Solution-Focused Brief Therapy With Substance-Using Individuals

Abstract

Objective:

This study examined the effectiveness of solution-focused brief therapy (SFBT) intervention on substance abuse and trauma-related problems.

Methods:

A randomized controlled trial design was used to evaluate the effectiveness of SFBT in primary substance use treatment services for child welfare involved parents in outpatient treatment for substance use disorders. Mixed linear models were used to test within- and between-group changes using intent-to-treat analysis (N = 64). Hedges’s g effect sizes were also calculated to examine magnitude of treatment effects.

Results:

Both groups decreased on the Addiction Severity Index-Self-Report and the Trauma Symptom Checklist-40. The between group effect sizes were not statistically significant on either measures, thus SFBT produced similar results as the research supported treatments the control group received.

Conclusion:

Results support the use of SFBT in treating substance use and trauma and provide an alternative approach that is more strengths based and less problem focused.

Keywords

solution-focused brief therapy randomized controlled trial substance use mental health trauma child welfare foster care

The impact of parental substance use on families in the child welfare system continues to draw a lot of attention because of the negative consequences associated with misusing alcohol and other drugs. Additionally, providing effective treatment services to child welfare families for trauma experiences has become a major focus for clinicians, administrators, and policy makers (Strand, Hansen, & Courtney, 2013). While much research has been focused on the impact of parental substance use and traumatic experiences of children in the child welfare system, very little research has focused on effective treatment approaches for parents struggling to improve.

Parental substance use is highly associated with multiple forms of child maltreatment (Walsh, MacMillan, & Jamieson, 2003). It is estimated that substance use is identified or suspected in 66% of all substantiated child protective and 79% of cases where children are removed from their homes (Schaeffer, Swenson, Tuerk, & Henggeler, 2013). Studies have shown substance abusing parents are more likely to neglect their children by providing inadequate shelter, neglecting a child’s personal care, and having less economic stability (Grella, Needell, Shi, & Hser, 2009). The cumulative effect of untreated parental substance use is not fully known at this point; however, research indicates that mental health and substance use problems for these children are higher than nonsubstance use affected children, and children are at greater risk for child welfare involvement, at greater risk for foster care placement, and once in foster care, their stays are for longer periods and their likelihood of reentry is higher (Brook & McDonald, 2009; Brook, McDonald, Gregoire, Press, & Hindman, 2010; Schaeffer et al., 2013).

Another major challenge for child welfare service providers, besides providing effective treatment for substance use, is addressing the high rates of trauma among families involved in the child welfare system. According to the Substance Abuse and Mental Health Services Administration, 2014),

Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual being. (p. 7)

Thus, parents and children who have been exposed to community violence, child abuse and neglect, sexual abuse, domestic violence, and traumatic loss have all been exposed to varying levels of trauma (Stand, Hansen, & Courtney, 2013). Studies have reported that between 30% and 80% of individuals with substance use problems also reported experiencing some traumatic event in their lifetime (Blakey & Smith Hatcher, 2013). It is very common for substance-abusing parents in the child welfare system to also suffer from mental health problems, like trauma which complicates treatment (Schaeffer et al., 2013). Blakely and Smith Hatcher (2013) report on the range of traumatic experiences of women with substance use problems and found 10–82% reported childhood physical abuse, 23–82% reported sexual abuse, 18–80% reported being raped, and 30–75% reported intimate partner violence. The combination of substance misuse and trauma-related mental health problems for parents can negatively impact parent functioning leading, thereby contributing to child maltreatment and serving as a barrier to successful reunification. Additionally, the effects of trauma can hinder parent’s engagement in all aspects of public child welfare intervention, such as employment stability, treatment compliance, mental health, substance use, and other child welfare services (CWS; Brook, Yan, Lloyd, & Thomas, 2014; Chemtob, Griffing, Tullberg, Roberts, & Ellis, 2011).

Unfortunately providing effective treatment services to address substance use and trauma in child welfare families continues to be a challenge for service providers, with no clear guidelines available to local practitioners for what works, with whom, and under what conditions (Semidei, Radel, & Nolan, 2001; Strand et al., 2013). Parents in the child welfare system are less likely to complete substance use treatment with studies showing about a quarter of those parents actually completing treatment (Grella et al., 2009). Despite the efforts being made to reduce substance use and trauma-related symptoms in this country using a problem-focused approach (e.g., cognitive behavioral therapy), more research needs to be conducted to evaluate other methods that work to enhance solution-building strategies to motivate and foster effective coping mechanisms. This study addresses the noted needs by evaluating the implementation of solution-focused brief therapy (SFBT) in primary substance use treatment services for child welfare involved parents in outpatient treatment for substance use disorders using an experimental design.

SFBT is a short-term, strength-based intervention which focuses on creating client-generated solutions to problems. The application of SFBT with persons experiencing substance use has been recommended by clinicians who describe the usefulness of SFBT with alcoholics and drug users (Berg & Miller, 1992; Berg & Reuss, 1997; Juhnke & Coker, 1997; Mason, Chandler, & Grasso, 1995; McCollum & Trepper, 2001; Miller & Berg, 1995); however, more outcome studies using rigorous research methods are needed. Additionally, there is a dearth of outcome research on the effectiveness of SFBT on trauma-related problems.

