Brief Intervention and Brief Therapies for Substance Abuse

Substance Abuse and Mental Health Services Administration Center for Su stance A use Treatment

Brief Interventions nd Brief Ther pies for Subst nce Abuse

Treatment Improvement Protocol (TIP) Series

34

Brief Interventions and Brief Therapies For Substance Abuse

Treatment Improvement Protocol (TIP) Series

34

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road Rockville, MD 20857

Acknowledgments This publication was prepared under contract number 270-95-0013 for the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). Sandra Clunies, M.S., I.C.A.D.C., served as the Contracting Officer's Representative.

Disclaimer The opinions expressed herein are the views of the consensus panel members and do not necessarily reflect the official position of SAMHSA or HHS. No official support of or endorsement by SAMHSA or HHS for these opinions or for the instruments or resources described are intended or should be inferred. The guidelines presented should not be considered substitutes for individualized client care and treatment decisions.

Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS.

Electronic Access and Printed Copies This publication may be ordered for free from SAMHSA's Publications Ordering Web page at . Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Espa?ol). The document can be downloaded from the KAP Web site at .

Recommended Citation Center for Substance Abuse Treatment. Brief Interventions and Brief Therapies for Substance Abuse. Treatment Improvement Protocol (TIP) Series, No. 34. HHS Publication No. (SMA) 123952. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999.

Originating Office Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857.

HHS Publication No. (SMA) 12-3952 First Printed 1999 Revised 2002, 2003, 2004, 2007, 2009, 2011, and 2012

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Contents

What Is a TIP?.......................................................................................................................................................... vii

Editorial Advisory Board........................................................................................................................................ ix

Consensus Panel ...................................................................................................................................................... xi

Foreword.................................................................................................................................................................. xiii

Executive Summary and Recommendations ..................................................................................................... xv Summary and Recommendations................................................................................................................... xvi

Chapter 1--Introduction to Brief Interventions and Therapies........................................................................1 An Overview of Brief Interventions ...................................................................................................................3 An Overview of Brief Therapies .........................................................................................................................7 The Demand for Brief Interventions and Therapies.........................................................................................8 Barriers to Increasing the Use of Brief Treatments.........................................................................................10 Evaluating Brief Interventions and Therapies ................................................................................................11

Chapter 2--Brief Interventions in Substance Abuse Treatment ....................................................................13 Stages-of-Change Model ....................................................................................................................................14 Goals of Brief Intervention.................................................................................................................................16 Components of Brief Interventions ..................................................................................................................18 Brief Intervention Workbooks...........................................................................................................................24 Essential Knowledge and Skills for Brief Interventions ................................................................................25 Brief Interventions in Substance Abuse Treatment Programs......................................................................27 Brief Interventions Outside Substance Abuse Treatment Settings...............................................................28 Research Findings ...............................................................................................................................................30

Chapter 3--Brief Therapy in Substance Abuse Treatment..............................................................................37 Research Findings ...............................................................................................................................................38 When To Use Brief Therapy ..............................................................................................................................39 Approaches to Brief Therapy ............................................................................................................................41 Components of Effective Brief Therapy...........................................................................................................41 Therapist Characteristics....................................................................................................................................49

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Contents

Chapter 4--Brief Cognitive?Behavioral Therapy..............................................................................................51

Behavioral Theory...............................................................................................................................................51 Behavioral Therapy Techniques Based on Classical Conditioning Models................................................53 Behavioral Therapy Techniques Based on Operant Learning Models ........................................................55 Cognitive Theory ................................................................................................................................................61 Cognitive Therapy ..............................................................................................................................................63 Cognitive?Behavioral Theory............................................................................................................................68 Cognitive?Behavioral Therapy .........................................................................................................................77

Chapter 5--Brief Strategic/Interactional Therapies ..........................................................................................87

Solution-Focused Therapy for Substance Abuse ............................................................................................88 Compatibility of Strategic/Interactional Therapies and 12-Step Programs ...............................................89 When To Use Strategic/Interactional Therapies ............................................................................................90 Case Study ...........................................................................................................................................................92 Strategic/Interactional Therapies .....................................................................................................................99

Chapter 6--Brief Humanistic and Existential Therapies ...............................................................................105

Using Humanistic and Existential Therapies................................................................................................106 The Humanistic Approach to Therapy ..........................................................................................................109 The Existential Approach to Therapy ............................................................................................................117

Chapter 7--Brief Psychodynamic Therapy.......................................................................................................121

Background ........................................................................................................................................................ 121 Introduction to Brief Psychodynamic Therapy.............................................................................................122 Psychodynamic Psychotherapy for Substance Abuse .................................................................................123 Psychodynamic Concepts Useful in Substance Abuse Treatment .............................................................128 Transference.......................................................................................................................................................131 Models of Brief Psychodynamic Therapy......................................................................................................135 Other Research ..................................................................................................................................................140

Chapter 8--Brief Family Therapy.......................................................................................................................143

Appropriateness of Brief Family Therapy .....................................................................................................144 Definitions of "Family" ....................................................................................................................................145 Theoretical Approaches ...................................................................................................................................147 Using Brief Family Therapies..........................................................................................................................152 Followup ............................................................................................................................................................154 Cultural Issues...................................................................................................................................................154

Chapter 9--Time-Limited Group Therapy .......................................................................................................157

