brief interventions and brief therapy for substance abuse

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Brief

InterventionsAnd Brief

Therapies for

SubstanceAbuse

Treatment Improvem ent Protocol (TIP) Series

34

Kristen Lawton Barry, Ph.D.

C o n s e n s u s P a n e l C h a i r

U .S . D E P A R T M E N T O F H E A L T H A N D H U M A N S E R V IC E S

Public Heal th Service

S u b s t a n ce A b u s e a n d M e n t a l H e a l t h S e r v ic e s A d m i n i s tr a t io n

C e n t e r f o r S u b s ta n c e A b u s e T r e a t m e n t

Rockwal l I I , 5600 Fishers Lane

R o c k v i ll e, M D 2 0 8 5 7


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This publication is part of the Substance A buse

Prevention and Treatment Block Grant technical

assistance program. All m aterial appearing in

this volume except that taken d irectly from

copyrighted sou rces is in the public dom ain andmay be reproduced or copied without

permission from the Substance Abuse and

Mental Health Services Administration's

(SAMH SA) Center for Substance Abuse

Treatmen t (CSA T) or the authors. Citation of

the source is appreciated.

This publication w as w ritten und er contract

number 270-95-0013 with The CDM Group, Inc.

(CDM ). Sandra Clunies, M .S. , I .C.A.D.C., served

as the CSA T governm ent project officer. Rose

M. Urban, L.C.S.W ., J .D., C.C.A.S. , served as the

CDM TIPs project director. Other CDM TIPs

personnel included Raquel Ingraham, M.S.,

project manager; Jonathan Max Gilbert , M.A.,

managing editor; Janet G. Humphrey, M.A.,

editor/writer; Cara Smith, prod uction editor;

Erica Fl ick, editorial assistant; Y-Lang Ngu yen,

former production editor; and Paul Seaman,

forme r editorial assistant. Special thanks go to

consulting writers Scott M. Buchanan, M.S.Ed.;

Dennis M. Donovan, Ph.D.; Jeffrey M. Georgi ,

M.Div.; Delinda E. Mercer, Ph.D.; Larry Schor,Ph .D.; and George E. W oody, M.D.

The opinions expressed herein are the views of

the Consensus Panel members and do not reflect

the official posit ion of CSAT, SAMHSA, or the

U.S . Department of Heal th and Hum an Serv ices

(DHHS). No off i cia l suppo rt or endorsement of

CSAT, SA M HSA , or DHH S for these opin ions or

for particular instruments or software that may

be described in this document is intended or

should be inferred. The guidelines proffered in

this document should not be considered as

substi tutes for individualized cl ient care and

treatment decisions.

DH HS P ubl icat ion No. (SMA) 99-3353

Printed 1999


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Contents

What I s a TIP? .................................................................................................................................................................................................. vii

Edi tor ia l Advisory Board ........................................................................................................................................................................... ix

C o n s en s us P a n e l ............................................................................................................................................................................................. xi

F or ew or d ............................................................................................................................................................................................................ xiii

E x ec u ti ve S u m m a r y a nd R e c o m m e n d a t io n s ............................................................................................................................... xv

S u m m a r y a n d R ec om m en da t i on s ................................................................................................................................................. xvi

Chapter 1— Introduct ion to Br ief In tervent ions andT h e r a p i e s ............................................................................................ 1

An Overview of Br ief In terv ent ion s ................................................................................................................................................ 3

A n O v er v iew of Br ie f T h er a p i es ........................................................................................................................................................ 7

The Dem and for Br ief In tervent ions and Th erapies ............................................................................................................... 8

Barriers to Increasing the Use of Brief Tre atm en ts ................................................................................................................ 10

Evaluat ing Br ief In tervent ions and T he rap ies ........................................................................................................................ 11

Ch a p t er 2 — Br i e f I n te r v en t i on s i n S u b s t a n c e A b u s e T r e a tm e n t ....................................................................................... 13

S t ag es -o f -Ch a n g e M od el ...................................................................................................................................................................... 14

Goals of Brief Intervention .................................................................................................................................................................. 16

Com ponents of Br ief In tervent ions ................................................................................................................................................ 18

Brief In tervent ion W ork boo ks .......................................................................................................................................................... 24

Essential Knowledge and Skil ls for Brief Interventions ..................................................................................................... 25

Brief In terventions in Substance Abuse Treatm ent Pro gram s ....................................................................................... 27

Brief In tervent ions O uts ide Substance Abuse Treatm ent Set t ings ............................................................................... 28

R es ea r ch F i n di n g s ................................................................................................................................................................................... 30

Ch a p t er 3 — Br i e f T h er a p y in S u b s t a n c e A b u s e T r ea t m en t ................................................................................................. 37

Research Findings ................................................................................................................................................................................... 38

When To Use Br ief Therap y ............................................................................................................................................................... 39

Approaches to Br ief Therap y ............................................................................................................................................................ 41

Com ponents of Effect ive Br ief Thera py ...................................................................................................................................... 41

Therapis t Ch aracter i s ti cs..................................................................................................................................................................... 49


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Contents

Ch a p t er 4 — Br i e f Co g n i t i v e -Beh a v i or a l T h er a p y ...................................................................................................................... 51

Behaviora l Th eory ................................................................................................................................................................................... 51

Behaviora l Therapy Techniques Based on Class ica l Cond i tioning M od els ............................................................ 53

Behaviora l Therapy Techniques Based on Operant Learning M od els ...................................................................... 55

Cogni t ive Theo ry ...................................................................................................................................................................................... 61

Cog n it iv e T h er a p y .................................................................................................................................................................................. 63

Cogni t ive-Behaviora l Theory ............................................................................................................................................................ 68

Cogni t ive-Behaviora l Therapy ......................................................................................................................................................... 77

Ch apter 5— Brief Stra tegic/Interact iona l T h era p ies ................................................................................................................. 87

Solut ion-Focused Therapy for Substance A bu se ................................................................................................................... 88

Compatibi l i ty of Strategic/Interactional Therapies and 12-Step Programs ............................................................ 89

When To Use Strategic/Interactional Therapies ..................................................................................................................... 90

Case Study .................................................................................................................................................................................................... 92

S tr at eg ic / In te ra ct io nal T h e r a p ie s ...................................................................................................................................................99

Ch a p t er 6 — Br i e f H u m a n i st ic a n d Ex i s t en ti a l T h e r a p i es ................................................................................................... 10 5

Using Hum anist ic and Exis tent ia l The rapies ......................................................................................................................... 106

The Humanis t i c Approach to Therapy ..................................................................................................................................... 10 9

The Existential Approach to Therapy ......................................................................................................................................... 11 7

Ch a p t er 7 — B r i e f P s y c h ody n a m i c T h er a p y ................................................................................................................................. 121

Ba c k g r ou n d ............................................................................................................................................................................................... 121

Introduction to Br ief Psychodynamic T herap y ..................................................................................................................... 12 2

Psychodynamic Psychotherapy for Substance A bu se ...................................................................................................... 123

Psychodynamic Concepts Useful in Substance Abuse Treatm en t ............................................................................. 12 8

Transference .............................................................................................................................................................................................. 131

Models of Br ief Psychodynam ic Therap y ................................................................................................................................ 13 5

O t h er R es e a r c h ....................................................................................................................................................................................... 14 0

Ch a p t er 8 — B r i e f F a m i l y T h er a p y ..................................................................................................................................................... 143

Appropria teness of Br ief Fami ly The rap y ............................................................................................................................... 14 4

Def in it ion s o f " F a m i l y " ...................................................................................................................................................................... 14 5

Theoret ica l App roaches ...................................................................................................................................................................... 14 7

Using Brief Fami ly The rapie s ......................................................................................................................................................... 15 2

