Research Article

Research on Social Work Practice

2019, Vol. 29(1) 19-35
Solution-Focused Brief Therapy for Individuals ª The Author(s) 2017
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With Alcohol Use Disorders in Chile DOI: 10.1177/1049731517740958
journals.sagepub.com/home/rsw

Karla González Suitt1, Pablo Geraldo2, Marlene Estay1,

and Cynthia Franklin3

Abstract
Purpose: This article presents a pilot study exploring the applicability of a linguistically adapted, solution-focused brief therapy
(SFBT) program, implemented by social workers in Chilean primary care. Method: We completed a single-case design with eight
replications. To analyze the results of the program on participants’ alcohol use and other related variables, we conducted visual
and percentage of nonoverlapping data analyses. Results: Social workers successfully implemented 10 of the 13 SFBT techniques.
Although results need to be interpreted with caution, positive trends were observed. Participants increased their “percentage
of days abstinent,” diminished “consequences of alcohol use,” decreased their “depression index,” and increased their “self-
reported well-being.” Discussion: Results are consistent with previous studies on SFBT and alcohol use. Exception and coping
questions may serve to increase abstinent days. SFBT focus on issues other than alcohol that are important to clients could help to
reduce harm on individuals who use alcohol.

Keywords
alcohol use disorders, solution-focused brief therapy, Chile, primary care, single-system design, outcome study

Alcohol use disorders (AUDs) are a major public health prob- program to provide alcohol and drug treatment for individuals
lem in the world that is associated with a reduced life expec- who were arrested for noncriminal offenses (e.g., driving under
tancy, mental health conditions, and familial and social the influence, neighborhood disturbance, family violence) as a
problems and are also a direct cause of death (Rehm & complement or alternative to punishment (Ministerio de Salud
Monteiro, 2005; World Health Organization, 2014). Chile de Chile, 2006). In 2007, Law No 19,966 established “Explicit
reports the highest average amount of alcohol consumption in Health Guarantees,” which stipulate that private and public
the Americas, citing the highest percentage of population with health insurance companies must provide quality coverage that
AUDs (8.5%). This has resulted in serious health conse- is accessible, timely and that covers 69 diseases including
quences, namely, the highest alcohol attributable fraction to AUDs (Aprueba Garantı́as Explı́citas en Salud del Régimen
cirrhosis among Latin American countries, which was 66.3% General de Garantı́as en Salud/Ley 19.966, 2013). In addition,
for men and 66.9% for women who have the disease (World this Law mandated that the Alcohol Use Disorders Identifica-
Health Organization, 2014, 2015). In addition, the proportion tion Test (AUDIT) be applied in the primary care setting and be
of the Chilean population whose deaths were wholly attributa- part of the screening for alcohol use. The expectations are that
ble to alcohol use was almost 2 times greater (9.8%) than the this measure will be used to identify individuals that can be
proportion of the worldwide population that met that indicator provided with brief interventions (BIs; Ministerio de Salud de
(5.9%; Castillo-Carniglia, Kaufman, & Pino, 2013; World Chile, 2010). In 2010, 50% of Chilean individuals with mild to
Health Organization, 2014). Mental health conditions, such moderate AUDs were treated in primary care settings with
as anxiety, depression, and social problems like domestic part- some type of BI (Minoletti, Rojas, & Horvitz-Lennon, 2012),
ner violence, are also frequently associated with AUDs. This is
true among both adolescent and adult populations in Chile
(Basso Musso, Mann, Strike, Brands, & Khenti, 2012; Toledo, 1
School of Social Work, Pontifical Catholic University of Chile, Santiago, Chile
Pizarro, & Castillo-Carniglia, 2015; Rojas et al., 2012; 2
Department of Sociology, University of California, Los Angeles
3
Vizcarra, Cortés, Bustos, Alarcón, & Muñoz, 2001a, 2001b), Steve Hicks School of Social Work, The Univeristy of Texas at Austin, Austin,
pointing to a need for behavioral health interventions that can TX, USA
address comorbid AUDs and mental health conditions.
Corresponding Author:
In response to the pervasive use of alcohol and its associated Karla González Suitt, School of Social Work, Pontifical Catholic University of
problems, Chile created a National Alcohol Policy. Conse- Chile, Vicuña Mackenna 4860, Macul, Santiago, Chile, 7810000.
quently, in 2006, the Chilean Ministry of Health launched a Email: [email protected]
20 Research on Social Work Practice 29(1)

