Brief Interventions and Therapies
Introduction to Brief Interventions and Therapies
Introduction
Brief interventions and therapies are increasingly important in substance abuse treatment.
The changing healthcare system and reimbursement policies favor short, problem-specific approaches.
These approaches can be used independently or as additions to other treatments, increasing positive outcomes.
They are applicable in various settings, including primary care and specialized substance abuse treatment centers.
Brief interventions can:
Reduce or stop substance abuse.
Serve as a first step to determine if clients can self-manage.
Change specific behaviors before or during treatment.
Examples include addressing treatment compliance, family problems, personal finances, and work attendance.
The primary goal is to reduce harm to clients, families, and the community resulting from substance use.
Brief Therapies Overview
Brief therapies discussed include:
Brief cognitive-behavioral therapy.
Brief strategic and interactional therapies.
Brief humanistic and existential therapies.
Brief psychodynamic therapy.
Short-term family therapy.
Time-limited group therapy.
Selection is based on research and clinical expertise.
These therapies are used in substance abuse treatment and contribute to the eclectic practitioner's toolkit.
Continuum of Care
Brief interventions and brief therapies exist on a continuum of care.
Interventions aim to motivate specific actions (e.g., entering treatment, changing behavior).
Therapies address broader concerns (e.g., altering personality, maintaining abstinence).
This manual presents interventions as a way to improve client motivation for treatment, while therapies change client attitudes and behaviors.
Distinctions between brief interventions and brief therapies:
Length of sessions: Interventions can be as short as 5 minutes, while therapies involve more than six 1-hour sessions.
Extensiveness of assessment: Therapies require more extensive assessment than interventions.
Setting: Interventions are used in non-traditional settings like social services, whereas therapies are used in traditional substance abuse treatment settings.
Personnel: Interventions can be administered by a wide range of professionals, but therapy requires specific training.
Materials: Interventions may use written materials or computer programs, unlike therapies.
The theoretical bases may differ, but the distinction blurs in practice.
The success of brief interventions is being understood and refined, with theories developing to explain their mechanisms of action.
Motivational enhancement therapy is an example of a brief intervention that overlaps with therapy.
Refer to Manual 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT, 1999c).
Definitions
Brief therapy: A series of steps to treat a substance abuse problem.
Brief interventions: Practices to investigate a potential problem and motivate action against substance abuse.
Therapy involves movement toward change, focusing on problem-solving in consultation with the client.
Interventions generally involve a therapist giving advice.
Emphasis on Brief Approaches
The increasing emphasis on brief approaches is due to changes in healthcare delivery.
Clinicians are urged to reduce costs while maintaining treatment efficacy.
They face constraints of time and resources while treating more individuals with substance abuse problems.
Research Support
There is literature supporting brief approaches for substance abuse disorders.
Brief interventions have been widely tested and show promise in changing client behavior.
Brief therapies have been unevenly researched, but clinical and anecdotal evidence supports their efficacy.
The brevity and lower costs make them ideal for settings from primary care to substance abuse treatment.
Client Suitability
Brief interventions and therapies are suitable for clients unwilling or unable to expend significant resources on longer-term treatments.
While longer treatment is often associated with better outcomes, some clients do not experience a loss in effectiveness when treatment length and intensity are reduced.
Overview of Brief Interventions
Definitions of brief interventions vary and have been referred to as "simple advice," "minimal interventions," "brief counseling," or "short-term counseling."
They range from simple suggestions to series of interventions within a treatment program.
Brief interventions represent a family of interventions varying in length, structure, and personnel, underpinned by different theories and philosophies (Heather, 1995, p. 287).
Brief interventions offer a set of principles different from, but not conflicting with, conventional treatment (Heather, 1994).
Approaches to change drinking behaviors range from unstructured counseling and feedback to structured therapy.
They rely on concepts and techniques from behavioral self-control training (BSCT) literature (Miller and Hester, 1986b; Miller and Munoz, 1982; Miller and Rollnick, 1991; Miller and Taylor, 1980).
Refer to Chapter 4 for more information on BSCT.
Brief treatment interventions typically have flexible goals, allowing for moderation or abstinence.
The typical counseling goal is to motivate the client to change without assigning self-blame.
While research has focused on alcohol-related problems, similar approaches can be used for other substances.
Role in Treatment
Brief interventions are a valuable part of a full spectrum of treatment options.
They are particularly useful when more extensive treatments are unavailable or when a client is resistant to such treatment.
Too few clinicians are skilled in using brief interventions and therapies to address the large group of midrange substance users.
This group is responsible for a disproportionate share of substance-related morbidity.
Hazardous substance users are identified in EAPs, DWI programs, urine testing, and health screening efforts.
Despite appeals from the National Academy of Sciences and the National Academy of Physicians and Surgeons, widespread adoption of brief interventions has not yet occurred (Drummond, 1997; Institute of Medicine [IOM], 1990).
Substance Abuse Severity and Level of Care
Figure 1-1 illustrates the relationship between substance abuse severity and the level of care.
Specialized treatment is indicated for substantial or severe problems.
Brief intervention is indicated for mild or moderate problems.