F o l l o w u p .................................................................................................................................................................................................... 15 4

Cul tura l I ssue s ......................................................................................................................................................................................... 15 4

C h a p te r 9— T i m e - L im i t e d G r o u p T h e r a p y ................................................................................................................................. 15 7

Appropria teness of Group Therapy ........................................................................................................................................... 15 7

Group Therapy Approaches ............................................................................................................................................................ 158

Theories of Group Therap y .............................................................................................................................................................. 16 0

Use of Psychodrama Techniques in a Group Set t in g ........................................................................................................ 16 4

Therapeut ic F actors .............................................................................................................................................................................. 16 6

Using T ime-Limited Group The rapy .......................................................................................................................................... 16 8

iv


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Contents

A p p e n d i x A — B i b l i o g r a p h y .................................................................................................................................................................. 173

A p p e n d ix B — I n fo r m a t i o n a nd T r a i n in g R e s o u r c e s ............................................................................................................. 20 9

G en er al Br i e f T h er a p y ........................................................................................................................................................................ 20 9

Cog n i t iv e -Beh a v i ora l T h er a p y ....................................................................................................................................................... 20 9

Stra tegic/Interact iona l T he rap ies ................................................................................................................................................ 21 0

Humanis t i c and Exis tent ia l Therapies ...................................................................................................................................... 211

P s y c h ody n a m i c T h er a p y ................................................................................................................................................................... 21 3

F a m i l y T h er a p y ...................................................................................................................................................................................... 21 3

G r ou p T h er a p y ....................................................................................................................................................................................... 21 4

A p p e n d i x C — G l o s s a r y ............................................................................................................................................................................ 21 5

A p p e n d ix D — H e a lt h P ro m o t io n W o r k b o o k ............................................................................................................................. 221

Part 1: Summ ary of Heal th H ab i ts............................................................................................................................................... 221

Part 2 : Types of Drinkers in the U.S. Population ................................................................................................................. 22 2

Part 3: Consequences of Heavy D rinking ................................................................................................................................ 22 3

Part 4 : Reasons To Qui t or Cut Dow n on Your D rinking ............................................................................................... 22 4

Part 5: Drinking Agreem ent ............................................................................................................................................................. 22 5

Part 6 : Handling Risky Situations ................................................................................................................................................ 22 7

A p p e n d ix E — R e s o u r c e P a n e l .............................................................................................................................................................. 22 9

A p p en di x F — F i e l d R ev i ew er s ............................................................................................................................................................. 231

Figures

1-1 Substance Abuse Sever ity and Level of Ca re ................................................................................................................... 4

1-2 Goal of Brief Interventions Acco rding to Se tt ing .......................................................................................................... 6

2-1 The Stages of C ha ng e .................................................................................................................................................................. 15

2-2 Sample O bject ives .......................................................................................................................................................................... 16

2-3 Am erican Society of Ad dict ion Med ic ine (ASAM ) Patient Placement Cri ter ia ......................................... 18

2 - 4 F R A M E S .............................................................................................................................................................................................. 19

2-5 Scripts for Brief Interv entio n ................................................................................................................................................... 20

2-6 Screening for Brief Interventions for A lcoh olism ........................................................................................................22

2-7 C lien t Feed b ac k an d P la n of A c ti o n ....................................................................................................................................232-8 Ta lking About Change a t Di f ferent Stages ...................................................................................................................... 24

2-9 Steps in Active Lis ten ing .......................................................................................................................................................... 26

2-10 Profess iona ls Outs ide of Substance Abuse Treatm ent W ho Can A dm inister

Brief In tervent ions ........................................................................................................................................................................ 28

3-1 Cri ter ia for Longer Term Tre atm en t .................................................................................................................................. 39

3-2 Selected Criter ia for Providing Br ief Th era py .............................................................................................................. 40

3-3 Approaches to Br ief Th era py ................................................................................................................................................. 42

3-4 Character is t ics of Al l Br ief Th era pies ................................................................................................................................ 44

3-5 Sample Battery of Br ief Assessm ent Instru m ents ...................................................................................................... 45

4-1 Class ica l Cond i tioning and Op erant Lea rning ............................................................................................................. 52


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Contents

4-2 Basic Assum ptions of Behav ioral Theo ries of Sub stance Abu seand I ts Treatm ent .................................. 53

4-3 Ad vantages of Behavioral Theo ries in Treating Substance Ab use D i s o r d e r s ............................................... 54

4-4 Funct iona l An alys is ...................................................................................................................................................................... 56

4 -5 T ea ch i n g S t res s M a n a g em en t ................................................................................................................................................ 60

4-6 Programm ed Therapy and W ri ting The rapy.................................................................................................................

614-7 The Relationship Amo ng Factors M aintaining Behav ior in Beh avioral and

Cogni t ive Models ........................................................................................................................................................................... 62

4-8 F i fteen Com mon Cogn i tive E rror s ....................................................................................................................................... 63

4-9 Characteri s ti c Thinking of People W ith Substance Abuse D isord ers ............................................................. 64

4-10 C omm on I rra t iona l Bel iefs Abou t Alcohol and Drugs With More Rat iona l A l tern at ive s .................. 65

4-11 Thoughts , Feelings, and B eh avio rs ..................................................................................................................................... 66

4-12 In troducing Cogni t ive Therapy: A Samp le Scr ipt ....................................................................................................... 67

4-13 Common Elements of Br ief Cogni t ive-Behaviora l Therapies .............................................................................. 69

4-14 Attr ibutiona l S ty les ...................................................................................................................................................................... 70

4-15 Relapse Prevent ion M odel Based on Self -Eff icacy Th eo ry....................................................................................

734-16 T axono m y of High -Risk Situations Based on M arlatt 's Original

Categoriza t ion System ............................................................................................................................................................... 75

4-17 A Cog ni t ive-Beha viora l Model of the Relapse Pro ces s .......................................................................................... 76

4-18 E ssentia l and Unique Elements of Co gni t ive-Behaviora l In terv ent ion s ....................................................... 78

4-19 In trapersonal and Interpersonal Skil ls Tra in ing E lem en ts .................................................................................... 80

4-20 Assert iveness Tra in ing ............................................................................................................................................................... 80

4-21 Types of Clients for W hom Ou tpat ient CBT Is Genera l ly Not Ap pro pria te ............................................... 85

5-1 Del ibera te and Random Except ions to Substance Abuse Beh avio rs ................................................................ 89

5-2 Strategic/Interactional Therap y in Practice: A Case St u d y ................................................................................... 93

6-1 A Case Stu d y.................................................................................................................................................................................

I l l7 -1 Defense M echan isms ................................................................................................................................................................. 132

7-2 Br ief Psychodynam ic Th erap y ............................................................................................................................................. 136

VI


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What Is a TIP?

T

reatment Improvement Protocols (TIPs)

are best practice guide lines for the

treatment of substance abuse disorders,

provided as a service of the Substance Abuse

and Mental Health Services Administration's

Center for Substance Abuse Treatment (CSAT).

CSA T's Office of Evaluation, Scientific Analysis

and Synthesis draws on the experience and

know ledge of cl inical , research, and

adm inistrative experts to produce the TIPs,

which are distributed to a growing number of

facilities and individuals across the country.

The audience for the TIPs is expanding beyond

public and private substance abuse treatment

faci li ties as alcoholism and o ther substance

abuse disorders are increasingly recognized as

major problems.

The TIPs Editorial Advisory Board, a

distinguished group of substance abuse experts

and professionals in such related fields as

primary care, m ental health, and social services,

works with the State Alcohol and Other Drug

Abuse Directors to generate topics for the TIPs

based on the field's current need s forinformation and guidance.