underscoring the importance of developing culturally relevant association between alcohol use and these factors (Gonzalez,
and effective BIs that can be implemented in primary care Franklin, Cornejo, Castro, & Jordan, 2017). For this reason,
settings. It is important to note that public primary care pro- this study examines the implementation and outcomes for a
vides health services to about three quarters of the Chilean linguistically adapted SFBT intervention in primary care, as
population and that 60% of them belong to low-income fami- this particular BI is a strengths-based approach that relies on
lies (Fondo Nacional de Salud, 2015). systems and communication theories (Berg & De Jong, 1996),
focuses on social interactions, mental health conditions, and
solution-building, and it has been shown in other studies to
BIs for AUDs in Primary Care be effective in addressing depression, anxiety, and family prob-
BIs are defined as “any therapeutic or preventive activity deliv- lems (Gingerich & Peterson, 2013; Kim, 2008; Kim, Brook, &
ered by a health worker within a short period of time” (Babor, Akin, 2016; Kim et al., 2015; Schmit, Schmit, & Lenz, 2016;
1994, p. 1128) oriented to detect problematic use of alcohol, Smock et al., 2008).
and elicit change in individuals and its length may be from a
single 15-min session up to four sessions (Babor, 1994). Every
Linguistically Adapted Solution-Focused Brief
indication is that BIs are effective and have potential for use in
high demand settings, such as primary care, because they allow
Interventions (SFBI)
practitioners to implement effective interventions that are low Even though BIs for AUDs have been implemented within
cost in terms of time and resources (Substance Abuse and diverse ethnic/racial groups and countries (e.g., Botvin,
Mental Health Services Administration, 2012). For example, Schinke, Epstein, Diaz, & Botvin, 1995; de Shazer & Isebaert,
one review of 29 studies on BIs in primary care settings showed 2003; Field, Caetano, Harris, Frankowski, & Roudsari, 2010;
similar outcomes in alcohol consumption when compared to Rodriguez-Martos et al., 2005), most of research has not
extended interventions (Kaner et al., 2007). Other studies have reported results disaggregated by race. This includes the SFBT
also shown that, in different settings and countries, BIs have (Franklin & Montgomery, 2014; O’Donnell et al., 2014). Cul-
had significant effects on drinking-related outcomes, measured turally adapted interventions with Latinos have been shown to
up to 12 months after the intervention (Bertholet, Daeppen, be more effective than those that are not culturally adapted,
Wietlisbach, Fleming, & Burnand, 2005; Bien, Miller, & Toni- suggesting that SFBT may also benefit from linguistic and
gan, 1993; Moyer, Finney, Swearingen, & Vergun, 2002; Vasi- other cultural adaptations (Field & Caetano, 2010; Lee et al.,
laki, Hosier, & Cox, 2006). Specifically, solution-focused brief 2013). In this regard, no specific studies on SFBT with AUD
therapy (SFBT) was found to be efficacious for patients with have been reported in Chile, suggesting that a minimum lin-
AUDs (mild to severe; Hendrick, Isebaert, & Dolan, 2012) and guistic adaptation and subsequent study are warranted.
with Level 1 alcohol users with comorbid depressive symptoms One Randomized Control Trial (RCT) on SFBT that was
(Smock et al., 2008). Different ranges of AUDs and depressive implemented in Chile was with patients presenting somatoform
comorbid symptoms are common among patients treated symptoms, and this study showed effectiveness in symptom
within Chilean primary care settings (Minoletti et al., 2012). reduction, service utilization, and medical expense reduction
None of the BI studies mentioned, however, were conducted in (Schade, Torres, & Beyebach, 2011). The results of this SFBT
Chile, despite the recommendations by the Ministry of Health study suggest that SFBT can be effectively applied to mental
to universally implement BIs in primary care. health conditions. In addition, SFBT has been implemented in
There is a definite need to implement and study BIs for Mexico (another Spanish-speaking Latin American country)
AUDs in primary care settings in Chile. This need is driven with AUDs (Cordero, Cordero, Natera, & Caraveo, 2009).
by the pervasiveness of AUDs, policy and program mandates, Among this, study’s findings were that individuals with lower
and the practicalities of addressing behavioral health disorders incomes and more severe AUDs had better outcomes and that
within primary care. In addition, BIs can be used by different individuals who sought to modify problems associated to alco-
health-care professionals, and promising research indicates that hol use were more likely to remain abstinent and to actually
BIs in primary care are effective and that their implementation modify their alcohol-related problems than clients who wanted
remained effective regardless of the health provider that deliv- to modify their drinking patterns (Cordero et al., 2009). None
ered the BI (O’Donnell et al., 2014; Sullivan, Tetrault, of these studies reported a linguistic or cultural adaptation of
Braithwaite, Turner, & Fiellin, 2011). In this vein, Cochran SFBT to either Chilean or Mexican culture, indicating that
and Field (2013) suggested that social workers could play key modifications may be warranted for future studies that are con-
roles in the implementation of BIs in the primary care settings. ducted with Spanish-speaking populations.
In order to prepare social workers for these roles within pri- SFBT researchers suggest that the approach is consistent
mary care in Chile, decisions need to be made on what BIs to with the notions of familismo and personalismo because SFBT
implement and study, since these practitioners may implement considers an interpersonal context and relies on cooperation
several different types of BIs for AUDs. We believe that in (Corcoran, 2000; Oliver, Flamez, & McNichols, 2011). A
Chile, BIs for AUDs also need to include a relational approach recently conducted study on the linguistic adaptation of SFBT
(e.g., mental health and family dynamics), because in Latin to the Chilean population suggests that individuals value the
America, and specifically in Chile, there is an important inclusion of significant others in treatment for AUDs
González Suitt et al. 21

