Why a Quick Guide?...2
What s a TIP?...3
Introduction ...4
Brief Interventions...5
Brief Therapies ... 13
Brief Cognitive–Behavioral Therapy ... 20
Brief Strategic/Interactional Therapies ... 24
Brief Humanistic and Existential Therapies ... 26
Brief Psychodynamic Therapy ... 28
Brief Family Therapy ...30
Time-Limited Group Therapy ...33
Glossary ...36
INTRODUCTION
Theuseof brief intervention and brief therapy techniques has becomean increasingly important part of thecontinuum of care in thetreatment of substanceabuseproblems. They providethe opportunity for clinicians toincreasepositive out-comes by using thesemodalities independently as stand-aloneinterventions ortreatments andas additions to other forms of substanceabuseand mental health treatment.
Used for a variety of substanceabuseproblems from at-risk usetodependence, brief interven-tions can help clients reduceor stop abuse, act as a first step in thetreatment process todetermine if clients can stop or reduceon their own, and act as a method tochangespecific behaviors before or during treatment.
5 Brief Interventions
BRIEF INTERVENTIONS
Brief interventions arethosepractices that aim to investigatea potential problem andmotivatean individual tobegin todosomething about his sub-stanceabuse, either by natural, client-directed means or by seeking additional treatment.
Thebasic goal of any intervention is tolower the likelihood of damagethat could result from contin-ued use of substances. The specific goal for each individual client is determined by his useand by thesetting in which thebrief intervention is deliv-ered.
Professionals whocan administer brief interven-tions
•Primary carephysicians
•Substanceabusetreatment providers •Substanceabuseclinicians
•Emergency department staff members •Nurses
•Social workers •Health educators •Lawyers
•Teachers
•Employeeassistanceprogram counselors •Crisis hotlineworkers, student counselors •Clergy
Objectives to Address with Brief Interventions •Learning to scheduleandprioritize time •Expanding a sobersupport system
•Socializing with recovering peopleor learning to havefun without substanceabuse
•Beginning skills exploration or training if unem-ployed
•Attending an AA or NA meeting
•Giving up resentments or choosing toforgive others and self
•Staying in the"hereand now"
Treatment Needs During the Stages of Change
•Precontemplation. Theclient needs information linking his problems with his substanceabuse. A brief intervention might betoeducatehim about thenegativeconsequences of substance abuse.
7 Brief Interventions
brief intervention might seek toincreasethe client's awareness of theconsequences of con-tinued abuseand thebenefits of decreasing or stopping use.
•Preparation. Theclient needs work on strength-ening commitment. A brief intervention might givetheclient a list of options fortreatment, then help theclient plan how to goabout seek-ing the treatment.
•Action. Theclient requires help executing an action plan and may havetowork on skills to maintain sobriety. Theclinician should acknowl-edgetheclient's feelings and experiences as a normal part of recovery.
•Maintenance. Theclient needs help with relapseprevention. A brief intervention could reassure, evaluatepresent actions, and rede-finelong-term sobriety plans.
It is important toextract onemeasurablechange in theclient's behavior, such as
FRAMES
A brief intervention consists of fivebasic steps that incorporateFRAMES andremain consistent regardless of thenumber of sessions or thelength of theintervention:
•Feedback is given totheindividual about
per-sonal risk or impairment.
•Responsibility for changeis placed on the partic-ipant.
•Advicetochangeis given by theprovider.
•Menuof alternativeself-help or treatment options is offered totheparticipant.
•Empathic styleis used in counseling.
•Self-efficacy or optimistic empowerment is
engendered in theparticipant.
A brief intervention consists of fivebasic steps that incorporateFRAMES:
•Introducing theissuein thecontext of client health
•Screening, evaluating, and assessing •Providing feedback
9 Brief Interventions
Screening, Evaluating, and Assessing
This is a process of gaining information on the tar-getedproblem; it varies in length from a single question toseveral hours of assessment on the targeted topic of change. Additional information about andexamples of screening and assessment instruments can be found in theTIP.
