Portrayal of families and relationships

As societal norms evolve, a variety of popular entertainment media (books, movies, TV shows, etc.) feature stories of characters who are a part of traditional and non-traditional family or relationship structures. Examples include but are not limited to: traditional families, cohabitation, single-parent households, blended families, same-sex couples, and grandparents as the primary caregivers for their grandchildren.

In a 3-page paper, written in APA format using proper spelling/grammar, address the following:

Describe a book, movie, or TV show that you are familiar with which features characters in families or personal relationships.

Select at least two families/relationships from your chosen story and explain the relationship characteristics and dynamics between individuals.

Apply terminology presented within the module when analyzing the relationships. Be sure to include APA citations for any resources you used as references.

You were provided with literature on Solution-Focused Brief Therapy with the case of Jim. You will write 5 pages in the APA 7th Edition format. You will use the literature and Jim’s case to justify your critical thinking on Motivational Interviewing and Solution-Focused Brief Therapy.  Respond to the following:

Briefly state Jim’s presenting problem and background history. You must be succinct and brief using the facts of the case.  

How would you use Motivational Interviewing to help Jim with his crack/cocaine and alcohol use? Where in the Cycle of Change do you think Jim is? Why? 

Using Solution-Focused Brief Therapy, what might you help prioritize with Jim? Why? What will be the skills you will use to help Jim prioritize the problem(s) that need to be addressed?

How would you work with Jim’s physician to help him gain trust and an understanding of how ACE may have an impact on his health?

What are some of the cultural considerations you will need to consider in working with Jim? How would you intervene to engage Jim so that he feels you are aligning with him?

This work must be written in English and literature to substantiate your thoughts.  
 

hapter 9 Solution-Focused Brief Therapy: The Case of Jim

Philip Miller

Introduction to Solution-Focused Brief Therapy

Two frameworks are used in this case. The first framework is the solution-focused brief therapy (SFBT) clinical approach, and the second framework is the behavioral health in primary care model. The SFBT framework is a therapeutic approach that emphasizes client strengths, construction of solutions rather than solving problems, and the development of personalized goals to produce change as quickly as possible (Gingerich & Eisengart, 2000; O’Hanlon & Weiner-Davis, 1989; Rothwell, 2005). The behavioral health in primary care framework provides guidance integrating behavioral health services into the primary care setting (Robinson & Strosahl, 2009). To comprehend the intricacies of this case, the SFBT clinical approach must be examined in the context of the primary care model.

Solution-Focused Brief Therapy Framework

Development of the solution-focused brief therapy approach originated from clini- cal practice within the Brief Family Therapy Center in Milwaukee, Wisconsin in 1980 and, a short time later in 1982, this new therapeutic approach was officially named solution-focused brief therapy (de Shazer & Berg, 1997; Gingerich & Eisengart, 2000). The SFBT approach quickly became popular because of its appli- cability in a variety of settings with a diverse clientele. SFBT is now used world- wide (Franklin, 2015). Professionals from diverse disciplines and work settings have broadly applied SFBT to include physicians and nurses in health care settings, teachers to creatively engage with students and families, mental health providers to

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facilitate individual, group, and family therapy, and businesses to better equip man- agement by integrating SFBT into coaching strategies (Franklin, 2015; Redpath & Harker, 1999; Shilts & Thomas, 2005; Stevenson, Jackson, & Barker, 2003). Ongoing research on SFBT has further reinforced its popularity by favoring SFBT as an effective approach to quickly produce sustainable behavior changes (Corcoran, 2016; Franklin, Zhang, Froerer, & Johnson, 2016; Gingerich & Eisengart, 2000; Macdonald, 1997; Rothwell, 2005).

The SFBT approach challenges the traditional structure of mental health services in a variety of ways and may cause dissonance with new SFBT practitioners. As a result, clinical knowledge and beliefs may need to be restructured and familiar clini- cal methods modified. SFBT is not a series of easily applied techniques but a way of thinking about the process of therapy and how change occurs. Without under- standing the assumptions and underlying beliefs of SFBT, techniques will be mini- mally effective. Learning the SFBT approach is an ongoing process and requires openness, training, observation, mentoring, and practice (Froerer & Connie, 2016; Lee, 2011; Shilts & Thomas, 2005).

