Brief Therapy in Substance Abuse Treatment

Brief Therapy Definition

• Brief therapy is a systematic, focused process.

• It uses assessment, client engagement, and rapid change strategies.

• Aims to achieve significant behavioral changes quickly.

• Considered a self-contained treatment, not a segment of long-term therapy.

Scope of Brief Therapy

• Encompasses a variety of approaches with different lengths and goals.

• Typically involves more and longer sessions than brief interventions.

• Duration varies from 1 to 40 sessions, commonly 6 to 20.

• Often limited to a maximum of 20 sessions due to managed care.

• Focus is on planned, time-limited therapy with clear boundaries for therapist and client.

Brief Therapy vs. Brief Interventions

• Brief therapy aims at changing basic attitudes and handling underlying problems.

• Brief interventions are more motivational, targeting specific changes in thought or action.

Brief Therapy vs. Longer Term Therapy

• Focuses on the present.

• Downplays psychic causality.

• Emphasizes rapid use of therapeutic tools.

• Targets specific behavioral changes, not pervasive change.

• Cognitive-behavioral approaches are often designed for brevity.

• Longer approaches, including psychodynamic, can be adapted for brief therapy.

  • References: Davanloo, 1980; Luborsky, 1984; Mann, 1973; Sifneos, 1972; Strupp and Binder, 1984.

Chapter Overview

• Presents evidence for the efficacy of brief therapy.

• Discusses appropriateness and criteria for determining therapy duration.

• Explores components of brief therapies.

• Describes essential therapist knowledge and skills.

Variety of Approaches

• Chapters 4-9 present a cross-section of brief therapy approaches.

• No single approach is universally endorsed.

• Therapies chosen represent widely used methods or models with good potential.

• Some approaches suit the entire range of substance abuse disorders, while others are for subsets.

• Individual therapy techniques within theses approaches can be useful for the eclectic practitioner.

Brief Interventions

• Used by various professionals in diverse settings.

• Effective for clients unable or unwilling to access specialty care.

• Examples: Non-use trials, self-help group encouragement (AA, NA), time-limited efforts with pregnant clients.

Research Findings

• Mixed results on brief vs. longer-term therapies.

• Some studies show short-term therapies as effective as lengthier ones (Koss and Shiang, 1993; Smyrnios and Kirkby, 1993).

• Other studies suggest longer treatments yield better outcomes (Seligman, 1995; Blatt et al., 1995; Elkin, 1994).

• Effectiveness depends on modality and treatment goals.

• Promising evidence supports brief therapies for substance abuse disorders (Bien et al., 1993; Gottheil et al., 1998; McLellan et al., 1993; Miller and Hester, 1986a; Miller and Rollnick, 1991).

• However, studies are limited by smaller sample sizes; future research should replicate work with rigorous experimental designs and randomization.

• Optimum conditions, cost-benefits, provider level/type, and suitable client types require further study.

Duration of Therapy

• Most clients stay in therapy for 6-22 sessions; 90% end before 20 visits (Friedberg, 1999).

• Brief therapy techniques should be more common (Pekarik and Wierzbicki, 1986; Phillips, 1987).

• Therapists trained in long-term modalities often avoid planned short-term therapies (Bloom, 1997).

• Alcohol and drug counselors could use brief therapy techniques even for different disorders.

• Brief therapy is more effective than being on a waiting list.

• Wolberg suggests brief therapy initially for all clients (Wolberg, 1980), reserving longer treatments for those with greater need.

• Exceptions exist, like clients with severe and persistent mental illness.

Criteria for Longer Term Treatment (Figure 3-1)

The following criteria suggest when clients might benefit from longer term treatment:

• Failure of previous shorter treatment.

• Multiple concurrent problems.

• Severe substance abuse (i.e., dependence).

• Acute psychoses.

• Acute intoxication.

• Acute withdrawal.

• Cognitive inability to focus.

• Long-term history of relapse.

• Many unsuccessful treatment episodes.

• Low level of social support.

• Serious consequences related to relapse.

Serial or Intermittent Therapy

• Brief therapy can be adapted as part of a course of serial or intermittent therapy (Budman and Gurman, 1988; Cummings, 1990).

• Long-term treatment is conceived as a series of shorter treatments, addressing problems serially.

