors remain curious about and intrigued by the client's idiosyncratic perspectives and preferences. Although the tributaries of such a respectful stance originate from different sources (SFC from a constructivistic/ social constructionistic philosophy, and MI from Rogerian therapy), the resulting integration reflects a cohesive and adamant appreciation for and use of client constructions and presentations. That is, clients are regarded as the experts about or the authorities on their experiences. This means that the counselor invites and welcomes the client's unique contributions to therapeutic interactions and conversations and adjusts to the client's proclivities. SF and MI counselors are therefore the students of their clients' preferences, adjusting their stance to "fit" with or accommodate and adapt to the client's needs.

Motivation as a Client Resource: Client motivation in MI can be likened to client preference in SFC. Both refer to client resources and strengths that are identified and amplified in the course of therapeutic encounters. What is critical is that the client's intrinsic intentions and preferences are recognized (e.g., client's image of being reunited with his or her children, client's eagerness to fulfill the requirement of counseling) and incorporated into counseling interactions and tasks. This includes the client's ambivalence about change, for this taps into the client's source of energy or energy reserves (e.g., client mental and emotional investment in the consideration of several possibilities, which may have resulted in a feeling of "stuckness") and makes room for the possibility of client engagement and cooperation. Such recognition and arousal of intrinsic motivation in constituents is regarded as a necessary characteristic of effective leaders (Kouzes & Posner, 1995). Kouzes and Posner stated that "Reliance upon external incentives and pressures doesn't liberate people to perform their best, and it constrains leaders from ever learning why people want to excel" (p. 41). Identifying and appreciating what propels the client to either filibuster or consider change opens the door for more collaborative dialogue and encourages client aspirations of something different and rewarding.

Change in Relation: The process of identifying and cultivating client intrinsic motivation or preferences takes place within a relationship, and it is in this therapeutic relational and conversational process that change occurs or emerges. Indeed, both SFC and MI exemplify one of the prominent common factors--the therapeutic relationship--credited with being responsible for approximately 30% of positive client change (Lambert, 1992). From an integrated SFC and MI perspective, however, change is not something that happens only to the client or that is limited to the client. That is, movement in counseling is not confined to client performance or status, as if the client directs or is solely responsible for such movement and change. Rather, when considered in the light of SFC and MI confluence, change is understood in terms of conversational or relational movements or fluctuations over time, illustrating the systemic, holistic, dynamic or interactional, and recursive nature of counseling and the counseling process. Indeed, SFC speaks of three types of client-therapist relationships (customer, complainant, and visitor; Berg & Miller, 1992) and not three types of clients. Although MI refers to stages of change based on client presentations, it is understood that change is an interactive phenomenon, reflecting both client and counselor contributions, and recent discussions (e.g., Prochaska, 2000) have focused on the therapeutic relationship at each stage. The integration of SFC and MI, therefore, suggests a reconceptualization of therapeutic change as relational and communal (i.e., the relationship as not only the agent of change, but also the subject of change).
- Lewis, Todd F.; Osborn, Cynthia J.; Solution-Focused Counseling and Motivational Interviewing: A Consideration of Confluence;  Journal of Counseling & Development, Winter2004, Vol. 82 Issue 1

Promising Strategies to Reduce Substance Abuse

- U.S. Department of Justice. (2000). Promising Strategies to Reduce Substance Abuse. Office of Justice Programs.

Personal Reflection Exercise #10
The preceding section contained information about solution-focused counseling for controlled drinking.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Brief Counseling for Smoking Cessation
and Alcohol Use Reduction Concomitant
with Hospital Procedures: A Randomized Clinical Trial

- Alba, L. H., Penãloza, M., Olejua, P., Cespedes, E., Cuevas, V., Almonacid, I., Olaya, L., & Becerra, N. (2022). Brief counseling for smoking cessation and alcohol use reduction concomitant with hospital procedures: a randomized clinical trial. Revista brasileira de psiquiatria (Sao Paulo, Brazil : 1999), 44(5), 507–516. https://doi.org/10.47626/1516-4446-2021-2413

Peer-Reviewed Journal Article References:
Breuninger, M. M., Grosso, J. A., Hunter, W., & Dolan, S. L. (2020). Treatment of alcohol use disorder: Integration of Alcoholics Anonymous and cognitive behavioral therapy. Training and Education in Professional Psychology, 14(1), 19–26.

Cho, S. B., Su, J., Kuo, S. I-C., Bucholz, K. K., Chan, G., Edenberg, H. J., McCutcheon, V. V., Schuckit, M. A., Kramer, J. R., & Dick, D. M. (2019). Positive and negative reinforcement are differentially associated with alcohol consumption as a function of alcohol dependence. Psychology of Addictive Behaviors, 33(1), 58–68.

Marczinski, C. A., Stamates, A. L., & Maloney, S. F. (2018). Differential development of acute tolerance may explain heightened rates of impaired driving after consumption of alcohol mixed with energy drinks versus alcohol alone. Experimental and Clinical Psychopharmacology, 26(2), 147–155.

Pedrelli, P., Borsari, B., Merrill, J. E., Fisher, L. B., Nyer, M., Shapero, B. G., Farabaugh, A., Hayden, E. R., Levine, M. T., Fava, M., & Weiss, R. D. (2020). Evaluating the combination of a Brief Motivational Intervention plus Cognitive Behavioral Therapy for Depression and heavy episodic drinking in college students. Psychology of Addictive Behaviors, 34(2), 308–319.

QUESTION 17
What are the three types of client-therapist relationships in solution-focused counseling? To select and enter your answer go to Test.

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