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8/9/2019 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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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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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