PRACTICE FORUM
Strengths-Oriented Referrals for Teens (SORT):
Giving Balanced Feedback to Teens and Families
Douglas C. Smith and James A. Hall
D
espite the great advances in the development of assessment procedures for
adolescent substance abuse (Dennis. 1998;
Rahdert, iy91;Winters, 1992), very little literature
exists that informs chnicians about how to best
deliver clinical feedback from substance abuse evaluations to teens and families. We address this gap in
the literature by describing a strengths-based protocol called Strengths-Oriented Referral for Teens
(SORT). Following is a look at the theoretical basis
for SORT, a description of tbe intervention, and a
discussion of quality assurance procedures used in
training therapists.
SORT was developed through a project funded by
the Substance Abuse and Mental Health Services Administration, which sotight to expand and enhance
adolescent substance abuse treatment. It is a clinical
feedback session that occurs after an initial substance
abuse evaluation at our comprehensive assessment
center. Modeled after Dembo's Juvenile Assessment
Center concept (L">embo&: Brown, 1994), this onestop assessment program is structured specifically to
help teens navigate the fragmented service delivery
system, reduce duplication in assessment across the
system of care, and provide targeted referrals.
MOTIVATIONAL INTERVIEWING
A major component of SORT is motivational
interviewing (MI), which combines elements of
client-centered therapy with behavioral principles
(Miller & Rollnick, 2002). The major concepts
underpinning this approach include empathic listening, rolling with resistance, providing feedback,
and otfering a menu of options. Tbis model can be
contrasted with the Minnesota Model of substance
abuse (Winters, Stincbfield, Opiand, Weiler, & Latimer,2000), which emphasizes clients'acceptance of
their substance abuse as a disease. In the Minnesota
Model, which was heavily influenced by 12-step
pbilosophy, abstinence from chemicals was the only
CCC Code: 0360-7283/07 53.00 62007 National Asiociation of Social Workers
viable goal. One of the major strategies in treatment was confronting clients' denial related to their
substance use. In MI tbe emphasis is on getting the
client to elicit self-change statements through careful questioning and active listening.Thus, mutually
developed and appropriate treatment goals emerge
and facilitate behavior change.
MI has only recently been applied to adolescent
populations. Some adaptations exist, including a
five- and 12-session intervention (that is, the Motivational Enhancement Therapy/Cognitive Behavioral
Therapy fMET/CBT5,MET/CBT12|) developed
in the Cannabis Youth Treatment study (Dennis,
Titus,Diamond,etal.,2002;Diamond etal.,2002).
These two Ml~based interventions are cost-effective
and were found to reduce substance use and abuse
or dependency problems in a large randomized trial
(Dennis et al.,2004). Our application of Ml elements
in SORT is designed to increase an adolescent's
motivation to use services (particularly drug treatment) beyond the initial assessment.
SOLUTION-FOCUSED THERAPY
In solution-focused therapy (Berg & Miller, 1992;
deShazer, 1988), therapists use caretully constructed
questions that presuppose action and active problem
solving. It is inherently present focused and action
oriented. Techniques in solution-focused therapy
include asking scaling questions, exception-finding
questions, and other questions designed to elicit the
clients' goals. A scaling question used in our intervention is, "On a scale of one to 10 where one is
'not wiUing at all' and 1 ((is 'completely ready,' how
ready are you to follow through with this referral?"
This question can be followed up with a question to
gauge what would make the client more wilting to
use a service. For example, if a client responds that
he or she is a three on this scale, a therapist might
ask, "What would have to be different for you to
move up to a four or a five?" In this way, barriers
69
It is perhaps axiomatic that social workers
recognize the benefits of both viewing clients'
problems systemically and recognizing their
unique strenphs.
to going to treatment are explored in greater depth.
Exception-finding questions are designed to elicit
the client's strengths by asking what they have done
to prevent their problems from becotning worse.
For example, a therapist might say, "You've had
a difficult run lately, and I'm surprised you're not
doing worse. What is it about you that has gotten
you through this difficult time?" Most solutionfocused questions are designed to get the chent to
elicit actions they can take to remedy a situation.
For example, a therapist might ask a client, "When
this is no longer a problem, what will you be doing
differently?" Tliis asks what the client can do and is
meant to elicit an action word from the client that
becomes part of the solution plan.
SOCIAL WORK'S STRENGTHS TRADITION
Social work emphasizes the need for therapists to
recognize clients'strengths and not focus entirely on
their problems. This focus on strengths is a natural
extension of social work's focus on viewing problems
systemically and avoiding descriptions that attribute
problems to personal pathology (Wakefield, 2002).
Saleebey (2001) even proposed creadng a diagnostic
manual to provide social workers with labels for
client resiliencies. It is perhaps a>domatic that social
workers recognize the benefits of both viewing
clients' problems systemically and recognizing their
unique strengths. However, cliniciansfrequentlyrecognize the importance of addressing existing client
problems {Saleebey, 1996). Families frequently want
advice on problems as well, which social workers
trained in the strengths orientation may be reluctant
to give. The SORT protocol is a model for giving
balanced feedback that incorporates elements of
both the normative approach to assessment with
elements of the strengths perspective to create a
directive yet strengths-based intervention.
