Brief Interventions And Brief Therapies for Substance Abuse [Front Matter] [Title Page] Brief Interventions And Brief Therapies for Substance Abuse Treatment Improvement Protocol (TIP) Series 34 Kristen Lawton Barry, Ph.D. Consensus Panel Chair U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857 DHHS Publication No. (SMA) 99-3353 Printed 1999 [Disclaimer] This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated. This publication was written under contract number 270-95-0013 with The CDM Group, Inc. (CDM). Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT government 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, production editor; Erica Flick, editorial assistant; Y-Lang Nguyen, former production editor; and Paul Seaman, former 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. Woody, M.D. The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions 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 substitutes for individualized client care and treatment decisions. What Is a TIP? Treatment Improvement Protocols (TIPs) are best practice guidelines 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). CSAT's Office of Evaluation, Scientific Analysis and Synthesis draws on the experience and knowledge of clinical, research, and administrative 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 facilities as alcoholism and other substance abuse disorders are increasingly recognized as major problems. [Front Matter] Brief Interventions And Brief Therapies for Substance Abuse The TIPs Editorial Advisory Board, a distinguished group of substance abuse experts and professionals in such related fields as primary care, mental 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 needs for information and guidance. After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends 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-Federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which it reaches consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration. A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http://text.nlm.nih.gov. The move to electronic media also means that the TIPs can be updated more easily 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 it 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 major goal of each TIP is to convey "front line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided. This TIP, Brief Interventions and Brief Therapies for Substance Abuse, is intended primarily for counselors and therapists working in the substance abuse treatment field, but parts of it will be of value to other audiences, including health care workers, social services providers, clergy, teachers, and criminal justice personnel. In fact, those portions of this TIP dealing with brief interventions will be of use to any professional service provider who may need to make an intervention to help persons with substance abuse disorders alter their use patterns or seek treatment. However, brief therapy should only be practiced by those who are properly qualified, educated, and licensed. The first chapter of this TIP presents an overview of brief interventions and brief therapies, describing their basic characteristics and the reasons for increased interest in them. Chapter 2 describes the goals and components of brief interventions, and Chapter 3 discusses some of the basic elements of all brief therapies. Chapters 4 through 9 each highlight a different type of brief therapy, describing the theory behind it as well as some of the techniques developed from that theory that can be used to treat clients with substance abuse disorders. Separate chapters are presented describing cognitive-behavioral therapy, strategic/interactional therapies, humanistic and existential therapies, psychodynamic therapies, family therapy, and group therapy. Appendixes 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 interventions. The goal of this TIP is to make readers aware of the research, results, and promise of brief interventions and brief therapies in the hope that they will be used more widely in clinical practice and treatment programs across the United States. Other TIPs may be ordered by contacting SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889. [Front Matter] Brief Interventions And Brief Therapies for Substance Abuse Editorial Advisory Board Karen Allen, Ph.D., R.N., C.A.R.N. Professor and Chair Department of Nursing Andrews University Berrien Springs, Michigan Richard L. Brown, M.D., M.P.H. Associate Professor Department of Family Medicine University of Wisconsin School of Medicine Madison, Wisconsin Dorynne Czechowicz, M.D. Associate Director Medical/Professional Affairs Treatment Research Branch Division of Clinical and Services Research National Institute on Drug Abuse Rockville, Maryland Linda S. Foley, M.A. Former Director Project for Addiction Counselor Training National Association of State Alcohol and Drug Abuse Directors Washington, D.C. Wayde A. Glover, M.I.S., N.C.A.C. II Director Commonwealth Addictions Consultants 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. Former State Director Substance Abuse Services Division of Mental Health, Mental Retardation and Substance Abuse Georgia Department of Human Resources Atlanta, Georgia James G. (Gil) Hill, Ph.D. Director Office of Substance Abuse American Psychological Association Washington, D.C. Editorial Advisory Board Brief Interventions And Brief Therapies for Substance Abuse Douglas B. Kamerow, M.D., M.P.H. Director Office of the Forum for Quality and Effectiveness in Health Care Agency for Health Care Policy and Research Rockville, Maryland Stephen W. Long Director Office of Policy Analysis National Institute on Alcohol Abuse and Alcoholism Rockville, Maryland Richard A. Rawson, Ph.D. Executive Director Matrix Center and Matrix Institute on Addiction Deputy Director, UCLA Addiction Medicine Services Los Angeles, California Ellen A. Renz, Ph.D. Former Vice President of Clinical Systems MEDCO Behavioral Care Corporation Kamuela, Hawaii Richard K. Ries, M.D. Director and Associate Professor Outpatient Mental Health Services and Dual Disorder Programs Harborview Medical Center Seattle, Washington Sidney H. Schnoll, M.D., Ph.D. Chairman Division of Substance Abuse Medicine Medical College of Virginia Richmond, Virginia 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 Consensus Panel Brief Interventions And Brief Therapies for Substance Abuse Seattle, Washington Jerry P. Flanzer, D.S.W., L.C.S.W., C.A.C. Director Recovery and Family Treatment, Inc. Alexandria, Virginia Stephen Gedo, Ph.D. Clinical Psychologist Gaffney, South Carolina Eugene Herrington, Ph.D. Associate Professor Department of Counseling and Psychological Services Clark Atlanta University Atlanta, Georgia Fredrick Rotgers, Psy.D. Director Program for Addictions Consultation and Treatment Center of Alcohol Studies Rutgers University New Brunswick, New Jersey Terry Soo-Hoo, Ph.D. Clinic Director/Assistant Professor Counseling Psychology Department University of San Francisco San Francisco, California Panelists Janice S. Bennett, M.S., C.S.A.C. Owner/Consultant Pacific Consulting and Training Services of Hawaii Honolulu, Hawaii Robert L. Chapman, M.S.S.W., C.A.D.O.A.C., C.R.P.S. Cumberland Heights Nashville, Tennessee John W. Herdman, Ph.D., C.A.D.A.C. Psychologist The Encouragement Place Lincoln, Nebraska Fanny G. Nicholson, C.C.S.W., A.C.S.W., N.C.A.C.I., C.S.A.E. Alcohol and Drug Specialist Oconaluftee Job Corps Cherokee, North Carolina Panelists Brief Interventions And Brief Therapies for Substance Abuse Mary Alice Orito, C.S.W., C.A.S.A.C., N.C.A.C.I. Evaluation Supervisor Stuyvesant Square Outpatient Services for Chemical Dependency New York, New York Jerome J. Platt, Ph.D. Professor of Psychiatry and Public Health Director, Institute for Addictive Disorders Hahnemann School of Medicine Allegheny University of the Health Sciences Philadelphia, Pennsylvania Marilyn Sawyer Sommers, Ph.D., R.N. Professor College of Nursing University of Cincinnati Cincinnati, Ohio José Luis Soria, M.A., L.C.D.C., I.C.A.D.C., C.C.G.C., C.A.D.A.C. Clinical Deputy Director Aliviane NO-AD, Inc. El Paso, Texas Ava H. Stanley, M.D. Somerset, New Jersey Robert S. Stephens, Ph.D. Associate Professor Department of Psychology Virginia Polytechnic Institute and State University Blacksburg, Virginia Foreword The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance abuse by providing best practices guidance to clinicians, program administrators, and payors. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and client advocates debates and discusses its particular areas of expertise until it reaches consensus on best practices. This panel's work is then reviewed and critiqued by field reviewers. The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field. Nelba Chavez, Ph.D. Administrator Substance Abuse and Mental Health Services Administration H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Foreword Brief Interventions And Brief Therapies for Substance Abuse Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Executive Summary and Recommendations This Treatment Improvement Protocol (TIP) responds to an increasing body of research literature that documents the effectiveness 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 the usefulness 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. 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 are 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 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 of theoretical 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. This TIP presents the historical background, outcomes research, rationale for use, and state-of-the-art practical methods and case scenarios for implementation of brief interventions and therapies for a range of problems related to substance 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 clinical expertise of the Consensus Panel. Because many therapists and other practitioners are eclectically trained, elements from each of the chapters may be of use to a range of professionals. This discussion of brief therapies is in no way intended to detract from the value of longer term therapies that clinicians have found to be effective in the treatment of substance abuse disorders. However, the Consensus Panel believes it necessary to discuss innovative and/or often-used theories that members have encountered and applied in their clinical practice. The Consensus Panel's recommendations summarized below are based on both research and clinical experience. Those supported 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 presented in full detail. Executive Summary and Recommendations Brief Interventions And Brief Therapies for Substance Abuse Many of the recommendations made in the latter chapters of this TIP are relevant only within a particular theoretical framework (e.g., the Panel might recommend how a person practicing strategic therapy should approach a particular situation); 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 Statistical Manual of Mental Disorders, 4th Edition [DSM-IV] [American Psychiatric Association, 1994]). Because the term "substance abuse" is commonly used by substance abuse treatment professionals to describe any excessive use of addictive substances, it will be used to denote both substance dependence and substance abuse. The term includes the use of alcohol as well as other substances of abuse. Readers should attend to the context 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 described by DSM-IV. Summary and Recommendations Brief Interventions Brief interventions are those practices that aim to investigate a potential problem and motivate an individual to begin to do something about his substance abuse, either by natural, client-directed means or by seeking additional substance abuse treatment. A brief intervention, however, is only one of many tools available to clinicians. It is not a substitute for care for clients with a high level of dependency. It can, however, be used to engage clients who need specialized treatment in specific aspects of treatment programs, such as attending group therapy or Alcoholics Anonymous (AA) meetings. ¨ The Consensus Panel believes that brief interventions can be an effective addition to substance abuse treatment programs. These approaches can be particularly useful in treatment settings when they are used to address specific targeted client behaviors and issues in the treatment process that can be difficult to change using standard treatment approaches. (2) ¨ Variations of brief interventions have been found to be effective both for motivating alcohol-dependent individuals to enter long-term alcohol treatment and for treating some alcohol-dependent persons. (1) ¨ 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) Goals of brief interventions The 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 long-term 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) Summary and Recommendations Brief Interventions And Brief Therapies for Substance Abuse ¨ 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) 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 individual about personal risk or impairment. ¨ Responsibility for change is placed on the participant. ¨ Advice to change is given by the clinician. ¨ Menu of alternative self-help or treatment options is offered to the participant. ¨ Empathic style is used by the counselor. ¨ Self-efficacy or optimistic empowerment is engendered in the participant. 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: 1. Introducing the issues in the context of the client's health. 2. Screening, evaluating, and assessing. 3. Providing feedback. 4. Talking about change and setting goals. 5. Summarizing and reaching closure. 