After selecting a topic, CSAT invites staff

from pertinent Federal agen cies and national

organizations to a R esource P anel that

recomm ends specific areas of focus as well as

resources that should be considered in

developing the content of the TIP. Then

recommendations are communicated to a

Consensus Panel composed of non-Federa l

experts on the topic who have been nominated

by their peer s. This Pan el particip ates in a series

of discussions; the information and

recomm endat ions on w hich i t reaches consensus

form the foundat ion of the TIP. The mem bers of

each Consensu s Panel rep resent substance abuse

trea tme nt programs, hosp i ta ls , comm unity

health centers, counseling programs, criminal

ju sti ce and ch ild w e lfare agencie s, an d pri vate

practi t ioners. A Panel Ch air (or Co-C hairs)

ensures that the gu idelines m irror the results of

the group's col laboration.

A large and diverse group of experts closely

reviews the draft docum ent. Once the changes

recomm ended by these f ield rev iewers have

been incorporated, the TIP is prepared for

publication, in print and on line. The TIPs can be

accessed via the Internet on the National Library

of Med ic ine ' s home page a t the URL:

ht tp ://text .n lm.nih .gov . T he m ove to electronic

media also means that the TIPs can be updated

more easi ly so they continue to provide the field

with state-of-the-art information.

Although each TIP strives to include an

evidence base for the practices i t recommends,CSAT recognizes that the field of substance

abuse treatment is evolving and that research

frequently lags behind the innovations

pioneered in the field. A m ajor goal of each TIP

is to convey "front l ine" information quickly but

responsibly. For this reason, recom m endations

proffered in the TIP are attributed to either

Pan elists ' cl inical experien ce or the l iterature.

I f there is research to supp ort a particular

approach, ci tations are provided.

http://text.nlm.nih.gov/http://text.nlm.nih.gov/


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What Is a TIP?

This TIP, Brie f Interventions and B rie f Therapies

fo r Su bst an ce A buse , is intended prim arily for

counselors and therapists working in the

substance abuse treatment field, but parts of i t

wil l be of value to other aud iences, including

health care workers, social services providers,

clergy, teachers, and criminal justice personne l .

In fact, those portions of this TIP dealing with

brief interventions w il l be of use to any

professional service provider who may need to

make an intervention to help persons with

substance abuse d isorders alter their use

patterns or seek treatment. Ho w ever, brief

therapy should only be practiced by those who

are properly qualified, educated , and l icensed.

The first chapter of this TIP presen ts an

overview of brief interventions and brief

therapies, describing their basic characterist ics

and the reasons for increased interest in them.

Chapter 2 describes the goals and components

of brief interventions, and C hapter 3 discusses

some of the basic elements of all brief therapies.

Chapters 4 throug h 9 each highlight a different

type of brief therapy, d escribing the theory

behind i t as well as some of the techniques

developed from that theory that can be used to

treat cl ients with substance abuse disorders.

Separate chapters are presented describing

cogni t ive-behav iora l therapy,

strategic/interactional therapies, humanistic and

existential therapies, psychodynamic therapies,

family therapy, and grou p therapy. Ap pendixes

are also included that provide resources for

further information and training, a glossary of

terms used in the TIP, and a sample workbook

for use in brief interven tions.

The goal of this TIP is to make readers aware

of the research, results , and pro m ise of brief

interventions and brief therapies in the hope

that they wil l be used m ore w idely in cl inical

practice and treatment programs across the

United States.

Other TIPs may be ordered by contacting

SAM HSA's Nat iona l C l earinghouse f o r Alcoho l and

Drug In format ion (NC AD I) , (800) 729-6686 or

(301) 468-2600; TDD (for hear ing impaired) ,

(800) 487-4889.

viii


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Editorial Advisory Board

Karen Allen, Ph.D., R.N., C.A.R.N.

Professor and Chair

Department of N urs ing

Andrews Univers ityBerrien Springs, Michigan

Richard L. Brown, M.D., M.P.H.

Associate Professor

Department of Fami ly M edic ine

University of Wisconsin School of Medicine

Madison , W isconsin

Dorynne Czechowicz , M.D.

Associate Director

Medical/Professional AffairsTreatment Research Branch

Division of Clinical and Services Research

National Insti tute on Drug Abuse

Rockvil le, Maryland

Linda S. Foley, M.A.

Former Director

Project for Addiction Counselor Training

National Association of State Alcohol and

Drug A buse D irectors

Washington, D.C.

Wayde A. Glover, M.I .S. , N.C.A.C. I I

Director

Com mo nweal th Addict ions Consul tants and

Trainers

Richmond, Virginia

Pedro J . Greer, M.D.

Assistant Dean for Homeless Education

University of Miami School of Medicine

Miami, Florida

Thomas W. Hester , M.D.

Form er Sta te Director

Substance Abu se Serv ices

Div is ion o f Menta l H eal th , M enta lRetardat ion and Substance Abuse

Georgia Department of Human Resources

Atlanta, Georgia

Ja m es G. (G il) H il l, Ph .D .

Director

Off ice of Substance Abuse

Am erican Psych ologica l Associa tion

Washington , D.C.

Douglas B. Kamerow, M.D. , M.P.H.Director

Office of the Forum for Quality and

Effectiveness in Health Care

Agency for Heal th Care Po l icy and Research

Rockvi l le , M aryland

Stephen W. Long

Director

Office of Policy Analysis

National Insti tute on Alcohol Abuse and

Alcohol i sm

Rockvil le, Maryland

Richard A. Rawson, Ph.D.

Execut ive D irector

Matrix Center and Matrix Insti tute on

Addict ion

Deputy Director , UCLA Addict ion Medic ine

Services

Los Angeles, California

I X


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Editorial Advisory Board

Ellen A. Renz, Ph.D.

Former Vice President of Clinical Systems

MEDCO Behaviora l Care Corporat ion

Kamuela , Haw aii

Richard K. Ries, M.D.

Director and Associate Professor

Outpatient Mental Health Services and Dual

Disorder Programs

Harborview Med ica l Center

Seattle, W ashington

Sidney H. Schnoll , M.D., Ph.D.

Chairman

Divis ion of Substance A buse M edic ine

Med ica l Col lege of Virgin ia

Richmond , V irgin ia


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Consensus Panel

Chair

Kristen Lawton Barry, Ph.D.

Associate Research Scientist

Alcohol Research Center

University of Michigan

Ann Arbor, Michigan

Workgroup Leaders

Christopher W. Dunn, Ph.D., M.A.C., C.D.C.

Psychiatry and Behavioral Science

University of Washington

Seattle, W ashington

Je rr y P. F la nzer, D .S .W ., L .C .S .W ., C .A .C .Director

Recovery and Family Treatment, Inc.

Alexandria, V irginia

Stephen Gedo, Ph.D.

Clinical Psych ologist

Gaffney, South Carolina

Eugene Herrington, Ph.D.

Associate Professor

Department of Co unsel ing and P sychologica lServices

Clark Atlanta Un iversity

Atlanta, Georgia

Fredrick R otgers, Psy.D.

Director

Program for Addictions Consultation and

Treatment

Center of Alcohol Studies

Rutgers U niversity

New B runswick, New Jersey

Terry Soo-Hoo, Ph .D.

Clinic Director /A ssistant Professor

Counsel ing Psychology Department

University of San FranciscoSan Francisco, California

Panelists

Ja n ic e S. Ben nett , M .S ., C .S .A .C .

O w n er / Con s u l t a n t

Pacific Consulting and Training Services of

Hawai i

Honolulu , Hawai i

Robert L. Chap m an, M .S .S .W . , C.A.D.O.A.C.,

C.R.P.S.

