Uses of Brief Therapy in Addiction Counseling

Therapist first began implementing brief therapy techniques during the community

mental health movement of the 1960s (Miller, 2021). Since that time, brief therapy (or solution-

focused therapy) has received much support from counselors and insurance agencies looking for

effective, cost-efficient forms of treatment. This paper seeks to examine the implementation of

brief therapy in a case study of Jane, a 26-year old woman referred to counseling after receiving

her second DUI (Miller, 2021, p. 295). The paper begins with an examination of the key

concepts, efficacy, and role of the therapist in brief therapy. From there, the paper goes on to

examine Jane’s particular situation and the nature of her substance use. Finally, the paper turns to

a recommendation of a brief-therapy-informed treatment protocol that could be implemented in

working with Jane. It is the hope of the author that this paper will provide the reader with a clear

understanding of what brief therapy is and how it can be applied in the specific context of

working with Jane.

The Efficacy of Brief Therapy

Evidence-based psychotherapy seeks to provide safe, reliable, economical forms of

treatment (Cook et al., 2017). Part of having an ethical practice in psychotherapy is

implementing the most relevant, up-to-date information in work with clients (Blease et. al.,

2016). Brief therapy has been used successfully in treating alcohol and drug use disorders

(Miller, 2021). Moreover, researchers believe that one of the benefits of these therapies is their

strength-based orientation, which provides an alternative to other more problem-focused

approaches (Kim et al., 2016).

Role of the Therapist

In brief therapy, the therapist views herself as a consultant (Miller, 2021). Brief therapists

seek to use the hierarchy and power-dynamics in the relationship to their advantage without

being authoritarian and seek to expand the options and choices available to their clients (de

Shazer et al., 2021). To this end, therapists guide the client gently, not analyzing or judging, but

rather steering the client’s attention in directions of new options and possibilities.

Key Concepts and Theoretical Approaches Used in Brief Therapy

Miller (2021) notes that a central focus of brief therapy is the “here and now” (p. 289).

Moreover, brief therapy aims to find strengths and resources within clients to help them solve

their problems. Brief therapy additionally meets the client where they are at in helping them to

establish realistic goals. To this end, Miller states that brief therapy strives to make small

changes over time that can have positive, wide-ranging, systemic effects. There are several

different theoretical approaches to brief therapy. Miller presents three approaches—

psychodynamic, cognitive and behavioral, and strategic and systemic—as being useful in

working with addictions.

The psychodynamic approach to brief therapy assist clients in identifying relationship

triangles in their lives (Miller, 2021). An example of this is the “triangle of conflict,” which

looks for connections between impulses, anxieties, and defenses. Impulses could include

negative relationships with others or triggering situations. Anxieties result from the attempt to

manage such impulses, and defenses (such as substance use) occur as an attempt to manage the

anxiety. In this way, a vicious cycle emerges in the addict’s life. Another example of a technique

psychodynamic brief therapy uses is “triangle of the person” which looks at how past
experiences with people effect the present and future. Miller sees this technique as being

specifically helpful in understanding the nature of the transference relationship in therapy.

Other forms of brief therapy, such as cognitive and behavioral therapy, seek to address

the underlying beliefs and thought patterns that underlie behavior (Miller, 2021). Rational

emotive therapy is one such technique, and it seeks to examine underlying beliefs and their

relationship to emotion and behavior. Beck’s cognitive behavioral therapy is another approach

that looks to identify and challenge unrealistic thought patterns that underlie behavior. Miller

notes that Beck’s approach has been found to work particularly well in cases where clients

experience hopelessness. Additionally, Beck’s approach has the beneficial effect of increasing

self-esteem and self-awareness in clients (Miller, 2021, p. 293). As the specific techniques used

in cognitive and behavioral therapy will not be implemented in the case study of Jen, they will

not be examined at greater depth in this paper.

Within the strategic and systemic category of brief therapy, de Shazer’s solution-based

brief therapy is one of the most well-known forms (Miller, 2021). Solution-based brief therapy

seeks to change client perception, behavior, and uncover strengths. While the other forms of

therapy outlined above tend to address the problem directly, solution-based brief therapy

paradoxically looks for exceptions to the problem. De Shazer et al. (2021) describe the goal as

being to discover the resources of personal power present at those times when the problem is

absent from the client’s life and to empower the client to access those resources again in the

future. The authors further pronounce the central guiding principle in this form of therapy to be,

“if it works, do more of it,” and “if it’s not working, do something different” (p. 2). Kim et al.