A critical element to the success of SFBT is the therapist’s belief about the pro- cess of change. Beliefs regarding change need to be critically examined because the SFBT approach assumes that change can and does occur quickly without exploring history, diagnosing, and offering ongoing intervention (O’Hanlon & Weiner-Davis, 1989; Reiter, 2010). In contrast, traditional clinical approaches are problem and complaint focused, rely on finding a cause for the presenting problem, emphasize advice-giving, and oriented toward establishing a diagnosis (Froerer & Connie, 2016; Gingerich & Eisengart, 2000; O’Hanlon & Weiner-Davis, 1989; Rothwell, 2005). SFBT is based on empowering the client by drawing on strengths and abili- ties to construct solutions, rather than the therapist emphasizing the resolution of problems (Gingerich & Eisengart, 2000; Rothwell, 2005; Stevenson et al., 2003). SFBT practitioners also believe that client life struggles and presenting problems are not due to pathology but originate from the patient being overwhelmed and los- ing sight of their ability to solve problems and mobilize their existing strengths and resources. SFBT practitioners assume clients want to change, have the ability to change, and are already taking steps to change. Therefore, within the treatment structure of six sessions or less, a core duty of the therapist is to amplify change, create hope and expectancy, and co-create a path to change through a collaborative process (Franklin, 2015; Franklin et  al., 2016; Gingerich & Eisengart, 2000; O’Hanlon & Weiner-Davis, 1989).

The delivery of the SFBT approach requires specific language skills designed to create hope and expectancy and empower clients to realize inherent solutions (Franklin, 2015). The hope of successful outcomes leads to positive change and the expectation that this will happen is created by the therapist (Reiter, 2010). It is the responsibility of the therapist to shift the client’s problem-focused thinking and speech to solution talk and future-oriented thinking. Solution-focused language is carefully used throughout treatment to promote the realization of positive outcome possibilities and ensure clients link their actions to treatment progress and success (Froerer & Connie, 2016; Reiter, 2010; Taylor, 2005). The use of presuppositions is

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embedded in SFBT language and permeates all SFBT techniques. The use of pre- sumptive language is a type of strategic communication that infers something with- out saying it directly and is a way to introduce change and promote client acceptance that change is occurring (O’Hanlon & Weiner-Davis, 1989). For example, asking the client “What is better?” instead of “Is anything better?” assumes improvements were made and emphasizes change.

The first session involves developing a strong therapeutic relationship and uses the initial assessment as an intervention. SFBT is a collaborative process and prac- titioners rely on the expertise of the client. Therefore, a healthy therapeutic relation- ship is critical for success. Initial engagement requires SFBT practitioners to adopt the language of the client, accept the client’s perspective, understand the context of their identified problem, and intentionally reduce the pathology of the presenting problem by normalizing their concerns (Corcoran, 2016). The initial assessment in SFBT is used as an intervention by immediately engaging the client in the process of change. This may differ from traditional binary assessment models where first the objective is to obtain an elaborate history to understand the client’s presenting com- plaint and to develop a diagnosis, and then move forward with the treatment process (Lee, 2011).

At the beginning of the first session, the SFBT practitioner asks the client, “Please tell me what brought you in today.” However, after this opening statement, the first session becomes an open and fluid exchange that doesn’t follow a rigid protocol (Lee, 2011). Taylor (2005) developed a helpful guide for trainees learning how to implement SFBT for the first session that includes five areas of inquiry. The five areas of inquiry include the major focal points of client engagement with accompanying SFBT techniques. The five areas of inquiry include the client’s: (1) awareness of what improvement will look like; (2) recognition of improvements already occurring; (3) acknowledging actions leading to improvements; (4) expand- ing possible solutions; and (5) establishment of goals.

The first area of inquiry from Taylor’s (2005) work is associated with specific SFBT techniques such as exploration of pre-session change, the miracle question, and identification of what improvement will look like. This line of inquiry occurs at the beginning of the first session and challenges the idea that a client’s situation is defined by a “problem.” Often, exploring pre-session change occurs immediately following asking the client what brought them into treatment. The practitioner may simply ask the client, “What is better since you made the appointment?”. Exploration of pre-session change assumes that positive changes have likely occurred between the time of making the appointment and the first session. The focus of pre-session change creates hope and expectancy that change can occur and attributes the change to the client’s actions (O’Hanlon & Weiner-Davis, 1989; Taylor, 2005). The miracle question is often asked to promote a future-oriented focus and produce images of living without the expressed problem. The miracle question may be phrased, “What if you wake up tomorrow and the problem is solved, what would that look like?” Asking the client to describe the future without the problem provides insight into potential solutions and can oftentimes be the spark to move toward change (de Shazer & Berg, 1997; O’Hanlon & Weiner-Davis, 1989; Reiter, 2010). Following

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the client’s response to the miracle question, the therapist asks, “What aspects of this miracle are already occurring?”. Further intentional questioning can elicit how the client sees themselves behaving or thinking differently without the problem, who will be the first to notice the miraculous changes, and how their life will be different (Franklin et al., 2016; O’Hanlon & Weiner-Davis, 1989).