Cumberland Heights

Nashvi l le , Tennessee

Jo hn W . H erd m an , P h .D ., C .A .D .A .C .

Psychologis t

The Encouragement Place

Lincoln, Nebraska

Fanny G. Nicho lson, C.C.S.W ., A.C.S.W .,

N.C.A.C.I . , C.S.A.E.

Alcohol and Drug Special ist

Oconaluftee Job Corps

Cherokee, N orth Carol ina

Mary Alice Orito, C.S.W., C.A.S.A.C., N.C.A.C.I .

Eva luat ion Supervisor

Stuyvesant Squ are O utpat ient Serv ices for

Ch em i ca l Dep en den c y

New York, New York


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Consensus Panel

Je rom e J. Pla tt , Ph. D.

Professor of Psychiatry and Pub lic Health

Director, Insti tute for Add ictive Disorders

Hahnem ann School of Medic ine

Allegheny U niversity of the Health Sciences

Philadelphia, Pennsylvania

Marilyn Sawyer Sommers, Ph.D., R.N.

Professor

College of Nursing

University of C incinnati

Cincinnati , Ohio

Jo se Luis Sori a , M .A ., L .C .D .C ., I.C .A .D .C .,

C.C.G.C. , C.A.D.A.C.

Clinical Deputy D irector

Aliviane NO-AD, Inc.

El Paso, Texas

Ava H. Stanley, M.D.

Somerset , New Jersey

Robert S. Stephens, Ph.D.

Associate Professor

Departm ent of Psychology

Virginia Po lytechnic Insti tute and State

University

Blacksburg, Virginia


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Foreword

T

he Treatment Im provem ent Protocol

(TIP) ser ies fu l fi ll s SAM HS A/ CSA T's

mission to improve treatment of

substance abuse by providing best practices

guidance to cl inicians, program administrators,

and payors. TIPs are the result of careful

consideration of al l relevant cl inical and he alth

services research findings, demonstration

experience, and implementation requirements.

A panel of non -Federa l cl inical researchers,

cl inicians, program administrators, and cl ient

advocates deb ates and d iscusses i ts particular

areas of expertise unti l i t reaches consen sus on

best practices. This pane l 's work is then

reviewed and critiqued by field review ers.

The talent, dedication, and hard work that

TIPs panelists and reviewe rs bring to this highly

participatory process have bridged the gap

between the promise of research and the needs

of practicing clinicians and adm inistrators. We

are grateful to al l wh o hav e joined with us to

contribute to advances in the substance abuse

treatment field.

Nelba Ch avez , Ph .D.

Adminis tra tor

Substance Abuse and M enta l Heal th

Serv ices Adm inis tra t ion

H. W estley Clark, M .D., J .D., M.P.H.,

CA S , F A S A M

Director

Center for Substance Abuse Treatment

Substance Abu se and M enta l Health

Serv ices Adm inis tra t ion


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Executive Summary and

Recommendations

This Treatment Improvement Protocol

(TIP) responds to an increasing body of

research literature that documents the

ceffectiveness of brief interventions and therapies in

both the mental health and substance abuse

treatment fields. The general purpose of this

document is to link research to practice by providing

counselors and therapists in the substance abuse

treatment field with up-to-date information on theusefulness of these innovative and shorter forms of

treatment for selected subpopulations of people with

substance abuse disorders and those at risk of

developing them. The TIP will also be useful for

health care workers, social service providers who

work outside the substance abuse treatment field,

people in the criminal justice system, and anyone else

who may be called on to intervene with a person who

has substance abuse problems.

efforts and more intensive treatment for persons with

serious substance abuse disorders. However, studies

have shown that brief interventions are effective for a

range of problems, and the Consensus Panel believes

that their selective use can greatly improve substance

abuse treatment by making them available to a greater

number of people and by tailoring the level of

treatment to the level of client need.

Brief interventions can be used as a method of

providing more immediate attention to clients on

waiting lists for specialized programs, as an initial

treatment for nondependent at-risk and hazardous

substance users, and as adjuncts to more extensive

treatment for substance-dependent persons.

Brief therapies can be used to effect significant

changes in clients' behaviors and their understanding

of them . The term "brief therapy" covers several

treatment approaches derived from a number oftheoretical schools, and this TIP considers many of

them . The types of therapy presented in these chapters

have been selected for a variety of reasons, but by no

means do they represent a comprehensive list of

therapeutic approaches currently in practice. Some of

these approaches (e.g., cognitive-behavioral therapy)

are supported by extensive research; others (e .g.,

existential therapy) have not been, and perhaps cannot

be, tested in as rigorous a manner .

Brief interventions and brief therapies have

become increasingly important modalities in the

treatment of individuals across the substance abuse

continuum. The content of the interventions and

therapies will vary depending on the substance used,

the severity of problem being addressed, and the

desired outcome.

Because brief interventions and therapies a

re less costly yet have proven effective in substance

abuse treatment, clinicians, clinical researchers, and

policymakers have increasingly focused on them as

tools to fill the gap between primary prevention


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Executive Summary and Recommendations

This TIP presents the historical backgrou nd,

outcomes research, rationale for use, and state-

of-the-art practical method s and case scenarios

for impleme ntation of brief interventions and

therapies for a range of problems related tosubstance abuse. This TIP is based on the body

of research conducted on brief interventions and

brief therapies for substance abuse as well as on

the broad cl inical expertise of the Con sensus

Panel . Because many therapists and other

practitioners are eclectically trained, elements

from each of the chapters may be of use to a

range of p rofessionals.

This discussion of brief therapies is in no

way intended to detract from the value of longer

term therapies that cl inicians have found to be

effective in the treatmen t of substance abuse

disorders. How ever, the Co nsensus Panel

believes it necessary to discuss innovative

and/or often-used theories that members have

encountered and applied in their clinical

practice.

The Consensus Pan el 's recomm endat ions

summarized below are based on both research

and clinical experience. Those sup ported by

scientific evidence are followed by (1); clinically

based recommendations are marked (2).

Citations for the former are referenced in the

body of this document, where the guidelines are

presen ted in full detail. M any of the

recommendations made in the latter chapters of

this TIP are relevant only within a particular

theoretical framew ork (e.g. , the Panel might

recommend how a person practicing strategic

therapy should approach a particular si tuation);

because such recommendations are not

applicable to all readers, they have not been

included in this Executive Summary.

Throughout this TIP, the term "substance

abuse " has been used in a general sense to cover

both substance abuse disorders and substance

dependence disorders (as defined by the

Diagnostic and Statis t ical M anual o f M ental

Disorders, 4th Edition [DSM-IV] [American

Psychiatric Asso ciation, 1994]). Because the

term "substance abu se" i s com mo nly used by

substance abuse treatment professionals to

describe any excessive use of addictive

substances, i t wil l be used to denote both

substance dependence and substance abuse.

The term includes the use of alcohol as well as

other substances of abuse. Reade rs should

attend to the contex t in which the term occurs in

order to determine the meaning; in most cases,

the term will refer to all varieties of substance

abuse disorders as descr ibed by D SM-IV.

Summary and

Recommendations

Brief Interventions

Brief interventions are those p ractices that aim

to investigate a potential problem and motivate

an individual to begin to do something about his

substance a buse, ei ther by na tural , cl ient-

directed means or by seeking additional

substance abuse treatment.

A brief intervention, however, is only one of

m any too ls available to clinicians. It is not a

substi tute for care for cl ients with a high level of

depen dency . I t can, how ever, be used to engage

clients who n eed spec ial ized treatment in specific

aspects of treatment programs, such as

attending group therapy or Alcoholics

Anonymous (AA) meet ings .