(2018) found this approach helpful in treating substance use and working with trauma; however,
de Shazer et al. (2021) note that there is still a lack of evidence regarding the efficacy of this

treatment approach as a whole.

A session of solution-focused brief therapy often begins with the therapist asking, “what

changes have you noticed in your life since scheduling this appointment” (de Shazer et al., 2021,

p. 5). The authors state that, depending on the clients answer, the therapist explores in great

depth the nature of the changes, or simply asks how she can be most helpful to the client.

Afterwards during the session, the client is guided to explore exceptions to their current problem,

or times in their life when the problem was absent. In some cases, de Shazer et al. (2021)

proscribe the miracle question: “if a miracle happens tonight and you wake up in the morning

without the problem. How will you know? How will others know? What will you be doing

differently” (p. 6). At the end of a session, depending on what resources and strengths have been

discovered, the therapist may give a homework assignment to experiment with some of the

resources that were discovered in the session.

Case Study Demographic

In the case study that Miller (2021) presents, Jane is a 26-year-old single woman with no

children who has an undergraduate degree and works as a court reporter (p. 295). Perhaps the

most significant demographic presented by Jane is her identity as a young woman. Women

addicts are often stereotyped as being powerless and are subject to harsh judgments by those they

are in relation with (Miller, 2021). What’s more, Miller writes that women tend to use substances

for stress-reduction purposes and have fewer social, economic, and familial supports then men.

This is important to take into account with Jane as her referral to treatment was due to her

receiving a DUI. The fact that Jane is young, single, and driving under the influence may suggest

that she lacks social support, friends, and family in her life. In the author’s experience,
supportive friends look after each other and ensure that nobody is making bad decisions around

drinking and driving. Jane, therefore, may be experiencing challenges in her social and personal

life. In the author’s opinion, the presence or absence of social supports is an area that should be

addressed in treatment.

Factors of resilience that are present with Jane is her educated background and her status

as a court-reporter. Being a court-reporter suggest that Jane is very intelligent and likely has a

good grasp on the legal consequences of her actions as well. Ideally, her intelligence can be used

to her advantage when working with her in therapy.

Addiction Type

In the United States, 28% of all traffic-related deaths in 2016 involved alcohol,

underscoring the severity of the problem (Center for Disease Control and Prevention [CDC],

2020). The CDC further states that other substances are involved in 16% of all crashes.

Additionally, among those fatal crashes in 2016, 25 to 34 year olds composed the largest group

of fatalities. This is relevant in the case of Jane as she falls within that age range. It is not

currently known the extent and history of Jane’s drinking or whether there are other substances

being used. It is known that women addicts often experience other issues in their physical,

mental, and sexual health (Miller, 2021). Therefore, it is important to assess for co-occurring

disorders that may be present.

Bender et al. (2018) investigated differences and similarities between women with single

and multiple DUIs. While they found that many women with DUIs had a history of co-occurring

mental disorders, parental alcohol use, abuse, and marital conflict, they found that the main

predictor of recidivism is the severity of alcohol use. While Jane may be an exception to this

trend, it is important to know when assessing for the severity of Jane’s substance use.
 For the benefit of this analysis, it will be assumed that the main addiction Jane is

experiencing is with alcohol. There is yet still much unknown about alcohol and substance use in

women (Miller, 2021). However, Miller notes that researches have observed that women tend to

use alcohol for the purpose of stress reduction and self-medication (p. 320). Physiologically, it is

known that women’s bodies are more responsive to the negative effects of alcohol than their

male counterparts. This is in part due to the fact that women have been found to become

intoxicated faster due to higher levels of fat (Harvard Medical School Special Report, 2008). It

has also been found that women who drink often have challenges with self-esteem and feelings

of powerlessness (Miller, 2021).