Attitude of Understanding and Acceptance Clinicians must assuretheir clients that they will listen carefully and make every effort to under-stand theclient's point of view during a brief inter-vention. Activelistening saves timeby reducing or preventing resistance, focusing on theclient, focusing theclinician, encouraging self-disclosure, and helping theclient remember what was said during theintervention. Skilled activelisteners perform thesethreesteps automatically, naturally, smoothly, and quickly:
•Listen towhat theclient says.
•Form a reflectivestatement. Toreflect your understanding, repeat in your own words what theclient said.
Brief Interventions in Substance Abuse Treatment Programs
Brief interventions can beused before, during, and after substanceabusetreatment. The follow-ing is a list of thepotential benefits of using brief interventions in substanceabusetreatment set-tings:
•Reduceno-show rates for thestart of treatment, no-show rates for continuing care, and dropout rates after thefirst session of treatment •Increasetreatment engagement after intake
assessment
•Increasecompliancefor doing homework •Increasegroup participation and mutual-help
group attendance
•Address noncompliancewith treatment rules •Reduceaggression, violence, and isolation from
other clients
•Obtain a sponsor, if involved with a 12-Step pro-gram
•Increasecompliancewith psychotropic medica-tion therapies and outpatient mental health referrals
Brief Interventions 11
Brief Interventions Outside Substance Abuse Treatment Settings
Brief interventions arecommonly administeredin nonsubstanceabusetreatment settings, often referred to as opportunistic settings, whereclients arenot seeking help for a substanceabuse disor-der but havecometoreceivemedical treatment, tomeet with an EmployeeAssistanceProgram counselor, orto respond toa court summons. Treatment providers whowork in settings other than substanceabusetreatment must beflexible when assessing, planning, and carrying out brief interventions. When delivering a brief intervention in any treatment setting, theprovider should be mindful of room conditions and interruptions becauseclient confidentiality is of utmost impor-tance.
Essential Knowledge and Skills
Thefollowing arefour essential skills for providing effectivebrief interventions:
•An overall attitudeof understanding and accept-ance
•A working knowledgeof thestages-of-change through which a client moves when thinking about, beginning, andtrying to maintain new behavior
Brief Therapies 13
BRIEF THERAPIES
Thefollowing is a list of characteristics pertaining toall brief therapies:
•They areeither problem focusedor solution focused; they target thesymptom and not what is behind it.
•They clearly definegoals related toa specific changeor behavior.
•They should beunderstandabletoboth client and clinician.
•They should produceimmediateresults. •They can beeasily influenced by thepersonality
and counseling styleof thetherapist. •They rely on rapid establishment of a strong
working relationship between client and therapist.
•Thetherapeutic styleis highly active, empathic, and sometimes directive.
•Responsibility for changeis placed clearly on theclient.
•Theclient is helped tohaveexperiences that enhanceself-efficacy and confidencethat changeis possible.
•Outcomes aremeasurable.
Determining when to usea particulartypeof brief therapy is an important consideration for coun-selors and therapists. Client needs and the suit-ability of brief therapy must beevaluatedon a case-by-casebasis. Thefollowing aresomecriteria for considering theappropriateness of brief therapy:
•Dual diagnosis issues
•Therangeand severity of presenting problems •Theduration of substancedependence •Availability of familial and community supports •Thelevel and typeof influencefrom peers,
fami-ly, and community
•Previous treatment or attempts at recovery •Thelevel of client motivation
•Theclarity of theclient's short- and long-term goals
Brief Therapies 15
Criteriafor Longer–Term Treatment
•Failureof previous shorter treatment •Multipleconcurrent problems •Severe substance abuse •Acutepsychoses
•Acuteintoxication •Acutewithdrawal
•Cognitiveinability tofocus •Long-term history of relapse
•Many unsuccessful treatment episodes •Low level of social support
•Serious consequences related torelapse
Screening and Assessment
Core Assessment Areas
Beforeproceeding with brief therapy for substance abusedisorders, a number of areas should be assessed:
•Current usepatterns •History of substanceabuse •Consequences of substanceabuse
•Information about major medical problems and health status
•Information about education and employment •Support mechanisms
•Client strengths and situational advantages •Previous treatment
•Family history of substanceabusedisorders and psychological disorders
The Opening Session
In thefirst session, themain goals for the thera-pist aretogain a broad understanding of the client's presenting problems, begin toestablish rapport and an effectiveworking relationship, and implement an initial intervention. During thefirst session, theclinician must accomplish certain crit-ical tasks including
•Producing rapid engagement
Brief Therapies 17
•Working with theclient todevelop possible solu-tions tosubstanceabuseproblems anda treat-ment plan that requires theclient's active par-ticipation
•Negotiating theroute toward change with the client
•Eliciting client concerns about problems and solutions
•Understanding client expectations
•Explaining thestructural framework of brief therapy, including theprocess and its limits •Making referrals for critical needs that have been identified but cannot bemet within the treatment setting
Maintenance Strategies
Maintenancestrategies must bebuilt intothe treatment design from thebeginning. A practition-er of brief thpractition-erapy must continuetoprovide sup-port, feedback, and assistancein setting realistic goals. Also, thetherapist should help theclient identify relapsetriggers and situations that could endanger continued sobriety.