• Insurance constraints often lead to billing by episode and treating one problem at a time.

Application to Substance Abuse

• Brief therapy can reconceive how therapy is delivered.

• Therapy could be applied to specific problems related to a client's substance abuse.

• Treating allied problems may increase the likelihood of long-term goals, like continued abstinence (Iguchi et al., 1997; McLellan et al., 1993).

Appropriateness of Brief Therapy

• Insufficient data exists to determine which populations benefit most from brief therapy.

• Client needs and suitability must be evaluated case-by-case.

Considerations for Providing Brief Therapy (Figure 3-2)

• Dual diagnosis issues (coexisting psychiatric disorder or developmental disability).

• Range and severity of presenting problems.

• Duration of abuse.

• Availability of familial and community supports.

• Level and type of influence from peers, family, and community.

• Previous treatment or attempts at recovery.

• Level of client motivation (brief therapy may need more work on the part of the client but a less extensive time commitment).

• Clarity of the client's short- and long-term goals (brief therapy will require more clearly defined goals).

• The client's belief in the value of brief therapy ("buy in").

• Large numbers of clients needing treatment.

Criteria derived from clinical experience:

• Less severe substance abuse, 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 (e.g., 7-day average length of stay in county-jail-level correctional facilities; 30- to 45-day limitation in Job Corps program).

• Presence of coexisting medical or mental health diagnoses.

• Large numbers of clients needing treatment leading to waiting lists for specialized treatment.

Examples

• Brief therapy may suit a moderate to heavy drinking college student but is unsuitable as the sole treatment for an alcohol-dependent commercial airline pilot.

• Therapists must consider extenuating circumstances.

Mutually Determined Duration

• In some programs, duration is determined mutually by client and therapist.

• Brief therapy might be the best option if the client objects to longer term treatment or expense is an issue.

Research Needs

• Research needed to identify specific populations for which brief therapy catalyzes resolution.

• The impact of brief therapy on chronically relapsing individuals hasn't been investigated.

• Therapists must rely on clinical judgment to determine appropriateness and modality effectiveness.

• Selection criteria are critical since many clients will not meet eligibility.

Cautions About Managed Care

• The Consensus Panel hopes brief therapy will be adequately investigated before managed care deems it the only payable modality.

Brief Therapy in Context

• Brief therapy is valuable but limited and not a standard of care for all.

• Time in treatment correlates with better outcomes across modalities. Hubbard et al, 1997 found that longer therapeutic communities, psychotherapy, methadone maintenance therapy, and extended detoxification resulted in better outcomes.

• Brief therapy should target clients most likely to benefit.

Readiness for Change

• Consider a client's readiness for treatment.

• The Prochaska and DiClemente stages-of-change model is widely used (see also CSAT, 1999c).

• Therapy should be compatible with the client's stage and tasks needed to move forward.

Targeted Interventions

• Clinical interventions should target the client's readiness stage to increase motivation and empowerment.

• Experiential processes (consciousness raising, self-re-evaluation, cognitive restructuring) are important for transitioning from preparation to action and from action to maintenance (Prochaska et al., 1994).

• Information seeking and observation are primary activities during contemplation (Prochaska et al., 1992).

• Clients should be provided with addiction information and consequences of continued use.

• A risk appraisal of continued use and a benefit/risk-reduction appraisal of abstinence can facilitate decision-making (Janis and Mann, 1977).

Addressing Obstacles

• Essential to learn the client's perceived obstacles to treatment and dysfunctional beliefs.

• The basic assumption is that how individuals evaluate and cope determines their emotional reaction.

• The therapist should help the client recognize self-messages and correct problematic thinking patterns (Kendall and Turk, 1984).

• Dysfunctional beliefs lead to low self-efficacy and inability to adopt or maintain desired behavior (Bandura, 1986).

• Self-efficacy shifts predictably across stages of change (Marcus et al., 1992; Prochaska et al., 1994).

Approaches to Brief Therapy

• Brief therapy changes a specific problem based on an underlying theory.

Cognitive Therapy:

• Substance abuse disorders reflect habitual, automatic, negative thoughts and beliefs.

• These must be identified and modified to change erroneous ways of thinking and associated behaviors.

