Solution-Focused Substance Abuse Treatment

Teri Pichot, Sara A. Smock

• Publisher: Routledge
• Year: 2011
• eBook ISBN: 9781136915567
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Solution-Focused Substance Abuse Treatment describes the standard of care for substance abuse treatment, demonstrates how solution-focused brief therapy exceeds this standard, and shows how it can effectively be used in substance abuse evaluation, case management, and both individual and group treatment. Beginning and advanced concepts are provided to address the questions of even the most advanced clinician, all placed in the context of cultural awareness.

Most importantly, the author answers the many questions professionals may have about how solution-focused brief therapy can be successfully integrated into the field of substance abuse. It provides a thorough understanding of the issues that therapists face when working with this at times challenging population, and demonstrates how the use of solution-focused brief therapy can minimize power struggles and enhance client success. Sample forms and handouts are included, as are additional resources for effective evaluation and treatment.

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Substance Abuse Treatment

An Overview

We have come to believe that there are many alcoholisms—perhaps as many as there are problem drinkers.

Insoo Kim Berg and Scott Miller

Before we explore how to effectively apply solution-focused brief therapy in substance abuse treatment, it is important to understand how the use of substances has evolved throughout history. Let us take a look back in time to understand the historic use patterns in the United States and the resultant need for treatment services.

Substance Abuse in the United States

The History of Substance Misuse in the United States

While tobacco and alcohol were the first known substances to be used in this country, the introduction of other drugs soon followed. The Jamestown settlers first brought cannabis (also known as marijuana) to Virginia in 1611, and it quickly became a major crop in North America (Brecher, 1972). The next nonindigenous substance to arrive in the United States was opium. The primary use of opium in these early years was medicinal. However, it did not take long for the abuse of opium to occur. Brecher states that women were using opium while their husbands were out at saloons drinking. Morphine soon followed and began to be used as a substitute for opium in medicinal settings. Next, cocaine entered the picture and became a main ingredient in Coca Cola. While states began to prohibit the illegitimate use of some substances in the late 19th century, most were widely used and not made illegal by the federal government until the early 20th century.

Use of substances such as heroin and cannabis continued throughout the 1960s, at which time hallucinogen use became more widespread. While the manufacturing of the hallucinogen lysergic acid diethylamide (LSD) occurred during the 1930s, it was not until the 1960s that LSD was widely used and impacted the American culture. In the 1980s, methylenedioxymethamphetamine (MDMA or ecstasy) and other “club drugs,” such as ketamine, gamma hydroxybutyrate (GHB), Rohypnol (flunitrazepam), and methamphetamine, returned and became a hit in the rave scene.

During the 1990s, the Substance Abuse and Mental Health Administration (SAMSHA) reported an increase in methamphetamine deaths (2007). In addition, the 1990s showed an increase in heroin use among high school students. A 100% increase in heroin use occurred from 1990 to 1996 according to the National Institute on Drug Abuse (NIDA) monograph Monitoring the Future (Johnston, O’Malley, & Bachman, 1997). Throughout the early years of the millennium there has also been an increase in the potency of marijuana (National Drug Intelligence Center, 2006) and a rise in prescription drug abuse (NIDA, 2006a).

The Legal and Social Response

In response to the increased use of substances, laws were passed to curtail the resultant social problems. Substance misuse was initially viewed as a moral issue (something that one could simply stop doing), and therefore the legal system was the logical way to address these concerns. One of the first legal acts passed concerning alcohol was the Whiskey Excise Tax of 1791 (Barr, 1999). While this was an attempt by the government to help reduce federal debt and not an attempt to control the use or distribution of substances, it did not take long for the government to begin controlling the regulation of substances. In 1848, the Drug Importation Act required all medications to be inspected for the cleanness and quality of substances used for medical purposes (Higby, 2002). It was at this point that the government first began to regulate and officially approve substances in the United States, despite the fact that substances such as opium and heroin were being widely used among Americans.

The peak of U.S. regulation of alcohol occurred in 1920 with the passing of the 18th Amendment and the Volstead Act. These legal declarations began the prohibition period in the United States, which outlawed the manufacturing and selling of alcohol. It is important to note that the United States outlawed alcohol, but other substances such as cannabis and heroin were still legal. It was not until later that these substances became illegal. The prohibition of alcohol was lifted by the federal government in 1933 by passing of the 21st Amendment. The federal government allowed each state the right to control the distribution of alcohol. Separate acts followed that outlawed the use and distribution of other substances.

The Treatment Response

In addition to various social and legal responses, numerous religious groups and organizations supported prohibition and viewed the abuse of alcohol and drugs as a sin. This resulted in the only assistance these early, well-intentioned helpers knew to give: to tell people not to drink or use drugs. While this may have worked for some, it left others with a sense of shame and stigma for their perceived lack of moral ability to discontinue their use. There was no true understanding of addiction, and therefore individuals in the early 20th century did not have official treatment available to help them deal with issues regarding the abuse.