The second area of inquiry focuses on recognizing when improvements have occurred and exploring what was different or better during these moments (Taylor, 2005). The SFBT practitioner assumes there are always times, places, and circum- stances when the expressed problem doesn’t occur. Using exception questions examines the times when the problem doesn’t occur and elucidates possibilities to solve the problem. A simple exception question is, “What is different during the times when you are not as stressed?”. As a reminder, the therapist doesn’t ask “Have there been times you have not been as stressed?”. As the therapist, you are implying there must be times when the client is feeling less stressed (Franklin et al., 2016; O’Hanlon & Weiner-Davis, 1989; Reiter, 2010).

The third area of inquiry from Taylor (2005) amplifies what the client is doing to create identified improvements to ensure they take credit for the positive changes. When the client provides an exception to their expressed problem, a quick follow- up question is, “How did you make that happen?”. The therapist may have to be persistent and insist that the client must have done something to create the excep- tion, no matter how small. Additional questions can include, “What did you do dif- ferently?”, or “How is what you did different from the way you might have responded 1 month ago?”. The underlying assumption of this line of inquiry is once the client recognizes their part in creating the exception, increased self-confidence will occur to do more of the same (Corcoran, 2016; O’Hanlon & Weiner-Davis, 1989; Reiter, 2010).

According to Taylor (2005), the fourth line of inquiry directs the client to acknowledge the positive results from their actions and explore how other areas of their life are impacted. Targeted questions are used to expand potential solutions and explore what occurred following their action. For example, the SFBT practitio- ner may ask a range of question to include “Who else notices when you do______ (insert behavior)?”, “How do people react differently to you?”, “If you were to do _______ repeatedly over the next month, how would it impact your life?”, “How is your day different when you_______?”, or “What will have to happen for you to do it that same way more often?”. Using this line of questioning can expand clients’ narrow view of their problem and prompt them to not overlook the positive impact one small exception can have in their lives (Franklin et  al., 2016; Lee, 2011; O’Hanlon & Weiner-Davis, 1989; Reiter, 2010).

The fifth and final area of inquiry from Taylor (2005) occurs toward the end of the first session and is focused on the future and the establishment of achievable goals. Collaborative goal setting, scaling questions, and compliments are techniques typically used. Collaborative goal setting involves questioning allowing the client to define treatment goals that drive the trajectory of treatment. Questions such as, “What will indicate to you that your situation is improving?”, and “What will indi- cate to you that things are continuing to improve?” can facilitate the identification

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of concrete and achievable goals (Bodenheimer & Handley, 2009; O’Hanlon & Weiner-Davis, 1989). Scaling questions are an important technique that can facili- tate the identification of specific observable goals that are meaningful to the client. For example, the client may be asked, “On a scale from 1 to 10 where would you place your stress?” An immediate follow-up question might be, “You chose a #6, what would a #8 look like?”, and “What will it take for you to reach a #8?” (de Shazer & Berg, 1997; Lee, 2011; O’Hanlon & Weiner-Davis, 1989; Reiter, 2010). Additional scaling questions can focus on the client’s level of confidence to achieve a higher number on the scale. The therapist can ask, “On a scale of 1–10, how con- fident are you that you can reach a #8?”, and “What would it take for your confi- dence to be higher? (Taylor, 2005). The goals identified through scaling questions can also be used for follow-up appointments to monitor progress.

The SFBT practitioner concludes the first session by offering authentic compli- ments to reinforce successful actions by the client to correct the presenting concern. Compliments accentuate client strengths and should be based on the conversation that occurred during the session. A compliment can be stated as “I appreciate your willingness to seek help. I think you are a person that doesn’t give up easily and you are already using this strength to create change.” Also, no-fail homework is assigned such as, “Observe the times you feel less stressed” (de Shazer & Berg, 1997; Lee, 2011; Macdonald, 1997; O’Hanlon & Weiner-Davis, 1989; Reiter, 2010; Rothwell, 2005).