• The desire to use substances is typically activated in specific high-risk situations.

• Helps clients examine negative thoughts and replace them with more positive beliefs.

• Relapse prevention strategies use cognitive processes to identify triggering events and replace them with more healthful responses.

Behavioral Therapy:

• Based on learning theories.

• Teaches the client specific skills to improve identified deficiencies in social functioning, self-control, or other behaviors that contribute to substance use disorder.

• Techniques include assertiveness training, social skills training, contingency management, behavior contracting, community reinforcement and family training (CRAFT), behavioral self-control training, coping skills, and stress management.

Cognitive-Behavioral Therapy:

• Combines elements of cognitive and behavioral therapies.

• Focuses on learning and practicing a variety of coping skills, especially early in the therapy.

• Works by changing what the client does and thinks rather than just focusing on changing how the client thinks.

Strategic/Interactional Therapies:

• Seek to understand a client's viewpoint on a problem, the meaning attributed to events, and ineffective interpersonal interactions and coping strategies.

• Shifts the focus to competencies, helping clients change their perception of the problem and apply existing personal strengths to finding and applying a more effective solution.

Solution-Focused Therapy:

• Helps a client recognize exceptions to use as a means to reinforce and change behavior.

• Future behavior is based on finding solutions to problem behaviors.

• Therapy is focused on solutions that have already worked for the client in the past, rather than on problems.

Humanistic and Existential Therapies:

• Assume that the underlying cause of substance abuse disorders is a lack of meaning in one's life, a fear of death, disconnectedness from people, spiritual emptiness, or other overwhelming anxieties.

• Through unconditional acceptance, clients are encouraged to improve their self-respect, self-motivation, and growth.

• The approach can be a catalyst for seeking alternatives to substances to fill the emptiness.

Psychodynamic Therapy:

• Works with the assumption that a person's problems with substances are rooted in unconscious and unresolved past conflicts, especially in early family relationships.

• The goal is to help the client gain insight into underlying causes of manifest problems, understand what function substance abuse is serving, and strengthen present defenses to work through the problem.

• A strong therapeutic alliance with the therapist assists the client to make positive changes.

Interpersonal Therapy:

• Combines elements of cognitive and psychodynamic therapies.

• Originally developed for clients with depression but has been used successfully with substance-abusing clients.

• Focuses on reducing the client's dysfunctional symptoms and improving social functioning by concentrating on a client's maladaptive patterns of behavior.

• Supportive in nature, providing encouragement, reassurance, reduction of guilt, and help in modifying the client's environment.

Family Therapy:

• Either treats the client as part of a family system or considers the entire family as "the client."

• Examines the family system and its hierarchy to determine dysfunctional uses of power that lead to negative or inappropriate alignments or poor communication patterns that contribute to substance use disorder by one or more family members.

• Helps family members discover how their own system operates, improve communication and problem-solving skills, and increase the exchange of positive reinforcement.

Group Therapy:

• Uses many of the techniques and theories described to accomplish specified goals.

• In some group therapy, the group itself and the processes that emerge are central to helping clients see themselves in the reactions of others, although the content and focus of the groups vary widely.

Components of Effective Brief Therapy

• All brief therapies have common characteristics.

• Incorporate several stages, including screening and assessment, an opening session, subsequent sessions, maintenance strategies, ending treatment, and follow-up.

Characteristics of All Brief Therapies (Figure 3-4)

• Problem or solution-focused, targeting the symptom.

• Clearly defined goals related to a specific change or behavior.

• Understandable to both client and clinician.

• Produce immediate results.

• Easily influenced by the personality and counseling style of the therapist.

• Rely on rapid establishment of a strong working relationship.

• Highly active, empathic, and sometimes directive therapeutic style.

• Responsibility for change is placed clearly on the client.

• Focus on enhancing self-efficacy and confidence that change is possible early in the process.

• Termination is discussed from the beginning.

• Outcomes are measurable.

Screening and Assessment

• Critical initial steps involving identification and analysis of substance abuse.

• Procedures do not differ significantly from lengthier treatments.

• Determines whether the client's problem is suitable for a brief therapy approach, applying criteria from Figures 3-1 and 3-2.

• Effective with clients whose problems are of short duration with strong ties to family, work, and community.