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) Essential knowledge and skills for brief interventions Providing effective brief interventions requires the clinician to possess certain knowledge, skills, and abilities. The following are four essential skills (2): 1. An overall attitude of understanding and acceptance 2. Counseling skills such as active listening and helping clients explore and resolve ambivalence 3. A focus on intermediate goals 4. A working knowledge of the stages-of-change through which a client moves when thinking about, beginning, and trying to maintain new behavior Brief Therapies Brief therapy is a systematic, focused process that relies on assessment, client engagement, and rapid implementation of change strategies. The brief therapies presented in this TIP should be seen as separate modalities of treatment, not episodic forms of long-term therapy. Brief therapies usually feature more (as well as longer) sessions than brief interventions. The duration of brief therapies is reported to be anywhere from 1 to 40 sessions, with the typical therapy lasting between 6 and 20 sessions. Brief therapies also differ from brief interventions in that their goal is to provide clients with tools to change basic attitudes and handle a variety of underlying problems. Brief therapy differs from longer term therapy in that it focuses more on the present, downplays psychic causality, emphasizes the effective use of therapeutic tools in a shorter time, Brief Interventions Brief Interventions And Brief Therapies for Substance Abuse and focuses on a specific behavioral change rather than large-scale or pervasive change. Research concerning relative effectiveness of brief versus longer term therapies for a variety of presenting complaints is mixed. However, there is evidence suggesting that brief therapies are often as effective as lengthier treatments for certain populations. ¨ The best outcomes for brief therapy may depend on clinician skills, comprehensive assessments, and selective criteria for eligibility. Using selective criteria in prescribing brief therapy is critical, since many clients will not meet its eligibility requirements. (2) ¨ Brief therapy for substance abuse treatment is a valuable approach, but it should not be considered a standard of care for all populations. (1) The Consensus Panel hopes that brief therapy will be adequately investigated in each case before managed care companies and third-party payors decide it is the only modality for which they will pay. ¨ Brief interventions and brief therapies are well suited for clients who may not be willing or able to expend the significant personal and financial resources necessary to complete more intensive, longer term treatments. (2) ¨ Both research and clinical expertise indicate that individuals who are functioning in society but have patterns of excessive or abusive substance use are unlikely to respond positively to some forms of traditional treatment, but some of the briefer approaches to intervention and therapy can be extremely useful clinical tools in their treatment. (1) When to use brief therapy Determining when to use a particular type of brief therapy is an important consideration for counselors and therapists. The Panel recommends that client needs and the suitability of brief therapy be evaluated on a case-by-case basis. (2) Some criteria for considering the appropriateness of brief therapy for clients include ¨ Dual diagnosis issues ¨ The range and severity of presenting problems ¨ The duration of substance dependence ¨ Availability of familial and community supports ¨ The level and type of influence from peers, family, and community ¨ Previous treatment or attempts at recovery ¨ The level of client motivation ¨ The clarity of the client's short- and long-term goals ¨ The client's belief in the value of brief therapy ¨ The numbers of clients needing treatment The following criteria are derived from Panel members' clinical experience: ¨ Less severe substance dependence, as measured by an instrument like the Addiction Severity Index (ASI) ¨ Level of past trauma affecting the client's substance abuse ¨ Insufficient resources available for more prolonged therapy ¨ Limited amount of time available for treatment ¨ Presence of coexisting medical or mental health diagnoses ¨ Large numbers of clients needing treatment leading to waiting lists for specialized treatment The Consensus Panel also notes that ¨ Planned brief therapy can be adapted as part of 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 client's problems to be addressed serially rather than concurrently. (1) Brief Therapies Brief Interventions And Brief Therapies for Substance Abuse ¨ Brief therapies will be most effective with clients whose problems are of short duration and who have strong ties to family, work, and community. However, a number of other conditions, such as limited client resources, may also dictate the use of brief therapy. (2) ¨ It is essential to learn the client's perceived obstacles to engaging in treatment as well as to identify any dysfunctional beliefs that could sabotage the engagement process. The critical factor in determining an individual's response is the client's self-perception and associated emotions. (1) Components of effective brief therapy While there are a variety of different schools of brief therapy available to the clinician, all forms of brief therapy share some common characteristics (2): ¨ They are either problem focused or solution focused--they target the symptom, not its causes. ¨ They clearly define goals related to a specific change or behavior. ¨ They should be understandable to both client and clinician. ¨ They should produce immediate results. ¨ They can be easily influenced by the personality and counseling style of the therapist. ¨ They rely on rapid establishment of a strong working relationship between client and therapist. ¨ The therapeutic style is highly active, empathic, and sometimes directive. ¨ Responsibility for change is placed clearly on the client. ¨ Early in the process, the focus is to help the client enhance his self-efficacy and understand that change is possible. ¨ Termination is discussed from the beginning. ¨ Outcomes are measurable. Screening and assessment Screening and assessment are critical initial steps in brief therapy. Screening is a process in which clients are identified according to characteristics that indicate they are possibly abusing substances. Screening identifies the need for more in-depth assessment but is not an adequate substitute for complete assessment. Assessment is a more extensive process that involves a broad analysis of the factors contributing to and maintaining a client's substance abuse, the severity of the problem, and the variety of consequences associated with it. Screening and assessment procedures for brief therapy do not differ significantly from those used for lengthier treatments. ¨ Clinicians can use a variety of brief 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 employment status, support mechanisms, client strengths and situational advantages, and family history. (2) ¨ The screening and assessment process should determine whether the client's substance abuse problem is suitable for a brief therapy approach. (2) ¨ Assessment is critical not only before beginning brief therapy but also as an ongoing part of the process. (2) ¨ Therapists who primarily provide brief therapy should be adept at determining early in the assessment process which client needs or goals are appropriate to address. Related to this, and equally important, the therapist must establish relationships that facilitate the client's referral when her needs or goals cannot be met through brief therapy. (2) Brief Therapies Brief Interventions And Brief Therapies for Substance Abuse The first session In the first session, the main goals for the therapist are to gain a broad understanding of the client's presenting problems, begin to establish rapport and an effective working relationship, and implement an initial intervention, however small. ¨ Counselors should gather as much information as possible about a client before the first counseling session. However, when gathering information about a client from other sources, counselors must be sensitive to confidentiality and client consent issues. (2) ¨ Therapists should identify and discuss the goals of brief therapy with the client early in treatment, preferably in the first session. (2) ¨ Although abstinence is an optimal clinical goal, it still must be negotiated with the client (at least in outpatient treatment settings). Abstinence as a goal is not necessarily the sole admission requirement for treatment, and the therapist may have to accept an alternative goal, such as decreased substance use, in order to engage the client effectively. (2) ¨ The provider of brief therapy must accomplish certain critical tasks during the first session (2), including ¨ Producing rapid engagement ¨ Identifying, focusing, and prioritizing problems ¨ Working with the client to develop a treatment plan and possible solutions for substance abuse problems ¨ Negotiating the approach toward change with the client (which may involve a contract between client and therapist) ¨ Eliciting client concerns about problems and solutions ¨ Understanding client expectations ¨ Explaining the structural framework of brief therapy, including the process and its limits (i.e., those items not within the scope of that treatment segment or the agency's work) ¨ Making referrals for critical needs that have been identified but cannot be met within the treatment setting Maintenance strategies, termination of therapy, and followup Maintenance strategies must be built into the treatment design from the beginning. A practitioner of brief therapy must continue to provide support, feedback, and assistance in setting realistic goals. Also, the therapist should help the client identify relapse triggers and situations that could endanger continued sobriety. (2) Strategies to help clients maintain the progress made during brief therapy include the following (2): ¨ Educating the client about the chronic, relapsing nature of substance abuse ¨ Considering which circumstances might cause a client to return to treatment and planning how to address them ¨ Reviewing problems that emerged but were not addressed in treatment and helping the client develop a plan for addressing them in the future ¨ Developing strategies for identifying and coping with high-risk situations or the reemergence of substance abuse behaviors ¨ Teaching the client how to capitalize on personal strengths ¨ Emphasizing client self-sufficiency and teaching self-reinforcement techniques ¨ Developing a plan for future support, including mutual help groups, family support, and community support Termination of therapy should always be planned in advance. (2) When the client has made the agreed-upon behavior changes and has resolved some problems, the therapist should prepare to end the brief therapy. If a client progresses more quickly than anticipated, it is not necessary to complete the full number of sessions. Brief Therapies Brief Interventions And Brief Therapies for Substance Abuse Therapist characteristics Therapists will benefit from a firm grounding in theory and a broad technical knowledge of the many different approaches to brief therapy that are available. (2) When appropriate, elements of different brief therapies may be combined to provide successful outcomes. However, it 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. ¨ The therapist must use caution in combining and mingling certain techniques and must be sensitive to the cultural context within which therapies are integrated. (2) ¨ Therapists should be sufficiently trained in the therapies they are using and should not rely solely on a manual such as this to learn those therapies. (2) ¨ Training for brief therapies, in contrast to the training necessary to conduct brief interventions, requires months to years and usually results in a specialist degree or certification. The Consensus Panel recommends that anyone seeking to practice the therapies outlined here should receive more thorough training appropriate to the type of therapy being delivered. (Appendix B of the TIP provides contact information for some organizations that may be able to provide such training.) (2) ¨ Providers of brief therapy should be able to focus effectively on identifying and adhering to specific therapeutic goals in treatment. (2) ¨ Providers who practice brief therapy should be able to distill 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 it provides the basis for a more inclusive and comprehensive approach to treating substance abuse disorders. CBT can be used by properly licensed and trained mental health practitioners even if they have limited experience with this type of therapy--either as a cost-effective primary approach or in conjunction with other therapies or a 12-Step program. CBT can be also used early in and throughout the treatment process whenever the therapist feels it is important to examine a client's inaccurate or unproductive thinking that could lead to risky or negative behaviors. (2) CBT is generally not appropriate for certain clients, namely, those ¨ Who have psychotic or bipolar disorders and are not stabilized on medication ¨ Who have no stable living arrangements ¨ Who are not medically stable (as assessed by a pretreatment physical examination) (2) Cognitive-behavioral techniques The cognitive-behavioral model assumes that substance abusers are deficient in coping skills, choose not to use those they have, or are inhibited from doing so. It also assumes that over the course of time, 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 of the positive effects of substances. ¨ CBT is generally effective because it helps clients recognize the situations in which they are likely to use substances, find ways of avoiding those situations, and cope more effectively with the variety of situations, feelings, and behaviors related to their substance abuse. (2) To achieve these therapeutic goals, CBT incorporates three core elements: Brief Therapies Brief Interventions And Brief Therapies for Substance Abuse ¨ Functional analysis--This analysis attempts to identify the antecedents and consequences of substance abuse behavior, which serve as triggering and maintaining factors. ¨ Coping skills training A major component in CBT is the development of appropriate coping skills. ¨ Relapse prevention These approaches rely heavily on functional analyses, identification of high-risk relapse situations, and coping skills 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 positive self-efficacy. ¨ Overall, behavioral, cognitive, and cognitive-behavioral interventions are effective, can be used with a wide range of substance abusers, and can be conducted within the timeframe of brief therapies. (1) ¨ A broad range of cognitions will be 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 client's strengths and actively create personal and environmental situations in which success can be achieved. The primary strength of strategic/interactional approaches is that they shift the focus from the client's weaknesses to his strengths. The strategic/interactional model has been widely used and successfully tested on persons with serious and persistent mental illnesses. (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 believes that these therapeutic approaches are potentially useful for clients with substance abuse disorders and should be introduced to offer new knowledge and techniques for treatment providers to consider. (2) Using strategic/interactional therapies No matter which type of strategic/interactional therapy is used, this approach can help to ¨ Define the situation that contributes to substance abuse in terms meaningful to the client (2) ¨ 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) Strategic/interactional approaches are most useful in ¨ Learning how the client's relationships deter or contribute to substance abuse (2) ¨ Shifting power relationships (2) ¨ Addressing fears (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. 