Behavioral Health in Primary Care Framework

Early models of behavioral health in primary care began to surface in the 1960s (Robinson & Strosahl, 2009), but complex issues of funding, reimbursement, and the challenges of integrating two different treatment models representing the medi- cal and behavioral health fields have stunted the growth of this innovative approach (Pomerantz, Corson, & Detzer, 2009; Robinson & Strosahl, 2009). The foundation of behavioral health services in primary care is a population health management paradigm. This paradigm is identified by Bryan, Morrow, and Appalonio (2009) as either having a horizontal or vertical structure. The horizontal structure emphasizes providing care to the entire population of primary care patients to better manage the needs of the primary care patient to improve overall health and well-being. In con- trast, the vertical structure provides targeted specialty care to a select few of the general primary care population (Bryan et al., 2009). Within the horizontal or verti- cal structure of population health management, the level of actual integration into primary care exists on a continuum (see Fig. 9.1). On one end of the continuum is coordinated care with primary care that resembles traditional mental health care with a reciprocal referral process in place. In the middle is a co-location model where the behavioral health specialist has a physical presence in primary care, mostly keeps autonomy over the treatment, and has occasional engagement with the primary care team. On the opposite end of the continuum, the behavioral health

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Coordinated Co-Located

Levels of Behavioral Health Integration into Primary Care

Practitioner: Practitioner: Practitioner: Is not located in primary care

Has office in primary care Is a consultant to PCP

Provides frequent feedback to PCP

Is part of the PCP team

Collaborative decision- making

Uses brief/targeted treatment

Yields autonomy to PCP

Occasionally consults & collaborates with PCP

Has separate schedule

Is semi-autonomous with treatment goals

Uses brief & traditional treatment modalities

Provides no consultation to PCP

Has full autonomy with treatment

Provides traditional mental health care

Uses traditional referral process

Fully Integrated

Fig. 9.1 Continuum of Primary Care Integration

specialist is fully integrated into the primary care team, acts as a consultant to the primary care physician, frequently communicates with the entire primary care team, and provides brief and targeted interventions (Bryan et  al., 2009; Mauer, 2003; Robinson & Strosahl, 2009).

Integrating mental health services into primary care improves access to care, provides an opportunity for prevention and education, lessens the stigma of seeking mental health care, reduces demand on the primary care provider, and patients can receive short-term and more precise care (Miller & Malik, 2009; Pomerantz et al., 2009; World Health Organization, 2008). According to the National Council for Community Behavioral Healthcare (2002), about 30% of primary care office visits are mental health in nature. Furthermore, 50–80% of people that have a common mental health issue are treated in primary care (Bryan et  al., 2009; Mauer, 2003;Miller & Malik, 2009; World Health Organization, 2008). Consequently, pri- mary care providers may not be adequately trained and can feel overwhelmed treat- ing mental health issues and often don’t have the time to adequately address these types of patient concerns (Robinson & Strosahl, 2009). However, when patients have direct access to a mental health professional to address their concerns, they can be treated earlier with targeted care and will require fewer medical-related appoint- ments creating less demand on the primary care provider (Miller & Malik, 2009; World Health Organization, 2008). According to Mauer (2003), patients prefer to have mental health care coordinated within primary care because it is more efficient and also reduces the stigma of seeking mental health services. During a medical appointment, a medical provider can accompany a patient down the hall to connect with a mental health provider for a drop-in session. This type of in-house coordina- tion helps to overcome the 30–40% rate of “no-shows” for follow-up appointments when patients are referred to mental health services outside the primary care clinic (Miller & Malik, 2009; National Council for Community Behavioral Healthcare, 2002).

Interventions offered by the mental health specialist complement the care pro- vided by the primary care physician because the mental health specialist can address

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a wide spectrum of disease management or lifestyle concerns. Moving beyond the biomedical approach and drawing on psychosocial factors of patients, mental health specialist can offer effective health education and utilization of functional interven- tions to assist patients to adapt to an illness, be compliant with medication or diet, learn stress-management techniques, improve sleep hygiene, and practice improved self-care that impacts the overall quality of life (Mauer, 2003; Miller & Malik, 2009; Pomerantz et al., 2009; Population Health Support Division Air Force Medical Support Agency, 2006). Furthermore, patient outcomes are positive when mental health issues are addressed in primary care. In as few as one to three, 30-min ses- sions, improvements in symptom reduction, behavioral change, sense of well-being, and improved life functioning can be achieved (Bryan et al., 2009; Cape, Whittington, Buszewicz, Wallace, & Underwood, 2010; Miller & Malik, 2009; Pomerantz et al., 2009; Robinson & Strosahl, 2009).

Introduction to the Case of Jim

In the context of this case, the SFBT practitioner’s integration into primary care at the free medical clinic aligns with the horizontal framework as described by Bryan et al. (2009), where the entire primary care population is available for a referral. The level of integration in the clinic includes characteristics of being both co-located and fully integrated. The SFBT practitioner’s office is physically located in primary care but full integration into the primary care team is not evident. Referrals are received from the physicians and consultation will occasionally occur to clarify the referral details. Appointment schedules between the SFBT practitioner and physi- cian are not fully coordinated and the SFBT retains significant autonomy with treat- ment protocol and goals. When appointment schedules do overlap, the primary care physicians can do an on-site referral, and the patient is seen as a walk-in. Behavioral health appointment slots are 30 min in length which follows the brief therapy model.