Strategies tohelp maintain theprogress made during brief therapy includethefollowing:
•Developing a list of circumstances that might providereasons fortheclient toreturn to treat-ment and plans toaddress them
•Reviewing problems that emerged but werenot addressed in treatment andhelping theclient develop a plan for addressing them in thefuture •Developing strategies foridentifying and coping
with high-risk situations or thereemergenceof substanceabusebehaviors
•Teaching theclient how tocapitalizeon person-al strengths
•Emphasizing client self-sufficiency
•Developing a plan for futuresupport, including mutual help groups, family support, and com-munity support
Ending Treatment
Termination of therapy should always beplanned in advance. In many types of brief therapy, the end of therapy will bean explicit focus of discus-sion in which thetherapist should
•Leavetheclient on good terms, with an enhanced senseof hopefor continued change and maintenanceof changes already accom-plished
Brief Therapies 19
•Elicit commitment for the client to try tofollow through on what has been learned or achieved •Review what positiveoutcomes theclient can
expect
•Review possiblepitfalls the client may encounter
•Review theearly indicators of relapse
BRIEF COGNITIVE–BEHAVIORAL
THERAPY (CBT)
Thecognitive–behavioral model assumes that substanceabusers aredeficient in coping skills, choosenot tousethosethey have, or are inhibit-ed from doing so. Cognitive–behavioral theory is generally effectivebecauseit helps clients recog-nizethesituations in which they arelikely touse substances, find ways of avoiding those situa-tions, and copemoreeffectively with thevariety of situations, feelings, and behaviors related totheir substanceabuse. Toachievethesetherapeutic goals, CBT incorporates threecoreelements: •Functional analysis—This analysis attempts to
identify theantecedents and consequences of substanceabusebehavior, which serveas triggering and maintaining factors.
•Coping skills training—A major component in CBT is thedevelopment of appropriatecoping skills.
Brief Cognitive-Behavioral Therapy 21
When Not to Use Brief Cognitive–Behavioral Therapy
CBT is generally not appropriatefor certain clients, namely, those
•Whohavepsychotic or bipolar disorders andare not stabilizedon medication
•Whohavenostableliving arrangements •Whoare not medically stable(as assessed by a
pretreatment physical examination)
Initial Session for Behavioral Techniques Theinitial session in brief behavioral therapy involves an exploration of the:
•Reasons theclient is seeking treatment •Extent towhich this motivation for treatment is
intrinsic, rather than influenced by external sources
•Areas of concern that theclient and significant others may haveabout his substanceabuse •Situations in which shedrinks or uses
excessively
•Consequences sheexperiences
problems rationally. Therearethree majorsteps in this process:
•Thetherapist establishes a rapport by listening carefully totheclient, using questions and reflectivelistening to try tounderstand how the client thinks about his life circumstances and how thosethoughts relatetoproblematic feel-ings andbehavior. Thus, theclient educates the therapist about himself andhis problems. •Thetherapist educates theclient about the
cog-nitivemodel of therapy and determines if heis satisfied with themodel.