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 existential approaches share a belief that people have the capacity for self-awareness and choice. However, the two schools come to this belief through different theories. Strategic/Interactional Therapies Brief Interventions And Brief Therapies for Substance Abuse Humanistic and existential therapeutic approaches may be particularly appropriate for short-term substance abuse treatment because 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) 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 any type 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. ¨ 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) ¨ 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) ¨ Gestalt approaches can be used throughout therapy to facilitate a genuine encounter with the therapist and the client's own experience. (2) ¨ Transpersonal therapy can enhance spiritual development by focusing on the intangible aspects of human experience and awareness of unrealized spiritual capacity. (2) Using a humanistic or existential therapy framework, the therapist can offer episodic treatment, with a treatment plan that focuses on the client's tasks and experiences between sessions. (2) For many clients, momentary circumstances 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, humanistic and existential approaches can help clients focus on the fact that they do indeed make decisions about substance abuse and are responsible for their own recovery. (2) Psychodynamic Therapies Psychodynamic therapy focuses on unconscious processes as they are manifested in the client's present behavior. The goals of psychodynamic therapy are client self-awareness and understanding of the past's influence on present behavior. In its brief form, a psychodynamic approach enables the client to examine unresolved conflicts 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 appropriate for use with persons with substance abuse disorders, partly because their altered perceptions make it difficult to achieve insight and problem resolution. However, many psychodynamic therapists use forms of brief psychodynamic therapy with substance-abusing clients in conjunction with traditional substance abuse treatment programs or as the sole therapy for clients with coexisting disorders. (2) Humanistic and Existential Therapies Brief Interventions And Brief Therapies for Substance Abuse Although there is some disagreement in the details, psychodynamic brief therapy is generally thought more suitable for (2) ¨ Those who have coexisting psychopathology with their substance abuse disorder ¨ Those who do not need or who have completed inpatient hospitalization or detoxification ¨ Those whose recovery is stable ¨ Those who do not have organic brain damage or other limitations to their mental capacity Integrating psychodynamic concepts into substance abuse treatment Most therapists agree that people with substance abuse disorders comprise a special population, one that often requires more than one approach if treatment is to be successful. Therapists whose orientations are not necessarily psychodynamic may still find these techniques and approaches useful, and therapists whose approaches are psychodynamic may be more effective if they conduct psychotherapy in a way that complements the full range of services for clients with substance abuse disorders. (2) Family Therapy For many individuals with substance abuse disorders, interactions with their family of origin, as well as their current family, set the patterns and dynamics for their problems with substances. Furthermore, family member interactions with the substance abuser can either perpetuate and aggravate the problem or substantially assist in resolving it. Family therapy is particularly appropriate when the client exhibits signs that his substance abuse is strongly influenced by family members' behaviors or communications with them. (2) Family involvement is often critical to success in treating many substance abuse disorders--most obviously in cases where the family is part of the problem. (2) Family therapy can be used to ¨ Focus on the expectation of change within the family (which may involve multiple adjustments) ¨ Test new patterns of behavior ¨ Teach how a family system works--how the family supports symptoms and maintains needed roles ¨ Elicit the strengths of every family member ¨ Explore the meaning of the substance abuse disorder within the family Appropriateness of brief family therapy Long-term family therapy is not usually necessary for the treatment of substance abuse disorders. While 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 subsequent individual therapy. (2) Short-term family therapy is an option that could be used in the following circumstances (2): ¨ When resolving a specific problem in the family and working toward a solution ¨ When the therapeutic goals do not require in-depth, multigenerational family history, but rather a focus on present interactions ¨ When the family as a whole can benefit from teaching and communication to better understand some aspect of the substance abuse disorder Psychodynamic Therapies Brief Interventions And Brief Therapies for Substance Abuse Definitions of "family" 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 several families at once. (2) The definition of "family" varies in different cultures and situations and should be defined by the client. Therapists can "create" a family by drawing on the client's network of significant contacts. (2) A more important question than whether the client is living with a family is, "Can the client's problem be seen as having a relational (involving two or more people) component?" Using brief family therapies In order to promote change successfully within a family system, the therapist will need the family's permission to enter the family space and share their closely held confidences. The therapy, however, will work best if it varies according to the cultural background of the family. (1) Most family therapy is conducted on a short-term basis. Sessions are typically 90 minutes to 2 hours in length. The preferred timeline for family therapy is not more than 2 sessions per week (except in residential settings), to allow time to practice new behaviors and experience change. Therapy may consist of as few as 6 or as many as 10 sessions, depending on the purpose and goals of the intervention. Group Therapy Group psychotherapy is one of the most common modalities for treatment of substance abuse disorders. Group therapy is defined as a meeting of two or more people for a common therapeutic purpose or to achieve a common goal. It differs from family therapy in that the therapist creates open- and closed-ended groups of people previously unknown to each other. Appropriateness of group therapy Group psychotherapy can be extremely beneficial to individuals with substance abuse problems. (2) It gives them the opportunity to see the progression of abuse and dependency in themselves and others; it also provides an opportunity to experience personal success and the success of other group members in an atmosphere of support and hope. Use of psychodrama techniques in a group setting Psychodrama has long been effectively used with substance-abusing clients in a group setting. Psychodrama can be used with different models of group therapy. It offers persons with substance abuse disorders an opportunity to better understand past and present experiences--and how past experiences influence their present lives. (2) Using time-limited group therapy The focus of time-limited therapeutic groups varies a great deal according to the model 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-limited group experience. Clients should be thoroughly assessed before their entry into a group for therapy. (2) Group participants should be given a thorough explanation of group expectations. Family Therapy Brief Interventions And Brief Therapies for Substance Abuse The preferred timeline for time-limited group therapy is not more than 2 sessions per week (except in the residential settings), with as few as 6 sessions in all, or as many as 12, depending on the purpose and goals of the group. Sessions are typically 1 1/2 to 2 hours in length. Residential programs usually have more frequent sessions. Group process therapy is most effective if participants have had time to find their roles in a group, to "act" these roles, and to learn from them. The group needs time to define its identity, develop cohesion, and become a safe environment in which there is enough trust for participants to reveal themselves. (2) Conclusion The brief interventions and therapies described in this TIP are intended to introduce a range of techniques to clinicians. Clinicians will find different portions of this TIP more useful than others depending on their theoretical orientation, but all clinicians who work with substance-abusing clients should find material of value here. Brief interventions will be useful for a wide variety of service providers; brief therapies are intended for properly qualified, educated, and licensed professionals. Chapter 1 -- Introduction to Brief Interventions and Therapies The use of brief intervention and brief therapy techniques has become an increasingly important part of the continuum of care in the treatment of substance abuse problems. With the health care system changing to a managed model of care and with changes in reimbursement policies for substance abuse treatment, these short, problem-specific approaches can be valuable in the treatment of substance abuse problems. They provide the opportunity for clinicians to increase positive outcomes by using these modalities independently as stand-alone interventions or treatments and as additions to other forms of substance abuse and mental health treatment. They can be used in a variety of settings including opportunistic settings (e.g., primary care, home health care) and specialized substance abuse treatment settings (inpatient and outpatient). Used for a variety of substance abuse problems from at-risk use to dependence, brief interventions can help clients reduce or stop abuse, act as a first step in the treatment process to determine if clients can stop or reduce on their own, and act as a method to change specific behaviors before or during treatment. For example, there are some issues associated with treatment compliance that benefit from a brief, systematic, well-planned intervention such as attending group sessions or doing homework. In other instances, brief interventions address specific family problems with a client and/or family members or deal with specific individual problems such as personal finances and work attendance. The basic goal for a client regardless of setting is to reduce the risk of harm that may result from continued use of substances. The reduction of harm, in its broadest sense, pertains to the clients themselves, their families, and the community. The brief therapies discussed in this TIP are brief cognitive-behavioral therapy, brief strategic and interactional therapies, brief humanistic and existential therapies, brief psychodynamic therapy, short-term family therapy, and time-limited group therapy. The choice to include these therapeutic modalities was based on a combination of relevant research and, in some instances where there is a smaller research base, the clinical knowledge and expertise of the Consensus Panel. All of these approaches are currently being used in the treatment of substance abuse disorders, and all of them can contribute something to the array of treatment techniques available to the eclectic practitioner. Brief interventions and brief therapies may be thought of as elements on a continuum of care, but they can be distinguished from each other according to differences in outcome goals. Interventions are generally aimed at Chapter 1 -- Introduction to Brief Interventions and Therapies Brief Interventions And Brief Therapies for Substance Abuse motivating a client to perform a particular action (e.g., to enter treatment, change a behavior, think differently about a situation), whereas therapies are used to address larger concerns (such