■ T h e Con s en s u s P an e l b e l iev es th a t b r ie f

interventions can be an effective ad dition tosubstance abuse t reatment programs. These

approaches can be particularly useful in

treatment sett ings when they are used to

address specific targeted cl ient behaviors and

issues in the treatm ent process that can be

difficult to change using standard treatment

approaches. (2)

■ V a r ia t ion s o f b r ie f in t e rv en t ion s h a v e b een

found to be effective both for motivating

alcohol-dependent individuals to enter

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1. Introducing the issues in the context of the client'shealth.

3. Providing feedback.

4. Talking about change and setting goals.

Goals of brief interventionsThe basic goal of any brief intervention is to reduce the

risk of harm that could result from continued use of

substances. The specific goal for each individual client

is determined by his consumption pattern, the

consequences of his use, and the setting in which the

brief intervention is delivered .

■ Focusing on intermediate goals allows for more

immediate success in the intervention and

treatment process, whatever the longterm goals

may be. Intermediate goals might include quitting

one substance, decreasing frequency of use, or

attending a meeting. Immediate successes are

important to keep the client motivated. (2)

■ The Consensus Panel recommends that programs

use quality assurance improvement projects to

determine whether the use of a brief intervention

or therapy in specific treatment situations is

enhancing treatment. (2)

■ The Consensus Panel recommends that agencies

allocate counselor training time and resources to

these modalities. It anticipates that brief

interventions will help agencies meet the increasing

demands of the managed care industry and fill the

gaps that have been left in client care. (2)

■ Substance abuse treatment personnel should

collaborate with other providers (e.g., primary

care providers, employee assistance program,

wellness clinic staff, etc.) in developing plans that

include both brief interventions and more

intensive care to help keep clients focused on

treatment and recovery.(2)

Components of brief interventions

There are six elements that are critical for effective

brief interventions. (1) The acronym FRAMES was

coined to summarize these six components:

■Feedback is given to the individualabout personal risk or impairment

■ Responsibility for change is placed onthe participant.

■Advice to change is given by theclinician.

■ Menu of alternative self-help or treatmentoptions is offered to the participant.

■ Empathic style is used by the counselor.

xv ii

■ When conducting a brief intervention, the clinician

should set aside the final treatment goal (e.g.,

accepting responsibility for one's own recovery) to

focus on a single behavioral objective. Once this

objective is established, a brief intervention can be

used to help reach it. (2)

long-term alcohol treatment and for treating

some alcohol-dependent persons. (1)

■ Self-efficacy or optimisticempowerment is engendered in the

participant..

Essential knowledge and skills for briefinterventions

Providing effective brief interventions requires the

clinician to possess certain knowledge, skills, and

abilities. The following are four essential skills (2):

A brief intervention consists of five basic steps that

incorporate FRAMES and remain consistent regardless

of the number of sessions or the length of the

intervention:

Providers may not have to use all five of these

components in any given session with a client.

However, before eliminating steps in the brief

intervention process there should be a well-defined

reason for doing so. (2)

Screening, evaluating, and assessing.

5. Summarizing and reaching closure.

2.

1. An overall attitude of understanding and

acceptance.


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Executive Summary and Recommendations

2 . Counse l ing sk i ll s such as act ive l is tening

and helping cl ients explore and resolve

ambivalence

3 . A f oc u s o n in t e rm e d i a t e g o a ls

4 . A w o r k in g k n o w l e d g e o f t he s ta g e s- o f-change through wh ich a c li ent mo ves when

thinking about , beginning, an d trying to

mainta in new behavior

Brief Therapies

Brief therapy is a systematic , focused process

that relies on assessm ent , c l ient engagem ent,

and rapid implementat ion of change strategies .

The b rief therapies presen ted in this TIP shou ld

be seen as separate m odal i t ies of treatmen t , notepisodic forms of long-term therapy.

Brief therapies usual ly feature m ore (as wel l

as longer) sessions than brief interventions. The

durat ion of brief therapies is reported to be

anyw here from 1 to 40 sessions, with the typical

therapy last ing b etwee n 6 and 20 sessions.

Brief therapies also differ from brief

interventions in that their goal is to provide

cl ients w ith tools to chan ge b asic at t i tudes and

handle a variety of und erlying problem s. Brief

therapy differs from longer term therapy in that

i t focuses more on the present , downplays

psychic causal i ty , emphasizes the effect ive use

of therapeutic tools in a shorter time, and

focuses on a speci f ic behavioral change rather

than large-scale or pervasive change.

Research concerning relat ive effect iveness of

brief versus longer term therapies for a variety

of presenting comp laints is mixed . H ow ever,

there is evidence sug gest ing that brief therapies

are often as effective as lengthier treatments for

certain populat ions.

■ T h e b es t o u t co m e s f o r b r ie f th e ra p y m a y

depend on cl inician ski l ls , comprehensive

assessmen ts , and select ive cri teria for

eligibility. U sing selective criteria in

prescribing brief therapy is cr i tical , s ince

m any cl ients wil l not m eet i ts eligibi li ty

requirements . (2)

■ B r ie f t h e ra p y fo r su b s t a n ce a b u se tr e at m e n t

is a valuable approach, but i t should no t be

considered a s tandard of care for al l

popu lat ions . (1) The Consensus Panel hopes

that brief therapy wil l be adequatelyinves t igated in each case before m anaged

care compan ies and th i rd-par ty payors

decide i t i s the only modal i ty for which they

will pay.

■ B r ie f i n te r v e n ti o n s an d b r i ef th e r a p ie s ar e

wel l sui ted for c li ents who m ay no t be

wil l ing or able to expend the s ignificant

personal and financial resources necessary to

com plete more intens ive , longer term

treatments . (2)

■ B o th r e s e a rc h a n d c l in i c al e x p e rt is e in d i ca te

that individuals who are funct ioning in

society but have patterns of excessive or

abusive substance use are unl ikely to

respond p os i tive ly to som e forms of

tradit ional treatment , but some of the briefer

approaches to intervention and therapy can

be extrem ely useful c l inical tools in their

treatment . (1)

When t o use br i ef t herap y

Determining w hen to use a par t i cular type of

brief therapy is an important considerat ion for

coun selors and therapists . T he Panel

recommends that c l ient needs and the suitabi l i ty

of brief therapy be evaluated on a case-by-case

basis . (2) Som e criteria for considering the

appropriateness of brief therapy for c l ients

include

■ D u a l d ia g no sis is su e s

■ T h e r a n g e an d s ev e r it y o f p r e s en t in g

problems

■ T h e d u ra ti on o f s u b st an c e d ep e n d en c e

■ A v a i la b i li ty o f f a m i li a l a n d c o m m u n i ty

supports

■ T h e le v e l a n d ty p e o f i n fl u e n ce f ro m p e e r s,

fami ly , and communi ty

■ P r e v io u s t re a t m e n t o r a t te m p t s a t r e co v e ry

■ T h e le v e l o f c li en t m o t iv a tio n

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19/254

Execut ive Summary and Recommendat ions

■ The c lar ity of the c l ient' s short - and long

term goals

■ T h e c li en t's b e l ie f in t h e v al u e o f b r ie f

therapy

■ T h e n u m b er s o f c l ien ts n eedi n g tr ea tm en t

The fol lowing criteria are derived from Panel

members' cl inical experience:

■ Less s ev er e su b s ta n c e dep en den c e , a s

measured by an instrument l ike the

Addiction Severity Index (ASI)

■ Level of past t rauma a ffecting the c lient 's

substance abuse

■ I n su f fi ci ent r esou r ces a v a i la b le for m or e

prolonged therapy■ Lim i ted a m ou n t of ti m e a v a il ab l e for

treatment

■ P r esen c e o f c oex is ti n g m edic a l or m en t a l

health diagnoses

■ La r ge n u m b er s o f c li en t s n eedin g t rea tm en t

leading to waiting lists for specialized

treatment

The Consensus Panel also notes that

■ P la n ned b r i ef th er ap y c a n b e a da p ted a s p ar tof a course of serial or intermittent therapy.

