Professional Documents
Culture Documents
34
Treatment Improvement Protocol (TIP) Series
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.
ii
Contents
Foreword.................................................................................................................................................................. xiii
iii
Contents
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
Appendix A—Bibliography.................................................................................................................................173
Figures
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 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 CognitiveBehavioral 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 CognitiveBehavioral Model of the Relapse Process ........................................................................ 76
4-18 Essential and Unique Elements of CognitiveBehavioral 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
x
Consensus Panel
xii
Foreword
T
he Treatment Improvement Protocol (TIP) they reach a consensus on best practices. This
series fulfills the Substance Abuse and panel’s work is then reviewed and critiqued by
Mental Health Services Administration’s field reviewers.
(SAMHSA’s) mission to improve prevention and The talent, dedication, and hard work that TIPs
treatment of substance use and mental disorders panelists and reviewers bring to this highly
by providing best practices guidance to clinicians, participatory process have helped bridge the gap
program administrators, and payers. TIPs are the between the promise of research and the needs of
result of careful consideration of all relevant practicing clinicians and administrators to serve,
clinical and health services research findings, in the most scientifically sound and effective ways,
demonstration experience, and implementation people in need of behavioral health services. We
requirements. A panel of non-Federal clinical are grateful to all who have joined with us to
researchers, clinicians, program administrators, contribute to advances in the behavioral health
and patient advocates debates and discusses their field.
particular area of expertise until
xiii
Executive Summary and
Recommendations
T
his Treatment Improvement Protocol prevention efforts and more intensive treatment
(TIP) responds to an increasing body of for persons with serious substance abuse
research literature that documents the disorders. However, studies have shown that
effectiveness of brief interventions and therapies brief interventions are effective for a range of
in both the mental health and substance abuse problems, and the Consensus Panel believes that
treatment fields. The general purpose of this their selective use can greatly improve substance
document is to link research to practice by abuse treatment by making them available to a
providing counselors and therapists in the greater number of people and by tailoring the
substance abuse treatment field with up-to-date level of treatment to the level of client need.
information on the usefulness of these Brief interventions can be used as a method
innovative and shorter forms of treatment for of providing more immediate attention to clients
selected subpopulations of people with on waiting lists for specialized programs, as an
substance abuse disorders and those at risk of initial treatment for nondependent at-risk and
developing them. The TIP will also be useful for hazardous substance users, and as adjuncts to
health care workers, social service providers more extensive treatment for substance-
who work outside the substance abuse dependent persons.
treatment field, people in the criminal justice Brief therapies can be used to effect
system, and anyone else who may be called on significant changes in clients’ behaviors and
to intervene with a person who has substance their understanding of them. The term “brief
abuse problems. therapy” covers several treatment approaches
Brief interventions and brief therapies have derived from a number of theoretical schools,
become increasingly important modalities in the and this TIP considers many of them. The types
treatment of individuals across the substance of therapy presented in these chapters have been
abuse continuum. The content of the selected for a variety of reasons, but by no
interventions and therapies will vary depending means do they represent a comprehensive list of
on the substance used, the severity of problem therapeutic approaches currently in practice.
being addressed, and the desired outcome. Some of these approaches (e.g., cognitive–
Because brief interventions and therapies are behavioral therapy) are supported by extensive
less costly yet have proven effective in substance research; others (e.g., existential therapy) have
abuse treatment, clinicians, clinical researchers, not been, and perhaps cannot be, tested in as
and policymakers have increasingly focused on rigorous a manner.
them as tools to fill the gap between primary
xv
Executive Summary and Recommendations
This TIP presents the historical background, Psychiatric Association, 1994]). Because the
outcomes research, rationale for use, and state- term “substance abuse” is commonly used by
of-the-art practical methods and case scenarios substance abuse treatment professionals to
for implementation of brief interventions and describe any excessive use of addictive
therapies for a range of problems related to substances, it will be used to denote both
substance abuse. This TIP is based on the body substance dependence and substance abuse.
of research conducted on brief interventions and The term includes the use of alcohol as well as
brief therapies for substance abuse as well as on other substances of abuse. Readers should
the broad clinical expertise of the Consensus attend to the context in which the term occurs in
Panel. Because many therapists and other order to determine the meaning; in most cases,
practitioners are eclectically trained, elements the term will refer to all varieties of substance
from each of the chapters may be of use to a abuse disorders as described by DSM-IV.
range of professionals.
This discussion of brief therapies is in no Summary and
way intended to detract from the value of longer
term therapies that clinicians have found to be
Recommendations
effective in the treatment of substance abuse
disorders. However, the Consensus Panel Brief Interventions
believes it necessary to discuss innovative Brief interventions are those practices that aim
and/or often-used theories that members have to investigate a potential problem and motivate
encountered and applied in their clinical an individual to begin to do something about his
practice. substance abuse, either by natural, client-
The Consensus Panel’s recommendations directed means or by seeking additional
summarized below are based on both research substance abuse treatment.
and clinical experience. Those supported by A brief intervention, however, is only one of
scientific evidence are followed by (1); clinically many tools available to clinicians. It is not a
based recommendations are marked (2). substitute for care for clients with a high level of
Citations for the former are referenced in the dependency. It can, however, be used to engage
body of this document, where the guidelines are clients who need specialized treatment in specific
presented in full detail. Many of the aspects of treatment programs, such as
recommendations made in the latter chapters of attending group therapy or Alcoholics
this TIP are relevant only within a particular Anonymous (AA) meetings.