The first structured model of how to address substance abuse problems was developed in the 1930s when a group of alcoholics came together out of desperation to provide support and develop solutions. This group later became known as Alcoholics Anonymous (1976). This group began the movement away from the moral view of alcoholism, toward the disease or medical approach. This movement was necessary to change the view of those who abused substances from that of being sinful to that of one having a disease that is beyond one’s control. While these early efforts could not be classified as treatment, this opened the door to understanding and formalized treatment for this population, for this approach to treatment views substance abuse as a chronic illness. Early formalized treatment (initially residential) incorporated the basic tenets of Alcoholics Anonymous and the 12 steps, and was conducted by counselors who were former addicts and alcoholics themselves. Treatment programs based on this early model are still in existence at the time of this writing.

As the mental health field developed and became professionalized, the field of addictions also began to change. Agencies became more aware of the necessity of having formally trained therapists conduct treatment in lieu of exclusively recovering alcoholics and addicts. Engel’s (1977) development of the biopsychosocial model led to using this approach with the substance-dependent population during the 1980s, and the use of this model continues to this day (as of this writing). This approach takes into account the many factors that contribute to substance misuse (biological, psychological, and social) and postulates that each client is using due to a unique combination of these factors. This therefore necessitates a more individualized course of treatment to address these underlying factors. Over time, concepts such as focusing on clients’ strengths and discovering ways to motivate clients have become part of many treatment models across the United States. However, the prevailing belief remains that addiction is a chronic disease.

The Prevalence of Substance Use and Abuse in the United States

Statistics show a steady use and abuse of substances throughout U.S. history. It is said that 2.8 million people over the age of 11 in the United States used an illicit drug for the first time within the past 12 months (SAMHSA, 2006a). SAMHSA’s 2005 National Survey on Drug Use reported that 19.7 million Americans ages 12 or older were current illicit drug users. The survey goes on to report that marijuana was the most common illicit drug used by Americans. Reported alcohol use varied among age categories, with the highest category (21–25 year olds) at 67.4% of the U.S. population. Heavy episodic drinking has been on a rise among young adults over the past several years.

It is also important to note the differences in substance use by gender and race/ethnicity. The National Institute on Drug Abuse (2003) reports the prevalence of past-month drug use in the United States. The report shows the ethnic group with the least illicit drug use (2.8%) as Asian/ Pacific Islanders, and American Indian/Alaska Natives as the highest (9.3%). While men show a greater use of substances than women, up to 5.4% of women report illicit use. All of these statistics show that there is a need for effective treatment for substance abusers in this country.

Current Trends in the Substance Abuse Field

Treatment Trends

Curriculum- or Manual-Based Treatment

There has been a recent trend toward the use of manual- or curriculum-based treatment. Manual- or curriculum-based treatment is any type of treatment that has a manual or preset curriculum to follow during treatment sessions. An example of this is Driving with Care (Timken, Wanberg, & Milkman, 2004). This is a three-level education and treatment program that was developed to be used with people who have been convicted for driving while their ability was impaired by substances. This manual provides worksheets, exercises, and discussion formats based upon cognitive-behavioral and psychoeducational approaches. A second example is Strategies for Self-Improvement and Change (Wanberg & Milkman, 1998), which was specifically designed for use with substance abusing offenders. This is a 9- to 12-month curriculum designed to prevent criminal recidivism and substance abuse relapse within community-based and correctional settings. At the time of this writing, both of these curricula are widely used in the state of Colorado as well as throughout the United States.

While the content in both of these cognitively based curricula has obvious strengths, using such an approach neglects to address the specific needs of individual clients, and the prescribed format restricts the therapist’s ability to address individual clients’ needs within the sessions since such curricula are designed to be done primarily in the prescribed order. Despite their rigidity, cognitively based manualized treatment curricula are becoming increasingly popular due to the evidence-based treatment emphasis in the United States (since the easiest and surest way to test a model to see if it is evidence based is to have a treatment manual). Thus, one lends itself to the other. While we support the need for accountability and strong outcomes in substance abuse treatment, a one-size-fits-all treatment approach fails to address the fact that individual differences obviously exist within the substance abusing client populations. We would therefore argue that the goal of providing evidence-based treatment should not compel therapists to marginalize, neglect, or mistreat the substance abuse client population for whom individualized treatment is essential for success.

Culturally and Gender-Sensitive Treatments

Any time therapists are using a prescribed treatment approach, there is the unintended consequence that treatment is tailored for the majority and may not be effective with the minority groups. Traditional treatments have struggled with this issue, and effectiveness has been challenging with minority populations and nonreligious people (Galaif & Sussman, 1995; Tonigan, Miller, & Schermer, 2002). Thus, there has been a recent awareness of the need for culturally sensitive treatments to help serve underrepresented populations. Almost 38.2% of clients entering treatment in 2003 were from a minority group (with 23.6% identifying as African American; Treatment Trends, 2003).