Jim is a pseudonym to protect his identity. The identifiers of this case have been changed to maintain the confidentiality of the client. Jim was referred by one of the free medical clinic physicians after disclosing his pattern of substance use. Jim was scheduled within a week, and at the time of the appointment, the SFBT practitioner had minimal history about Jim’s substance use because there was no access to records and the referring physician did not provide details regarding Jim’s substance use. The physician wants Jim assessed and his substance use addressed in treatment.

Jim, a 57-year-old black, divorced, male, presents with an extensive substance use history. On two occasions, Jim has been voluntarily admitted into an inpatient substance abuse treatment facility and has engaged with outpatient counseling on several occasions. However, he has not had any type of mental health treatment for the past 6–7  years. Jim drinks beer daily to help him sleep and he is frequently exposed to drugs because he allows prostitutes to smoke crack in his trailer in exchange for occasional sexual activities. Jim reports using crack cocaine one or two times a week 2 years ago, but he has tried to quit and now uses it about two or

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three times a month. Specific details about past mental health diagnosis and medical history are insufficient due to his limited recall ability and sparse medical records. However, through the free medical clinic, Jim is being treated for high blood pres- sure and ongoing headaches. He does not report any current or past legal issues. His education level is a high school diploma. Jim grew up in the south and currently resides in a southern state. He lives alone in a run-down rental trailer, isolated on a dead-end street in an extremely rural part of the county. The street where he lives contains a pocket of small houses consisting mainly of low-income, black individu- als and families. Jim describes his neighbors as acquaintances versus friends, but reports they keep an eye out for each other. Details regarding his divorce are unclear but he does not have any contact with his ex-wife. However, he sees his adult daugh- ter and her 13-year-old child about once every 3–4 months. Jim has a sister that tries to be supportive and occasionally provides him rides to medical appointments. Both his sister and adult daughter live approximately 30 miles away which limits their contact. The relationships with his sister and daughter are very meaningful to Jim. He expresses guilt regarding his history with substances that have interfered with developing a deeper relationship with his daughter and grandchild. Jim does not identify with any religion and does not indicate spirituality is integrated into his life. Jim has not worked consistently in the last few years and has primarily worked manual labor jobs. Jim doesn’t own any type of transportation which increases his sense of isolation. He relies on friends to take him to work odd jobs and to obtain food at the nearby country store.

Theoretical Integration

SFBT is an excellent fit to use in primary care and is compatible with population health management goals to better manage mental health-related issues commonly seen in primary care such as medication compliance, anxiety, depression, stress management, sleep hygiene, and substance use (Khatri & Mays, 2011). The core tasks of the SFBT approach are consistent with brief healthcare goals to provide patient-centered care while targeting specific behavior change using goal-driven, time-limited solution-focused strategies, follow-up, and support (Bodenheimer & Handley, 2009; Flemming & Manwell, 1999; Khatri & Mays, 2011; National Council for Community Behavioral Healthcare, 2002; Rothwell, 2005).

Providing services in primary care requires flexibility to accommodate characteris- tics associated with the primary care environment and discard many of the traditional mental health practices. For example, to manage time efficiently to stay within a 15- to 30-min time limit, a more active and directive approach with patients is required. This may be uncomfortable for traditionally trained mental health clinicians. Delicately balancing being empathic and directive without compromising the critical develop- ment of the therapeutic relationship is a developed skill. Accomplishing this balance can be facilitated by using the assessment process as an intervention during the first session. Even during a 15–30 min initial session, Taylor’s (2005) areas of inquiry can be applied to join with the client, explore exceptions, set goals, and provide homework.

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Joining: (10 min) includes being genuine and authentic while engaging in small- talk to quickly connect with the patient. Attention to the development of the helping relationship occurs immediately and undergirds all treatment activities. The role of the clinician and structure of the first session is quickly explained to the client. The clinician inquires if the patient understands the process and asks if they are willing to continue. Open-ended and presuppositional questions are used throughout the session, and thoughts and feelings are validated to normalize their concerns.