• Also indicated when client resources are limited or clients resist longer treatment.

TAP 21

• Technical Assistance Publication 21, Addiction Counselling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice (CSAT, 1998a) contains further guidance on screening and assessment for brief therapy.

Gathering Information

• Gather as much information as possible before the first counseling session.

• Obtain notes from intake workers or referral sources, sensitive to confidentiality and client consent.

• Administer questionnaires, use computerized assessments, or ask the client to complete an assessment form before the first session.

• The assessment instrument can be brief and informal.

• Initial screening and assessment should ideally be conducted before, but continue throughout, treatment.

Assessment Instruments

• A variety of brief assessment instruments, many of which are free, are available to clinicians.

• Assessing Alcohol Problems (National Institute on Alcohol Abuse and Alcoholism, 1995) is a useful source of research-validated instruments.

Sample Battery of Brief Assessment Instruments (Figure 3-5)

• These instruments can provide the therapist with a quick assessment of the most critical domains about which clinical decisions should be made.

• Most clients can complete these instruments in less than 1 hour.

Assessment Domain and Corresponding Instrument(s):

• Quantity/frequency of use: Timeline Follow Back Technique

• Severity of dependence: Short Alcohol Dependence Data (SADD), Severity of Dependence Scales (SDS), CAGE

• Consequences of use: Michigan Alcoholism Screening Test (MAST), Drug Abuse Screening Test (DAST), Substance Abuse Subtle Screening Inventory (SASSI), DRINK

• Commitment to Change: Algorithm, SOCRATES

• Readiness to change: SOCRATES

• Problem areas: Problem Checklist from Comprehensive Drinker Profile, Problem Oriented Screening Instrument for Teenagers (POSIT), Adolescent Assessment/Referral System (AARS)

• Treatment placement: Addiction Severity Index (ASI)

• Goal choice and commitment: Intentions Questionnaire

  • Sources: Allen and Columbus, 1995; Miller, 1991.

Contextual Considerations

• Treatment setting dictates the kind of assessment.

• Clients seek treatment in agencies that best meet their needs.

• Insurance companies or other outside forces may place constraints.

• Managed care environments generate their own assessment criteria.

• Assessment often must be conducted outside of the treatment facility.

• Private practitioners often lack easy access to background information.

• In a primary care office, screening and assessment consist only of taking a client's history and conducting a physical examination.

Core Assessment Areas

• Crucial areas to assess before proceeding include:

  • Current use patterns.

  • History of substance abuse.

  • Consequences of substance abuse (especially external pressures).

  • Coexisting psychiatric disorders.

  • Information about major medical problems and health status.

  • Information about education and employment.

  • Support mechanisms.

  • Client strengths and situational advantages.

  • Previous treatment.

  • Family history of substance abuse disorders and psychological disorders.

• Ongoing assessment is critical to accomplish the goals of brief therapy, helping clients identify risks.

The Opening Session

• Goals: Gain understanding, establish rapport, implement an initial intervention.

• Critical tasks:

  • Producing rapid engagement.

  • Identifying, focusing, and prioritizing problems.

  • Developing possible solutions and a treatment plan with client participation.

  • Negotiating the route toward change (may involve a contract).

  • Eliciting client concerns about problems and solutions.

  • Understanding client expectations.

  • Explaining the structural framework of brief therapy.

  • Making referrals for critical needs that cannot be met within the treatment setting.

Goals of Treatment

• Discuss goals early, preferably in the first session, with the client playing a crucial role.

• Therapist recommends goals, but they are established through interaction and negotiation.

• Consider other approaches or make a referral if a client cannot commit to the goals and procedures of brief therapy.

Treatment Goals

• Should focus on the central problem of substance abuse, including:

  • Making a measurable change in specific target behaviors.

  • Helping the client demonstrate a new understanding.

  • Improving the client's personal relationships.

  • Resolving other identified problems.

• May be more client-driven than long-term therapies.

• Address a variety of goals, but limit the number of issues due to time.

• Identify most important goals to the client, keeping in mind the ultimate goal of sobriety or decreased use.

Abstinence

• Although abstinence is optimal, it must be negotiated with the client.

• Abstinence isn't necessarily the sole requirement for treatment.

• Therapist may have to accept an alternative goal, such as decreased use, to engage the client.

