Module 30 - Brief Interventions and Therapies in Substance Abuse Treatment Notes

What Is a TIP?

• Treatment Improvement Protocols (TIPs) are guidelines for substance use disorder treatment, developed by SAMHSA/CSAT and based on expert consensus.
• TIPs aim to bridge the gap between research and clinical practice by providing up-to-date information.
• TIPs are designed to improve service quality and effectiveness.

Introduction to Brief Interventions and Therapies

• Brief interventions and therapies are valuable in treating substance abuse, especially within managed care models.
• These approaches can be used independently, as stand-alone treatments, or as additions to other forms of treatment.
• Harm reduction is a basic goal, benefiting clients, families, and the community.
• Brief therapies include cognitive-behavioural, strategic/interactional, humanistic, psychodynamic, family, and group therapies.
• Brief interventions aim to motivate specific actions, while therapies address larger concerns.
• Key Differences Between Brief Interventions and Brief Therapies:
  • Session Length: Interventions are shorter (as little as 5 minutes), while therapies involve multiple longer sessions (e.g., six 1-hour sessions).
  • Assessment: Therapies involve more extensive assessment.
  • Setting: Interventions are used in non-traditional settings (e.g., primary care), while therapies are used in traditional substance abuse treatment settings.
  • Personnel: Interventions can be administered by various professionals, while therapies require specific training.
  • Materials: Interventions may use written materials or computer programs.
• Brief approaches are increasingly emphasized due to healthcare changes demanding cost reduction and treatment efficacy.
• Brief interventions and therapies have research support and appeal due to brevity and lower costs.

An Overview of Brief Interventions

• Brief interventions include "simple advice," "minimal interventions," "brief counselling," and "short-term counselling."
• Heather (1995) defines brief interventions as a family of interventions that differ in various aspects.
• Brief interventions are consistent with conventional treatment principles.
• Approaches range from unstructured counselling to structured therapy, often using behavioural self-control training (BSCT) techniques.
• Goals are flexible, with options for moderation or abstinence, and focus on motivating change without assigning blame.
• Brief interventions are valuable when extensive treatments are unavailable or the client is resistant.
• Lack of clinician education and skills is a barrier to wider use of brief interventions.
• Hazardous substance users contribute disproportionately to substance-related morbidity.
• Medical practitioners have not widely adopted brief interventions (Drummond, 1997; IOM, 1990).
• WHO study (Babor and Grant, 1991) categorized drinking patterns:
  • Hazardous drinking is likely to result in harm if it persists.
  • Harmful drinking has already resulted in adverse effects.
  • Dependent use has resulted in physical, psychological, and social consequences (APA, 1994; ICD-9-CM, 1995).
• Brief interventions are adaptable and can be used in emergency departments for injured patients with substance abuse problems.

Useful Distinctions Between the Goals of Brief Interventions as Applied in Different Settings

• Opportunistic Setting:
  • Purpose: Facilitate referrals for additional specialised treatment.
  • Affect substance abuse directly by recommending a reduction in hazardous or at-risk consumption patterns.
• Neutral Environments:
  • Purpose: Assess substance abuse behaviour and give supportive advice about harm reduction.
• Health Care Setting:
  • Purpose: Facilitate referrals for additional specialised treatment.
• Substance Abuse Treatment Programs:
  • Purpose: Act as a temporary substitute for more extended treatment for persons seeking assistance but waiting for services to become available (e.g., an outpatient treatment centre that offers potential clients assessment and feedback while they are on a waiting list).
  • Act as a motivational prelude to engagement and participation in more intensive treatment (e.g., an intervention to help a client commit to inpatient treatment when the assessment deems it appropriate but the client believes outpatient treatment is adequate).
  • Facilitate behaviour change related to substance abuse or associated problems.
• Brief interventions are client-centered and enhance the working relationship.
• Assessments typically involve substance abuse frequency, quantity, consequences, and related health behaviors.
• Interventions raise awareness of problems and recommend specific changes or activities.
• Clients are offered options and encouraged to take responsibility for behavioral change.
• Follow-up visits monitor progress and encourage motivation.
• Brief interventions are empathic and encouraging, often using written materials or computer programs.
• Interventions can target related health problems to reduce substance abuse indirectly.
• Client distress about substance abuse and external forces can encourage change.

An Overview of Brief Therapies

• Brief therapies are for individuals seeking or already in treatment for substance abuse.
• Therapy is client-driven and builds solutions using client strengths.
• Choice of therapy is based on comprehensive assessment (IOM, 1990).
• Brief therapies are useful if resources for more extensive therapy are not available.
• Therapies target more severe problems than interventions.
• Therapies require at least six sessions, are more intensive than interventions, and are targeted to a symptom or behaviour.
• Goals include remediation of psychological, social, or family dysfunction related to substance abuse and focus on present concerns.
• Therapists are trained in psychological or psychosocial models, often becoming eclectic practitioners.

The Demand for Brief Interventions and Therapies

• Historical developments in the field encourage a comprehensive, community-based continuum of care.
• There is a growing body of evidence that 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.
• Treatment and prevention components to serve clients who have a wide range of substance abuse-related problems.
• Client interest in shorter term treatments.

Factors for Treatment

• The increasing demand for treatment coupled with decreased public funding leaves two options:
  • Provide diluted treatment in traditional models for a few.
  • Develop a system in which different levels and types of interventions are provided to clients based on their identified needs and characteristics (Miller, 1993).
• Federal support shifted to insurance-supported private sector with a focus on the Minnesota model and 12-step philosophy (CSAT, 1995).
• Providers recognized the need for tailored treatment approaches based on assessments.

Factors in Treatment

• Assessments began to address the effects of substance abuse patterns on multiple systems (biopsychosocial approach).
• Project MATCH assessed matching clients to treatments (Project MATCH Research Group, 1997).
• McLellan's study matched clients to services, resulting in better outcomes (McLellan et al., 1993).
• The IOM called for community involvement in health care (IOM, 1990).
• Briefer interventions are warranted for individuals unwilling to accept referral for specialized care (Bien et al., 1993).
• Cost-effectiveness studies appeal to policymakers, leading to managed care environments with objective proof of appropriateness and effectiveness.
• Mass screenings and brief interventions could reduce substance abuse-related morbidity and health care costs (Kahan et al., 1995).

Barriers to Increasing the Use of Brief Treatments

• Clinicians have long standing notions that clients are resistant to change, unmotivated, and in denial of problems associated with their substance abuse disorders (Miller, 1993).
• Some attitudes persist in the specialist treatment community.
• Focus on harm reduction in interventions is not always acceptable to counsellors trained to insist on abstinence.
• Pharmacotherapy proponents may be skeptical of behavioral approaches.
• Spontaneous remission and self-directed change are acknowledged.
• Overwhelming responsibilities of frontline staff limit adoption of new approaches (Schuster and Silverman, 1993).

Evaluating Brief Interventions and Therapies

• Quality improvement is an important consideration in the contemporary health care environment.
• These approaches can be used to improve treatment outcomes in specific areas.

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
• Reduce aggression and violence
• 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