•Thetherapist asks theclient todescribea recent event that has triggered somerecent negativefeelings, as a way of illustrating the cognitivetherapy process.
Sample Script to Introduce Cognitive Therapy "I want tospend a few minutes telling youabout my approach. It seems that how wefeel and how weact in certain situations depend on how we think. In working with you, my goal is to under-stand how youseethings—theimportant things in your lifethat relatetosubstanceabuse. I want to help youlook at thosethings objectively and hon-estly.
Brief Cognitive-Behavioral Therapy 23
about themselves and their circumstances. They don't examinethefacts carefully.
"So, let's exploresomepossibilities and find out how youthink about things. How does that sound toyou?"
BRIEF STRATEGIC/INTERACTIONAL
THERAPIES
In brief strategic/interactional therapies, thefocus is on theindividual's strengths rather than on pathology, therelationship to thetherapist is essential, andinterventions arebased on client self-determination with thecommunity serving as a resourceratherthan an obstacle.
No matter which typeof strategic/interactional therapy is used, this approach can help to
•Definethesituations that contributeto sub-stanceabusein terms meaningful totheclient •Identify steps needed tocontrol or end
sub-stanceuse
•Heal thefamily system soit can better support change
•Maintain behaviors that will help control sub-stanceuse
•Respond tosituations in which theclient has returned tosubstanceuseafter a period of abstinence
Brief Strategic/Interactional Therapies 25
Initial Session of Brief Strategic/Interactional Therapies
Thefirst question that a therapist using a strategic/ interactional approach shouldask is,
"Why are youhere?"
Thefirst session should bespent trying to under-stand theclient's problem.
Oncethe therapist has encourageda person with a substanceabusedisorder totakefurther steps toward change, thesubsequent sessions will focus on identifying and supporting additional steps in thesamedirection. As theend of the therapeutic process nears, thetherapist can fol-low thesesuggestions tohelp theclient prepare for thefuture:
•Preparetheclient tomaintain positivechange through difficult times.
•Identify what thepotential next stressors and challenges will be.
•Devotesometimetopreparing theclient for changes totheenvironment.
•Ask theclient tolook intothefutureat theend of thetreatment period and tell thetherapist whereheintends tobeat a certain time.
BRIEF HUMANISTIC AND EXISTENTIAL
THERAPIES
Humanistic and existential therapies areunited by an emphasis on understanding human experience and a focus on the client rather than the symp-tom. Psychological problems areviewed as the result of inhibitedability to make authentic, mean-ingful, andself-directed choices about how tolive.
Initial Session for Brief Humanistic and Existential Therapies
Theopening session is extremely important in brief therapy for building an alliance, developing therapeutic rapport, and creating a climateof mutual respect
•Start todevelop thealliance.
•Emphasizetheclient's freedom of choiceand potential for meaningful change.
•Articulateexpectations and goals of therapy (how goals aretobereached).
Brief Humanistic and Existential Therapies 27
•Client-centeredtherapy can beused immediate-ly toestablish rapport and toclarify issues throughout thesession.
•Existential therapy may beused most effectively when a client has access to emotional experi-ences or when obstacles must beovercometo facilitatea client's entry intoor continuation of recovery.
•Narrativetherapy can be used tohelp theclient conceptualizetreatment as an opportunity to assumeauthorship and begin a "new chapter" in life.
•Gestalt approaches can beused throughout therapy tofacilitatea genuineencounter with thetherapist and theclient's own experience. •Transpersonal therapy can enhancespiritual
development by focusing on theintangible aspects of human experienceand awareness of unrealized spiritual capacity.