According to NIDA, the main gender difference in treatment is that women are less likely to enter treatment; however, their success rates are similar to those of men (Women and Substance Abuse, 2006). The National Institute on Drug Abuse suggests that women-specific treatment is especially beneficial for pregnant women and can provide services for women needing childcare, job training, transportation, and housing assistance. Because women who are pregnant face additional obstacles (such as prenatal care, care of other young children, nutritional needs, etc.) in addition to their substance abuse, it is imperative that therapists are sensitive to these needs and that additional case management services are provided to ensure success. In addition, postpartum women can experience challenges of postpartum depression as well as a lack of childcare and lack of adequate parenting skills. Add to this that postpartum women are at increased risk of relapse due to lack of sleep, increased stress, and their belief that the baby will no longer be negatively impacted by their use since they are no longer pregnant. Since women are less likely than men to enter treatment, most likely due to the factors just mentioned, it is imperative to offer gender-sensitive treatment that can help in meeting the logistical needs of women.

Treatment providers are becoming increasingly aware of the high prevalence of trauma that women who abuse substances have experienced. Many are victims of sexual assault or are survivors of child abuse or neglect. In fact, there is a strong correlation between substance abuse and sexual abuse (Dolan, 1991). Several studies show that a significant proportion of substance abusing women have suffered from traumas such as sexual abuse, domestic violence, and child physical abuse (Brems & Namyniuk, 2002; Freeman, Collier, & Parillo, 2002; Ouimette, Kimerling, Shaw, & Moos, 2000; Simpson & Miller, 2002). Many women use substances to cope with this past trauma, while others experience trauma as a result of their poor choices and resultant vulnerabilities caused by their use. This trauma and its aftermath necessitate the employment of trauma-informed professionals in order to resolve the lingering issues and to prevent these women from relapsing back into the painful cycle. This move toward a greater awareness of individual factors is key to effective, long-term recovery.

Individualized Treatment

The field of addictions (like most other fields) is riddled with contradictions. There is simultaneously a push toward manualized or curriculum-based treatment and another push toward ensuring that all treatment is individualized. In fact, individualized treatment is considered by NIDA to be one of the scientifically based approaches in the substance abuse field (2000b). This positive trend takes into account the fact that each client is unique, and therefore requires an individualized approach to increase the odds of success. This approach requires an individualized treatment plan, understanding of the client, and resulting treatment interventions. In summary, this trend is a move away from the cookie-cutter approach of one size fits all, toward honoring and respecting the clients for who they are.

Strength-Based Treatment

One of the latest trends in the field of substance abuse treatment is what is best described as strength based. This approach remains problem focused in that the professionals’ focus remains on solving the presenting problem; however, it values and seeks to include the clients’ strengths as part of the solution. While using a strength-based approach is a new trend in psychotherapy in general, it has found its way into substance abuse treatment as well. One of the most common strength-based models is motivational interviewing (Miller & Rollnick, 2002), or motivational enhancement therapy. This approach aids clients in increasing motivation to produce change. This and other strength-based approaches focus on clients’ strengths instead of their deficiencies.

Ironically, part of this focusing on clients’ strengths has resulted in the inclusion of solution-focused language within the field while discarding the foundational principles and philosophy. It has become increasingly common for agencies to blur the distinction between solution-focused and strength-based/problem-focused approaches when upon further investigation they are in fact working from a more traditional, problem-solving, medical model-driven philosophy. As therapists become more curious about the solution-focused approach, it is important to clarify the differences between solution-focused and problem-solving approaches, such as the strength-based model, in order to avoid misunderstanding and maintain well-formed, consistent treatment.

Substance Abuse Treatment Federal Agencies

Several federal agencies exist that aid in the research and treatment of substance abuse. We want to give a quick overview of the three most prominent: NIDA, NIAAA, and SAMHSA. The National Institute on Drug Abuse (NIDA) was established in 1974 as the main federal agency in charge of research to improve the treatment and prevention of drug abuse and addiction. NIDA’s mission is “to lead the Nation in bringing the power of science to bear on drug abuse and addiction” (NIDA, n.d.). Their site is a helpful place to gain information, research, and statistics about drug abuse.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) is one of 27 institutes and centers that make up the National Institutes of Health. In 1970 the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act passed, allowing the federal government to create an institute to administer treatment and prevention of alcoholism. This was the birth of NIAAA. Its mission is to reduce alcohol-related problems by supporting and conducting research to be disseminated to mental health providers, politicians, and the general public (NIAAA, 2006).

The Substance Abuse and Mental Health Services Administration (SAMHSA) is a division of the U.S. Department of Health and Human Services. The mission of SAMHSA is “building resilience and facilitating recovery for people with or at risk for mental or substance use disorder...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• List of Figures
• Authors
• Foreword
• Acknowledgments
• Preface
• What to Expect From This Book
• 1. Substance Abuse Treatment: An Overview
• 2. Solution-Focused Brief Therapy: The Basics
• 3. Beyond the Solution-Focused Basics
• 4. Assessment and Evaluation
• 5. Case Management and Individual Work With Clients
• 6. Solution-Focused Group Therapy
• 7. A More In-Depth Look at Working With Groups
• 8. Additional Applications and Practice Issues
• 9. Forms and Handouts
• Appendix: Resources
• References
• Index