The empirical support on the effectiveness of SFBT has grown significantly over the past two decades. Gingerich and colleagues (2012) provide the most comprehensive review on the quantitative research of SFBT to date both in the United States and in abroad. Based on their review of meta-analyses and randomized controlled trial (RCT) studies, the authors found that the outcome research to date shows SFBT to have a small to moderate, positive outcome. Furthermore, when compared with established treatments in well-designed studies, SFBT sometimes produces results in substantially less time and at less cost (Knekt et al., 2008). Several other studies have examined SFBT in substance use and mental health clinics (Cockburn, Thomas, & Cockburn, 1997; Eakes, Walsh, Markowksi, Cain, & Swanson, 1997), with significant positive findings for internalizing problem behaviors, externalizing problem behaviors, and family-related problems. A more recent systematic review conducted by Gingerich and Peterson (2013) found significant positive benefits from SFBT including successful treatment of depression and other behavioral and psychological disorders in adults. Smock et al. (2008) compared six sessions of manualized SFBT group therapy with a 6-week adaptation of the Hazelden model on the mental health functioning of 38 Level 1 substance use outpatients. The SFBT group showed statistically significant improvement on both the Beck Depression Inventory (effect size of 0.64) and the Outcome Questionnaire 45 (effect size of 0.61) Symptom Distress subscale. The Hazelden comparison group showed a positive trend on both measures, but changes were not significant. The SFBT group had higher scores on both measures at pretest, but by posttest, the scores of the two groups were roughly comparable, thus between-group differences at posttest did not reach statistical significance.

The previous studies show that SFBT has promise as an effective intervention with adults who have been identified with a substance use disorder, but more rigorous research is needed with families in the child welfare system who present unique challenges for engagement and treatment services. In addition, there is currently a scarcity of empirical studies on the effectiveness of SFBT with trauma-related problems in adults, although several articles have made the argument for its appropriateness (e.g., Bakker, Bannink, & Macdonald, 2010; Bannink, 2008; de Castro & Guterman, 2008). Researchers have also noted that SFBT research needs to improve on the research designs used in previous testing by employing more rigorous research methods and design (Kim, 2008). Thus, the aim of this study is to test the effectiveness of SFBT, using rigorous research methods, as an alternative approach in helping child welfare involved parents for substance misuse and trauma symptom–related problems. The two hypotheses examined in this research study are:

Hypothesis 1: Parents who receive SFBT counseling services will experience lower scores on the Addiction Severity Index (ASI) subscales and total scores relative to parents who receive treatment-as-usual (TAU) counseling services.

Hypotheisis 2: Parents who receive SFBT counseling services will experience lower scores on the Trauma Symptom Checklist (TSC) subscales and total scores relative to parents who receive TAU counseling services?

The questions we seek to answer have clear implications for the practice field as well as future research in substance use and trauma.

Method

Design

In order to answer these research questions, the study used an RCT design. Half of the counselors at each of the two agencies selected for participation received SFBT training. These SFBT counselors were recommended by the clinical directors at the agency and volunteered to receive the SFBT training. The rest of the counselors at each agency continued working with their clients, as they have done and served as a TAU control group.

Sample

Families were recruited from two different substance use and mental health counseling centers in Oklahoma to participate in this study. The population for this study was parents who have had their children removed from their custody and into foster care by CWS, have been referred by CWS for substance use treatment, and have a case plan goal of family reunification. Inclusion criteria for participation included (1) families must have a child(ren) placed in out-of-home care with a case plan goal of reunification at the time of recruitment for participation in this study, (2) parent’s or legal guardian’s alcohol or other drug use must be a contributing condition to the reason the child was placed in out-of-home care, (3) families must have an open deprived case in which parental substance use is alleged or families must have at least one parent who met the criteria specified in Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) for substance use disorder at the time of child removal, (4) parents or guardians must be older than 18 years of age, (5) parents or guardians must consent to participate in this study.

Recruitment and Screening

Participants were recruited through the two counseling agency’s normal recruitment and interaction process. Parents seeking substance use treatment services from May 2014 through October 2015 were screened by a trained intake clinician to determine their eligibility for study participation. The agency intake clinician informed potential participants about the research protocol and then offered the option of an initial assessment or to not participate in the study but still receive the agency’s services as usual. If parents agreed to participate, then the agency intake clinician scheduled another meeting as soon as possible for clients to complete consent forms and pretest questionnaires.

Procedures

After all the consent forms and pretest questionnaires were completed by the parent, the agency intake clinician provided information to the research team. Participants’ study numbers were entered into the Research Electronic Data Capture (REDCap) software, version 6.8.1, (Harris et al., 2009) for randomization into either the SFBT or control condition in a randomized blocked fashion; subsequent participants were assigned to the opposite condition to ensure balance across conditions. Both the staff members at the agencies and potential participant were blind to study condition until the informed consent process was complete.