When doing this , the therapist conceives of

long-term treatment as a number of shorter

treatments, which require the cl ient 's

problems to be addressed serial ly rather than

concurrently. (1)

■ Br ie f th er ap i es w i ll b e m os t e ffect iv e w i t h

cl ients whose problems are of short duration

and who have strong t ies to family, work,

and comm unity . How ever , a num ber of

other conditions, such as l imited cl ient

resources, may also dictate the use of brief

therapy. (2)

■ I t i s essentia l to learn the c lient 's perceived

obstacles to engaging in treatm ent as well as

to identify any d ysfunction al bel iefs that

could sabotage the eng agem ent process. The

crit ical factor in determ ining an ind ividual 's

response is the cl ient 's self-percep tion and

associated emotions. (1)

Component s o f effect i ve

br i ef therapy

While there are a variety of different schools of

brief therapy available to the cl inician, al l forms

of br ief therapy share some com m oncharacterist ics (2):

■ T h ey ar e ei th er p r ob lem foc u s ed or s o lu t ion

focused— they target the sym ptom, not i ts

causes.

■ They c lear ly define goa ls re la ted to a specif ic

change or behavior .

■ T h ey s hou l d b e u n ders t an da b l e to b ot h c li en t

and cl inician.

■ T h e y sh o u ld p r o d u c e im m e d ia te r es ul ts .

■ T h ey ca n be eas il y in f lu en c ed by th e

personali ty and counseling style of the

therapist .

■ T h ey r el y on ra p id es t a b l is h m en t o f a s tr ong

wo rking rela t ionship between c l ient and

therapist.

■ T h e t h era p eu t ic s ty l e is h ig h ly a c ti ve ,

emp athic , and som et imes direct ive .

■ R es p on s ib i li ty for c h a ng e i s p l ac ed c lea rl y on

the client.■ Early in the process , the focus is to help the

cl ient enhance his self-efficacy and

understand that change is possible.

■ T er m i n a ti on is d is c u ss ed f rom t h e b eg in n in g .

■ O u tc om e s ar e m e a su ra ble .

Screeni ng and assessment

Screening and assessment are cri t ical init ial

steps in brief therapy. Screen ing is a process in

which cl ients are identified according to

characterist ics that indicate they are possibly

abusing substances. Screen ing identifies the

need for m ore in -depth assessm ent but i s not an

adequate sub st itute for com plete assessment .

Assessment is a more extensive process that

involves a broad analysis of the factors

contributing to and maintaining a cl ient 's

substance abuse, the severity of the problem,

and the variety of consequences associated with

it. Screening and assessm ent proced ures for

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Executive Summary and Recomm endat ions

brief therapy do not d iffer significantly from

those used for lengthier treatments.

■ Cl in ic ians can use a var iety of br ief

assessment instruments, many of which are

free. These instruments should be

supplemented in the first session by a clinical

assessment interview that covers current use

patterns, history of substance use,

consequences of substance abuse, coexisting

psychiatric disorders, major medical

problems and health status, education and

emp loyment s ta tus , support mechanisms,

cl ient strengths and s ituational advantages,

and family history. (2)

■ T h e s c reen in g a nd a s ses s m en t p r oces s

should determine whether the cl ient 's

substance abuse problem is suitable for a

brief therapy ap proach. (2)

■ A s s ess m en t is c ri ti ca l n ot on ly b e fore

beginning b rief therapy but also as an

ongoing part of the process. (2)

■ T h era p is ts w h o p r im a r i ly p r ov ide b r ie f

therapy should be ad ept at determining early

in the assessm ent process w hich cl ient needs

or goals are appropriate to address. Related

to this, and equally important, the therapist

must establish relationships that faci l i tate the

cl ient 's referral when her ne eds or goals

cannot be me t through brief therapy. (2)

The fi r st sessi on

In the first session, the main goals for the

therapist are to gain a broad unde rstanding of

the client 's presenting prob lems, beg in to

establish rappo rt and an effective working

relationship, and imp lemen t an initial

intervention, however small .

■ C o u n se lo r s s ho u ld g a th e r as m u c h

information as p ossible about a cl ient before

the first counseling session. Ho wever, when

gathering inform ation about a cl ient from

other sources, counselors m ust be sensit ive to

confidential i ty and cl ient consen t issues. (2)

■ T h er a p is t s s h ou ld i den t ify a nd d i s cu s s th e

goals of brief therapy with the cl ient early in

treatment, p referably in the first session. (2)

■ A l th ou g h a b s t in en c e is a n op ti m a l c li ni ca l

goal , i t st i ll mu st be nego tiated w ith thecl ient (at least in ou tpatient treatme nt

sett ings). Ab stinence as a goal is not

necessar ily the sole adm iss ion req uirement

for treatment, and the therapist may have to

accept an alternative goal , such as decreased

substance use, in order to engage the cl ient

effectively. (2)

■ T h e p ro v id e r o f b r ie f th e ra p y m u s t

accom plish certain cri t ical tasks during the

first session (2), including

♦ P ro d uc in g ra pid e n g ag e m e nt

♦ I dent ify in g , foc u si n g , a nd p r i ori ti zi n g

problems

♦ W or k i n g w it h th e c l ien t to dev e lop a

treatment plan and possible solutions for

substance abuse problem s

♦ N eg ot i at in g th e a p p r oa ch tow a r d c h an g e

with the cl ient (which may involve a

contract between cl ient and therapist)

♦ E l ic it in g c li en t c on c er ns a b ou t p r ob lem s

and solutions

♦ U n d e r st an d i ng c l ie n t e xp e c ta ti on s

♦ Ex p l ai n in g th e s t ru c t u r al f ra m ew or k of

brief therapy, including the process and i ts

l imits (i .e. , those i tems n ot w ithin the

scope of that treatment segment or the

agency ' s work)

♦ M a k in g r e fe rr a ls for c r it ic a l n eeds th a t

have been ident i f ied bu t cannot be met

within the treatment sett ing

M ai nt enance str at egi es,

termi nat i on of therapy ,and f ol l ow up

Maintenance strategies must be built into the

treatmen t design from the beginn ing. A

practi t ioner of brief therapy must continue to

provide support , feedback, and assistance in

sett ing real ist ic goals. Also, the therapist should

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Execut ive Sum mary and Recommendat ions

help the cl ient identify relapse triggers and

situations that could endanger continued

sobriety. (2)

Strategies to help cl ients ma intain the

progress made during brief therapy include the

following (2):

■ Edu c a ti n g th e c li en t a bou t th e ch r on ic ,

relapsing nature of substance abuse

■ C o n si de ri ng w h i c h c ir cu m s t an c es m i g h t

cause a cl ient to return to treatmen t and

planning how to address them

■ R e v ie w in g p ro b le m s t h at e m e rg e d b u t w e re

not addressed in treatment and helping the

cl ient develop a plan for addressing them in

the future

■ Dev e lop i ng s t r at eg ies for iden t ify in g a n d

coping w ith high-risk si tuations or the

reemergence of substance abuse behaviors

■ T ea ch i ng t h e c li ent how t o c a p it a li z e on

personal strengths

■ Em p h a s i zi n g cl ien t s el f- s u ff ic i en c y a n d

teaching self-reinforcement techniques

■ Dev e lop in g a p l a n for fu tu r e su p p or t,

including mutual help groups, family

support , and comm unity support

Termination of therapy should always be

planned in advance. (2) W hen the client has

made the agreed-upon behav ior changes and

has resolved some problems, the therapist

should prepare to end the brief therapy. I f a

cl ient progresses more quickly than anticipated,

i t is not necessary to com plete the ful l num ber of

sessions.