The moment Jim is called back to the behavioral health office, efforts begin immediately to positively connect with him to develop the helping relationship and initiate the assessment. Jim’s frail physical structure and his slightly disheveled appearance are immediately noticed. Jim slowly walks down the hallway toward the office with an imbalanced gait. Jim has a noticeable smile, friendly disposition, and steady eye contact. Once in the office, Jim is engaged in small talk which involves joint laughter at some of his responses. His sincerity about attending the appoint- ment stood out, but he could only articulate a minimal understanding as to why his medical provider referred him. Uncertainty existed about why Jim believed to be at this appointment. Regardless, careful attention is given to responding to Jim so that he does not feel alienated due to the details of the referral being unclear. Jim is dif- ficult to understand at times because he sometimes mumbles, speaks in generalities, and has several front teeth missing. As a result, a cognitive impairment (substance- induced or biological), or Jim being currently impaired by a substance is immedi- ately considered. The SFBT practitioner speaks slowly and is mindful to keep speech simple and asks specific, clarifying questions that seem to work well with Jim. An explanation is quickly given to Jim outlining limits of confidentiality, the goal of the first session, and the role of the SFBT practitioner being a consultant to his primary care provider. There is a moment of silence to see if Jim wanted to respond, then Jim is asked, “Do you understand what was just explained?” He responds by nodding and mumbling “Yes, I understand.” Permission to continue with the session is asked to reinforce his voice in the process. Jim agreed to continue.

Due to the paucity of Jim’s responses, the SFBT practitioner recognizes staying within the 30-min allotted time is going to be difficult. Fortunately, there are no patients scheduled immediately following Jim so a little more time can be spent with him. With experience, the SFBT practitioner has learned that being flexible to take advantage of the time with patients is imperative because they may not return due to limited transportation and resources.

Exploration: (10 Min) Exploration includes rapidly identifying patient concerns as the patient sees them, not necessarily as the primary care provider sees them. The clinician may ask, “What brings you in” and then follow-up with questions designed to uncover exceptions to the problem. Careful attention is given to the context and functional impact of the patient’s described problem and the associated thoughts and feelings. Listening for areas of pre-session change or when the presenting con- cern is not present or is less intense allows the clinician to amplify strengths and evidence of existing change already occurring.

The SFBT practitioner acknowledges the brief referral note from Jim’s medical provider and explains that she is concerned about his current level of substance use.

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He nods in agreement and says, “Yes, I believe she must be concerned.” Wanting to know his perspective, Jim is asked, “Tell me what brings you in this evening.” He pauses and mumbles a few things and has difficulty articulating why he is at the appointment. The SFBT practitioner quickly asks, “Are you okay talking about your substance use?” Jim indicates he is fine discussing his current use and began telling, “I drink a 40oz beer each night to help me sleep.” The SFBT practitioner asks follow- up questions designed to explore patterns associated with his use and search for exceptions to his substance use. A reflective statement is provided by the SFBT prac- titioner, “You are having trouble sleeping each night and the beer helps with getting sleep.” Jim replied, “Yes, I haven’t slept in years and drinking helps.” An open-ended prompt is stated, “Jim, tell me more about your substance use.” He admits, “I do use sleeping pills at times with the beer, but I like my beer better.” Based on his matter- of-fact response and tone, it seems Jim’s daily drinking is a well-established pattern and the possibility exists of other substances being used. The SFBT practitioner asks, “Jim, I appreciate your honesty regarding the beer and the use of sleeping pills, are you using any other substances?” Jim acknowledges smoking a pack of cigarettes daily for the past 20 years. There is a moment of silence, and then Jim confesses to smoking crack cocaine about two or three times a month. Jim quickly interjected that he is not interested in attending inpatient care or any type of detox services.

Once Jim mentioned his crack cocaine use, the SFBT practitioner began fighting a dismissive attitude and internal dialogue turned negative. A feeling of anxiousness surfaced with the SFBT practitioner because Jim’s situation is complex and imme- diately challenges two of the SFBT goals associated with the first session; abolish- ing the label that a problem exists and create confidence that the situation can be managed by the client. Jim’s extensive substance abuse history and continued use is an overwhelming problem, and the SFBT practitioner begins doubting how Jim is going to feel more confident managing his situation based on his prior treatment attempts, continued use, and limited insight. The SFBT practitioner is apprehensive about Jim’s success with the limited resources and time constraints within the pri- mary care setting. Consequently, the SFBT practitioner prematurely assumes that this is a one-session experience resulting in a referral to the local mental health clinic where Jim can have access to more consistent and robust services. However, the SFBT practitioner intentionally focuses on staying connected to Jim and main- tains trust in the possibility of change, no matter how small.