Primary prevention is indicated for those at risk but without existing problems.
Most people have no substance abuse problems, some have a few, and a few have many.
Traditional Settings
Brief interventions in traditional settings involve in-depth assessment of substance abuse patterns.
Characterizations of hazardous, harmful, or dependent use (Edwards et al., 1981) were used in a WHO study (Babor and Grant, 1991).
Hazardous drinking: A level or pattern likely to result in harm.
Harmful drinking: Alcohol use that has already caused adverse effects.
Dependent use: Drinking with physical, psychological, or social consequences, as defined by diagnostic tools like DSM-IV (American Psychiatric Association [APA], 1994) and ICD-9 (ICD-9-CM, 1995).
Categorizing drinking patterns helps identify individuals at risk who may not meet criteria for alcohol dependence.
Defining similar levels of use for other substances is more challenging due to their illicit nature.
Studies and Settings
Studies of brief interventions have been conducted in various healthcare settings, from hospitals and primary care (Babor and Grant, 1991; Chick et al., 1985; Fleming et al., 1997; Wallace et al., 1988) to mental health clinics (Harris and Miller, 1990).
Individuals in these settings have likely had contact with healthcare professionals.
Many patients would not be identified as having an alcohol problem and would not receive alcohol-specific intervention.
General Characteristics
Brief interventions are conducted in various settings, target different goals, may be delivered by various professionals, and do not require extensive training.
They can be used with injured patients in the emergency department.
Goals of Brief Interventions by Setting
Figure 1-2 lists goals of brief interventions according to the setting.
Opportunistic setting: Facilitate referrals.
Neutral environments: Affect substance abuse directly by recommending reduction in consumption or establishing a plan for abstinence.
Health care setting: Assess substance abuse behavior and give supportive advice about harm reduction.
Substance abuse treatment programs:
Facilitate referrals.
Act as a temporary substitute for extended treatment.
Act as a motivational prelude to engagement.
Facilitate behavior change.
Traditional Settings (In-Depth)
Brief interventions in traditional settings involve in-depth assessment and examine attitudes toward change.
They can address specific behavior change issues in treatment settings and enhance the working relationship with clients.
Brief interventions should not substitute for care for clients with a high level of abuse.
Assessments
Some assessments for research studies are extensive and may have been conducted during prior treatment.
Brief interventions offer detailed feedback about assessment findings.
Assessment typically involves information on frequency and quantity of substance abuse, consequences, and related health behaviors.
Intervention Structure
The intervention is structured and focused on substance abuse.
Primary goals are to raise awareness and recommend specific changes (e.g., reduced consumption, accepting a referral).
Participants are offered a menu of options and encouraged to take responsibility for selecting behavioral change.
Follow-up visits monitor progress and encourage motivation.
The person delivering the intervention is trained to be empathic and encouraging.
Delivery Methods
Brief interventions are typically conducted in face-to-face sessions, with or without written materials.
Some consist of mailed materials, automated computer screening, or telephone contacts.
Some interventions target health problems affected by substance abuse, rather than substance abuse itself.
For example, an intervention may help a client reduce the risk of HIV by using clean needles.
By raising awareness, brief interventions can act as a powerful catalyst for changing substance abuse patterns.
Influences on Change
The distress clients feel about their substance abuse behavior can encourage change.
Positive and negative external forces, such as life events, can contribute to the desire to change.
Brief interventions can address these events and feelings with the goal of changing substance abuse behaviors.
Overview of Brief Therapies
Brief therapies are usually delivered to individuals seeking or already in treatment for a substance abuse disorder.
Individuals typically have some awareness of the problem.
The therapy is often client-driven, with the client identifying problems and the clinician using the client's strengths to build solutions.
Choice of therapy should be based on a comprehensive assessment (IOM, 1990).
Brief therapy may also be used if resources for more extensive therapy are unavailable.
Brief therapies often target a substance-abusing population with more severe problems than those suitable for brief interventions.
They can be useful for special populations if the therapist understands client issues may be developmental or physiological.
Refer to Manual 26, Substance Abuse among Older Adults, and Manual 32, Treatment of Adolescents with Substance Use Disorders (CSAT, 1998b, 1999b).
Characteristics of Brief Therapies
Brief therapies typically require at least six sessions and are more intensive and longer than brief interventions.
Brief therapy is not simply a shorter version of psychotherapy but a focused application of techniques targeted to a symptom or behavior.
Goals include remediation of psychological, social, or family dysfunction related to substance abuse.
Focuses primarily on present concerns and stressors rather than historical antecedents.
Conducted by therapists trained in psychological or psychosocial models of treatment.
Training requires months or years and usually results in a specialist degree or certification.
Therapists often borrow techniques from other models, becoming eclectic practitioners.
Demand for Brief Interventions and Therapies
Historical developments encourage a comprehensive, community-based continuum of care.
A growing body of evidence consistently demonstrates the efficacy of brief interventions.
There is 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.
There is 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).
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.
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 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 follow-up rates
Aftercare compliance rates
Alumni participation rates
Discharge against medical advice rates
Counselor's 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
Follow-up 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.