Therapi st character i st i cs

Therapists wil l benefit from a firm grounding in

theory and a broad technical knowledge of the

many different approaches to brief therapy that

are available. (2) W hen appro priate, elem ents of

different brief therapies may be combined to

provide successful outcom es. H ow ever, i t is

important to remember that the effectiveness of

highly defined interventions (e.g. , workbook-

driven interventions) used in some behavioral

therapies depends on administration of the

entire regimen.

■ T h e t h er a p is t m u s t u s e c a u ti on i n c om b in in g

and m ingl ing certa in techniques and mu st be

sensit ive to the cultural context within which

therapies are integrated. (2)

■ T h er a p is t s sh ou l d b e su f f ic i en t ly t r ai n ed i n

the therapies they are using and should not

rely solely on a m anu al such as this to learn

those therap ies. (2)

■ Tra in ing for br ief therapies , in contrast to the

tra in ing necessary to condu ct br ief

interventions, requires months to years and

usually results in a special ist degree or

cert if i ca t ion . The Co nsensus Panel

recomm ends that anyone seeking to pract ice

the therapies outl ined here should receive

more thorough training appropriate to the

type of therapy being delivered. (Append ix

B of the TIP provides contact information for

some organizat ions that m ay be able to

provide such training.) (2)

■ P r ov ider s o f b r i ef th er a p y sh ou ld b e ab le to

focus effectively on identifying and adhering

to specific the rapeu tic goals in treatment. (2)

■ P r ov ider s w h o p ra c t ic e b r ie f th er ap y sh ou ld

be able to disti l l approaches from longer

term therapies and apply them within the

parameters of brief therapy. (2)

Cognitive-Behavioral Therapy

CBT represents the integration of principles

derived from behavioral theory, cognitive social

learning theory, and cognitive therapy, and i t

provides the basis for a more inclusive and

com prehensive ap proach to trea t ing substance

abuse disorders.

CB T can be used by p roperly l icensed and

trained mental health practi t ioners even i f they

have l imited experience with this type of

therapy— either as a cost-effective primary

approach or in conjunction with other therapies

or a 12-Step program . CB T can be also used

early in and throughout the treatment process

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22/254

Executive Summ ary and Recommendat i ons

wh enever the therapist feels i t is imp ortant to

examine a cl ient 's inaccurate or unproductive

thinking that could lead to risky or negative

behaviors. (2)

CB T is generally not ap propriate for certain

clients, namely, those

■ W h o h a v e p sy c h oti c or b ip o l a r d i sor ders a nd

are not stabil ized on m edication

■ W h o h a ve n o s ta b le l iv in g a r ra n g em en ts

■ Who are not med ica lly s table (as assessed by

a pretreatm ent physical examination) (2)

Cognit i ve-behav i oral t echniques

The cogn i t ive-behaviora l m odel assumes that

substance abu sers are deficient in coping skills ,

choose not to use those they have, or are

inhibited from doing so. It also assum es that

over the course of t ime, substance abusers

develop a particular set of effect expectancies

based on their observations of peers and

significant others abusing substances to try to

cope with difficult situations, as well as through

their own experiences o f the posit ive effects of

substances.

■ CBT is genera lly effective because i t helps

clients recognize the situations in which they

are likely to use substances, find ways of

avoiding those si tuations, and cope more

effectively with the variety of situations,

feelings, and behaviors related to their

substance abuse. (2) To achieve these

therapeutic goals, CBT incorpo rates three

core elements:

♦ Functional analys is— This analysis attemp ts

to identify the antecedents and

consequences of substance abuse behavior,

which serve as triggering and m aintaining

factors.

♦ Coping skills training— A m a jor com p on en t

in CBT is the development of appropriate

coping skills.

♦ Relapse prevention — These approaches re ly

heavily on fu nctional analyses,

identification of high-risk relapse

situations, and co ping skil ls training, but

also incorporate additional features. These

approaches attempt to deal directly with a

number of the cognitions involved in the

relapse process and focus on helping the

individual gain a more posit ive self-

efficacy.

■ O v er a ll , b eh a v ior a l, c og n it iv e , an d c og n i t iv e -

behavioral interventions are effective, can be

used with a wide range of substance abusers,

and can be conducted w i th in the t imeframe

of brief therapies. (1)

■ A b roa d r an g e of c og n i ti on s w il l b e

evaluated in CBT, including attributions,

appraisals , self-efficacy expectancies, and

substance-related effect expectancies. (2)

Strategic/Interactional Therapies

Strategic/interactional therapies attempt to

identify the cl ient 's strengths and actively create

personal and environmental si tuations in which

success can be achieved. The primary strength

of strategic/interactional ap proa ches is that they

shift the focus from the cl ient 's weaknesses to

his strengths.

The s t ra tegic/interactiona l m odel has been

widely used and successfully tested on persons

with serious and persistent m ental i l lnesses. (1)

Although the research to date on these therapies

(using nonexperimental designs) has not

focused on substance abuse disorders, the use of

these therapies in treating substance abuse

disorders is growing.

The Consensus Panel bel ieves that these

therapeutic approaches are potential ly useful for

cl ients with substance abuse disorders and

should be in troduced to offer new know ledge

and techniques for treatment providers to

consider. (2)

Using st r a t egi c/ in t eract i ona l

therapies

No matter which type of strategic/interactional

therapy is used, this approach can help to


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■ Define the situation that contributes to substance

abuse in terms meaningful to the client (2)

Strategic/interactional approaches are most

useful in

Humanistic and Existential Therapies

Humanistic and existential psychotherapies use a

wide range of approaches to the planning and

treatment of substance abuse disorders. They are,

however, united by an emphasis on understanding

human experience and a focus on the client rather

than the symptom. Humanistic and existentialapproaches share a belief that people have the

capacity for selfawareness and choice. However, the

two schools come to this belief through different

theories.

they tend to facilitate therapeutic rapport, increase

self-awareness, focus on potential inner resources

and establish the client as the person responsible for

recovery. Thus, clients may be more likely to see

beyond the limitations of short-term treatment and

envision recovery as a lifelong process of working to

reach their full potential. (2)

■ Client-centered therapy can be used immediately to

establish rapport and to clarify issues throughout the

session. (2)

■ Existential therapy may be used most

effectively when a client has access to emotional

experiences or when obstacles must be

overcome to facilitate a client's entry into or

continuation of recovery (e.g., to get someone

who insists on remaining helpless to accept

responsibility for her actions). (2)

■ Gestalt approaches can be used throughout therapy

to facilitate a genuine encounter with the therapist

and the client's own experience. (2)

■ Narrative therapy can be used to help the client

conceptualize treatment as an opportunity to assume

authorship and begin a "new chapter" in life. (2)

Using humanistic and existential

therapies

Many aspects of humanistic and existential

approaches (including empathy, encouragement of

affect, reflective listening, and acceptance of the

client's subjective experience) can be useful in anytype of brief therapy. They help establish rapport and

provide grounds for meaningful engagement with all

aspects of the treatment process. (2)

Humanistic and existential approaches can be

used at all stages of recovery in creating a foundation

of respect for clients and mutual acceptance of the

significance of their experiences. (2) There are,

however, some therapeutic moments that lend

themselves more readily to one or more specific

approaches.

■ Identify steps needed to control or end substance

abuse (2)

■ Heal the family system so it can better support

change (2)

■ Maintain behaviors that will help control

substance abuse (2)

■ Respond to situations in which the client has

returned to substance use after a period of

abstinence (2)

Most forms of strategic/interactional therapies are

brief by the definition used in this TIP. Strategic/

interactional therapies normally require 6 to 10

sessions, with 6 being most common.