as altering personality, maintaining abstinence, or addressing long-standing problems that exacerbate substance abuse). This TIP presents brief interventions as a way of improving client motivation for treatment. The brief therapies considered here are ways of changing client attitudes and behaviors. Other differences that help distinguish brief interventions from brief therapies include ¨ Length of the sessions (from 5 minutes for an intervention to more than six 1-hour therapy sessions) ¨ Extensiveness of assessment (which will be greater for therapies than for interventions) ¨ Setting (nontraditional treatment settings such as a social service or primary care setting, which will use interventions exclusively, versus traditional substance abuse treatment settings where therapy or counseling will be used in addition to interventions) ¨ Personnel delivering the treatment (brief interventions can be administered by a wide range of professionals, but therapy requires training in specific therapeutic modalities) ¨ Materials and media used (certain materials such as written booklets or computer programs may be used in the delivery of interventions but not therapies) Although the theoretical bases for brief therapy and brief intervention may be different, this distinction is less obvious in practice. These two approaches to substance abuse problems and behavior change reflect a continuum rather than a clear dichotomy. The distinction may be further blurred as the change process associated with the success of brief interventions is better understood or refined and as theories are developed to explain a brief intervention's mechanism of action. Already, some forms of brief intervention overlap with therapy, such as motivational enhancement therapy, which has a clearly articulated theoretical rationale (for more on this topic, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment, which was conceived as a companion volume to this TIP [Center for Substance Abuse Treatment (CSAT), 1999c]). For the purposes of this TIP, brief therapy involves a series of steps taken to treat a substance abuse problem, whereas brief interventions are those practices that aim to investigate a potential problem and motivate an individual to begin to do something about his substance abuse. Therapy involves movement (or an attempt at movement) toward change. Brief therapy concentrates particularly on investigating a problem in order to develop a solution in consultation with the client; brief interventions generally involve a therapist giving advice to the client. The increasing emphasis on brief approaches is partly attributable to recent changes in the health care delivery system, in which clinicians are urged to reduce costs while maintaining treatment efficacy. Essentially, clinicians are constrained by time and diminishing resources yet are treating an increasing number of individuals with substance abuse problems. Fortunately, there is a body of literature on brief approaches in the treatment of substance abuse disorders. Brief interventions and brief therapies have the appeal not only of being brief but also of having research backing that supports their use. Brief interventions have been widely tested with both general clinical and substance-abusing populations and have shown great promise in changing client behavior. Brief therapies, however, have been unevenly researched. As indicated in the discussion of each type, in addition to the empirical results reported in scientific journals, clinical and anecdotal evidence supports the efficacy of brief therapies in the treatment of substance abuse. The brevity and lower delivery costs of these brief approaches make them ideal mechanisms for use in settings from primary care to substance abuse treatment where cost often plays as much of a role as efficacy in determining what treatments clients receive. Brief interventions and brief therapies are also well suited for clients who may not be willing or able to expend the significant personal and financial resources necessary to complete more intensive, longer term treatments. Although much research supports the theory that longer time in treatment is associated with better outcomes, research also suggests that for some clients, there is no loss in effectiveness when length and intensity of treatment are reduced. Chapter 1 -- Introduction to Brief Interventions and Therapies Brief Interventions And Brief Therapies for Substance Abuse An Overview of Brief Interventions Definitions of brief interventions vary. In the recent literature, they have been referred to as "simple advice," "minimal interventions," "brief counseling," or "short-term counseling." They can be simple suggestions to reduce drinking given by a professional (e.g., social worker, nurse, alcohol and drug counselor, physician, physician assistant) or a series of interventions provided within a treatment program. As one researcher notes, Brief interventions for excessive drinking should not be referred to as an homogenous entity, but as a family of interventions varying in length, structure, targets of intervention, personnel responsible for their delivery, media of communication and several other ways, including their underpinning theory and intervention philosophy (Heather, 1995, p. 287). Brief interventions, therefore, can be viewed as a set of principles regarding interventions which are different from, but not in conflict with, the principles underlying conventional treatment (Heather, 1994). Brief interventions for alcohol problems, for example, have employed various approaches to change drinking behaviors. These approaches have ranged from relatively unstructured counseling and feedback to more formal structured therapy and have relied heavily on concepts and techniques from the behavioral self-control training (BSCT) literature (Miller and Hester, 1986b; Miller and Munoz, 1982; Miller and Rollnick, 1991; Miller and Taylor, 1980) (see Chapter 4 for more information on BSCT). Usually, brief treatment interventions have flexible goals, allowing the individual to choose moderation or abstinence. The typical counseling goal is to motivate the client to change her behavior and not to assign self-blame. While much of the research to date has centered on clients with alcohol-related problems, similar approaches can be taken with users of other substances. Brief interventions are a useful component of a full spectrum of treatment options; they are particularly valuable when more extensive treatments are unavailable or a client is resistant to such treatment. Too few clinicians, however, are educated and skilled in the use of brief interventions and therapies to address the very large group of midrange substance users who have moderate and risky consumption patterns (see Figure 1-1). Although this group may not need or accept traditional substance abuse treatment, these individuals are nonetheless responsible for a disproportionate share of substance-related morbidity, including lowered workforce performance, motor vehicle accidents and other injuries, marital discord, family dysfunction, and medical illness (Wilk et al., 1997). These hazardous substance users are identified in employment assistance programs (EAPs), programs for people cited for driving while intoxicated (DWI), and urine testing programs, as well as in physicians' offices and other health screening efforts (Miller, 1993). Despite appeals from such distinguished bodies as the National Academy of Sciences in the United States and the National Academy of Physicians and Surgeons in the United Kingdom, widespread adoption of brief interventions by medical practitioners or treatment providers has not yet occurred (Drummond, 1997; Institute of Medicine [IOM], 1990). Brief interventions in traditional settings usually involve a more in-depth assessment of substance abuse patterns and related problems. The characterizations of hazardous, harmful, or dependent use as they relate to alcohol consumption patterns (Edwards et al., 1981) were used to distinguish the targets of brief intervention in a World Health Organization (WHO) study (Babor and Grant, 1991). Hazardous drinking refers to a level of alcohol consumption or pattern of drinking that, should it persist, is likely to result in harm to the drinker. Harmful drinking is defined as alcohol use that has already resulted in adverse mental or physical effects. Dependent use refers to drinking that has resulted in physical, psychological, or social consequences and has been the focus of major diagnostic tools, such as the Diagnostic and Statistical Manual, 4th Edition (American Psychiatric Association [APA], 1994) or the International Classification of Diseases, 9th Revision (ICD-9) (ICD-9-CM, 1995). Categorizing drinking patterns in this fashion provides both clinicians and researchers with flexible guidelines to identify individuals at risk for alcohol problems who may not meet criteria for alcohol dependence. Similar levels of use for other substances are much more difficult to define, since most of them are illicit and those that are not have often not been widely studied in relation to An Overview of Brief Interventions Brief Interventions And Brief Therapies for Substance Abuse substance abuse. Studies of brief interventions have been conducted in a wide range of health care settings, from hospitals and primary health care locations (Babor and Grant, 1991; Chick et al., 1985; Fleming et al., 1997; Wallace et al., 1988) to mental health clinics (Harris and Miller, 1990). (Refer to "Research Findings" in Chapter 2 for more discussion of research on brief interventions.) Individuals recruited from such settings are likely to have had some contact with a health care professional during the study participation and therefore had alcohol-related professional assistance available. Nonetheless, many of these patients would not be identified as having an alcohol problem by their health care providers and would not ordinarily receive any alcohol-specific intervention. In general, brief interventions are conducted in a variety of opportunistic and substance abuse treatment settings, target different goals; may be delivered by treatment staff or other professionals, and do not require extensive training. Because of the short duration of brief intervention strategies, they can be considered for use with injured patients in the emergency department who have substance abuse problems. Useful distinctions between the goals of brief interventions as applied in different settings are listed in Figure 1-2. Brief interventions in traditional settings usually involve a more in-depth assessment of substance use patterns and related problems than interventions administered in nontraditional settings and tend to examine other aspects of participants' attitudes, such as readiness for or resistance to change. They can be useful for addressing specific behavior change issues in treatment settings. Because they are timely, focused, and client centered, brief interventions can quickly enhance the overall working relationship with clients. However, brief interventions should not be a care substitute for clients who have a high level of abuse. Some of the assessments conducted for research studies of brief interventions are very extensive and may have been conducted during prior treatment (e.g., in detoxification programs, during treatment intake procedures). Most brief interventions offer the client detailed feedback about assessment findings, with an opportunity for more input. The assessment typically involves obtaining information regarding frequency and quantity of substance abuse, consequences of substance abuse, and related health behaviors and conditions. The intervention itself is structured and focused on substance abuse. Its primary goals are to raise awareness of problems and then to recommend a specific change or activity (e.g., reduced consumption, accepting a referral, self-monitoring of substance abuse). The participant in a brief intervention is usually offered a menu of options or strategies for accomplishing the target goal and encouraged to take responsibility for selecting and working on behavioral change in a way that is most comfortable for him. Any followup visits will provide an opportunity to monitor progress and to encourage the client's motivation and ability to make positive changes. The person delivering the brief intervention is usually trained to be empathic, warm, and encouraging rather than confrontational. Brief interventions are typically conducted in face-to-face sessions, with or without the addition of written materials such as self-help manuals, workbooks, or self-monitoring diaries. A few have consisted primarily of mailed materials, automated computer screening and advice, or telephone contacts. Some interventions are aimed at specific health problems that are affected by substance abuse, rather than substance abuse itself. For example, an intervention may be conducted to help a client reduce her chances of contracting human immunodeficiency syndrome (HIV) by using clean needles; as a result, if the client only has dirty needles, she might avoid using them in order to reduce her risk of HIV and thus reduce her use of heroin. By raising an individual's awareness of her substance abuse, a brief intervention can act as a powerful catalyst for changing a substance abuse pattern. The distress clients feel about their substance abuse behavior can act as an influence to encourage change as they recognize the negative consequences of that behavior to themselves or others. Positive and negative external forces are An Overview of Brief Interventions Brief Interventions And Brief Therapies for Substance Abuse also influences. Life events, such as a major illness or the death of significant others, career change, marriage, and divorce, can contribute to the desire to change. Brief interventions can address these events and feelings that accompany them with the underlying goal of changing clients' substance abuse behaviors. An Overview of Brief Therapies In