(Gonzalez et al., 2017). SFBT targets not only individuals’ was low-income individuals who used alcohol and who
behaviors but also their interactions with their family members received primary care. To that end, five social workers received
and other systems. SFBT helps clients reach alcohol-related a 30-hr training in SFBT. Each social worker implemented
goals differently from traditional treatments. The therapist’s SFBT with two clients while receiving direct supervision of
role is to assist clients in building their own solutions by asses- their work. This study was submitted for review and deter-
sing their own goals, analyzing their past experiences, and mined Non-Human Subjects Research by the Institutional
discovering what works for stopping or diminishing drinking Review Board of The University of Texas at Austin.
(de Shazer & Isebaert, 2003; Pichot & Smock, 2009). This
process often involves the clients’ realization that their solu-
tion involves much more than stopping or reducing their
Participants
drinking and that their goal should also include the enhance- Two women and six men between 38 and 60 years of age
ment of other aspects of their lives (de Shazer & Isebaert, participated in this study. Individuals in this study were patients
2003; Pichot & Smock, 2009). to two primary health clinics in southern Santiago, Chile, and
presented a moderate to severe risk level of alcohol use as
Rationale for the Study measured by the AUDIT (part of the preventive examination
undertaken regularly in the clinic). To participate in this study,
AUDs are serious health and social problems in Chile and are individuals had to be between 18 and 65 years of age, able to
likely to co-occur with mental conditions such as depression verbally communicate with others, willing to participate in the
and anxiety disorders; they can also result in family problems, intervention, and willing to fill out measures forms. Individuals
such as domestic violence and child abuse. For these reasons, it were excluded if they presented a severe and untreated mental
is important for BIs for alcohol use to be able to treat depressive illness such as schizophrenia.
and anxiety symptoms as well as family relationships. SFBT is
a mental health intervention that has shown promise in impact-
ing alcohol use, mental health conditions, and family relation- Procedures
ships, and it harmonizes with the notions of familismo and Sampling procedures. Study participants were recruited through
personalismo that characterize Latino culture (Corcoran, three strategies: referrals from medical or paramedical person-
2000; Oliver et al., 2011). The SFBT intervention can also be nel who detected any AUD as measured by the AUDIT, self-
applied within primary care. From an exhaustive literature referrals from people in the community who heard of the
review prior this study, we learned that there are no linguistic research project through flyers and signboards, or from refer-
adaptations of SFBT that have been implemented for AUDs in rals from a third party that told them about the project. Study
Latin America (González Suitt, Franklin, & Kim, 2016). There- participants received compensation of 3,000 Chilean pesos
fore, this study presents a pilot test of a linguistically adapted (about US$5) for coming to the clinic to fill out the measures
SFBT that is delivered by social workers in a primary care forms. Each time a patient was referred, the Principal Investi-
setting. The linguistic adaptation of SFBT has been reported gator (PI) called the potential participant for a meeting to invite
elsewhere (Gonzalez et al., 2017), and the focus of this present him or her to the project. The potential participants received
study is to examine to what extent Chilean social workers are information about the project and were advised of their rights.
able to adhere to the SFBT intervention and to further investi- Additionally, participants signed a written informed consent.
gate the outcomes as they relate to alcohol risk and usage and
depression and mental well-being. Examining the applicability Linguistic adaptation. The official manual of the SFBT Associa-
of a linguistically adapted SFBT by Chilean social workers will tion (Bavelas et al., 2013) was translated into Spanish by the PI
set the basis for the effectiveness of SFBT in primary care with and subsequently reviewed and edited by a Chilean psycholo-
AUDs and for further research on its efficacy and comparisons gist who is an expert in SFBT. The manual was further back
with other interventions such as motivational interviewing or translated by another professional social worker. This material
cognitive behavioral therapy. We hypothesized that social was complemented by other literature related to the develop-
workers would be able to adhere to the SFBT approach as ment of SFBT in Latin America and Spain (e.g., Beyebach,
measured by a fidelity instrument. In addition, we expected 2014; Schade et al., 2011). In addition, each of the interven-
that, after the SFBT intervention, individuals would improve tions detailed in the manual (e.g., asking for exceptions, coping
their alcohol use patterns and other factors associated to alco- questions, scaling questions, future-oriented questions) were
hol use, such as consequences of alcohol, depression, self- supplemented with the linguistically adapted questions that
reported well-being, and family relationships. were formulated in a previous stage of the study (Gonzalez
et al., 2017). These linguistically adapted questions were writ-
ten in Spanish based on cognitive interviews conducted with
Method Chilean individuals and then were back translated to English by
The purpose of this study was to conduct a pilot test of the two social workers who are native English speakers and who
linguistic adaptation of SFBT by social workers who received are also fluent in Chilean Spanish. After this process, the list of
training in this BI. The target population of the intervention questions in English was reviewed by two SFBT expert
22 Research on Social Work Practice 29(1)