Research staff notified the respective agency’s intake counselor within 2 days of receiving the participant’s information as to which of the two conditions the parent was assigned. The agency’s intake workers then scheduled an appointment for the participant with either an SFBT clinician or TAU clinician based on counselor caseload availability. There were three clinicians from the first site, two clinicians from second site, and both clinical directors at the two sites were trained in SFBT. All clinicians and clinical directors delivering SFBT and TAU were master’s-level clinicians. The only difference between conditions was that the SFBT condition was assigned to clinicians using SFBT, while the control condition was assigned to clinicians using TAU. Both agency sites have indicated that it was typically 1 week after the intake meeting before parents were assigned to a clinician for treatment services; thus, parents did not experience delays in receiving services by participating in the study.

A battery of assessments was administered at baseline, which was prior to randomization to treatment condition and which included substance use and trauma measures. Posttest data were collected with participants in both study conditions at the end of treatment (program exit) or 3 months after treatment services began, whichever occurred first. Participants were given a US$20 gift card for completing all instruments prior to start of treatment services and US$30 gift card for completing all questionnaires at posttest. Institutional review board approval from the University of Denver was obtained prior to data collection.

Intervention Integrity and Fidelity Promotion

SFBT training was provided by internationally recognized SFBT trainers over a year prior to data collection. The SFBT trainers initially provided an intensive 2-day training (8 hr per day) to introduce the SFBT model. The training consisted of lectures, role-play exercises, video demonstrations, and discussion. This was followed by three additional 1-day (8 hr per day) trainings that provided additional role-play exercises, video demonstrations, and case consultation discussions. The SFBT clinician also participated in 1-hr case consultation conference phone calls in-between on-site trainings to provide clinicians with consultation on specific cases from the SFBT trainers.

To address treatment fidelity, SFBT clinicians completed the SFBT Fidelity Instrument (Lehmann & Patton, 2012) at the sixth session. This self-report instrument rates clinicians’ adherence to using SFBT questions and techniques. This instrument contains 13 items using a 7-point Likert-type scale ranging from 1 = not at all to 7 = yes clearly and specifically. Internal consistency reliability was good with a Cronbach’s α score of 0.83 and the goodness-of-fit indices were above the recommended 0.90 level, thereby indicating a good model fit in measuring adherence to the SFBT protocol (Lehmann & Patton, 2012). Clinicians averaged a mean score of 6.22 on the Solution-Focused Fidelity Instrument, indicating a very high level of treatment fidelity.

Adherence to SFBT model was also examined by having clinical directors at both sites independently observe a random number of SFBT sessions and rate the session using the SFBT session form. This SFBT session form is adapted from Smock and colleagues’ (2008) form used on a substance use SFBT group study. This form asks an evaluator to observe and document (yes/no) whether eight solution-focused techniques (e.g., scaling questions asked, exception questions asked, gave compliments) were used in an SFBT session. REDCap (version 6.8.1) randomization software was used to randomly select 25% of the SFBT cases at each site and counseling sessions that the SFBT clinical directors observed to assess how closely clinicians adhered to the SFBT model. These sessions were either observed in-person or audio taped and then later reviewed by the clinical directors to ensure SFBT fidelity.

SFBT Intervention

SFBT is a research supported therapy model that asserts the importance of building on the resources and motivation of clients because they know their problems best and are capable of generating solutions to solve their own problems. Steve de Shazer and Insoo Kim Berg developed SFBT in an effort to reverse traditional psychotherapy practice by shifting the focus of treatment from problems to solutions (Trepper, Dolan, McCollum, & Nelson, 2006). SFBT views problems as fixable and change as viable by concentrating on the achievement of small, concrete behavioral goals (Berg & De Jong, 2008). Central to SFBT is client strengths and resiliencies, clients’ prior ability to develop solutions, and exceptions to problems (Trepper et al., 2006). The discussion of exceptions and movement toward future adaptive behaviors allows the clinician and client to focus on solutions to the client’s problem, rather than dwelling on the problem itself (Berg & De Jong, 2008). In fact, simply talking about improvement has an encouraging effect on the client (Banks, 2005). The emphasis of SFBT is on the process of developing an image of a realistic solution rather than dwelling on the past manifestation of the problem, with the focus being on identifying past successes and exceptions to the problem in an effort to accomplish set goals (Kim, 2014). Goals are cocreated by clinician and client; thus, it is critical that clinician and client foster an open and collaborative working relationship (Dielman & Franklin, 1998). An important assumption of SFBT posits that clients possess capabilities and resources for resolving their problems. Thus, the task of therapy is to assist clients in utilizing these resources to reach a solution to the problem in question (Kim, 2014).

More specifically, the foci and assumptions of SFBT are the following: (1) focus on solution building rather than problem-solving, (2) focus on client’s desired future rather than past problem, (3) focus on increasing current useful behavior, (4) focus on exceptions to the problems which can be used to construct solutions, (5) focus on coconstructing alternatives to current undesired behaviors, (6) focus on small changes which can lead to larger changes, (7) assumes that solution behaviors already exists in clients, (8) assumes solutions are not directly related to any identified problem by the client or therapist, and (9) focus on conversation skills that invite building solutions rather than diagnosing and treating client problems (Trepper et al., 2012). The average length of treatment for clients-seeking SFBT substance use treatment is 6–10 sessions but can vary depending on client factors.