Appropriateness of Group Therapy ...............................................................................................................157 Group Therapy Approaches............................................................................................................................158 Theories of Group Therapy .............................................................................................................................160 Use of Psychodrama Techniques in a Group Setting...................................................................................164 Therapeutic Factors ..........................................................................................................................................166 Using Time-Limited Group Therapy .............................................................................................................168 iv

Contents

Appendix A--Bibliography.................................................................................................................................173

Appendix B--Information and Training Resources .......................................................................................209

General Brief Therapy ......................................................................................................................................209 Cognitive?Behavioral Therapy .......................................................................................................................209 Strategic/Interactional Therapies ...................................................................................................................210 Humanistic and Existential Therapies ...........................................................................................................211 Psychodynamic Therapy..................................................................................................................................213 Family Therapy .................................................................................................................................................213 Group Therapy ..................................................................................................................................................214

Appendix C--Glossary .........................................................................................................................................215

Appendix D--Health Promotion Workbook....................................................................................................221

Part 1: Summary of Health Habits..................................................................................................................221 Part 2: Types of Drinkers in the U.S. Population ..........................................................................................222 Part 3: Consequences of Heavy Drinking......................................................................................................223 Part 4: Reasons To Quit or Cut Down on Your Drinking............................................................................224 Part 5: Drinking Agreement ............................................................................................................................225 Part 6: Handling Risky Situations...................................................................................................................227

Appendix E--Resource Panel ..............................................................................................................................229

Appendix F--Field Reviewers.............................................................................................................................231

Figures

1-1 Substance Abuse Severity and Level of Care ...........................................................................................4 1-2 Goal of Brief Interventions According to Setting.....................................................................................6 2-1 The Stages of Change.................................................................................................................................15 2-2 Sample Objectives ......................................................................................................................................16 2-3 American Society of Addiction Medicine (ASAM) Patient Placement Criteria.................................18 2-4 FRAMES ......................................................................................................................................................19 2-5 Scripts for Brief Intervention.....................................................................................................................20 2-6 Screening for Brief Interventions for Alcoholism ..................................................................................22 2-7 Client Feedback and Plan of Action.........................................................................................................23 2-8 Talking About Change at Different Stages .............................................................................................24 2-9 Steps in Active Listening ...........................................................................................................................26 2-10 Professionals Outside of Substance Abuse Treatment Who Can Administer

Brief Interventions......................................................................................................................................28 3-1 Criteria for Longer Term Treatment ........................................................................................................39 3-2 Selected Criteria for Providing Brief Therapy ........................................................................................40 3-3 Approaches to Brief Therapy....................................................................................................................42 3-4 Characteristics of All Brief Therapies ......................................................................................................44 3-5 Sample Battery of Brief Assessment Instruments ..................................................................................45 4-1 Classical Conditioning and Operant Learning.......................................................................................52

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Contents

4-2 Basic Assumptions of Behavioral Theories of Substance Abuse and Its Treatment .........................53 4-3 Advantages of Behavioral Theories in Treating Substance Abuse Disorders....................................54 4-4 Functional Analysis....................................................................................................................................56 4-5 Teaching Stress Management ...................................................................................................................60 4-6 Programmed Therapy and Writing Therapy..........................................................................................61 4-7 The Relationship Among Factors Maintaining Behavior in Behavioral and

Cognitive Models .......................................................................................................................................62 4-8 Fifteen Common Cognitive Errors...........................................................................................................63 4-9 Characteristic Thinking of People With Substance Abuse Disorders .................................................64 4-10 Common Irrational Beliefs About Alcohol and Drugs With More Rational Alternatives ...............65 4-11 Thoughts, Feelings, and Behaviors ..........................................................................................................66 4-12 Introducing Cognitive Therapy: A Sample Script ................................................................................. 67 4-13 Common Elements of Brief Cognitive-Behavioral Therapies..............................................................69 4-14 Attributional Styles ....................................................................................................................................70 4-15 Relapse Prevention Model Based on Self-Efficacy Theory ...................................................................73 4-16 Taxonomy of High-Risk Situations Based on Marlatt's Original

Categorization System ...............................................................................................................................75 4-17 A Cognitive-Behavioral Model of the Relapse Process ........................................................................76 4-18 Essential and Unique Elements of Cognitive-Behavioral Interventions............................................78 4-19 Intrapersonal and Interpersonal Skills Training Elements ................................................................... 80 4-20 Assertiveness Training ..............................................................................................................................80 4-21 Types of Clients for Whom Outpatient CBT Is Generally Not Appropriate......................................85 5-1 Deliberate and Random Exceptions to Substance Abuse Behaviors...................................................89 5-2 Strategic/Interactional Therapy in Practice: A Case Study..................................................................93 6-1 A Case Study.............................................................................................................................................111 7-1 Defense Mechanisms................................................................................................................................132 7-2 Brief Psychodynamic Therapy................................................................................................................136

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What Is a TIP?

Treatment Improvement Protocols (TIPs) are developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). Each TIP involves the development of topic-specific best-practice guidelines for the prevention and treatment of substance use and mental disorders. TIPs draw on the experience and knowledge of clinical, research, and administrative experts of various forms of treatment and prevention. TIPs are distributed

to facilities and individuals across the country. Published TIPs can be accessed via the Internet at .

Although each consensus-based TIP strives to include an evidence base for the practices it recommends, SAMHSA recognizes that behavioral health is continually evolving, and 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. If research supports a particular approach, citations are provided.

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