researchers who validated them as being consistent with the Measures

approach. These materials are available from the main author.
Background information. Age, gender, relationship status, educa-
tional attainment, income, and job status will be observed
Training. Four social workers received 30 hr of training consist-
at baseline.
ing of five 4-hr sessions (20 hr), which involved an exhaustive
review of the translated manual, other complementary materi-
als of SFBT such as videos of Insoo Kim Berg, and role-playing Alcohol, Smoking, and Substance Involvement Screening Test
practice and analysis. In addition to that, social workers (ASSIST). This is an 8-item questionnaire developed by the
received 10 hr of direct supervision in their workplace. The World Health Organization that aims to detect at-risk substance
trainer was an MSW and PhD student, who was an advanced use and predict low, moderate, and high risks due to substance
practitioner with 10 years of clinical practice in primary care use in primary care settings (Humeniuk & Ali, 2010). These
settings and with underserved families and who received train- classifications mirror the substance use disorders continuum
ing in SFBT leading to the International Solution-Focused toward which the Diagnostic and Statistical Manual of Mental
Practitioner Certificate. Disorders, Fifth Edition (DSM-5) and the International Statis-
tical Clasification of Diseases and Related Health Problems,
Intervention. Prior research has shown that the average length of Eleventh Edition (ICD-11) are trending (Humeniuk & Ali,
SFBT treatments is three to six sessions (Gonzalez et al., 2016; 2010). For moderate AUDs, the sensitivity was 83% and the
Kim et al., 2016), which is consistent with the length of BIs specificity was 79%, and for severe AUD, the sensitivity was
previously stated and other research indicating that commonly, 67% and the specificity was 60% (Humeniuk & Ali, 2010;
individuals dropout from mental health treatment before the Humeniuk et al., 2008). The validation in Chile (n ¼ 400) was
fifth session (Wells et al., 2013). Thus, we provided three indi- developed in several settings such as primary care, policy sta-
vidual sessions of SFBT to eight patients with AUDs. Sessions tions, and working places (Soto-Brandt et al., 2014). In terms of
lasted between 30 and 60 min and consisted of therapeutic convergent and discriminant validity, the cutoff points that
encounters between a social worker and a patient. We designed provided the best level of sensitivity and specificity were
a protocol (available from the first author) for each session, 11 for moderate risk (sensitivity 86%; specificity 78%) and
including the main techniques of SFBT, scale questions, rela- 21 for high risk (sensitivity 81%; specificity 54%). This
tionship questions, a break, compliments, and first-session for- screening instrument was used to measure high-risk alcohol
mula task (Bavelas et al., 2013). These interventions were use in participants before and after the intervention because
previously linguistically adapted to Chilean culture and this is the instrument employed in the first trial of BIs for
reported elsewhere (Gonzalez et al., 2017). Toward the end substance users in Chile. Therefore, using this measure will
of each session, social workers took a break to summarize result in comparable outcomes. This instrument was admi-
strengths and useful information regarding the strategies that nistered at the baseline and at a 1-month follow-up.
the client has already developed. After resuming from the
break, the practitioner provided a solution-focused feedback Timeline Follow-Back (TLFB). This is a self-reporting tool to
to the client and a suggestion (or homework). The suggestion observe the quantity and frequency of consumption (Sobell &
usually consisted of doing more of what works or observing Sobell, 1992). It consists of a calendar to record clients’ quan-
when exceptions occur. First and subsequent sessions had the tity and frequency of alcohol consumption during the prior
same structure. However, the second and third session included week. Several variables can be calculated from the information
what has worked well, specifically during the period between gathered by the TLFB, namely, maximum amount of drinks in
the last session and the current and enhancing the exceptions 1 day, average drinks per week, total amount of drinks in the
and strategies that will help the client to reach his or her desired past week, percentage of days abstinent, and number of times/
future. At the end of the third session, the social worker and the days of heavy drinking. The TLFB has been validated with
client completed a certificate, stating that the client has suc- several populations in several settings and modalities (Sobell
cessfully participated in the treatment. The certificate had a et al., 2001; Sobell, Brown, Leo, & Sobell, 1996). It was also
written statement in which the client acknowledged his or her validated in Mexico, using the validity criterion of comparing
strengths and exceptions that will help him or her to advance the TLFB to a self-monitoring measure of quantity and fre-
toward the solution. quency (Annis et al., 1996). Intraclass correlations were higher
than .90 for total number of drinks, number of drinks per drink-
Interviews. After the intervention was complete, social workers ing days, number of days with one to four drinks, number of
were interviewed individually to gather their feedback regard- days of heavy drinking, and number of abstinent days (Sobell
ing the applicability of the SFBT approach with the Chilean et al., 2001). For interpreting the TLFB, the cut points are
population in primary care settings. This interview followed a defined in relation to patterns of alcohol use that determine
semistructured format that consisted of reviewing each of the at-risk alcohol use, heavy drinking episodes, and their fre-
interventions contained in the manual and discussing whether quency or other patterns that researchers define depending on
some changes or suggestions to improve the model should be the setting. For example, Ayala, Cardenas, Echeverria, and
done for future interventions. Gutierrez (1995) and Ayala, Echeverrı́a, Sobell, and Sobell
González Suitt et al. 23