Self-esteem and powerlessness are particularly relevant in the case of Jane, as it has been

observed that she has been totally silent in group therapy, avoids eye contact, and speaks in a

quiet voice. In contrast, it has also been observed that Jane uses very eloquent words that even

the counselor does not know. Her articulateness would suggest a powerful intellect, yet it stands

in contrast to how she presents herself physically. There could be many reasons behind this

observation. However, the lack of congruence between her physical demeanor and her manner of

speaking would seem to convey a sense of powerlessness, or at least a shyness. Her reserved

demeanor could also be related to the fact that, as Miller (2021) notes, women who use alcohol

have more guilt and shame then men in similar situations.

Jane’s Treatment Plan

Jane is a good candidate for brief therapy because she has come to see her counselor for

only two sessions. Additionally, brief therapy is good at helping establish realistic goals, and in

Jane’s case there is a clearly defined and realistic goal of not driving under the influence again.

The pre-contemplation stage in addictions counseling is a stage where the client has no intention
of changing their behavior (Miller, 2021, p. 205). Since this is court-ordered therapy, Jane is

likely entering treatment at a pre-contemplative stage of change; therefore, it would not be

realistic to attempt to get Jane to commit to sobriety after only two sessions, nor would it be

reasonable to think that she would support that endeavor. By contrast, avoiding further DUIs,

further court-ordered treatment, and potentially jail time is something that Jane would likely

support.

The only potential aspects of Jane’s case that would not make her a good candidate for

treatment is not knowing the extent to which she is using alcohol. More serious alcohol use has

been found to not be as responsive to brief therapy as mild and moderate use (Miller, 2021).

Moreover, Jane has not shown almost no engagement up to this point in therapy.

The author’s first recommendation for Jane’s treatment is that another counselor be

assigned if possible. Miller (2021) summarizes that research shows recovery for women being

most effective in women-only environments or when services are tailored to women (p. 323). As

such, it may help Jane develop rapport if the counselor were female, and the author of this paper

identifies as a male.

Additionally, either in the initial intake session or at some other point during the court-

ordered treatment, it could be wise to administer the Driver Risk Inventory (DRI) to Jane. The

purpose of administering this test would be to get a better understanding of Jane’s driving risk.

The results from these tests could be used later as part of the FRAMES model when giving Jane

feedback on the reality and consequences of her behavior. Additionally, such information could

be useful to ensure that Jane does not pose a serious danger to other drivers.
Recommendations for Group Work Interventions

The above points aside, using a psychodynamic approach to brief therapy could be useful

when doing group work with Jane. The reason for this is because, until now, Jane has not shown

much affect or participation in group therapy. It would therefore seem that taking a cognitive-

behavioral approach in group work would at best result in Jane’s begrudging engagement. A

more useful approach in this case—and one that could provide the counselor with important

information about Jane’s history—would be to explore the psychodynamic technique of the

“triangle of the person.” Participants in the group could be asked how their past relationships

effect their current perceptions of other group members and the therapist. This could help group

members feel a sense of comradery over shared experience and see how their past experiences

effect the “here and now.” The engagement, or lack of engagement, by Jane would provide the

counselor with important information that could be used in individual sessions.

Implementing the FRAMES Model in Jane’s Therapy

Miller (2021) introduces the FRAMES model as a way to encourage change while

respecting client sovereignty (p. 291). Feedback must first be given to Jane in an empathic

manner. This could be explored initially in group work and then further in individual sessions.

The goal of giving feedback is to ensure that Jane understands the negative consequences of her

actions. In order that Jane does not feel like she is being talked down to, it is important to remind

Jane that she has total responsibility for her actions and choices. Giving Jane feedback and

responsibility together insure that she has the power to make decisions while being aware of their

consequences.

While the first two parts of the FRAMES model could be explored in group therapy, the

next step, advice, would be better to explore with Jane in session. If Jane were to give consent to
hear advice, she could then be provided with a menu of treatment options and approaches to take.

Throughout this process, it is important to convey a sense of self-efficacy to Jane, so that she

feels empowered to act on the advice and menu options provided by the counselor. Some of the

menu items suggested could include: finding a therapist if Jane does not already have one,

seeking more intensive treatment if serious addiction is present, finding a support group or a

women’s group to give Jane social contact and people to call if she is intoxicated and needing to

drive, and reading self-help books to improve Jane’s self-efficacy and understanding of

substance use in women.