STRENGTHS-ORIENTED REFERRAL
FOR TEENS
SORT is a one-hour session during which results
from a comprehensive assessment are reviewed
70
with teens and families. This session integrates the
strengths perspective with traditional normative
assessment approaches by relying on standardized
instruments with empirically validated severity level
cutoffs. Before the SORT session, teens complete
the Global Assessment of Individual Needs—Intake
Venion (GAIN I) (Dennis, 1998), and parents or
significant family members complete the Collateral Assessment Form (CAF) (Dennis,Titus,White,
Unsicker, & Hodgkins, 2002). The GAIN 1 is a
multidimensional.seniistructuredinterview that assesses substance abuse, mental health, environmental,
legal,physical health,and vocational issues.The CAF
collects information from a parent or guardian on
the same topics. These instruments have been validated in large studies, and interpretive ranges exist
for scale scores (Dennis,Titus,White, et al.). Upon
completion, the assessment is scored, reviewed, and
discussed in a group staffing in which substance
abuse placement decisions are made. During staff
meetings, counselors are asked what specific positive
feedback they are going to give teens and parents
so the strengths focus is retained at ail points of the
assessment process.
During the SORT session, the counselor first
spends approximately 20 minutes with the teen
alone reviewing strengths, concerns, and recommendations. Then, the counselor spends 20 minutes with the teen's parents or legal guardian to go
over similar issues. Finally, the counselor spends 20
minutes with the entire family to summarize and
close the session.
The teen segment begins with a brief scripted
introduction with the key points that include telling the client the layout of the session, mentioning
that both strengths and concerns wiU be discussed,
and appealing to the teen's autonomy by saying that
no matter what recommendations are given the
teen is the expert on his or her own Ufe. Next, the
counselor formally reviews strengths that the teen
endorsed on the GAIN I and adds personalized
positive feedback from his or her interactions with
the teen. After reviewing strengths the counselor
asks how these strengths may help the client with
his or her current situation. Next, the counselor
transitions to a dialogue about clinical concerns.
Clinical issues are reviewed with the client and
framed from the perspective of personal concern.
For example, therapists might say, "One thing that
I'm concerned about is that on the assessment you
scored high for depression." Rather than giving firm
Health & SocialWork VOLUME 32, NUMBER I
FEBRUARY
1007
Axis I DSM-IV {Diagnostic and Staiisticai Manual of
Mental Disorders, 4ch ed.} diagnoses in a top-down
manner, client respoases feeding diagnostic criteria
are fed back to the teen.The counselor refers back
to specific client responses and gives a rationale for
why the responses were concerning.This approach
makes the concern concrete for the adolescent and
allows him or her to elaborate.
Finally, the counselor gives the teen recommendations for formal and informal resources.
Services are described in detail by giving contact
names, a description ot the service, past successes in
referring teens there, information on cost, and any
other pertinent information. The counselor draws
connections between the recommendations and
assessment concerns. Throughout the session the
therapist uses empathy, active listening, and solution-focused questioning. For example, when giving recommendations the therapist may say, "What
does your probation officer have to see you doing
differently in order to feel confident that you no
longer need probation?" Finally, counselors gauge
how ready the client is to use the service with a scaling question.Teens are given written feedback that
includes lists of strengths and personalized feedback,
lists of concerns with specific responses they gave,
and a list of recommendations.
The parent segment follows the same format
as the teen segment. In the brief introduction,
the parent is praised for attending and told that
family involvement is often associated with better
outcomes. Personalized praise derived from active
listening in the session is also given to the parent.
All other a.spects of the parent segment are identical to the teen segment. The SORT session ends
with a meeting with both the parent and teen. It
is a time to consolidate agreements, observe family
dynamics, augment family communication, and
close the session.
Training and Quality Assurance
SORT training consists of education and supervised practice that includes lecturing, reading, and
watching videos on motivational interviewing and
solution-focused techniques, recording sessions,and
receiving supervisor feedback from a session rating
form. Feedback from session rating forms includes
concrete examples of how specific solution-focused
questions or empathy statements could have been
used in specific session segments. Items on the session rating form include "I gave positive feedback I
whenever possible," "I read or paraphrased the session introductions," and "I gave a clear rationale for
the recommendations I made."
CONCLUSION
SORT is a concrete application of the social work
strengths perspective to giving recommendations
to teens referred for substance abuse evaluations.
Because SORT is designed to increase teens'
motivation to follow through with assessment recommendations, future research should investigate
whether its use has a measurable effect on teens'
use of recommended services,
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Douglas C. Smith, PhD, LMSH^ is SCY project director,
Adakscent Health and Resource Center, Department of Pediatrics, Vniwrsity of hum, 509 Kirkwood Avemic. Iowa City, lA
52240; e-mail: dou^jlaS'C-smithCwuioim.fdu. James A. HaU,
PhD, USi^is professor, Dejxirtmnit of Pcdicitrici, Children's
Hospital ofhwa, Iowa City. The development of (his article tvas
supported by grant U79Ti13354.01,
Substance Abuse and
Mentitl Health St'n'icesAdmimstraiiim:Streti\jthening Communities- Youth, llie opinions in this article are those ofthe authors
and do not reflect official positions of the government.
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