(1997, 1998) categorized drinking patterns according to the Caetano, & von Sternberg, 2014). Through a confirmatory fac-
number of drinks consumed in one occasion (low ¼ 1–4 drinks, tor analysis, the study found that the English version (with
moderate ¼ 5–9 drinks, and excessive ¼ 10 or more drinks). Caucasian and Latino samples) and the Spanish version (with
This instrument was employed at the baseline and at a 1-month a Latino sample) were equivalent in terms of reliability and
follow-up to create a reconstructed record based on the client construct validity (Marra et al., 2014). They reported an inter-
memory. In addition to this tool, a calendar to record the daily nal consistency of a ¼ .94 for the Spanish-language version
alcohol use was provided to participants to be completed dur- and similar values for the other versions as well, and the factor
ing treatment. loading for the 15 items varied from .51 to .81 in the Spanish-
language version (Marra et al., 2014). Authors also found that
Patient Health Questionnaire (PHQ-9). This is a self-administered the English and Spanish version had strict factor invariance,
instrument that was designed to be employed in primary care which means that the two versions are comparable in terms of
settings and corresponds to the depression module of the Pri- each of their items (Marra et al., 2014). This instrument has
mary Care Evaluation of Mental Disorders screening question- not been normed and can be interpreted as higher scores,
naire for depressive symptoms (PRIME-MD), a tool for indicating higher severity or in terms of amount of conse-
identifying several mental health disorders (Kroenke, Spitzer, quences reported (higher number suggesting higher severity).
& Williams, 2001). The tool reflects the nine depression symp- The SIP was administered at the baseline and at a 1-month
toms of the DSM IV and has been found to have high conver- follow-up.
gent validity (r ¼ .73; p < .0001) with the short version of the
Beck Depression Inventory when detecting depression severity
Outcome Rating Scale (ORS). This 4-item self-reporting measure
(Martin, Rief, Klaiberg, & Braehler, 2006). The PHQ-9 has
gathers information about three areas, specifically, individual,
been translated into Spanish and validated in Chile with adult
interpersonal, and social, and also contains an overall well-
populations (Baader et al., 2012). In Chile, the convergent
being score. The ORS was designed as an alternative to a
validity of the PHQ-9 was measured against the Hamilton
longer instrument called the Outcome Questionnaire
Depression Rating Scale with 88% of sensitivity (major depres-
(45 items). The internal consistency was over .90, and test–
sion) and 92% of specificity (no depression; Baader et al.,
retest reliability were higher than .80 (Bringhurst, Watson,
2012). This instrument was administered at the baseline, at the
Miller, & Duncan, 2004). The ORS has been validated with
beginning of treatment, 2 weeks after the beginning of treat-
clinical populations, demonstrating positive variation after
ment, and at a 1-month follow-up.
psychotherapy (Miller, Duncan, Brawn, Sparks, & Claud,
2003). It was translated to Spanish and tested in Chile with
Family Health (Salud Familiar; SALUFAM). This is a 13-item
an internal consistency of .78 and a content validity through
screening instrument that was developed by a Chilean team
an expert panel (Cantuarias, Cofré, Mahaluf, & Sepúlveda,
using questions from several instruments and that assesses
2009). This instrument was applied at the beginning of each
familial aspects such as agreement, cohesiveness, emotional
session and served to establish therapeutic goals and chal-
expressions, conflict, commitment, trust, social support, labor
lenges in each area.
stressors, familial stressors, and health stressors (Püschel,
Repetto, Solar, Soto, & González, 2012). The final version of
the instrument contains the dimensions of “agreement” and Solution-focused fidelity instrument. We provided a 30-hr training
“family support.” Answers range from never ¼ 1 to always to four social workers, each of whom implemented three ses-
¼ 5. The SALUFAM was found to be efficacious in terms of sions of SFBT to two patients. Sessions were audio-taped and/
predicting health vulnerability associated with familial risk. or observed through a one-way mirror. To check for fidelity of
The cut point was established at 3.7 points wherein families the implementation of the SFBT approach by trained social
receiving scores 3.7 reflect lower agreement and family sup- workers, the interventions were audio-recorded and analyzed
port, which suggests higher health vulnerability (Püschel et al., by the PI and independently by another practitioner that was an
2012). This instrument was administered at the baseline and at expert in SFBT. To this end, the translated version of the
a 1-month follow-up. solution-focused fidelity instrument (Lehmann & Patton,
2012) was employed. This is a 13-item tool that asks for 13
Short Inventory of Problems (SIP). This is a short 15-item instru- specific SFBT interventions. This instrument was reviewed in
ment that derived from a longer instrument named DrInC accordance to the prior linguistic adaptation of the approach in
(Miller, Tonigan, & Longabaugh, 1995). It includes five order to maintain consistency and coherence among the lan-
dimensions of alcohol-related consequences. The correlations guage aspects, the manual, the training delivered to social
between the SIP and the Drinker Inventory of workers, and the evaluation of its fidelity.
Consequences (DrInC) were r  .80 and accounted for 92% Measures were administered in a private room by the PI or a
of the variance that these two scales shared (Forcehimes, Toni- trained research assistant. The implementation of baseline mea-
gan, Miller, Kenna, & Baer, 2007). Recently, a Spanish version sures lasted an hour, on average, whereas measures in the sec-
was validated among Latinos in the United States who were ond, third, fourth, and fifth observations took 15–30 min. The
injured and received emergency medical care (Marra, Field, follow-up interview took about 45 min (see Table 1).
24 Research on Social Work Practice 29(1)