Participants randomly assigned to TAU received the normal treatment modality the agency provides its clients. At both agency sites, TAU consisted of some type of research-supported treatment. Agency clinicians are required to use a research-supported treatment and clinicians mostly used cognitive–behavioral therapy, trauma-focused cognitive–behavioral therapy, and motivational interviewing. All clinicians were master’s-level practitioners.

Outcome Measures

This study examined two outcomes related to adult recovery: substance use and trauma symptomology. Two standardized instruments were used: the ASI (Self-Report [SR] Form; Rosen, Henson, Finney, & Moos, 2000) and TSC-40. These instruments were selected for reasonable time requirements and for prior study, showing that they were validated empirically as described below.

ASI-SR

The ASI-SR Form (Rosen et al., 2000) is a widely used instrument that was adapted from the longer clinical ASI (McLellan et al., 1992). The ASI-SR measures six functional domains: alcohol/drug use, medical status, employment/self-support, family/social relationship, psychiatric status, and legal status. Composite scores were calculated for these six domains (Rosen et al., 2000) to assess substance use severity and substance use–related problems over the past 30 days. The original ASI instrument has good reliabilities across studies which ranges from 0.44 (Luo, Wu, & Wei, 2010) to 0.89 (Leonhard, Mulvey, Gastfriend, & Shwartz, 2000). The ASI-SR has comparable results on its measurement properties as the ASI (Rosen et al., 2000).

Trauma Symptom Checklist-40

Parent trauma was measured using the TSC-40 (TSC-40) instrument. This self-report questionnaire measures posttraumatic stress and other trauma-related symptoms in adults who have experienced childhood or adult traumatic experiences (Briere & Runtz, 1989). The TSC-40 comprises 40 items and yields a total score as well as six subscales (anxiety, depression, dissociation, sexual abuse trauma index, sexual problems, and sleep disturbances) based on parent’s responses to how frequently (0 = never to 3 = often) items have occurred during the past 2 months. A study by Elliott and Briere (1992) supported the psychometric validity and reliability of the TSC-40 with subscale α coefficients ranging from 0.62 (sexual abuse trauma index) to 0.77 (sleep disturbance) and with a total score α coefficient of 0.90.

Sample Size

An a priori power analysis for power = 0.80 with a two-tailed α = 0.05 for a repeated measures model indicated that effect size is small (η² = 0.01), 198 total participants are required; if the effect size is medium (η² = 0.06), 34 total participants are required; and if the effect size is large (η² = 0.14), 16 total participants are required.

Data Analysis

The analyses used linear mixed models to both evaluate longitudinal change in outcomes between baseline and posttest for substance use and trauma outcomes and to evaluate differential longitudinal change across treatment and control groups for substance use and trauma outcomes. Linear mixed models accommodate repeated measures data and data containing unequal numbers of observations per individual (Gelman & Hill, 2007), both of which were characteristics of the present data. Mixed models are estimated using maximum likelihood and thus borrow information from observed data in the presence of missing data and make use of all observed data and include all participants regardless of whether they completed all assessments. Thus, mixed models are consistent with the intent-to-treat approach, unlike ordinary least square methods, such as analysis of covariance (ANCOVA) or repeated measures analysis of variance that estimate models based on ordinary least squares and thus drop data from respondents that have any missing data and therefore are not intent-to-treat analyses. Being able to estimate a time main effect, which provides information about the average pre- to postchange, is another advantage of implementing repeated measures in mixed models over ANCOVA models that only provide an estimate of postintervention differences. Each model contained independent variables for time (coded 0 for entry and 1 for exit), condition (coded 1 if the individual was in the treatment and 0 otherwise), and the interaction between age and condition (the product of the time and condition interaction). Individuals were analyzed according to the condition to which they were assigned regardless of whether they attended the intervention or completed a posttest assessment in adherence with the intent-to-treat approach. Models were fit with the lmer function from the R (version 3.2.2) lme4 package (Bates, Maechler, Bolker, & Walker, 2015), and p values were calculated using Satterthwaithe degrees of freedom implemented using the R lmer test package (Kuznetsova, Brockhoff, & Christensen, 2015). A value of p < .05 was considered statistically significant. Hedges’s g with a small sample bias correction was used to calculate effect sizes of mean difference between and within groups. Effect sizes are interpreted based on Cohen’s (1988) guidelines with 0.20 indicating a small effect, 0.50 indicating medium effect, and 0.80 indicating a large effect. Additionally, the significance of each effect size was tested to see if the effect size equals zero by calculating 95% confidence intervals (CIs; Shadish & Haddock, 1994).

Results

Participant Flow

Enrollment and client flow for this study is presented in Figure 1. Initially, 64 participants were recruited and screened for participation eligibility. All 64 eligible participants completed baseline measures for the ASI-SR and TSC-40 and then randomized into the two conditions, with 33 assigned to control group and 31 assigned to the SFBT treatment group. A total of 13 participants either refused or dropped out prior to collecting posttest data.

Figure 1.

Enrollment flowchart.