In individual therapy with Jane, a hybrid-approach that combines the best of several

forms of brief therapy may be effective. Pulling from solution-based brief therapy, a question

that could be asked in intake is, “If a miracle occurs tonight while you are asleep and the

problem is eliminated, how will you know the next morning? How will others know? What will

you be doing differently or saying differently” (Miller, 2021, p. 293). Based on Jane’s response,

the counselor can gleam greater insight into what Jane considers the nature of her problem to be

and what resources she feels she needs in order to resolve it. From here, the counselor and Jane

can engage in an exploration of Jane’s personal history, looking at times in her life when those

resourceful, problem-free states where present and discussing ways in which to recreate those

resources and states in her present life. Additionally, the counselor and Jane can explore times in

her life when she made smart decisions around drinking and driving. Once some of these times

have been identified, the counselor and Jane can discuss ways of making those resources more

available to Jane in the present.

Ideally, implementing the FRAMES model and the above techniques from solution-based

brief therapy, Jane would be armed with the self-efficacy and resources to avoid driving under
the influence in the future. Rapport and time permitting, it could then be helpful to take a

psychodynamic approach to brief therapy for the remaining time. Specifically, using the “triangle

of the person” to identify impulses, anxieties, and defenses around Jane’s use of substances and

driving under the influence could pair well with the solution-focused brief therapy approach of

identifying times in Jane’s life where those impulses and anxieties were not present for whatever

reason. The “triangle of the person,” however, may require more participation then Jane is

willing to give. In that case, falling back on solution-focused brief therapy to provide Jane with

as many internal resources as possible could be the most efficient maneuver.

Conclusion

The biopsychosocial was first introduced in the 1980s by Dr. George Engel and has come

to be a widely used model for treatment. It seeks to examine biological, psychological, and

sociological interactions and their contributions in disease states. The biopsychosocial model is

equally useful in planning treatment interventions (Engel, 1981). Jane’s case has mainly been

conceptualized through a psychological and social frame. The reason for her court-ordered

therapy—a second DUI—can be thought of as a behavioral manifestation of an underlying

psychological state that has social consequences. As Jane’s case relates to substance use, it is

possible that her behaviors have a biological basis. Namely, her family could have a history of

substance use, and Jane could have a genetic predisposition for addiction. Additionally, many

aspects of Jane’s social identity including her upbringing, her social supports, her family, and her

relationship to her work are not known.

The author recommends an approach to treatment that incorporates solution-focused brief

therapy. Specifically, the author recommends that the counselor and Jane examine times in her

life when she made good decisions around substance use and driving and seek to implement
those strategies and resources in a consistent way in Jane’s future. Jane is clearly a well-educated

woman, given her educational background, profession, and use of language while in session.

Therefore, it is hopeful that Jane has the conceptual and cognitive capacity to implement her

strengths in the future to make better decisions around driving. The author additionally

recommends that the FRAMES model be implemented in Jane’s intake session. If Jane is willing

to hear advice, suggestions for further treatment and social support can be made by the counselor

for when Jane leaves court-ordered therapy.

In order for the counselor to gain a better understanding of Jane’s use, it is also

recommended that the “triangle of conflict” technique be implemented to understand the patterns

of impulse, anxiety, and substance use around Jane’s driving. It is recommended that this

technique be employed either after or in unison with the solution-focused brief therapy

intervention. Once patterns have been identified, the counselor can shift to examine times in

Jane’s life where such patterns were not present.

Additionally, while in group therapy, implementing the technique of the “triangle of the

person” could help Jane understand how past relationships in her life affect her view on current

and future relationships. Finally, it is recommended that Jane be administered the Alcohol Use

Inventory (AUI) and the Driver Risk Inventory (DRI) in order to better understand her substance

use and level of risk as a driver. By assessing Jane’s level of risk, helping her understand

destructive patterns of behavior, and empowering her to use her inner-strengths to stay sober

while on the road in the future, it is hoped that all parties of interest will be satisfied in realizing

the goal of keeping Jane and other drivers safe.

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