Table 1. Measure Administration by Phase. the social workers adhered to the items during each session and
the frequency with which they employed each technique. This
Phase A Phase B
Estimated information was complemented with a content analysis of the
Measures Application Time W1 W2 W3 W4 W6 W10 social workers’ interviews that were conducted with the social
workers who implemented the model. The goal of the content
Background 5 min X analysis followed a deductive or directive approach since it was
ASSIST 5–15 min X X
TLFB 10–20 min X X X X X X
focused on examining a specific and predetermined issue—the
PHQ-9 5–10 min X X X X applicability of SFBT interventions (Elo & Kyngäs, 2008;
SALUFAM 5–10 min X X Hsieh & Shannon, 2005).
SIP 5–10 min X X
ORS 2 min X X X X X X Descriptive analysis. To analyze participants’ demographic infor-
Note. ASSIST ¼ Alcohol, Smoking, and Substance Involvement Screening Test; mation and baseline reports of outcome variables, we con-
TLFB ¼ timeline follow-back; PHQ-9 ¼ Patient Health Questionnaire; ducted descriptive analyses and also included participants
SALUFAM ¼ Salud Familiar; SIP ¼ Short Inventory of Problems; ORS ¼ who dropped out of the intervention. We also ran t-test and
Outcome Rating Scale.
w2 analysis in order to explore any significant differences
between participants who completed the treatment and partici-
Research Design pants who dropped out.
This study used a single-case AB design with eight replica-
tions. Single-case designs are time-series designs where the Visual analysis. We examined outcome measures applied in the
unit of intervention and data analysis is an individual case six observations—percentage of days abstinent, average of
(a participant or a group of participants), and the comparisons alcohol use during the last period, maximum amount of drinks
are different measures applied to the case at different stages of during the last period, and ORS—following a visual analysis
the intervention to observe changes in the dependent variable across all subjects, to observe their trends at baseline, interven-
(Kratochwill et al., 2010). Specifically, the AB design that is tion, and follow-up phases (Kratochwill et al., 2010).
used in this study is frequently used in practice evaluation and
is appropriate for applied settings where randomization and the Percentage of nonoverlapping data (PND). We also conducted
withholding of treatments are not possible. The design is pre- PND analysis to examine the efficacy of the program on the
experimental and relies on multiple replications to show that outcome variables “percentage of days abstinent,” “average of
clients are progressing in treatment after the introduction of an alcohol use during the last period,” “maximum amount of
intervention. As such, our research team applied the same mea- drinks during the last period,” “ORS,” and “depressive
sures to eight participants on repeated occasions with the aim to symptoms.” PND is a commonly employed nonoverlap
measure the case at the baseline, during intervention, and post- method in which we observed “the percentage of Phase B data
intervention (Kratochwill et al., 2010; Rubin & Babbie, 2014). exceeding the single highest Phase A data point” (Parker,
All eight participants had a 2-week baseline period during Vannest, & Davis, 2011). Since Phase B had only three obser-
which they were consulted on three occasions regarding their vations, the calculated PND can only result in 0%, 33%, 67%,
alcohol use during the last period. After the baseline period, all or 100%. Thus, the results must be interpreted considering
participants received the same intervention (three SFBT ses- these restrictions.
sions). As such, the plan considered three observations for the
baseline, two observations during the intervention, and one
observation 1 month after the end of the intervention. To check
for fidelity of the implementation of the SFBT approach, we
Results
audio- and/or video-taped the sessions and analyzed them with Recruitment and Participants
the solution-focused fidelity instrument (Lehmann & Patton, Sixteen patients in two primary clinics located in southern
2012). This instrument was translated into Spanish by the PI Santiago, Chile, were invited to participate, 15 of those agreed
and back translated to English with the collaboration of two to participate, 9 finished the treatment, and 8 completed all the
bilingual social workers whose native language is English and measures. Four social workers were trained in SFBT between
whose second language is Chilean Spanish. January and April 2016 and implemented the program between
April and July 2016. As shown in Table 2, participants who
completed the intervention had 49 years of age in average, and
Analysis Plan two of the eight participants were women. Half of participants
Fidelity and perceptions of social workers. Implementation of were in a partner relationship. Five of the eight only completed
SFBT by social workers will be examined with descriptive middle school while the other three completed high school. The
analyses that inform regarding their level of adherence to the income reported by participants was US$337 in average. Fam-
treatment techniques across sessions, settings, and practi- ily size varied from unipersonal families up to eight members.
tioners. In this regard, we observed the frequency with which Six of the eight participants had a job.
González Suitt et al. 25

Table 2. Descriptive Data per Subject at Baseline.

Subject Age Sex Partner Relationship Education Attainment Monthly Income (US$) Family Size Work

1 51 M No MS 550 1 Yes, independently

2 49 W No HS 250 2 Yes, independently
3 53 M Yes HS 550 8 Yes, with a contract
4 60 M No HS 250 1 Yes, independently
5 58 M Yes MS 150 1 Yes, independently
6 42 W Yes MS 250 5 no
7 38 M No MS 150 1 no
8 43 M Yes MS 550 5 Yes, with a contract
Average 49 337 3
Note. M ¼ male; W ¼ woman; MS ¼ middle school; HS ¼ high school.

Table 3. Frequency Analysis of Interventions by Session. helpfulness of the session.” Social workers assessed their per-
P formance with the same instrument, and, in general, there was
Sessions (n)
consistency between their responses and the analysis of the
1 2 3 Total sessions.
The Social Worker (5) (8) (6) f (%) Social workers, however, had the perception of having
implemented more often the techniques that in the analysis of
Asked what the client wanted out of today’s 3 3 3 9 (45)
session
the sessions were identified as having been less frequently
Asked “what’s better” in today’s session 5 8 7 20 (100) implemented. In addition, the sessions also involved
The client’s stated needs for today’s session 2 1 0 3 (15) problem-centered questions as clients presented their problems.
were related to overall goal(s) for therapy When problem talk appeared repeatedly in a session, the trainer
Summarized the client’s comments during 4 7 6 17 (85) supervised the subsequent sessions to coach social workers in
today’s session moving from problem talk toward solution talk, which was a
Complimented the client’s strengths/ 5 8 7 20 (100) strategy to foster fidelity with the practitioners. Each social
resources during today’s session
Asked exception/difference questions during 5 7 7 19 (95)
worker was supervised directly in at least three sessions, in
today’s session which the trainer provided feedback before, during, and after
Asked amplifying questions during today’s 5 8 7 20 (100) the session. Sessions lasted between 30 and 60 min, and all
session sessions included a break.
Asked reinforcing questions (e.g., 5 8 7 20 (100) After finishing the program, we interviewed the four social
summarizing/complimenting) of the client’s workers regarding their perceptions of the process. All four
reported change in today’s session social workers stated that the concrete and easy-to-practice
Was able to help the client behaviorally 5 7 6 18 (90)
describe a next small step of progress
techniques were what they liked the most, where having the
Asked scaling questions during today’s 5 8 7 20 (100) manual available was crucial. Two social workers highlighted
session the solutions- and resources-centered aspect as one of their
Asked coping questions related to the client’s 4 7 7 18 (90) favorite things of the approach. Regarding the difficult
abilities that emerged during today’s aspects, one social worker identified “staying silent,” another
session one indicated “keeping the structure of the session,” and two
Asked questions to help the client think 4 7 7 18 (90) others found it difficult to intervene with individuals who had
about how changes will affect the client’s
family and important others in their life
some cognitive damage or cultural deprivation because they
Asked for feedback on the helpfulness of the 3 5 5 13 (65) needed to make an effort to reformulate some questions. In
session today from the client terms of changes to the program, three of the four social
workers asserted that although the program is brief, three
sessions may be too brief for some cases and that, in more
complex cases, they would add more sessions and follow-ups.
Fidelity of the Intervention One social worker expressed that the fact that patients were
Twenty sessions were supervised via one-way mirrors, audio- compensated for participating in the study was confusing for
or video-recorded, or both. As Table 3 shows, 10 of the 13 her patients, and she suggested providing another type of
SFBT techniques measured by the fidelity instrument were compensation or giving the compensation at the end of the
implemented in 17 (85%) or more sessions. Three techniques program. Three social workers suggested adding more hours
were not consistently implemented by the social workers: of training and supervision including more instances of feed-
“asking the client what he or she expected from the session,” back from the trainer; and two social workers thought that this
“eliciting clients to state needs related to the goals of the approach should be employed with other conditions that are
therapy,” and “asking clients for feedback about the treated in primary care settings.
26 Research on Social Work Practice 29(1)