Jim exclaims, “I don’t like to smoke crack and I know it isn’t good for me. I would like to quit.” Indicating he would like to quit was the first time Jim expressed willingness to make any type of change. Adhering to the here-and-now focus of the SFBT approach, the SFBT practitioner amplifies his desire to quit and responds by stating, “So, you want to make changes to your crack use”, “What does this change look like?” Jim describes that quitting the use of crack is difficult because prosti- tutes that he befriended frequently come to his house to smoke crack in his trailer. He continues by saying he only uses crack when his female “friends” would come to his trailer. The SFBT practitioner is interested in the context of Jim’s described problem, so he is asked, “Tell me more about when the “friends” come to your trailer.” Jim verbalizes that he knows they are not his real friends, but they want a

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place to hang out and smoke crack without being bothered. He admits partially enjoying their company because he gets lonely and on occasion, sexual favors are exchanged for the use of his trailer. A reflective statement is used, “So, you are often lonely and when these “friends” come by, you don’t feel as lonely?” Jim replies, “Yes, and I tell myself that I’m not going to use with them and then I get talked into using the crack.” Jim continues, “I have told them not to come around in the past but they come back and I let them into my house.” In his remark, an exception is noted in his behavior when he told the prostitutes not to come around his trailer. Accentuating this exception is a priority so the SFBT practitioner states, “In the past, you have told them not to come around. How did you do that?” Jim responds with a wry smile, “I just told them to get lost in an agitated way.” Jim continues, “They didn’t come in and disappeared for a few months, but they came back and I let them in.” Despite that he let the prostitutes back into his trailer, the SFBT prac- titioner stays focused on Jim’s efforts to create change and guides him to consider using existing strengths to create future change. Therefore, Jim is asked, “What do you need to do to get rid of them in the future?” Jim replies, “I can run them off anytime, they’re no good anyway.” The SFBT practitioner quickly asks, “What is better when you are firm with them and don’t allow them into your trailer?” Jim notes, “I don’t use crack and feel better. I just stick to my nightly beer!”

Goal Setting: (10 Min) Collaborative goal setting is a shared process between the clinician and the patient to establish achievable, concrete, readily understood, and easily measured goals. Scaling questions are often used to illuminate future images of desired functioning to assist with establishing goals. Goals need to start small, described in specific behavioral terms and viewed as manageable by the client.

Based on Jim’s past, the SFBT practitioner knows that assuming the expert role and being directive about his need to stop using substances is not going to be suc- cessful. Instead, a partnering approach is used and demonstrates respect by allowing Jim to identify what is important to him and then work toward achieving small suc- cesses to increase self-efficacy. Therefore, the SFBT practitioner states, “Jim, it seems when you set firm boundaries with the prostitutes, you use less crack and feel better. Is it okay if we focus on ways for you to continue to set good boundaries with them since this aligns with your desire to use less crack?” He agrees, and the SFBT practitioner senses Jim’s interest and reasonable comfort level with working on this goal. Scaling questions are commonly used in the SFBT approach to establish a baseline and help identify small, achievable goals. Jim is asked, “On a scale from 1 to 10 (1 low confidence and 10 very confident) how confident are you that you can turn the prostitutes away when they come by again?” Jim indicates he is a #7. Next, Jim is asked, “What does a #9 level of confidence look like?” Jim replies, “I don’t know, maybe letting them know how serious I am.” The SFBT practitioner responds, “Jim, what will that look like when you are serious?” He fidgets with his hands, looks away in thought, and then replies, “I may have to get angry with them, maybe yell, and slam the door.” “Wow”, the SFBT practitioner says. “Jim, it seems you have identified a goal that will lead to using less crack.” Jim agrees to work on set- ting stronger boundaries with the prostitutes and verbalizes this is something he feels he can do.

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The SFBT practitioner successfully collaborates with Jim to formulate a work- able goal and receive buy-in. If a directive or educational stance was used to com- municate his need to stop using crack, Jim would have acquiesced to be polite, but not be invested. On the surface, the established goal to set better boundaries with prostitutes might seem minimal in the context of his crack use and use of other addictive substances. However, this was a straightforward, concrete goal that Jim was comfortable with and had confidence he could achieve. This goal provided him the opportunity to self-manage and experience the outcome based on his efforts.

Compliments/Homework: (5 Min) Providing feedback to the patient by offering genuine, relevant compliments and amplifying strengths and efforts already initi- ated to create change is a goal of this segment. Also, achievable, no-fail homework is given that is designed to alter the patient’s behavior or perception of the presenting complaint. For example, the patient may be encouraged to monitor the presenting complaint throughout the week to identify when it does not occur or occurs with less intensity or duration. Regardless of the patient returning for a follow-up appointment, homework is given.