BRIEF PSYCHODYNAMIC THERAPY
A psychodynamic approach enables theclient to examineunresolved conflicts and symptoms that arisefrom past dysfunctional relationships and manifest themselves in theneed and/or desireto abusesubstances. Psychodynamic therapy is gen-erally thought moresuitablefor thefollowing types of clients:•Thosewhohavecoexisting psychopathology with their substanceabusedisorder
•Thosewhodonot need or whohavecompleted inpatient hospitalization or detoxification •Thosewhoserecovery is stable
•Thosewhodonot haveorganic brain damageor other limitations duetotheir mental capacity In thetreatment of substanceabusedisorders, defenses areseen as a means of resisting change—changes that inevitably involve eliminat-ing or at least reduceliminat-ing drug use. Thefollowing strategies arerecommended for avoiding ineffec-tiveadversarial interactions around theclient's useof defenses:
•Working with theclient's perceptions of reality rather than arguing
Brief Psychodynamic Therapy 29
•Sidestepping rather than confronting defenses •Demonstrating thedenial defensewhile
inter-acting with theclient toshow her how it works The Therapeutic Alliance
Of all thebrief psychotherapies, psychodynamic approaches placethemost emphasis on the ther-apeutic relationship and providethemost explicit and comprehensive explanations of how to use this relationship effectively.
BRIEF FAMILY THERAPY
For many individuals with substanceabuse disor-ders, interactions with their family of origin, as well as their current family, set thepatterns and dynamics for their problems with substances. Furthermore, family member interactions with the substanceabuser can either perpetuateand aggravatetheproblem or substantially assist in resolving it.
Family therapy offers an opportunity to
•Focus on theexpectation of changewithin the family
•Test new patterns of behavior
•Teach how a family system works and how the family supports symptoms and maintains need-ed roles
•Elicit thestrengths of every family member •Explorethemeaning of substanceabusewithin
Brief Family Therapy 31
Opening Session for Brief Family Therapy •Thetherapist seeks to clarify thenatureof the
problem and to identify the family's goals with open-ended questions such as "What is your goal in coming here?"
•Thetherapist educates thefamily in what is needed to participateeffectively in the therapeu-tic process and tounderstand key biosocial issues related tosubstanceabuse.
•Thetherapist provides feedback tothefamily on what was said, demonstrating whosegoals are similar or different.
•Thetherapist can then moveon toprioritizing directions for changeor, if thedirection is suffi-ciently clear, start work.
Family therapy is particularly appropriatewhen theclient exhibits signs that his substanceabuse is strongly influenced by family members' behav-iors or communications with them. Short-term therapy is an option that could beused in the fol-lowing circumstances:
•When resolving a specific problem in thefamily and working toward a solution
•When thefamily as a wholecan benefit from teaching and communication tobetter under-stand someaspect of thesubstanceabuse disorder
Family therapy can involvea network beyond the immediatefamily, may involveonly onefamily member in treatment or a few members of the family system, or may even includeseveral fami-lies at once. Multiplefamily therapy offers an opportunity todeal with concerns for families in which substanceabusehas been a problem:
•Inadequateinternal family development •Family systems and roleimbalance •Selected socialization variances within the
family
•Dysfunctional, ineffectivefamily behaviors that maintain theproblem
Time-Limited Group Therapy 33
TIME-LIMITED GROUP THERAPY
Group psychotherapy is oneof the most common modalities for treatment of substanceabuse dis-orders. Groups can beextremely beneficial to indi-viduals with substanceabuseproblems andcan•Help reduce denial, process ambivalence, and facilitateacceptanceof alcohol abuse
•Increasemotivation forsobriety and other changes
•Treat theemotional conditions that often accompany drinking
•Increasethecapacity torecognize, anticipate, and copewith situations that may precipitate drinking behavior
•Meet theintenseneeds of alcohol-dependent clients for social acceptanceand support Assessment and Preparation
Initial Session for Time-Limited Group Therapy
•New group members introducethemselves at theopening session, responding toa simple request such as "Tell us what led youhere." In thecontext of substanceabusetreatment, the therapist shouldthereforeinitially discuss with group members how substanceabuseissues will beaddressed soas toensurethat focus is maintained.
•The"locus of control" forthegroup is clarified. Clients explorewhether they believethey have theability tochooseeffectiveactions or if they think of themselves as helpless victims of cir-cumstance.
•Goals for thegroup areclarified.
•Thetherapist seeks toestablish a safe, warm, supportiveenvironment. Theremay bea need toestablish rules toincreasesafety.
•Thetherapist helps group members establish connections with each other, pointing out com-mon concerns and problems.