A. Percentage of Days Abstinent B. Average Alcohol Consumption

10

5
Trend Trend

5
2

0 0

2 4 10 2 4 10
Weeks Weeks

C. Maximum Amount of Drinks in One Day

Trend

2 4 10
Weeks

Figure 1. Comparative global visual analysis of alcohol use patterns during Phase A and Phase B.

Results of Pilot Implementation As such, the three outcome variables of alcohol use, percentage of
A global visual analysis was conducted to examine trends of days abstinent, “daily average of drinks,” and “maximum amount
changes in outcome variables before and after the intervention. of drinks in 1 day,” changed in the expected trend—a decrease in
González Suitt et al. 27

A. Alcohol Use Risk Level B. Consequences of Alcohol Use

40

60
30

40
20

20
10

A B A B
Phase Phase

Figure 2. Comparative global visual analysis of “alcohol use risk level” and “consequences of alcohol use” before and after treatment.

A. Self−reported Wellbeing B. Depression Index Scores

3 2

2
Trend Trend
1

0 0

2 4 10 2 4 6
Weeks Weeks

Figure 3. Comparative global visual analysis of self-reported well-being and depression scores during Phase A and Phase B.

alcohol use. Nevertheless, the magnitude of the changes had high “consequences of alcohol use,” measured by the SIP tool, both
variation across participants (see Figure 1a–c). The variables observed only at baseline and at a 1-month follow-up, showed the
“alcohol use risk level” measured by the ASSIST tool and same tendency (see Figure 2a and b). In the former, the variability
28 Research on Social Work Practice 29(1)

Figure 4. Percentage of days abstinent per subject.

of scores increased in the follow-up, while in the latter, the varia- have occurred before treatment, so that three sessions of
bility of scores appeared to be more stable. Participants showed an SFBT may have helped them to maintain abstinence. In par-
increase in “self-reported well-being” and a decrease in allel, PND analysis reveals that Subjects 2 (woman), 5, 6
“depression index” (see Figure 3a and b). In addition, “family (woman), and 8 showed at least two observation points in
health” was the only outcome variable that did not change higher levels of percentage of days abstinent during Phase
in the expected trend. B, compared with the highest point of Phase A, which is a
Further, we conducted PND analyses to quantify trends PND of 67–100%.
observed in visual analyses. As discussed previously, even Regarding “average of alcohol consumption” and
when the observed trends in visual analyses moved in the “maximum amount of drinks,” presented in Figures 5 and 6,
expected direction, when observing the data per subject, dif- respectively, trends are observable across subjects, showing
ferences emerged. Figure 4 shows PND analyses and visual a slight decrease of alcohol consumption in Subjects 3, 5,
representations for percentage of days abstinent during the and 6 (woman) and a slight decrease in maximum amount
last period per subject. The results across subjects are mixed. of drinks in 1 day in Subjects 2, 5, 6 (woman), and 7. The
As shown in Figure 4, Subjects 1 and 4, both men, reported complementary PND analysis showed that most of subjects
100% abstinence following the second observation, and this diminished their level of alcohol use at only one observation
behavior was reported by them throughout all the subsequent point during Phase B (33%), when compared with the low-
observations. Thus, the PND analysis for these two cases is est point of Phase A. Only Subject 8 reported that the tree
0%. Although this analysis suggests that the program did not observation points on Phase B were under the lowest point
have any effect on the decision that these two individuals of Phase A (100%).
made regarding stop drinking, it may be possible that the In summary, subjects who did not stop drinking alcohol at
program contributed to their decision or that change may the beginning of the study—2 (women), 3, 5, 6 (women), 7, and
González Suitt et al. 29

Figure 5. Average alcohol consumption per subject.

8—showed in at least one of the variables of alcohol use pat- Discussion and Applications to Practice
terns a favorable trend, such as increasing days abstinent or
This study explored the implementation and effectiveness of an
decreasing average of alcohol consumption, or decreasing
SFBT intervention with patients referred for AUD using single-
maximum of alcohol use in 1 day. However, PND analyses
case designs at two primary clinics in urban low-income neigh-
suggested that most of changes were not significant and that
borhoods in Santiago, Chile, implemented by social workers.
positive trends are stronger in percentage of days abstinent.
Eight of the 15 participants in the study finished a three-session
Future case studies should consider more observation points
SFBI that was linguistically adapted for this population. Fre-
and longer periods of follow-ups, so that it is possible to gather
quency analysis of the fidelity measure indicated that the social
stronger evidence of changes.
workers who delivered the SFBT intervention adhered to at
In addition to alcohol patterns, we conducted PND anal-
least 10 of the 13 techniques identified in the fidelity instru-
ysis for self-reported well-being, presented in Figure 7. This
ment, and direct supervision was additionally helpful to rein-
analysis showed that six of the eight subjects reported hav-
force individual social workers’ fidelity to the model. These
ing improved their perceptions regarding personal, family
results resonate with the positive reception that practitioners
and friends, social relationships, and general well-being in
reported regarding the model. On the other hand, the items that
at least two observation points during Phase B compared
social workers implemented the least—“asking the client what
with the highest point of Phase A (67–100%). Subjects who
he or she expected from the session,” “eliciting clients to state
decided to stop drinking before treatment showed different
needs related to the goals of the therapy,” and “asking clients
tendencies. While Subject 1 reported only once in Phase B a
for feedback about the helpfulness of the session,” involve the
better level (33%), Subject 4 reported the three observation
clients’ active participation that should be elicited by therapists
points during Phase B better levels of self-reported well-
during the intervention. Paradoxically, social workers
being (100%).
30 Research on Social Work Practice 29(1)