The SFBT practitioner genuinely compliments Jim by stating, “Jim, I appreciate your sincerity about being at this appointment and your willingness to make a change in your drug use. I can tell making a change is important to you.” The SFBT practitioner continues, “Also, I want to point out that you have previously told the prostitutes to stay away and it worked. You have the ability to be firm and set good boundaries with them. If it’s okay with you, as a homework task, I would like you to continue setting good boundaries with them. If you need to get angry, slam the door, or yell to tell them to stay away and not allow them into your trailer, do it.” Jim nods in agreement and says, “Yes sir, I will do it.” It is common to see a patient only one session using SFBT in primary care. However, Jim is offered the option for a return appointment. He desires a follow-up appointment but scheduling quickly becomes an issue due to his lack of transportation. In this case, the SFBT practitio- ner consults with the referring physician and provides an overview of the session, clinical impressions, goals, and plan for follow-up.

Follow-Up Appointment: The SFBT practitioner works with the primary care team to schedule Jim for a follow-up appointment to coincide with his medical appointment. Due to misaligned schedules, Jim is scheduled for another appoint- ment in 6 weeks. The second session with Jim lasts 15–20 min due to his medical appointment going over the allotted time and his ride is waiting to take him home. Nevertheless, the SFBT practitioner completes a brief check-in with Jim by asking a presuppositional question, “Jim what is better since the last time we talked?” He answers, “I’m doing what you have said and I have used less crack.” The SFBT practitioner responds, “Wow, excellent news. Tell me how you are doing that?” Jim proceeds to explain that he has deterred the prostitutes from coming into his apart- ment a few times but let them in on one occasion. Jim is proud of his progress and encouraged that he experienced some success with his goal. Since time is limited during this session, Jim agrees to keep the same goal, and the SFBT practitioner proceeds to amplify his success by emphasizing the skills he has shown to manage this goal. Due to ongoing transportation and scheduling conflicts, Jim is not able to be scheduled for another follow-up appointment at this time.

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Several months pass and the SFBT practitioner often thinks about Jim and how he is doing. One evening, Jim unexpectedly appears on the SFBT practitioner’s schedule. Immediately, the SFBT practitioner notices a medium-sized lump on the left side of Jim’s neck. Jim explains he has been diagnosed with cancer and is cur- rently receiving chemotherapy. The prognosis didn’t sound positive based on his report. The SFBT practitioner is shocked that amid his cancer diagnosis and treat- ment, Jim is still committed to attending a follow-up appointment. Jim states, “I had to come and tell you in person how I was doing and that I achieved my goal.” The SFBT practitioner can tell Jim is extremely proud of his accomplishment. The SFBT practitioner is speechless and touched by his commitment to this seemingly small goal but amazed how meaningful this was to Jim.

Cultural Considerations

Several differences in diversity need to be considered in the case of Jim such as issues of race, social-economic status, level of education, and age. The SFBT prac- titioner is a white, middle class, educated male working in a free medical clinic located in the south. The practitioner must be mindful of his status working with Jim, an older, less educated, lower social-economic, black male. There are many historical and cultural reasons why Jim would not trust the practitioner and question his motivations and investment in his improvement. The practitioner is not from the south, and in fact, there was a moment when Jim asked the practitioner where he was from. The SFBT practitioner assumed Jim was possibly questioning if he could be understood or gauging to what extent he could relate to the practitioner. Furthermore, due to possible distrust and existing differences, Jim may be reluctant to disclose information to the practitioner.

The SFBT practitioner is perpetually sensitive about the significant power dif- ferential working with patients at the free medical clinic due to possible feelings of shame related to their life situation and differences associated with their current economic and healthcare status. The practitioner is in a precarious clinical situation to balance being directive with Jim, which aligns with the SFBT theoretical frame- work and primary care setting, and not coming across as abusing power. To mitigate the power differential, the practitioner diligently works to develop trust in the thera- peutic relationship and finds moments to invite Jim’s voice to the conversation and empower him to make a change. The SFBT practitioner can connect with Jim quickly by being nonjudgmental, genuine, and sincere about hearing his story.

The challenge of working with Jim using the SFBT approach is not fully under- standing his lived experience. Therefore, in this case, the practitioner exercised extreme caution to not react to Jim based on ethnocentric views, negative interpreta- tions, or assumptions. Reacting in this way would have threatened the therapeutic relationship, diminished his voice, and led the practitioner to overlook significant cultural elements. For instance, the practitioner struggled with dismissing or mini- mizing Jim’s battle to turn away prostitutes. From the practitioner’s perspective, it