Solution-focused brief therapy for substance use

Solution-focused brief therapy (SFBT) is a short, forward-looking form of talking therapy. Instead of examining the causes of a problem at length, it concentrates on what a person wants instead and on times when things already go better. It has been used with people who have substance use problems since the 1980s, but outcome research is still modest, as this page explains.

What SFBT is

A 2023 review of the approach in adult mental health, published in Frontiers in Psychiatry, describes SFBT as an effort to shift treatment from problems to solutions. It builds on identifying a person's resources and, when something works, doing more of it. Steve de Shazer, who developed SFBT in the 1980s, and Insoo Kim Berg outlined four features that mark an SFBT session: a miracle question, a request to rate something on a scale, a therapist's break, and a compliment with a homework task after the break.

The authors of a 2021 review of SFBT for substance use note that SFBT has been used with people who have substance use problems since the 1980s and that training materials exist for practitioners. They also note that, until that review, no published review of outcome studies had been available to guide them.

How it works in outline

The Frontiers review lists the techniques at the center of the method:

• Goals: the person describes a preferred future, in specific terms.
• The miracle question: the person is asked to imagine that a problem disappeared overnight and to describe what would be different and what other people would notice.
• Exceptions: times when the problem could have occurred but did not, or was less severe, are explored so the person can build on them.
• Scaling questions: the person rates their situation on a scale, typically one to ten, which turns a hard-to-describe experience into something that can be tracked.
• Compliments and homework: the therapist names strengths and suggests a small next step.

In the substance use trial described below, the average length of SFBT treatment was reported to be six to 10 sessions, though it can vary. For another short, conversation-based approach, see motivational interviewing.

What sessions can look like

Because SFBT is brief, a course may be short. The Frontiers review describes a session shape in which the therapist asks the miracle question, asks the person to rate something on a scale, takes a break to reflect, and returns with compliments and a suggested task. Along the way the conversation turns to exceptions, the times when the problem was absent or milder. Exact structure varies by therapist, so a clinician can say what to expect.

What the research says

The main source on substance use is a 2021 review by Franklin and Hai in Health and Social Work, which found nine published outcome studies. According to its abstract, all of them found promising evidence of effectiveness in improving substance use behaviors and related psychosocial problems, and five of the nine showed that SFBT can change substance use along with problems such as depression, trauma, and school- or work-related behavior. A base of nine studies is small.

The strongest single test comes from a randomized trial reported in 2021 by Kim, Brook and Akin in the Journal of the Society for Social Work and Research. It involved 179 parents involved in the child welfare system who sought outpatient treatment for a substance use disorder, split between SFBT and treatment as usual, which was based largely on cognitive behavioral therapy with some motivational interviewing. Both groups improved on most measures. The differences between them in substance use severity were small and not statistically significant, and drug use favored the comparison group slightly. The authors concluded that further study of SFBT for these parents is warranted.

A broader 2024 umbrella review of systematic reviews, in Psychotherapy Research, reports positive outcomes for SFBT across issues and settings with no evidence of harm. That review looks at SFBT in general, not substance use alone.

Limits and who it may not suit

• The substance use evidence is early. Similar results to usual treatment, as in the trial above, do not show that SFBT is better, and one trial cannot settle the question.
• The Frontiers review notes that solution-focused approaches do not offer broad contextual assessment and quotes critics who say they may not suit severe conditions, since important life factors may be missed in a brief therapy.
• The same review reports a criticism that the approach pays little attention to emotional experience.
• For people with serious co-occurring conditions or trauma, a clinician may suggest additional or different care; see co-occurring mental health conditions and trauma-informed care.

A qualified clinician decides what fits, and SFBT may be combined with other approaches such as relapse prevention.

Questions to ask a clinician

• How much of your practice with substance use is solution-focused, and how much follows other models?
• How many sessions would we plan, and what happens if the problem needs longer work?
• What would we do if there are few "exceptions" to point to right now?
• Does this approach suit me if I also have depression, anxiety or trauma?
• How will we track progress, and when would we reconsider the plan?