■ Learning how the client's relationships deter orcontribute to substance abuse (2)

■ Shifting power relationships (2)

■ Addressing fears (2)

Humanistic and existential therapeutic

approaches may be particularly appropriate for

short-term substance abuse treatment because ,


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Execut ive Summ ary and Recommendat i ons

■ Transpersonal therapy can enhance spiri tual

development by focusing on the intangible

aspects of human experience and awareness

of unrealized spiritual capacity. (2)

Using a hum anistic or existential therapy

framew ork, the therapist can offer episodic

treatment, with a treatment plan that focuses on

the cl ient 's tasks and exp eriences betwe en

sessions. (2)

For many c l ients , mom entary c i rcumstances

and other problems surrounding substance

abuse may seem more pressing than notions of

integration, spirituality, and existential growth,

which may be too remote from their immediate

situation to be effective. In such instances,

hum anistic and existential approaches can help

clients focus on the fact that they do indeed

make decisions about substance abuse and are

responsible for their ow n recovery. (2)

Psychodynamic Therapies

Psychodynamic therapy focuses on unconscious

processes as they are man ifested in the cl ient 's

present behavior. The goals of psycho dyn am ictherapy are cl ient self-awarene ss and

understanding of the past 's influence on present

behavior. In i ts brief form, a psychodyn am ic

approach enables the cl ient to exam ine

unresolved confl icts and symptoms that arise

from past dysfunctional relationships and

manifest themselves in the need and/or desire

to abuse substances.

Several of the brief forms of psychodynamic

therapy are less appro priate for use w ith

persons with substance abuse disorders, partly

because their altered p erceptions m ake i t

difficult to achieve insight and p roblem

resolut ion . How ever , many psychodynam ic

therapists use forms of brief psychodynamic

therapy with substance -abusing cl ients in

conjunction with traditional substance abuse

treatment program s or as the sole therapy for

cl ients w ith coexisting d isorders. (2)

Although there is some disagreement in the

detai ls , psychodynamic brief therapy is

general ly thought more suitable for (2)

■ T h o se w h o h a ve c o e xi st in g p s y ch o p at ho lo g y

with their substance abuse disorder

■ T h os e w ho d o n o t n ee d o r w h o ha ve

comp leted inpat ient hospi ta l iza t ion or

detoxification

■ T h o se w h o s e r e co v e ry i s s ta b le

■ T h o se w h o d o no t h a v e or g an ic b ra in

damage or other l imitations to their mental

capacity

I nt egrat i ng psychody nam i c concepts

i nto subst ance abuse t reat ment

Most therapists agree that people with substance

abuse disorders comprise a special population,

one that often requires more than one approach

if treatme nt is to be successful . Therap ists

whose orientations are not necessari ly

psychodynamic may sti l l f ind these techniques

and approaches useful , and therapists whose

approaches are psychodynamic may be more

effective i f they conduct psychotherapy in a way

that complements the ful l range of services for

cl ients with substance abuse disorders. (2)

Family Therapy

For many indiv iduals wi th substance abuse

disorders, interactions with their family of

origin, as well as their current fam ily, set the

patterns and dynamics for their problems with

substances. Furthermore, fami ly mem ber

interactions with the substance abuser can either

perpetuate and aggravate the problem or

substantial ly assist in resolving i t. Family

therapy is particularly appropriate when the

cl ient exhibits signs that his substance abu se is

s t rongly in f luenced by fami ly mem bers '

behaviors or communications with them. (2)

Family involvement is often cri t ical to

success in treating many substance abuse

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Execut ive Summ ary and Recommendat i ons

disorders— mo st obviously in cases where the

family is part of the problem. (2)

Family therapy can be used to

■ F ocu s on th e ex p ec ta t ion o f c h a n g e w it h in

the family (which may involve multiple

adjustments)

■ T e st ne w p a tt er n s of b eh a vio r

■ T ea ch how a fam i l y s y s tem w or k s — h ow t h e

family supports symptoms and maintains

needed roles

■ El ic it th e st ren g th s o f ev er y fa m il y m em b er

■ Ex p lor e th e m ea n i n g o f t he s u b s ta n c e a bu s e

disorder w ithin the family

A ppropr i at eness of bri ef f ami ly therapy

Long-term family therapy is not usually

necessary for the treatment of substance abuse

disorders. W hile family therapy may be very

helpful in the initial stages of treatment, it is

often easier to continue to help an individual

work within the family system through

subsequen t individual therapy. (2)

Short-term fam ily therapy is an option that

could be used in the fol lowing circumstances (2):

■ W h en r eso lv i ng a sp ec if ic p r ob lem i n t he

family and working toward a solution

■ When the therapeut ic goa ls do not require in-

depth, multigenerational family history, but

rather a focus on presen t interactions

■ W h en t he fam i ly a s a w h ole c an b en efi t f rom

teaching and communication to better

understand some aspect of the substance

abuse disorder

Def in i t i ons o f " f ami l y "

Family therapy can involve a network that

extends beyond the immediate family, involves

only a few members of the family system, or

even deals with seve ral families at once. (2) The

definit ion of “fam ily" varies in different cultures

and situations and should be defined by the

client.

Therapis ts can "cre a te" a fami ly by drawing

on the cl ient 's network of significant contacts.

(2) A more imp ortant question than wh ether the

cl ient is l iving with a fam ily is, "C an the cl ient 's

problem be seen as having a relational

( involv ing two or more people) com ponen t?"

U sing br i ef fam i l y therap ies

In order to promote change successfully within

a family system, the therapist wil l need the

family's permission to enter the family space

and share their closely held confidences. The

therapy, however, wil l work best i f i t varies

according to the cultural background of the

family. (1)Most family therapy is conducted on a short

term basis . Sessions are typical ly 90 minutes to

2 hours in length. The pre ferred t ime line for

family therapy is not more than 2 sessions per

week (except in residential sett ings), to allow

time to practice new behaviors and experience

change. The rapy m ay consist of as few as 6 or as

many as 10 sessions, depending on the purpose

and goals of the intervention.

Group Therapy

Group p sychotherapy i s one of the most

com mo n m odal i ties for t rea tment of substance

abuse disorders. Gro up therapy is defined as a

me et ing of two or more people for a comm on

therapeut ic purpose or to ach ieve a comm on

goal . I t differs from fam ily therapy in that the

therapist crea tes op en- and c losed-ended groups

of people previously unk now n to each other.

A ppr opri at eness of group t herapy

Group p sychotherapy can be ex tremely

beneficial to individuals with substance abuse

problem s. (2) I t gives them the oppo rtunity to

see the progression of abuse and dependency in

themselves and others; i t a lso provides an

opportunity to experience personal success and

the success of other group members in an

atmosphere of suppo rt and hope.

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Execut ive Summary and Recommendat ions

Use of psy chodrama t echni ques

in a group set t i ng

Psychodrama has long been ef fectively used

with substance-abusing cl ients in a group

setting. Psycho dram a can be used with different

mo dels of group therapy. I t offers persons w ith

substance abuse disorders an opportunity to

better understand past and present

experiences— and how past experiences

influence their present lives. (2)

Using t i me- l i mi ted group therapy

The focus of t ime-l imited therapeutic groups

varies a great deal according to the mo del

chosen by the therapist. Yet some

generalizations can be made about several

dimensions of the manner in which brief group

therapy is implemented.

Client preparation is particularly important

in any time-l imited group experien ce. Clients

should be thoroughly assessed before their entry

into a group for therapy. (2) Group pa rticipants

should be given a thorough explanation of

group expectations.

The preferr

brief interventions and brief therapy for substance abuse

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