contrast to most simple advice or brief interventions, brief therapies are usually delivered to persons who are seeking--or already in--treatment for a substance abuse disorder. That is, the individual usually has some recognition or awareness of the problem, even if he has yet to accept it. The therapy itself is often client driven; the client identifies the problems, and the clinician uses the client's strengths to build solutions. The choice of a brief therapy for a particular individual should be based on a comprehensive assessment rather than a cursory screening to identify potentially hazardous drinking or substance-abusing patterns (IOM, 1990). In some cases, brief therapy may also be used if resources for more extensive therapy are not available or if standard treatment is inaccessible or unavailable (e.g., remote communities, rural areas). Brief therapies often target a substance-abusing population with more severe problems than those for whom brief interventions are sufficient. Brief therapies can be useful for special populations if the therapist understands that some client issues may be developmental or physiological in nature (see TIP 26, Substance Abuse Among Older Adults, and TIP 32, Treatment of Adolescents With Substance Use Disorders [CSAT, 1998b, 1999b]). Although brief therapies are typically shorter than traditional versions of therapy, these therapies generally require at least six sessions and are more intensive and longer than brief interventions. Brief therapy, however, is not simply a shorter version of some form of psychotherapy. Rather, it is the focused application of therapeutic techniques specifically targeted to a symptom or behavior and oriented toward a limited length of treatment. In addition to the goals of brief interventions, the goals of brief therapy in substance abuse treatment is remediation of some specified psychological, social, or family dysfunction as it pertains to substance abuse; it focuses primarily on present concerns and stressors rather than on historical antecedents. Brief therapy is conducted by therapists who have been specifically trained in one or more psychological or psychosocial models of treatment. Therapist training requires months or years and usually results in a specialist degree or certification. In practice, many therapists who have been trained in specific theoretical models of change borrow techniques from other models when working with their clients. Although the models remain distinct, therapists often become eclectic practitioners. The Demand for Brief Interventions and Therapies The impetus for shorter forms of interventions and treatments for a range of substance abuse problems comes from several sources: ¨ Historical developments in the field that encourage a comprehensive, community-based continuum of care--with treatment and prevention components to serve clients who have a wide range of substance abuse-related problems ¨ A growing body of evidence that consistently demonstrates the efficacy of brief interventions ¨ An increasing demand for the most cost-effective types of treatment, especially in this era of health care inflation and cost containment policies in the private and public sectors ¨ Client interest in shorter term treatments The increasing demand for treatment of some sort--arising from the identification of more at-risk consumers of substances through EAPs, substance-testing programs, health screening efforts, and drunk driving arrests--coupled with decreased public funding and cost containment policies of managed care leave only two options: provide diluted treatment in traditional models for a few or develop a system in which different levels and types of interventions are provided to clients based on their identified needs and characteristics (Miller, 1993). An Overview of Brief Therapies Brief Interventions And Brief Therapies for Substance Abuse Expanding Treatment Options The development of public substance abuse treatment programs subsidized by Federal, State, and local monies dates to the late 1960s when public drunkenness was decriminalized and detoxification centers were substituted for drunk tanks in jails. At about the same time, similar efforts were made to curtail heroin use in major cities by establishing methadone maintenance clinics and residential therapeutic communities (IOM, 1990). By the 1980s, direct Federal financial support for treatment had slowed, and although some States continued to grant subsidies, the most rapid growth in the field switched to the insurance-supported private sector and the development of treatment programs targeted primarily to heavy consumers of alcohol, cocaine, and marijuana (Gerstein and Harwood, 1990). The standardized approach used in most of these private, hospital-based programs incorporated many aspects of the Minnesota model pioneered in the late 1950s, with a strong focus on the 12-Step philosophy developed in Alcoholics Anonymous (AA), a fixed-length, 28-day stay, and insistence on abstinence as the major treatment goal (CSAT, 1995). Initially, treatment programs in both the public and private sectors tended to serve the most seriously impaired populations; however, providers gradually recognized the need for treatment options for a wider range of clients who had different types of substance abuse disorders. Providers realized that not all clients benefit from a single standardized treatment approach. Rather, treatment should be tailored to individual needs determined by in-depth assessments of the client's problems and antecedents to her substance abuse disorder. Providers were also aware that interventions with less dysfunctional clients often had greater success rates. In the interest of reducing drunk driving, for example, educational efforts were targeted at offenders charged with DWI as an alternative to revoking their driving licenses. In such programs, more attention was given to outcomes and factors in the treatment setting than to the client's history; these seemed to affect success rates whether or not treatment was completed. As assessments became more comprehensive, treatment also began to address the effects of substance abuse patterns on multiple systems, including physical and mental health, social and personal functioning, legal entanglements, and economic stability. In recent years, this biopsychosocial approach to the treatment of substance abuse disorders has stimulated more cross-disciplinary cooperation. It has also prompted more attempts to match client needs to the most appropriate and expeditious intensity of care and treatment modality. Consideration is now given to differences not only in the severity and types of problems identified but also to the cultural or environmental context in which the problems are encountered, the types of substances abused, and differences in gender, age, education, and social stability. Determining a client's appropriateness for treatment is one of the 46 global criteria for competency of certified alcohol and drug abuse counselors (Herdman, 1997). Indeed, client assessment and treatment matching and referral has become a specialty area in itself that avoids the hazards of random treatment entry. In order to test the efficacy of current treatment-matching knowledge, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) initiated Project MATCH (Matching Alcoholism Treatment to Client Heterogeneity), which assessed the benefits of matching alcohol-dependent clients (using 10 client characteristics) to three types of treatments: 12-Step facilitation, cognitive-behavioral therapy, and motivational enhancement therapy (Project MATCH Research Group, 1997). Clients from two parallel but independent clinical trials (one in which clients were receiving outpatient treatment, the other in which clients were receiving aftercare therapy following inpatient treatment) were assigned to receive one of the three treatments. Although the results do not indicate a strong need to consider client characteristics to match clients to treatment, the findings do suggest that the severity of coexisting psychiatric disorders should be considered. Another study, conducted by McLellan and colleagues, identified specific problems of clients in treatment (e.g., employment, family, psychiatric problems), then matched the clients to services designed to address the problems (McLellan et al., 1993). These clients stayed in treatment longer, were more likely to complete treatment, and had better posttreatment outcomes than unmatched clients in the same treatment programs. Expanding Treatment Options Brief Interventions And Brief Therapies for Substance Abuse In this context, increasing emphasis has also been given to integrating specialized approaches to substance abuse treatment with the general medical system and the services of other community agencies. A 1990 IOM report called for more community involvement in health care, social services, workplace, educational, and criminal justice systems (IOM, 1990). Because the vast majority of persons who use substances in moderation experience few or minor problems, they are not likely to seek help in the specialized treatment system. Instead, the estimated 20 percent of the adult population who drink or use heavily or in inappropriate ways (Higgins-Biddle et al., 1997) are those most likely to come to the attention of physicians, social workers, family therapists, employers, teachers, lawyers, and police. Because the prevalence of harmful and risky substance use far exceeds the capacity of available services to treat it, briefer and less intensive interventions seem warranted for a broad range of individuals, including those who are unwilling to accept referral for more formal and extensive specialized care (Bien et al., 1993) and those whose substance use is risky but not abusive (Higgins-Biddle et al., 1997). Cost and Funding Factors Studies of the cost-effectiveness of different treatment approaches have been particularly appealing to policymakers seeking to reduce costs and better allocate scarce resources. In the managed care environment, however, cost containment has become a byword, and no standard type of care or treatment protocol for all clients is acceptable. In order to receive reimbursement, substance abuse treatment facilities must find the least intensive yet safe modality of care that can be objectively proven to be appropriate and effective for a client's needs. Now that more treatment is delivered in ambulatory care facilities, the usual time in treatment is being shortened, and the credibility of recommended treatment approaches must be increasingly documented through carefully conducted research studies. In this context, some of the most widely used substance abuse treatment approaches, such as the Minnesota model, halfway houses, and 12-Step programs, have only recently been subjected to rigorous tests of effectiveness in controlled clinical trials (Barry, 1997; Holder et al., 1991; Landry, 1996). In addition to the emphasis on cost containment and careful client-treatment matching, other researchers tout the potentially enormous public health impact that could be derived from conducting mass screenings in existing health care and other community-based systems to identify problem drinkers and then delivering brief interventions aimed at reducing excessive drinking patterns (Kahan et al., 1995). If appropriately selected persons with less severe substance abuse respond successfully to brief interventions with a consequent long-term reduction in substance abuse-related morbidity and associated health care costs, time and energy could be saved for treating those with more severe substance abuse disorders in specialized treatment facilities. Barriers to Increasing the Use of Brief Treatments Many clinicians and other care providers in community agencies retain the long-standing notion that clients are generally resistant to change, unmotivated, and in denial of problems associated with their substance abuse disorders. As a result, clinicians are hesitant to work with this population. Some of these attitudes also persist in the specialist treatment community (Miller, 1993). Although this perspective is shifting as clinicians better understand the many aspects of client motivation, there is still a tradition of waiting for a substance user to "hit bottom" and ask for help before attempting to treat him. Other ideological obstacles present barriers in earlier stages of substance abuse. The focus of brief interventions on harm or risk reduction and moderating consumption patterns as a first and sometimes only goal is not always acceptable to counselors who were trained to insist on total and enduring abstinence. Assumptions underlying brief interventions aimed at harm reduction may seem to challenge ideas that substance abuse disorders are a chronic and progressive disease requiring specialized treatment. However, if substance abuse is placed on a continuum from abstinence to severe abuse, any move toward moderation and lowered risk is a step in the right direction and not incongruous with a goal of abstinence as the ultimate form of risk reduction (Marlatt et al., 1993). Moreover, research indicates that substance-abusing individuals who are employed and generally functioning well in society are unlikely Cost and Funding Factors Brief Interventions And Brief Therapies for Substance Abuse to respond positively to some forms of traditional treatment which may, for example, tell them that they have a primary disease of substance dependency and must abstain from all psychoactive substances for life (Miller, 1993). In addition to resisting a harm reduction approach, treatment staffs in programs that incorporate pharmacotherapies may be skeptical of behavioral approaches to client change if they believe addiction primarily stems from disordered brain chemistry that should be treated medically. There are many models of pharmacotherapy that suggest that counseling (often in a brief form) coupled with medication provides the most well-rounded and comprehensive treatment regime (McLellan et al., 1993; Volpicelli et al., 1992). Moreover, research reveals that a longer time in treatment may contribute to a greater likelihood of success (Lamb et al., 1998). Brief interventions challenge this assumption by acknowledging that spontaneous remission and self-directed change in substance abuse behaviors do occur. A new perspective might reconcile these observations by recognizing that limited treatment can be beneficial--especially considering that at least half of all clients drop out of specialized treatment before completion. Probably the largest impediment to broader application of briefer forms of treatment is the already overwhelming responsibilities of frontline treatment staff members who are overworked and unfamiliar with the latest treatment research findings (Schuster and Silverman, 1993). Not only are these clinicians reluctant to make clinical changes, but their programs may also lack the financial and personnel resources to adopt innovative approaches. Treatment programs limit themselves by such inability and unwillingness to learn new techniques. Evaluating Brief Interventions and Therapies Quality improvement has become an important consideration in the contemporary health care environment. Because of changes in the nature and provision of health care delivery in the United States, health care organizations have been working to develop systematic quality improvement programs to monitor provision of care, client satisfaction, and costs. Brief interventions can be an important part of a treatment program's quality improvement initiative. These approaches can be used to improve treatment outcomes in specific areas. Not only can brief interventions improve client compliance with specific aspects of treatment and therapist morale by focusing on attainable goals, but they can also demonstrate specific clinical outcomes of importance to both clinicians and managed care systems. Importance of Evaluation 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 improving treatment. Examples of outcome measures include ¨ Aftercare followup rates ¨ Aftercare compliance rates ¨ Alumni participation rates ¨ Discharge against medical advice rates ¨ Counselors' ratings of client involvement in substance abuse following treatment ¨ The number of complaints related to the brief intervention or therapy Mechanisms To Use in Evaluation The effects of adding brief approaches to standard care should be evaluated as part of continuous quality improvement program testing. Some of these outcomes can be measured by ¨ Client satisfaction surveys Evaluating Brief Interventions and Therapies Brief Interventions And Brief Therapies for Substance Abuse ¨ Followup phone calls ¨ Counselor-rating questions added to clinical chart Programs should monitor client satisfaction over time, and whenever possible counselors should be involved in quality improvement activities. Identifying trends over time can indicate what improvements need to be made. Implementation of substance abuse prevention and brief intervention strategies in clinical practice requires the development of systematized protocols that can provide easier service delivery. The need to implement effective and unified strategies for a variety of substance abusers who are at risk for more serious health, social, and emotional problems is high, both from a public health and a clinical perspective. As the health care system undergoes changes, programs should take the opportunity to develop and advocate a comprehensive system of substance abuse interventions, combining the skills of clinicians with the knowledge gained from the research community Chapter 2 -- Brief Interventions in Substance Abuse Treatment Brief interventions for substance abuse problems have been used for many years by alcohol and drug counselors, social workers, psychologists, physicians, and nurses, and by social service agencies, hospital emergency departments, court-ordered educational groups, and vocational rehabilitation programs. Primary care providers find many brief intervention techniques effective in addressing the substance abuse issues of clients who are unable or unwilling to access specialty care. Examples of brief interventions include asking clients to try nonuse to see if they can stop on their own, encouraging interventions directed toward attending a self-help group (e.g., Alcoholics Anonymous [AA] or Narcotics Anonymous [NA]), and engaging in brief, structured, time-limited efforts to help pregnant clients stop using. Brief interventions are research-proven procedures for working with individuals with at-risk use and less severe abuse behaviors and can be successful when transported into specialist treatment settings and performed by alcohol and drug counselors. As presented in the literature, brief interventions to change substance abuse behaviors can involve a variety of approaches, ranging from unstructured counseling and feedback to formal structured therapy (Chick et al., 1985; Fleming et al., 1997; Kristenson et al., 1983; Persson and Magnusson, 1989). Brief interventions, as defined and discussed in this TIP are time limited, structured, and directed toward a specific goal. They follow a specific plan (and in some cases a workbook) and have timelines for the adoption of specific behaviors. Several studies have attempted to identify factors that result in differential responses to brief intervention by varying client characteristics or by conducting subgroup analyses. Most studies of brief interventions to date are limited by their lack of sufficient subject assessments. Findings from the available research suggest that client characteristics are not good predictors of a person's response to a brief intervention and that brief interventions may be applicable to individuals from a wide range of cultures and backgrounds (Babor, 1994; Babor and Grant, 1991). This chapter provides theoretical and practical information on brief interventions, both in opportunistic settings and in the substance abuse treatment setting. The stages-of-change model is presented first because of its usefulness in understanding the process of behavioral change. Next, the goals of brief intervention are described and applied to various levels of substance use. FRAMES elements critical to brief intervention are detailed, and five essential steps are listed with scripts to use in various settings. The brief intervention workbook, a practical tool for use during a brief intervention, is explained. Essential clinician knowledge and skills for conducting a successful brief intervention are then described. Discussions of the use of brief intervention in substance abuse programs and nonspecialized settings follow. The final section presents research findings on brief interventions for both at-risk users and dependent users. Chapter 2 -- Brief Interventions in Substance Abuse Treatment Brief Interventions And Brief Therapies for Substance Abuse Stages-of-Change Model The work of Prochaska and DiClemente and their "stages-of-change" model help clinicians tailor brief interventions to clients' needs (Prochaska and DiClemente, 1984, 1986). Prochaska and DiClemente examined several theories concerning how change occurs and applied their findings to substance abuse behavior modification. They devised a model consisting of five stages of change that seemed to best represent the process people go through when thinking about, beginning, and trying to maintain new behavior (see Figure 2-1). The stages-of-change model is explained more fully in TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT, 1999c). These stages have proven useful, for example, in predicting those most likely to quit smoking and in targeting specific kinds of interventions to smokers in different stages (DiClemente et al., 1991; Prochaska, 1999; Prochaska and DiClemente, 1986; Velicer et al., 1992). Stages of change are being examined in brief interventions with hazardous and harmful substance users as well, as a means of tailoring interventions to the individual's current stage of change (Hodgson and Rollnick, 1992; Mudd et al., 1995). Clients need motivational support appropriate to their stage of change. If the clinician does not use strategies appropriate to the stage the client is in, treatment resistance or noncompliance could result. To consider change, clients at the precontemplation stage must have their awareness raised. To resolve their ambivalence, clients in the contemplation stage must be helped to choose positive change over their current circumstances. Clients in the preparation stage need help in identifying potential change strategies and choosing the most appropriate ones. Clients in the action stage need help to carry out and comply with the change strategies. The clinician can use brief interventions to motivate particular behavioral changes at each stage of this process. For example, in the contemplation stage, a brief intervention could help the client weigh the costs and benefits of change. In the preparation stage, a similar brief intervention could address the costs and benefits of various change strategies (e.g., self-change, brief treatment, intensive treatment, self-help group attendance). In the action stage, brief interventions can help maintain motivation to continue on the course of change by reinforcing personal decisions made at earlier stages. Understanding these stages helps the clinician to be patient, to accept the client's current position, to avoid "getting too far ahead" of the client and thereby provoking resistance, and, most important, to apply the correct counseling strategy for each stage of readiness. Effective brief interventionists quickly assess the client's stage of readiness, plan a corresponding strategy to assist her in progressing to the next stage, and implement that strategy without succumbing to distraction. Indeed, clinician distraction can be a greater obstacle to change in brief intervention than time limitations. Regardless of the stage of readiness, brief interventions can help initiate change, continue it, accelerate it, and prevent the client from regressing to previous behaviors. Goals of Brief Intervention The basic goal for a client in any substance abuse treatment setting is to reduce the risk of harm from continued use of substances. The greatest degree of harm reduction would obviously result from abstinence, however, 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 successes in the intervention and treatment process, whatever the long-term goals are. In specialized treatment, intermediate goals might include quitting one substance, decreasing frequency of use, attending the next meeting, or doing the next homework assignment. Immediate successes are important to keep the client motivated. Setting goals for clients is particularly useful in centers that specialize in substance abuse treatment. Performing brief interventions in this setting requires the ability to simplify and reduce a client's treatment plan to smaller, measurable outcomes, often expressed as "objectives" in the Joint Commission on the Accreditation of Healthcare Organizations' Stages-of-Change Model Brief Interventions And Brief Therapies for Substance Abuse (JCAHO) language of treatment planning. The clinician must be aware of the many everyday circumstances in which clients with substance abuse disorders face ambivalence during the course of treatment. The key to a successful brief intervention is to extract a single, measurable behavioral change from the broad process of recovery that will allow the client to experience a small, incremental success. Clients who succeed at making small changes generally return for more successes. The clinician should temporarily set aside the final 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 reach it. Objectives vary according to the client's stage of recovery and readiness to change, but brief interventions can be useful at any stage of recovery. Figure 2-2 presents several objectives that might be addressed with a brief intervention. The following are suggested goals for brief interventions according to the client's level of consumption. Abstainer Even though abstainers do not require intervention, they can be educated about substance use with the aim of preventing a substance abuse disorder. Such prevention education programs are particularly important for youth. Light or Moderate User The goal of a brief intervention with someone who is a light or moderate user is to educate her about guidelines for low-risk use and potential problems of increased use. Even light or moderate use of some substances can result in health problems or, in the case of illicit substances, legal problems. These users may also engage in binge drinking (i.e., five or more drinks in a single occasion). Clients who drink should be encouraged to stay within empirically established guidelines for low-risk drinking (no more than 14 drinks per week or 4 per occasion for men and no more than 7 drinks per week or 3 per occasion for women [American Society of Addiction Medicine (ASAM), 1994]). Brief interventions can enhance users' insight into existing or possible consequences or draw attention to the dangers associated with the establishment of an abusive pattern of substance use. For example, a woman who drinks moderately and is pregnant or who is contemplating a pregnancy can be advised to abstain from alcohol in order to prevent fetal alcohol syndrome. Brief interventions can also educate clients about the nature and dangers of substance abuse and possible warning signs of dependency. Older adults who take certain medications and use alcohol, even at this level, may be at risk for problems due to the interaction of medications and alcohol. See TIP 26, Substance Abuse Among Older Adults (CSAT, 1998b), for guidelines on alcohol use in older adulthood. At-Risk User This group includes those whose use is above recommended guidelines for alcohol use (as described above) or whose use puts them at risk for problems related to their consumption or at risk for meeting the