“Suppose that Tonight, While You're Asleep, a Miracle Happens:” Pragmatic Solution-Focused Therapy for Substance Abuse

Solution-focused therapy (SFT), developed by Steve De Shazer and Insoo Kim Berg is a social constructivist model of brief therapy emphasizing the role of language in problem resolution (Nichols, 2008). Pichot, having studied and trained with De Shazer and Berg, has thoughtfully applied this approach to treating patients with significant substance abuse problems. Pichot's book, along with other newer approaches to substance abuse treatment such as motivational interviewing (Rollnick et al., 2007) and relapse prevention (Marlatt and Donovan, 2005), reflect a major shift in the field away from the disease model and an often confrontational treatment style, to a more collaborative, client-centered approach which downplays individual pathology.

therapist and client is more likely. A third element is that the miracle occurs tonight, indicating a sense of immediacy. By having change occur rapidly, extended treatment is unnecessary. Fourth, the miracles' premise is that the client is unaware that change has occurred which leads to the fifth dimension, the client must be attuned to their environment to detect change. Pichot prompts this reflection with specific questions such as "What will be the first things you would notice?" For clients who have difficulty with introspection, an important other's perspective may be elicited, "What would your wife notice?" Pichot emphasizes the power of this question since it permits the client to closely examine what their life would be like without the problem.

Practical asPects of substance abuse treatment
Many of Pichot's examples come from community agency settings with "involuntary" (my word, not Pichot's) clients in courtordered treatment. To integrate the reality of regular urine drops with postmodernism is no mean feat but Pichot does it well. With an appreciation of the elevated risks for suicide and homicide (both as perpetrators and victims), Pichot does not minimize the clinical challenges posed by her clients. She even includes attention to documentation for risk management.
I found her description and examples of applying solution-focused philosophy to the problem of "dirty" urines to be particularly useful. The therapist reports the result in a factual, neutral, non-punitive manner. Again, the test result is not presented as the client having failed but, instead solved. However, because you're sleeping, you don't know that the miracle has happened. So, when you wake up tomorrow morning, what will be different that will tell you a miracle has happened and the problem which bought you here is solved? (DeJong andBerg, 1998, pp. 77-78, cited in Pichot, 2009, p. 27).
In working with clients, Pichot is always on the alert for exceptions -episodes in which they responded to stress without drug use. She then encourages clients to reflect on how they achieved this self-control and its implications for their view of themselves.

the miracle Question
The miracle question, Pichot's central technique, has five key components. First, the change is unpredictable and does not occur naturally. Second, the problem that brought the client to treatment is solved. When working with substance abuse, defining the problem can be challenging since these patients often deny any difficulty. When faced with this response, Pichot, through questioning, usually finds that important others in the client's life, including probation officers and child protective service caseworkers, believe that that the client has a problem. The miracle then becomes successfully convincing these authorities that the client does not have a problem so that a desired outcome, such as regaining custody of children, will occur. This approach is interesting since it takes the therapist out of the role of social control agent as well as eliminates the need to confront the client about their substance use, but still requires the client to address the issue. As a result, a firm alliance between Solution-focused therapy (SFT), developed by Steve De Shazer and Insoo Kim Berg is a social constructivist model of brief therapy emphasizing the role of language in problem resolution (Nichols, 2008). Pichot, having studied and trained with De Shazer and Berg, has thoughtfully applied this approach to treating patients with significant substance abuse problems. Pichot's book, along with other newer approaches to substance abuse treatment such as motivational interviewing (Rollnick et al., 2007) and relapse prevention (Marlatt and Donovan, 2005), reflect a major shift in the field away from the disease model and an often confrontational treatment style, to a more collaborative, client-centered approach which downplays individual pathology.

background of solution-focused theraPy
Solution-focused therapy has its origins in postmodern-family therapy developed in the late 1980s and 1990s (Nichols, 2008). De Shazer, along with other systemic therapists of the time, was strongly influenced by anthropologist Gregory Bateson's writings about epistemology. Bateson's theoretical writing, while often difficult to digest, contains a core concept in solution-focused therapy: "…the difference that makes a difference or an idea that is news of difference" (De Shazer, 1982, p. 5). Bateson's influence on SFT is evident by its central technique, the miracle question: The book, itself, is well-written and would be valuable to several audiences. Professionals working in the substance abuse field lacking a firm grounding in SFT will find the book accessible and full of concrete case examples. For those new to the field, Pichot provides useful forms, treatment planning outlines, and an annotated bibliography of both SFT and substance abuse resources, which would be useful regardless of one's orientation. For those wanting to become more familiar with SFT, the book provides a readable overview of the key techniques and clinical principles upon which this approach is founded. Pichot's skill in making SFT accessible would make the book a useful secondary resource for classes in psychotherapy or family therapy. as a problematic event that leads, almost immediately, to a solution: "I want you to imagine that it's a couple of months down the road and you haven't had any more positive urine screens…What did you do differently to pull that off ?" (p. 98).
critiQue I found Pichot's book to be readable and eminently practical. I do have concerns about, how readily SFT should be employed in many settings. While SFT is incredibly popular, a strong evidence basis lags behind. Available evidence supporting this approach is primarily based on small clinical samples (Conoley et al., 2003;Gingrich and Eisengart, 2004). SFT, similar to many other family therapy models, was developed outside of a university setting. In part, because of this history, empirical findings on therapy process, outcome, and conditions, for which SFT and similar therapies are valid treatments, often lag behind clinical development and popularity.