Sample Characteristics

The mean age of the 64 participants was 31.3 years (SD = 8.0). The sample was 43.8% male and consisted of 9.4% American Indians/Alaskan Native, 14.1% African American, 1.6% Native Hawaiian/Pacific Islander, 56.3% White, and 18.8% mixed race; 3.1% reported Hispanic ethnicity. Participants reported the following relationship status: 10.9% were cohabiting with focal child’s biological parent, 4.7% were cohabiting with other individual, 26.6% were divorced or widowed, 17.2% were married to focal child’s biological parent, 6.3% were married to other individual, and 34.4% were single. Participants reported the following employment status: 29.7% were employed full time, 10.9% were not in the labor force, 15.6% were employed part time, 1.6% were self-employed, and 42.2% were unemployed. Reported income was 67.2% US$0–US$9,999, 18.8% US$10,000–US$19,000, 6.3% US$19,001–US$24,999, and 7.8% US$25,000 or more. Education level was 34.4% less than a high school diploma, 29.7% high school diploma, and 35.9% had some college or vocational/technical training.

Substance Use Results

Means and effect sizes for the SFBT and control groups on the ASI-SR measure are presented in Table 1. On all the subscales for the ASI-SR, mean scores decreased for both groups between pretest and posttest indicating improvements on substance use severity and related problems. The SFBT group within-group effect sizes ranged from small (0.14 for medical status) to medium (0.61 and 0.62 for drug use and psychiatric status, respectively), indicating improvement on all the ASI-SR subscales. The significance of each subscale effect size was tested to see if the effect size equals zero by calculating 95% CIs (Shadish & Haddock, 1994) and having a p value < .05. Only drug use and psychiatric subscales had CIs that did not contain zero and p values < .05, which indicates the SFBT group improved significantly within those two subscales.

Table 1.

ASI-SR Mean (SD) and Effect Sizes for SFBT and Control Groups.

Outcome	Pretest	Posttest	Within-Group Effect Size (95% CI)	Between-Group Effect Size (95% CI)
ASI medical status
Control group	.20 (.33)	.11 (.21)	0.32 [−0.17, 0.80]
SFBT group	.22 (.36)	.17 (.35)	0.14 [−0.35, 0.63]	0.14 [−0.35, 0.62]
ASI employment status
Control group	.59 (.20)	.58 (.26)	0.04 [−0.43, 0.51]
SFBT group	.69 (.22)	.59 (.27)	0.40 [−0.11, 0.90]	0.34 [−0.15, 0.82]
ASI legal status
Control group	.33 (.35)	.29 (.32)	0.12 [−0.36, 0.59]
SFBT group	.40 (.31)	.25 (.31)	0.47 [−0.04, 0.99]	0.35 [−0.14, 0.83]
ASI family/social status
Control group	.08 (.12)	.11 (.17)	−0.20 [−0.28, 0.68]^a
SFBT group	.20 (.25)	.15 (.18)	0.22 [−0.27, 0.72]	0.45 [−0.04, 0.94]
ASI psychiatric status
Control group	.29 (.27)	.18 (.20)	0.45 [−0.04, 0.95]
SFBT group	.36 (.28)	.20 (.22)	0.62 [0.09, 1.15]*	0.24 [−0.25, 0.72]
ASI alcohol use
Control group	.02 (.04)	.02 (.05)	0 [−0.47, 0.47]
SFBT group	.03 (.12)	.02 (.07)	0.10 [−0.39, 0.59]	0.16 [−0.32, 0.65]
ASI drug use
Control group	.08 (.12)	.01 (.05)	0.74 [0.21, 1.28]*
SFBT group	.15 (.17)	.06 (.11)	0.61 [0.08, 1.14]*	0.23 [−0.25, 0.72]

Note. ASI-SR = Addiction Severity Index–Self-Report; SFBT= solution-focused brief therapy; effect size = Hedges’s g with small sample bias correction; CI = confidence intervals.

^aEffect size in the opposite direction.

*Statistically significant at p < .05 level.

The control group had within-group effect size range from negative improvement, where clients reported doing worse (−0.20 for family/social relationship) to large (0.74 for drug use). Only the drug use subscale had a p value < .05 and a 95% CI that did not contain zero, which indicates statistically significant improvement on that subscale for the control group. Additionally, the between-group effect sizes slightly favored the SFBT group as indicated by the small effect sizes for all the subscales except for family/social status which had a near medium (0.45) effect size. Results from the p value and 95% CI for the between-group effect sizes did not show any statistical difference between the SFBT and control groups for substance use severity and related problems.

Results from the multivariate analysis for the ASI-SR are presented in Table 2. There were significant treatment main effects for the subscales ASI family/social status, t(109) = 2.52, p = .013) and ASI drug use, t(110) = 2.39, p = .019). The treatment main effects were all positive, indicating that participants in the SFBT condition exhibited higher levels of these outcomes irrespective of whether the outcome was assessed at the pretest or posttest assessment. Additionally, there was a significant negative follow-up main effect for ASI drug use, indicating that participants exhibited lower levels of drug use at posttest irrespective of study condition, t(110) = −2.01, p = .047. While there were no significant Follow-up × Treatment interactions, a marginally significant interaction effect was observed for the ASI employment status (t[53] = −1.81, p = .075). The interaction represented a greater decrease between the pretest and posttest assessments in the SFBT group than in the control group.

Table 2.

Model Parameters for ASI-SR.