criteria for a substance abuse disorder (e.g., people who may be able to report the requisite number of symptoms of a substance abuse disorder may not have three or more symptoms within a 12-month period). Brief interventions with this group address the level of use, encourage moderation or abstinence, and educate about the consequences of risky behavior and the risks associated with increased use. Brief interventions can help users understand the biological and social consequences of their substance use. Abstainer 28 Brief Interventions And Brief Therapies for Substance Abuse Abuser These are clients with a substance abuse disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) (American Psychiatric Association [APA], 1994). The goal of intervention with this population, depending on the clinician's theoretical perspective and the substances used, is to prevent any increase in the use of substances, to facilitate introspection about the consequences of risky behavior, to encourage the client to consider assessment or treatment, and to encourage moderation or abstinence. There is mixed evidence on whether persons who meet criteria for substance abuse can successfully reduce their use to meet lower-risk guidelines or if abstinence is the only reasonable goal. (See "Research Findings" later in this chapter for a discussion of this issue.) Both research and clinical experience have produced varying results regarding this issue. From a clinical standpoint, however, some clients who meet abuse criteria may not achieve abstinence but might benefit from a positive, nonjudgmental approach to change their behavior over time. For example, after working with a clinician to monitor problems associated with the substance abuse, a client might agree not to drive after using substances or might consider quitting. Goals of brief interventions with hazardous drinkers who are not alcohol dependent have been flexible, allowing the individual to choose drinking in moderation or abstinence. In such cases, the goal of the intervention is to motivate the problem drinker to change his behavior, not to assign blame. Helping clients to recognize the need for change is an essential step in this process. Substance-Dependent User Intervention at this level of use may focus on encouraging users to consider treatment, to contemplate abstinence, or to return to treatment after a relapse. The goal of intervention for dependent users is to recommend the optimal behavior change and level of care. In reality, however, the clinician may be able to negotiate a change the client is willing to accept and work over time toward abstinence. For example, if a client resists committing to prolonged abstinence, the provider could negotiate a limited period ending with a "checkup," at which time the client might consider extending abstinence further. It should be noted that some substance-dependent clients may be in a life-threatening stage in their addiction or risk serious consequences such as losing their jobs, going to jail, or losing their families. For these clients, brief interventions should be linked to a referral strategy in which the goal is a therapeutic alliance between the client and the referral treatment team. Brief intervention in this context is more like "case management," in which the primary care provider tracks the client's progress with other service providers and determines if the client needs any additional services. ASAM Criteria Under ASAM criteria (see Figure 2-3), brief interventions are aimed at the nondependent user, at level 0.5 or possibly level I. Individuals at level II may be appropriate for a brief intervention if relapse potential and recovery environment are major problems for those with relatively minor physiological and psychological substance problems and high motivation to change. ASAM criteria have been extremely useful for clinical management of persons with substance abuse disorders who require more care than is needed for at-risk drinkers. Brief interventions, whether directed at reducing at-risk use (often used in primary care settings) or assisting in specific aspects of the treatment process, can be helpful for clients at every ASAM level and in many treatment settings. Abuser 29 Brief Interventions And Brief Therapies for Substance Abuse Components of Brief Interventions There is tremendous diversity in the process of recovery from a substance abuse disorder. Clients make changes for different reasons, and an intervention that works well for one client may not work for another. Brief interventions are components of the journey toward recovery and can be integral steps in the process. For some clients, assistance with the decision to make the change will be enough to motivate them to start changing the behavior, whereas others may need more intensive clinical involvement throughout the change process. Brief interventions can be tailored to different populations, and many options are available to augment interventions and treatments, such as AA, NA, and medications. It should be noted, however, that brief interventions are not a substitute for specialized care for clients with a high level of dependency. They can be used to engage clients in specific aspects of treatment programs, such as attending group and AA or NA meetings. Brief interventions can also help potential clients move toward seeking treatment and can serve as a temporary measure for clients on waiting lists for treatment programs. Even clinicians who advocate abstinence as a goal can use brief interventions as tools to help clients reach that goal. There are six elements critical to a brief intervention to change substance abuse behavior (Miller and Sanchez, 1994). The acronym FRAMES was coined to summarize these active ingredients, which are shown in Figure 2-4. The FRAMES components have been combined in different ways and tested in diverse settings and cultural contexts. 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: 1. Introducing the issue in the context of the client's health 2. Screening, evaluating, and assessing 3. Providing feedback 4. Talking about change and setting goals 5. Summarizing and reaching closure Providers may not have to use all five of these components in every session. It is more important to use the components that reflect the needs of the client and her personal style. Before eliminating steps in the brief intervention process, however, there should be a well-defined reason for doing so. Moreover, a vital part of the intervention process is monitoring to determine how the patient is progressing after the initial intervention has been completed. Monitoring allows the clinician and client to determine gains and challenges and to redirect the longer term plan when necessary. Following are descriptions of the five basic steps. Sample scenarios are provided where brief interventions might be initiated, with practical information about that particular step. For each step, Figure 2-5 presents scripts for brief interventions that clinicians can use in substance abuse treatment units or other settings where interventions might occur. (For examples focused on at-risk drinkers, see TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians [CSAT, 1997]. For detailed descriptions of more techniques, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT, 1999c]). Introducing the Issue In this step, the clinician seeks to build rapport with the client, define the purpose of the session, gain permission from the client to proceed, and help the client understand the reason for the intervention. Counseling tips: Help the client understand the focus of the interview. State the target topic clearly and stress confidentiality; be nonjudgmental and avoid labels. Do not skip this opening; without it, the success of the next steps could be jeopardized. Components of Brief Interventions Brief Interventions And Brief Therapies for Substance Abuse Screening, Evaluating, And Assessing In general, this is a process of gaining information on the targeted problem; it varies in length from a single question to several hours of assessment on the targeted topic of change. It could involve a structured or nonstructured interview or a combination of both, coupled with questionnaires or standardized instruments, with the extent of the process determined largely by the setting, time, and available resources. A sample screening guideline for alcoholism is provided in Figure 2-6. Additional information about and examples of screening and assessment instruments can be found in the following TIPS: TIP 9, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse; TIP 10, Assessment and Treatment of Cocaine-Abusing Methadone-Maintained Patients; TIP 11, Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases; TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians; and TIP 31, Screening and Assessing Adolescents for Substance Use Disorders (CSAT, 1994b, 1994c, 1994d, 1997, 1999a). Counseling tips: Before you begin the brief intervention, decide how much information you have time to obtain and whether you want to have the client answer any questionnaires. Watch for defensiveness or other resistance, and avoid pushing too hard. Providing Feedback This component highlights certain aspects of the client's behavior using information gathered during screening. It involves an interactive dialog for discussing the assessment findings; it is not just clinician driven. Feedback should be given in small amounts. First, the clinician gives a specific piece of feedback, then asks for a response from the client. Sometimes the feedback is a brief, single sentence; at other times it could last an hour or more. Figure 2-7 provides an example of giving feedback. Counseling tips: Use active listening (see "Active listening" later in this chapter). Be aware of cultural, language, and literacy issues. Be nonjudgmental. Talking About Change And Setting Goals Talking about change involves talking about the possibility of changing behavior. It is used with clients in all stages of change, but it differs profoundly depending on the stage the client has reached. For example, in precontemplation, clients are helped to recognize and change their view of consequences; in contemplation, they are helped to resolve ambivalence about change. In action, the focus is on planning, removing barriers, and avoiding risky situations; in maintenance, the emphasis is on establishing new long-term behaviors. It is important that the clinician assess the client's readiness to change if it is not already known. (See Figure 2-8 for examples of discussing change with a client who is trying to stop using cocaine but wants to continue to drink alcohol.) In talking about change, the clinician often suggests a course of action, then negotiates with the client to determine exactly what he is willing to do. Sometimes, talking about change is premature (i.e., before the assessment and feedback have happened). In that case, it should be postponed until later in the intervention. Counseling tips: Offer change options that match client's readiness for change. Be realistic: Recommend the ideal change, but accept less if the client is resistant. Summarizing and Reaching Closure This step involves a summary of the discussion and a review of the agreed-upon changes. Screening, Evaluating, And Assessing Brief Interventions And Brief Therapies for Substance Abuse If no agreement was reached, review the positive action the client took during the session. At this point, it is important to schedule a followup visit to talk about how the client is progressing. The followup could be another face-to-face meeting, a telephone call, or even a voice mail message. The goals of closing on good terms are to arrange another session, to leave the client feeling successful, and to instill confidence that will enable the client to follow through on what was agreed upon Counseling tips: Tailor your closure to the client and the particular circumstance of this brief intervention; interpret any client resistance in a positive light leading to progress. Thus, if a client has been unwilling to commit to changes, thank her for her willingness to consider the issues and express the hope that she will continue to consider committing to changes. Brief Intervention Workbooks Brief intervention protocols often involve using a workbook that is based on the steps listed below. A workbook provides the client and clinician with opportunities to discuss the client's cues for using substances, reasons for using substances, and reasons for cutting down or quitting. It also usually provides a substance abuse agreement in the form of a prescription and substance abuse diary cards for self-reporting. These techniques, which often target reduction in substance abuse rather than abstinence, are similar to homework techniques used in substance abuse treatment programs. A sample of a workbook used to address drinking problems is provided in Appendix D. The steps in the workbook follow a script and may focus on the following: ¨ Identification of future goals for health, activities, hobbies, relationships, and financial stability ¨ Customized feedback on screening questions relating to substance abuse patterns and other health habits (also may include smoking, nutrition, etc.) ¨ Discussion of where the client's substance abuse patterns fit into the population norms for his age group ¨ Identification of the pros and cons of substance abuse--this is particularly important because the clinician must understand the role of substance abuse in the context of the client's life (given the opportunity to discuss the positive aspects of her substance abuse, the client may talk about her concerns honestly instead of feeling she should say what she thinks the clinician wants to hear; this builds a better working relationship) ¨ Consequences of continued substance use to encourage the client to decrease or stop abusing substances and avoid longer term effects of continued substance abuse ¨ Reasons to cut down or quit using (maintaining family, work, independence, and