Figure 6. Maximum amount of drinks in 1 day.

perceived that they did implement these interventions more co-construction and the building of client cooperation and com-
consistently than they actually did. Three possible explanations petencies. Social workers provided feedback on the program
appear regarding these findings. First, since the protocol and suggested increasing the number of sessions and follow-
designed for the treatment focused more on specific techniques ups, expanding the approach to other health issues in primary
of SFBT and did not include these aspects textually, social care and giving other types of compensation to participants. All
workers may have not implemented actions that resulted in of these are challenges to explore in future empirical studies
client’s self-determined goals or closely following the clients’ and to consider for social workers in their clinical practice.
language or the co-construction process during sessions. All are Overall, this study showed mixed but promising trends and
essential elements necessary to carry out the SFBT change outcomes that can be further explored in future studies. Regard-
process (Franklin, Zhang, Froerer, & Johnson, 2016). Second, ing alcohol outcomes, the clearest trend among participants
a confusion may have existed in terms of future-oriented ques- who completed the treatment was the decrease in percentage
tions that ask for what the client wants in regard to how these of days abstinent at the 1-month follow-up. These results are
questions relate to the goals of the session and the therapy. consistent with other studies on SFBT with alcohol users (de
Third, social workers may have not grasped the importance Shazer & Isebaert, 2003; Hendrick et al., 2012). The variability
of asking for feedback about each session as a way to assess of alcohol use frequency and quantity across the eight partici-
themselves and empowering clients, which is consistent with pants and their progression throughout the six observations
social workers’ perceptions regarding the need for more train- contributed to mixed results in other alcohol outcomes such
ing and supervision. Future trainings with social workers and as “average of daily drinks” and maximum amount of drinks
an improved version of the protocol will emphasize the inclu- in 1 day which, observed globally, changed in the expected
sion of interventions that consider the client-centered and direction. Studies with patients that present more similar pro-
resource perspectives of SFBT including the importance of files and/or bigger samples should explore how these outcomes
González Suitt et al. 31

Figure 7. Self-reported well-being.

change over time. In addition, future studies of SFBT with how SFBT treatment has different effects depending on cli-
alcohol use should consider longer follow-up ranges. Interest- ents’ characteristics.
ingly, the variable percentage of days abstinent is a clear rep- Another important finding is that individuals who com-
resentation of an “exception day.” Thus, practitioners working pleted the treatment reported a marked decrease in conse-
with individuals with alcohol consumption may explore absti- quences of alcohol use and depression index as well as a
nence through exception questions and may recommend more significant increase in their self-reported well-being, suggest-
of what works so that clients increase their days abstinent, ing a possible harm reduction in which SFBT helped individ-
maintain abstinence, and consequently, decrease alcohol use. uals improve in areas different to alcohol outcomes. These
Another SFBT technique that may serve to decrease alcohol results may relate to the focus of SFBT on clients’ developing
use during consumption days may be exploring through coping their own solutions and goals, which often resulted in work on a
questions such as what helped clients to stop drinking during client’s own behavior, family relationships, and living condi-
days that they drink less than the average? tions instead of a singular focus on abstinence or alcohol use
An interesting point is that participants who completed the decrease. The depression index as measured by the PHQ-9 at a
treatment showed a decrease on their “alcohol use risk level” 1-month follow-up, for example, decreased 5.3 points, on aver-
as measured by the ASSIST tool. In terms of clinical impact, age, which is considered clinically significant (Löwe, Unützer,
participants moved from high risk to moderate risk (Soto- Callahan, Perkins, & Kroenke, 2004). Further explorations
Brandt et al., 2014). Nevertheless, changes across participants should be conducted on this issue to examine how client char-
varied from an increase of 7 points to a decrease of 30 points acteristics and level of symptoms may impact the effectiveness
where, again, differences in subjects’ alcohol use patterns of the SFBT intervention. The improvements found in this
suggest that results must be interpreted with caution, and study on the depression index and self-reported well-being out-
future research including larger samples may help to explain comes for alcohol users who finished the treatment specifically
32 Research on Social Work Practice 29(1)

build on the study by Smock and colleagues (2008), where Funding

individuals participating in an SFBT intervention experienced The authors disclosed receipt of the following financial support for the
a significant diminishment of their depressive symptoms and a research, authorship, and/or publication of this article: Financial sup-
significant increase in their psychosocial well-being. These port was received from the School of Social Work of the Pontifical
findings further support previous research that has repeatedly Catholic University by research assistants.
shown that SFBT is an effective intervention for internalizing
disorders, demonstrating decreases in depression and anxiety
symptoms (Gingerich & Peterson, 2013; Kim et al., 2016; References
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