Outcome	Parameter	B	SE	df	t	p
ASI medical status	Intercept	.20	.06	77	3.6	<.001
	Follow-up	−.08	.05	49	−1.6	.117
	Treatment	.02	.08	77	0.19	.851
	Follow-up × Treatment	.04	.07	49	0.51	.615
ASI employment status	Intercept	.59	.04	81	14.11	<.001
	Follow-up	.00	.04	52	0.01	.990
	Treatment	.10	.06	81	1.68	.097
	Follow-up × Treatment	−.10	.05	53	−1.81	.075
ASI legal status	Intercept	.33	.06	85	5.87	<.001
	Follow-up	−.05	.06	52	−0.82	.415
	Treatment	.07	.08	85	0.83	.410
	Follow-up × Treatment	−.11	.08	53	−1.32	.191
ASI family/social status	Intercept	.08	.03	109	2.6	.011
	Follow-up	.02	.04	58	0.49	.627
	Treatment	.12*	.05	109	2.52	.013
	Follow-up × Treatment	−.08	.07	59	−1.18	.244
ASI psychiatric status	Intercept	.29	.04	96	6.69	<.001
	Follow-up	−.10	.05	52	−1.93	.059
	Treatment	.07	.06	96	1.14	.257
	Follow-up × Treatment	−.06	.07	52	−0.74	.464
ASI alcohol use	Intercept	.02	.01	110	1.27	.208
	Follow-up	.00	.02	110	0.05	.963
	Treatment	.01	.02	110	0.73	.470
	Follow-up × Treatment	−.01	.03	110	−0.31	.758
ASI drug use	Intercept	.08	.02	110	3.69	<.001
	Follow-up	−.06*	.03	110	−2.01	.047
	Treatment	.07*	.03	110	2.39	.019
	Follow-up × Treatment	−.03	.05	110	−0.7	.487

Note. ASI-SR = Addiction Severity Index–Self-Report.

*Statistically significant at p < .05 level.

Trauma Results

Mean scores and effect sizes for the SFBT and control groups on the TSC-40 measure are presented in Table 3. On all the subscales for the TSC-40, mean scores decreased for both groups between pretest and posttest indicating improvements on trauma-related problems. The SFBT group within-group effect sizes ranged from small (0.40 for sexual problems) to large (0.87 for depression), indicating improvement on all the TSC-40 subscales. The significance of each subscale effect size was tested to see if the effect size equals zero by calculating 95% CIs (Shadish & Haddock, 1994) and having a p value < .05. Six of the seven subscales, including total TSC score, had CIs that did not contain zero and p values < .05, which indicates the SFBT group improved significantly for those trauma-related subscales.

Table 3.

TSC-40 Mean (SD) and Effect Sizes for SFBT and Control Groups.

Outcome	Pretest	Posttest	Within-Group Effect Size (95% CI)	Between-Group Effect Size (95% CI)
TSC dissociation
Control group	4.09 (3.79)	2.11 (2.50)	0.60 [0.09, 1.12]*
SFBT group	6.35 (4.79)	3.33 (2.97)	0.74 [0.19, 1.29]*	0.38 [−0.11, 0.86]
TSC anxiety
Control group	6.72 (4.59)	3.70 (3.42)	0.73 [0.20, 1.26]*
SFBT group	8.26 (5.02)	5.38 (4.51)	0.59 [0.06, 1.12]*	0.04 [−0.45, 0.52]
TSC depression
Control group	8.06 (6.10)	5.22 (4.60)	0.51 [0.01, 1.02]*
SFBT group	10.29 (5.34)	6.04 (4.10)	0.87 [0.30, 1.44]*	0.32 [−0.17, 0.81]
TSC sexual abuse trauma
Control group	4.12 (3.95)	2.59 (3.14)	0.42 [−0.07, 0.91]
SFBT group	5.74 (4.52)	2.96 (2.76)	0.72 [0.18, 1.27]*	0.42 [−0.07, 0.91]
TSC sleep disturbance
Control group	7.61 (4.35)	5.70 (4.75)	0.41 [−0.08, 0.90]
SFBT group	10.13 (5.18)	6.25 (4.06)	0.81 [0.25, 1.38]*	0.44 [−0.05, 0.93]
TSC sexual problems
Control group	3.33 (3.27)	1.89 (2.24)	0.50 [0, 1.0]
SFBT group	3.03 (2.92)	1.88 (2.69)	0.40 [−0.11, 0.91]	0.12 [−0.37, 0.60]
TSC total
Control group	28.81 (17.81)	18.22 (15.22)	0.62 [0.11, 1.14]*
SFBT group	38.07 (22.10)	22.71 (17.24)	0.76 [0.20, 1.31]*	0.29 [−0.20, 0.78]

Note. TSC-40 = Trauma Symptom Checklist-40; SFBT= solution-focused brief therapy; Effect size = Hedges’s g with small sample bias correction; CI = confidence intervals.

*Statistically significant at p < .05 level.

Additionally, the between-group effect sizes slightly favored the SFBT group as indicated by the small effect sizes for all the subscales except for sexual abuse trauma and sleep disturbance which had a near medium effect size (0.42 and 0.44, respectively). Results from the p value and 95% CI for the between-group effect sizes did not show any statistical difference between the SFBT and control groups for trauma-related problems.