physical health all may be important motivators) ¨ Sensible use limits and strategies for cutting down or quitting--useful strategies include developing social opportunities that do not involve abusing substances and becoming reacquainted with hobbies and interests ¨ A substance abuse agreement--agreed-upon use limits (or abstinence) signed by the client and the clinician--can often be an effective way to alter use patterns ¨ Coping with risky situations (e.g., socializing with substance users, isolation, boredom, and negative family interactions) ¨ Summary of the session Essential Knowledge and Skills for Brief Interventions Providing effective brief interventions requires knowledge, skills, and abilities. Studies have shown that applying the clinician's skills listed below produces good outcomes, including getting clients to enter treatment, work harder in treatment, stay longer in treatment, and have better outcomes after treatment such as higher participation in aftercare and better sobriety rates (Brown and Miller, 1993; Miller et al., 1993). ¨ Overall attitude of understanding and acceptance ¨ Counseling skills such as active listening and helping clients explore and resolve ambivalence Brief Intervention Workbooks Brief Interventions And Brief Therapies for Substance Abuse ¨ A focus on intermediate goals (see discussion earlier in this chapter) ¨ Working knowledge of the stages-of-change model (see discussion earlier in this chapter) Attitude of Understanding And Acceptance Clinicians must assure their clients that they will listen carefully and make every effort to understand the client's point of view during a brief intervention. Brief interventions are by definition time limited, which increases the difficulty of adopting such an attitude. However, when clients experience this nonjudgmental, respectful interest and understanding from the clinician, they feel safe to openly discuss their ambivalence about change--rather than resist pressure from the clinician to change before they are ready to do so. The sooner they address their ambivalence, the sooner they progress toward lasting change (see also TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT, 1999c]). When clients feel they are being pushed toward change--even if the clinician is not pushing--they are likely to resist. Clients must summon all of their attention and strength to resolve their ambivalence, and resisting the clinician may cause them to lose track and argue against change. If the client and clinician begin arguing or debating, the clinician should immediately shift to a new strategy, otherwise the brief intervention will fail. In other words, resistance is a signal for the clinician to change strategies and defuse the resistance. Counseling Skills Active listening One of the most important skills for brief interventionists is "active listening" (see Figure 2-9). Active listening is the ability to accurately restate the content, feeling, and meaning of the client's statements. This is also called "reflective listening," "reflecting," or sometimes "paraphrasing." Active listening is one of the most direct ways to rapidly form a therapeutic alliance. When done well, it is a powerful technique for understanding and facilitating change in clients. Active listening goes beyond nonverbal listening skills or responses such as, "Hmmm," "Uh-huh," "I see," "I hear you," or "I understand where you're coming from." None of these short statements demonstrates that the clinician understands. Counselors should also ask open-ended questions to which the client must respond with a statement, rather than a simple yes or no. Instead of summarizing a situation and then asking, "Is this correct?" ask the client, "What do you think? How do you feel about the situation?" Open-ended questions are invitations to share and provide a means to probe for important information that emerges in the interview. Exploring and resolving ambivalence Another important skill is the ability to help clients explore and resolve ambivalence. Ambivalence is the hallmark of a person in the contemplation stage of readiness. It is one of the most prevalent clinical challenges encountered in brief interventions. Whether it takes 1 minute or 40 minutes, the goal is to help clients become more aware of their position and the discomfort that accompanies their ambivalence. Increasing awareness of this discomfort within an understanding and supporting relationship can inspire the client to progress to a stage of preparation or action. For example, a client might be willing to go to counseling but not an AA meeting; in that case, the clinician should work with the client's motivation and focus on the positive step the client is willing to make. One way to help a client recognize his ambivalence is to ask him to identify the benefits and costs of the targeted behavior (e.g., using alcohol) and the benefits and costs of changing the behavior. The clinician listens and summarizes these benefits and costs, then asks the client if any of them is more important than the others. This helps identify values that are important to the client and can therefore increase or decrease the chance of changing. Clinicians might also ask if any of the pros and cons is more or less accurate than others. This provides an opportunity for irrational thoughts to be refuted, which can help remove barriers to change (see example in the text box below). Attitude of Understanding And Acceptance Brief Interventions And Brief Therapies for Substance Abuse Another approach to raising awareness of ambivalence is to explore the client's experience of feeling caught between opposing desires. For more specific techniques for resolving ambivalence, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT, 1999c). Brief Interventions in Substance Abuse Treatment Programs Substance abuse treatment programs frequently use brief interventions, although they might not be called by that name. Brief interventions can be effectively integrated into more comprehensive treatment plans for clients with substance abuse disorders. These approaches can be particularly useful in treatment settings when they are used to address specific targeted client behaviors and issues in the treatment process that can be difficult to change using standard treatment approaches. Brief interventions can be used with clients before, during, and after substance abuse treatment. To integrate the use of brief interventions into specialized treatment, counselors and providers should be trained to provide this service. The Consensus Panel recommends that agencies consider allocating counselor training time and resources to these modalities. The Panel 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. It is also extremely important for substance abuse treatment personnel to collaborate with primary care providers, employee assistance program (EAP) personnel, wellness clinic staff, and other community-based service providers in developing plans that include both brief interventions and more intensive care to help keep the client focused on treatment and recovery. The following is a list of the potential benefits of using brief interventions in substance abuse treatment settings: ¨ Reduce no-show rates for the start of treatment ¨ Reduce dropout rates after the first session of treatment ¨ Increase treatment engagement after intake assessment ¨ Increase compliance for doing homework ¨ Increase group participation ¨ Address noncompliance with treatment rules (e.g., smoking in undesignated places, unauthorized visits, or phone calls) ¨ Reduce aggression and violence (e.g., verbal hostility toward staff and other clients) ¨ Reduce isolation from other clients ¨ Reduce no-show rates for continuing care ¨ Increase mutual-help group attendance ¨ Obtain a sponsor, if involved with a 12-Step program ¨ Increase compliance with psychotropic medication therapies ¨ Increase compliance with outpatient mental health referrals ¨ Serve as interim intervention for clients on treatment program waiting lists Removing a Barrier to Change Your client, Mary, is hospitalized because of an alcohol-related injury. You conduct a brief intervention in the hospital. During the session, she says that one of the good things about her drinking is that she "always had fun when she was drinking." In that case, you can ask her what her perspective is on the situation and whether she sees a connection between her drinking and her current behavior. This could lead to her challenging one of her reasons for drinking. By systematically exploring the reasons for and against drinking, you can help her tip the scale in favor of change. Brief Interventions in Substance Abuse Treatment Programs Brief Interventions And Brief Therapies for Substance Abuse Brief Interventions Outside Substance Abuse Treatment Settings Brief interventions are commonly administered in nonsubstance abuse treatment settings, often referred to as opportunistic settings, where clients are not seeking help for a substance abuse disorder but have come to receive medical treatment, to meet with an EAP counselor, or to respond to a court summons (see Figure 2-10 for a list of health care and other professionals who often conduct brief substance use interventions). These settings and many others provide a multitude of opportunities to help people change their substance abuse patterns. It is unrealistic and unnecessary for providers in opportunistic settings to avoid working with people with a range of substance abuse problems including substance abuse disorders and merely to refer them for specialty care (Miller et al., 1994). Many clients do not use alcohol, for example, at a level that requires specialized treatment. Others who use at moderate or severe levels may be unwilling or unable to participate in specialized, mainstream substance abuse treatment programs. Moreover, some individuals may attach a stigma to attending treatment versus general health care services. Older adults and women often do not seek or engage in treatment because of stigma. An individual's level of substance use is detected through screening instruments, medical tests (e.g., urine testing), observation, or simply asking about consumption patterns. Those considered to have risky or excessive patterns of substance abuse or related problems can receive a brief intervention that rarely requires more than several sessions, each lasting only 5 minutes to 1 hour (average = 15 minutes). The goal of a brief intervention is to raise the recipient's awareness of the association between the expressed problem and substance abuse and to recommend change, either by natural, client-directed means or by seeking additional substance abuse treatment. Because the recipient usually does not expect to have a substance abuse problem identified, he may or may not be motivated to apply any recommendations. The brief intervention is highly structured and focuses on delivering a message about the individual's substance abuse and advice to reduce or stop it. If the initial intervention does not result in substantial improvement, the professional may refer the individual for additional specialized substance abuse treatment. Treatment providers who work in settings other than substance abuse treatment must be flexible when assessing, planning, and carrying out brief interventions. For example, they will likely encounter more risky drinkers than alcohol-dependent individuals (in the United States there are four times as many risky drinkers as dependent drinkers [Mangione et al., 1999]). Some research indicates that the potential for brief interventions to reduce the harm, problems, and costs associated with moderate to heavy alcohol use by risky drinkers significantly surpasses the effectiveness from applications of brief interventions on substance-dependent individuals (Higgins-Biddle et al., 1997). Other research on brief interventions, as presented below, highlights some of the more rigorous studies with positive outcomes. The costs of alcohol abuse to society, as interpreted by health care costs, lost productivity, and criminal activity, are enormous, and brief interventions are a cost-effective technique to address such abuse. Typically these brief interventions act as an early intervention before or close to the development of alcohol-related problems and primarily entail instructional and motivational components addressing drinking behavior. In substance abuse treatment, brief interventions are used to assist in the treatment engagement process and to deal with specific individual, family, or treatment-related issues. When delivering a brief intervention in any treatment setting, the provider should be mindful of room conditions and interruptions because client confidentiality is of utmost importance. Federal law requires that chart notes or other records on substance abuse be kept apart from the rest of the client's main chart. For example, if a medical client in a primary care clinic is also seen by an alcohol and drug counselor for treatment of a substance abuse disorder, those medical records are strictly protected by Federal law and may not be put in the client's chart. (For more information on these Federal laws, see TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians [CSAT, 1997].) Heather makes an important distinction between brief interventions that are delivered in opportunistic settings where patients are not directly seeking help for a substance abuse disorder and those conducted in treatment environments Brief Interventions Outside Substance Abuse Treatment Settings Brief Interventions And Brief Therapies for Substance Abuse where patients are seeking the help of specialists (Heather, 1995). Brief interventions conducted in opportunistic settings tend to be shorter, rely less on theory and more on an existing clinician-client relationship, and are less expensive because they are offered as part of an existing service. Conducting Brief Interventions With Older Adults Older adults present unique challenges in applying brief interve