Brief Intervention and Brief Therapies for Substance Abuse

262 Pages·2012·2.03 MB·English

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

Brief Interventions

nd B rief 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 Electronic Access and Printed Copies
This publication was prepared under contract This publication may be ordered for free from
number 270-95-0013 for the Substance Abuse SAMHSA’s Publications Ordering Web page at
and Mental Health Services Administration http://store.samhsa.gov. Or, please call
(SAMHSA), U.S. Department of Health and SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727)
Human Services (HHS). Sandra Clunies, M.S., (English and Español). The document can be
I.C.A.D.C., served as the Contracting Officer’s downloaded from the KAP Web site at
Representative. http://kap.samhsa.gov.

Disclaimer Recommended Citation
The opinions expressed herein are the views of Center for Substance Abuse Treatment. Brief
the consensus panel members and do not Interventions and Brief Therapies for Substance
necessarily reflect the official position of Abuse. Treatment Improvement Protocol (TIP)
SAMHSA or HHS. No official support of or Series, No. 34. HHS Publication No. (SMA) 12-
endorsement by SAMHSA or HHS for these 3952. Rockville, MD: Substance Abuse and
opinions or for the instruments or resources Mental Health Services Administration, 1999.
described are intended or should be inferred.

The guidelines presented should not be
Originating Office
considered substitutes for individualized client
Quality Improvement and Workforce
care and treatment decisions.
Development Branch, Division of Services

Improvement, Center for Substance Abuse
Public Domain Notice
Treatment, Substance Abuse and Mental Health
All materials appearing in this volume except
Services Administration, 1 Choke Cherry Road,
those taken directly from copyrighted sources
Rockville, MD 20857.
are in the public domain and may be

reproduced or copied without permission from
HHS Publication No. (SMA) 12-3952
SAMHSA or the authors. Citation of the source
First Printed 1999
is appreciated. However, this publication may
Revised 2002, 2003, 2004, 2007, 2009, 2011, and
not be reproduced or distributed for a fee
2012
without the specific, written authorization of the

Office of Communications, SAMHSA, HHS.

ii
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
iii
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 .................................................................................................................................1 5
2-2 Sample Objectives ...................................................................................................................................... 16
2-3 American Society of Addiction Medicine (ASAM) Patient Placement Criteria .................................18
2-4 FRAMES ......................................................................................................................................................1 9
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 ......................................................................................................................................2 8
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
v
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 ofPeople 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
vi
What Is a TIP?
T reatment Improvement Protocols (TIPs) to facilities and individuals across the country.
are developed by the Substance Abuse Published TIPs can be accessed via the Internet
and Mental Health Services at http://kap.samhsa.gov.
Administration (SAMHSA) within the U.S. Although each consensus-based TIP strives
Department of Health and Human Services to include an evidence base for the practices it
(HHS). Each TIP involves the development of recommends, SAMHSA recognizes that
topic-specific best-practice guidelines for the behavioral health is continually evolving, and
prevention and treatment of substance use and research frequently lags behind the innovations
mental disorders. TIPs draw on the experience pioneered in the field. A major goal of each TIP
and knowledge of clinical, research, and is to convey "front-line" information quickly but
administrative experts of various forms of responsibly. If research supports a particular
treatment and prevention. TIPs are distributed approach, citations are provided.

vii

Editorial Advisory Board
Karen Allen, Ph.D., R.N., C.A.R.N. Thomas W. Hester, M.D.
Professor and Chair Former State Director
Department of Nursing Substance Abuse Services
Andrews University Division of Mental Health, Mental
Berrien Springs, Michigan Retardation and Substance Abuse
Georgia Department of Human Resources
Richard L. Brown, M.D., M.P.H.
Atlanta, Georgia
Associate Professor
Department of Family Medicine James G. (Gil) Hill, Ph.D.
University of Wisconsin School of Medicine Director
Madison, Wisconsin Office of Substance Abuse
American Psychological Association
Dorynne Czechowicz, M.D.
Washington, D.C.
Associate Director
Medical/Professional Affairs Douglas B. Kamerow, M.D., M.P.H.
Treatment Research Branch Director
Division of Clinical and Services Research Office of the Forum for Quality and
National Institute on Drug Abuse Effectiveness in Health Care
Rockville, Maryland Agency for Health Care Policy and Research
Rockville, Maryland
Linda S. Foley, M.A.
Former Director Stephen W. Long
Project for Addiction Counselor Training Director
National Association of State Alcohol and Office of Policy Analysis
Drug Abuse Directors National Institute on Alcohol Abuse and
Washington, D.C. Alcoholism
Rockville, Maryland
Wayde A. Glover, M.I.S., N.C.A.C. II
Director Richard A. Rawson, Ph.D.
Commonwealth Addictions Consultants and Executive Director
Trainers Matrix Center and Matrix Institute on
Richmond, Virginia Addiction
Deputy Director, UCLA Addiction Medicine
Pedro J. Greer, M.D.
Services
Assistant Dean for Homeless Education
Los Angeles, California
University of Miami School of Medicine
Miami, Florida
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