The control group had within-group effect size range from small (0.41 for sleep disturbance) to large (0.73 for anxiety). The within-group effect size for the TSC-40 total subscale was 0.62 and statistically significant with a medium effect size. Only three other subscales (dissociation, anxiety, depression) had a p value < .05 and a 95% CI that did not contain zero, which indicates statistically significant improvement on that subscale for the control group.

Results from the multivariate analysis for the TSC-40 are presented in Table 4. There were significant treatment main effects for TSC dissociation, t(94) = 2.44, p = .016; TSC sleep disturbance, t(93) = 2.22, p = .029; and TSC total, t(94) = 2.02, p = .046. The treatment main effects were all positive, indicating that participants in the SFBT condition exhibited higher levels of these trauma-related outcomes irrespective of whether the outcome was assessed at the pretest or posttest assessment. Additionally, significant follow-up main effects were observed for TSC dissociation, t(52) = −2.50, p = .016; TSC anxiety, t(52) = −3.28, p = .002; TSC depression, t(48) = −2.16, p = .036; TSC sexual abuse trauma index; t(55) = −2.01, p = .049; and TSC total, t(52) = −2.52, p = .015. The follow-up main effects were all negative, indicating that participants exhibited lower levels of each of these outcomes at posttest irrespective of which treatment condition they were in. While there were no significant Follow-up × Treatment interactions, a marginally significant interaction effect was observed for TSC sleep disturbance, t(56) = −1.72, p = .090. The interaction represented a greater decrease in sleep disturbance between the pretest and posttest assessments in the SFBT group than in the control group.

Table 4.

Model Parameters for TSC-40.

Outcome	Parameter	B	SE	df	t	p
TSC dissociation	Intercept	4.09	0.65	94	6.34	<.001
	Follow-up	−1.84*	0.74	52	−2.5	.016
	Treatment	2.26*	0.93	94	2.44	.016
	Follow-up × Treatment	−1.01	1.07	53	−0.94	.352
TSC anxiety	Intercept	6.75	0.79	90	8.58	<.001
	Follow-up	−2.73*	0.83	52	−3.28	.002
	Treatment	1.51	1.12	89	1.34	.184
	Follow-up × Treatment	−0.06	1.20	52	−0.05	.957
TSC depression	Intercept	8.06	0.91	94	8.85	<.001
	Follow-up	−2.30*	1.07	48	−2.16	.036
	Treatment	2.23	1.31	94	1.7	.092
	Follow-up × Treatment	−1.95	1.55	49	−1.26	.213
TSC sexual abuse trauma index	Intercept	4.12	0.65	95	6.36	<.001
	Follow-up	−1.47*	0.73	55	−2.01	.049
	Treatment	1.62	0.93	95	1.74	.085
	Follow-up × Treatment	−1.16	1.07	56	−1.09	.279
TSC sleep disturbance	Intercept	7.61	0.80	92	9.5	<.001
	Follow-up	−1.55	0.87	54	−1.78	.081
	Treatment	2.57*	1.16	93	2.22	.029
	Follow-up × Treatment	−2.20	1.27	56	−1.72	.090
TSC sexual problems	Intercept	3.33	0.49	111	6.75	<.001
	Follow-up	−1.44	0.72	56	−1.99	.051
	Treatment	−0.30	0.71	111	−0.42	.672
	Follow-up × Treatment	0.28	1.05	57	0.26	.793
TSC total	Intercept	28.85	3.25	94	8.88	<.001
	Follow-up	−9.25*	3.67	52	−2.52	.015
	Treatment	9.44*	4.67	94	2.02	.046
	Follow-up × Treatment	−5.89	5.34	52	−1.1	.276

Note. TSC-40 = Trauma Symptom Checklist-40.

*Statistically significant at p < .05 level.

Discussion

This study examined the effectiveness of a strength-based counseling intervention (SFBT) that focuses on client strengths and self-generated solutions in an effort to provide an alternative approach to more problem-focused interventions in treating substance use and trauma symptoms. Finding effective treatment for parental substance use is paramount because children are 3 times more likely to be neglected when their parents use substances (Schaeffer et al., 2013). This study significantly adds to the substance use and trauma intervention literature by examining an innovative approach to engaging and treating parents in the child welfare system, one that provides an alternative to the current problem-focused approaches.

Effect size and changes between mean pretest and posttest scores on the substance use and related problems showed slight improvements for both the SFBT and control groups based on the ASI-SR in all subscales, except for the family/relationship status subscale for control group which showed an increase in mean score and small effect size (g = −0.20) in the opposite desired direction. While these results demonstrate mostly small improvements for both groups, only the psychiatric status and drug use were statistically different from zero for the SFBT group, while drug use subscale was only statistically different from zero for the control group. It should be noted that the SFBT group had higher pretest scores on all the subscales of the ASI-SR measure and higher within-group effect sizes for all with the exception of the medical and drug use subscales. Results from the between-group effect sizes show that the SFBT group had small treatment effects over the control group on all the subscales except the family/social status subscale which was medium effect. However, none of these between group effect sizes were statistically significant, which shows the SFBT and control group, that received other research supported treatments like cognitive-behavioral therapy or motivational interviewing, produced similar results in the desired directions.