Duration of Therapy and Frequency of Sessions
Time-Limited Group Therapy 35
on thepurposeandgoals of thegroup. Thegroup needs timetodefineits identity, develop cohe-sion, and becomea safeenvironment in which thereis enough trust for participants to reveal themselves.
GLOSSARY
Attribution(s):An individual's explanation of why an event occurred.
Authenticity:In existential therapy, this concept refers totheconscious feelings, perceptions, and thoughts that one expresses and communicates honestly.
Classical conditioning:According to this theory,
an originally neutral stimulus becomes a condi-tioned stimulus when paired with an uncondi-tioned stimulus or with a condiuncondi-tioned stimulus.
Cognitive restructuring:Thegeneral term applied
totheprocess of changing theclient's thought patterns.
Contact: A term used in Gestalt therapy that refers tomeeting oneself and what is other than oneself.
Contingency management:This approach
attempts tochangethoseenvironmental contin-gencies that may influencesubstanceabuse behavior. Thegoal is toincreasebehaviors that areincompatiblewith use.
Glossary 37
concept refers totheway in which theclient inter-acts with others and with herself.
Core response from others (RO):A term used in
SE therapy toexplain oneway in which thecore conflictual relationship themeis unconsciously developed.
Core response of the self (RS):A term used in SE
therapy that helps todevelop an individual's core conflictual relationship theme.
Counterconditioning:A method that uses
classi-cal conditioning principles tomakebehaviors pre-viously associated with positiveoutcomes less appealing by moreclosely associating them with negativeconsequences.
Countertransference:Thephenomenon in which
thetherapist transfers his emotional needs and feelings ontohis client.
Covert sensitization:A techniqueused in
counter-conditioning therapy that pairs negative conse-quences with substance-related cues through visual imagery.
Cue exposure:This principleof classic
itself will diminish, andthebehaviorwill eventually vanish.
Defense mechanisms:Themeasures taken by an
individual's ego to relieveexcessiveanxiety.
Deliberate exception:A situation in which a client
has intentionally maintained a period of sobriety or reduced useforany reason.
Directive approach:This form of group therapy
offers structuredgoals and therapist-directed interventions toenableindividuals tochangein desired ways.
Effect expectancies:A set of cognitive
expectan-cies that theclient develops concerning anticipat-ed effects on her feelings and behavior as drink-ing and drug usearereinforced by thepositive effects of thesubstancebeing taken.
Family sculpting:A techniqueused in family
ther-apy. Thetherapist "sculpts" family members in typ-ical roles and presents significant situations relat-ed tosubstanceabusepatterns.
Functional analysis:A process used in behavioral
Glossary 39
Insight: A particular kind of realization or self-knowledge, usually regarding theconnections of experiences and conflicts in the past with present perceptions andbehavior, and therecognition of feelings or motivations that havebeen repressed.
Miracle question:A solution-focused interviewing
strategy in which thetherapist asks theclient the question, "If a miraclehappened andyour condi-tion weresuddenly not a problem for you, how wouldyour lifebedifferent?"
Operant learning:Refers totheprocess by which
behaviors that arereinforced increasein frequency.
Process-sensitive approach:The
process-sensi-tivegroup approach examines theunconscious processes of thegroup as a whole, using these energies tohelp individuals seethemselves more clearly and thereforeopen up theopportunity for change.
Psychodrama:A method of psychotherapy in
which clients act out their personal problems by spontaneously enacting specific roles in dramatic performances performed beforefellow clients.
Random exception:An occasion upon which a
of circumstances that are apparently beyond his control.
Selfobject:A term used in self psychology that
refers tosomething or someoneelse that is
expe-rienced and used as if it werepart of one's own
self.
Therapeutic alliance:Thedevelopment of a
posi-tiverelationship between thetherapist and client.
Transference:Theprocess, basic toall
psychody-namic therapies, of theclient's transferenceof
salient characteristics of unresolved conflicted
relationships with significant others ontothe
therapist.
Transpersonal awakening:Theprocess of
awak-ening from a lesser toa greater identity in
transpersonal psychotherapy.
For more detailed information, see TIP 34, Appendix C.