Subsequent Sessions

• In subsequent sessions, therapists should:

  • Work to maintain motivation and address identified problems.

  • Reinforce the need to do the work of brief therapy.

  • Remain prepared to rapidly identify and troubleshoot problems.

  • Maintain an emphasis on available skills, strengths, and resources.

  • Focus on immediate actions to address the client's problem.

  • Assess whether the client needs further therapy or other services.

  • Review reasons for dropping out of treatment.

Maintenance Strategies

• Built into the treatment design from the beginning.

• Practitioners must continue support, feedback, and assistance in setting realistic goals.

• Help clients identify relapse triggers.

Strategies

• Educating the client about the chronic, relapsing nature of substance abuse disorders.

• Developing a list of reasons for the client to return to treatment and plans to address them.

• Helping the client develop a plan for unaddressed or newly emerged problems.

• Developing strategies for identifying and coping with high-risk situations or the re-emergence 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, much earlier than in long-term therapy.

Progress Assessments

• Assessments are conducted throughout the therapy.

• Formal review midway through the agreed-upon number of sessions.

• Ensure that problems addressed and client recognizes risks.

• Consider the level of the client's progress.

• If the client progresses more quickly than anticipated, it is not necessary to complete the full number of sessions.

Ending Treatment

• Germinationof therapy should always be planned in advance.

• The end of therapy will be an explicit focus of discussion.

• Leave the client on good terms, with an enhanced sense of hope.

• Leave the door open for possible future sessions.

• Elicit commitment from the client to try to follow through.

• Review positive outcomes the client can expect.

• Review possible pitfalls the client may encounter.

• Review the early indicators of relapse.

• Issues regarding referral and follow-up are often different from those of longer term therapy because clients will not necessarily remain in contact with the therapist.

• If the goals of therapy have not been met, more intensive therapy may be suggested.

Referrals

• Referrals can be made at any time during treatment, not just at the end.

• Reasons for initiating referrals include:

  • The client needs ancillary services for other problems that have been recognized during therapy.

  • The client requires more intensive therapy.

  • The client may benefit from involvement with a support group

Follow Up

• It is always advisable to follow up with clients

• Reassures the client that the therapist is concerned

• An effective way to gather data regarding treatment effectiveness via telephone or mail client satisfaction survey

• Aftercare, when additional treatment is provided, is not part of brief therapy but offering reassurance and tracking client status is customary.

Therapist Characteristics

• Therapists benefit from a firm grounding in theory and a broad technical knowledge of the different approaches available.

• When appropriate elements of different brief therapies may be combined

• Remember that effectiveness 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

• Therapists should be sufficiently trained in the therapies and should not rely solely on a manual

• Appendix B provides resources for further education

• Although therapists with many levels of training and experience can conduct brief interventions, certain skills and training are particularly important for conducting effective brief therapy.

Skills

• Grounded in a specific model of psychotherapy but possess a general understanding of other models from which appropriate techniques may be drawn

• Adept at determining early in the assessment process the client needs or goals that are appropriate to address

• Establish relationships that facilitate referral when the client's needs or goals cannot be met through brief therapy.

TAP 21 Emphasizes that practitioners should

• Be empathic

• Be able to integrate their training with experience to create the best therapeutic environment for the client

• Have a mature sense of personal and professional boundaries

• Be sensitive to the cultural and spiritual needs of the client

• Follow appropriate Federal, State, and agency regulations in the provision of substance abuse treatment services

Focus and Techniques

• Focus effectively on identifying and adhering to specific therapeutic goals

• Extract techniques from longer term therapies and adapt them within the parameters of brief therapy

• Focus on short-term change that can have long-term benefits and avoid issues that are more global

• Shift approaches depending on what is learned about the client during treatment

Range of Techniques

• Amenable to a wide range of techniques from which the therapist can choose

• Aware of the broad range of therapeutic techniques available

• Exposure to several psychotherapeutic approaches allows therapists to understand how other clinicians might approach the situation, what a client might have experienced in previous treatments, and how to build on these experiences.

• Helpful but should not be considered a standard of care for all persons or populations

• Can be a contained modality of treatment and not an episodic form of long-term therapy

• Successful brief therapy may be the only treatment some clients will require.