Trauma-related problems, as measured by the TSC-40, showed that both the SFBT and control group clients improved in the desired direction. The total TSC score had a large effect size of 0.76 and was statistically different from zero for the SFBT group. Thus, indicating that the clients receiving SFBT intervention had a large treatment effect and it was statistically significant. The five TSC-40 subscales for the SFBT group that were statistically significant were dissociation, anxiety, depression, sexual abuse trauma, and sleep disturbance. These TSC-40 subscales had effect sizes that ranged from medium to large. Within-group effect sizes for the control group on the TSC-40 total score also showed statistically significant improvements with an effect size of 0.62, indicating a medium treatment effect. Three TSC-40 subscales (dissociation, anxiety, and depression) were statistically different from zero and those effect sizes were mostly medium. Between-group differences favored the SFBT with mostly small effect sizes for all the TSC-40 subscales, however none were statistically significant. Thus, SFBT intervention produced similar results as the research-supported treatments that the control group received.

Several limitations should be considered. First, it could be that the study’s small sample size limited our ability to detect statistically significant differences between the SFBT and control group. In our power analysis, a sample size of at least 198 participants was needed to detect a statistically significant difference between the two groups when the effect size is small, which is where most of our effect sizes ranged. This does not come as a surprise since the control group received research-supported treatments such as cognitive behavioral therapy or motivational interviewing, which have large empirical support for their effectiveness. However, the within-group and between-group effect sizes do show that the SFBT group produced slightly higher effect sizes than the control group on both the ASI-SR and TSC-40 measures. It might be the case that a larger sample size would provide enough statistical power to detect this small treatment effect and, therefore, further study is warranted. In addition to a larger sample size, future studies could benefit from a research design that incorporates a placebo control group (i.e., a control group that does not receive a known research-supported treatment). A second limitation of this study was the lack of random assignment of clinicians to see which ones are selected to receive the SFBT training. In discussion with the two participating agencies prior to the start of the study, it was decided that the clinical supervisors would be charged with selecting which counselors at their respective agencies would receive the SFBT training, which could have introduced possible selection bias in this selection process. A third potential limitation of this study was the absence of information on the TAU interventions. No fidelity measurement was conducted for TAU interventions to the control group. Also the dosage (i.e., number of sessions or amount of time) of TAU interventions to the control group is unknown. Finally, another limitation of this study is that clients in both study groups were also receiving multiple sources of support from various community providers and, therefore, it is difficult to fully account for those possibly additional contributions to the clients’ substance use and trauma-related problems. Unfortunately, this is a common limitation for this population under real-world conditions and hence the use of an RCT design was employed to help improve threats to internal validity.

Despite these limitations, this study provides an important contribution in that a more strength-based approach to treating substance use and trauma-related problems may be possible through the SFBT model. Currently, most social workers and clinicians using evidence-based treatment for substance use and trauma rely on identifying and modifying cognitive thinking and beliefs and changing maladaptive behaviors through rationalization. Unfortunately, clients may become defensive to this more confrontational approach, especially when addressing trauma. Clients may not want to discuss or explore past or current traumatic events in an effort to reprocess them as a criterion for moving forward in counseling treatment. SFBT provides an alternative approach to help clients manage their trauma-related problems without having to spend a great deal of time talking about their problems or personal history of traumatic events. Further, a significant limitation in the field of substance use treatment has been the absence of evidence-based models used for treatment. Given poor treatment compliance and completion rates, we return to the “what works, for whom, and under what conditions” notion. Without multiple evidence-based therapies to choose from, this question can never be adequately addressed. Having multiple therapeutic approaches to rely upon provides practitioners with a greater range of useful knowledge. Through systematic use of multiple modalities and approaches paired with rigorous evaluation approaches, more evidence should build over time.

Conclusion

The treatment of substance use and trauma-related problems is still dominated by interventions that involve a traditional, problem-centered approach, such as cognitive–behavioral therapy, dialectical behavior therapy, and the 12-steps of alcoholics anonymous. Results from this study shows that the strength-based SFBT approach can be just as effective in helping clients address substance use and trauma-related problems. These results support the use of SFBT in treating substance use and trauma among parents in the child welfare system and provides an alternative approach that is more strengths based and less problem focused. Future research with a larger sample size is needed to test whether there are any small statistically significant treatment effects between the SFBT and the evidence-based (e.g., cognitive behavioral therapy [CBT] and motivational interviewing) interventions control groups. In addition, future RCT studies on SFBT should be involved in registering their studies in a clinical trial registry to enhance transparency and access to the study article.

Footnotes

Acknowledgments

We would like to thank Nate Marti for his statistical analysis help and consultation. We would also like to thank Margaret Lloyd for her assistance with the data management. Special thanks to Elicia Berryhill from the Oklahoma Department of Mental Health and Substance Abuse Services and the staff and counselors at the Oklahoma sites. Lastly, we gratefully acknowledge the participating parents for their time.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is part of the Regional Partnership Grant project that is funded through the U.S. Department of Health and Human Services—Administration for Children and Families (Grant no. 90CU0066).

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