theoretical framework (e.g., the Panel might The Consensus Panel believes that brief
recommend how a person practicing strategic interventions can be an effective addition to
therapy should approach a particular situation); substance abuse treatment programs. These
because such recommendations are not approaches can be particularly useful in
applicable to all readers, they have not been treatment settings when they are used to
included in this Executive Summary. address specific targeted client behaviors and
Throughout this TIP, the term “substance issues in the treatment process that can be
abuse” has been used in a general sense to cover difficult to change using standard treatment
both substance abuse disorders and substance approaches. (2)
dependence disorders (as defined by the Variations of brief interventions have been
Diagnostic and Statistical Manual of Mental found to be effective both for motivating
Disorders, 4th Edition [DSM-IV] [American alcohol-dependent individuals to enter
xvi
Executive Summary and Recommendations
long-term alcohol treatment and for treating objective. Once this objective is established,
some alcohol-dependent persons. (1) a brief intervention can be used to help reach
The Consensus Panel recommends that it. (2)
programs use quality assurance
Components of brief interventions
improvement projects to determine whether
There are six elements that are critical for
the use of a brief intervention or therapy in
effective brief interventions. (1) The acronym
specific treatment situations is enhancing
FRAMES was coined to summarize these six
treatment. (2)
components:
The Consensus Panel recommends that
agencies allocate counselor training time and Feedback is given to the individual about
resources to these modalities. It anticipates personal risk or impairment.
that brief interventions will help agencies Responsibility for change is placed on the
meet the increasing demands of the managed participant.
care industry and fill the gaps that have been Advice to change is given by the clinician.
left in client care. (2) Menu of alternative self-help or treatment
Substance abuse treatment personnel should options is offered to the participant.
collaborate with other providers (e.g., Empathic style is used by the counselor.
primary care providers, employee assistance Self-efficacy or optimistic empowerment is
program, wellness clinic staff, etc.) in engendered in the participant.
developing plans that include both brief A brief intervention consists of five basic
interventions and more intensive care to help steps that incorporate FRAMES and remain
keep clients focused on treatment and consistent regardless of the number of sessions
recovery. (2) or the length of the intervention:
Goals of brief interventions 1. Introducing the issues in the context of the
The basic goal of any brief intervention is to client’s health.
reduce the risk of harm that could result from 2. Screening, evaluating, and assessing.
continued use of substances. The specific goal 3. Providing feedback.
for each individual client is determined by his 4. Talking about change and setting goals.
consumption pattern, the consequences of his 5. Summarizing and reaching closure.
use, and the setting in which the brief
Providers may not have to use all five of
intervention is delivered.
these components in any given session with a
Focusing on intermediate goals allows for client. However, before eliminating steps in the
more immediate success in the intervention brief intervention process there should be a
and treatment process, whatever the long- well-defined reason for doing so. (2)
term goals may be. Intermediate goals might
include quitting one substance, decreasing Essential knowledge and skills for
frequency of use, or attending a meeting. brief interventions
Immediate successes are important to keep Providing effective brief interventions requires
the client motivated. (2) the clinician to possess certain knowledge, skills,
When conducting a brief intervention, the and abilities. The following are four essential
clinician should set aside the final treatment skills (2):
goal (e.g., accepting responsibility for one’s 1. An overall attitude of understanding and
own recovery) to focus on a single behavioral acceptance
xvii
Executive Summary and Recommendations
2. Counseling skills such as active listening Brief therapy for substance abuse treatment
and helping clients explore and resolve is a valuable approach, but it should not be
ambivalence considered a standard of care for all
3. A focus on intermediate goals populations. (1) The Consensus Panel hopes
4. A working knowledge of the stages-of- that brief therapy will be adequately
change through which a client moves when investigated in each case before managed
thinking about, beginning, and trying to care companies and third-party payors
maintain new behavior decide it is the only modality for which they
will pay.
Brief Therapies Brief interventions and brief therapies are
Brief therapy is a systematic, focused process well suited for clients who may not be
that relies on assessment, client engagement, willing or able to expend the significant
and rapid implementation of change strategies. personal and financial resources necessary to
The brief therapies presented in this TIP should complete more intensive, longer term
be seen as separate modalities of treatment, not treatments. (2)
episodic forms of long-term therapy. Both research and clinical expertise indicate
Brief therapies usually feature more (as well that individuals who are functioning in
as longer) sessions than brief interventions. The society but have patterns of excessive or
duration of brief therapies is reported to be abusive substance use are unlikely to
anywhere from 1 to 40 sessions, with the typical respond positively to some forms of
therapy lasting between 6 and 20 sessions. traditional treatment, but some of the briefer
Brief therapies also differ from brief approaches to intervention and therapy can
interventions in that their goal is to provide be extremely useful clinical tools in their
clients with tools to change basic attitudes and treatment. (1)
handle a variety of underlying problems. Brief
therapy differs from longer term therapy in that
When to use brief therapy
Determining when to use a particular type of
it focuses more on the present, downplays
brief therapy is an important consideration for
psychic causality, emphasizes the effective use
counselors and therapists. The Panel
of therapeutic tools in a shorter time, and
recommends that client needs and the suitability
focuses on a specific behavioral change rather
of brief therapy be evaluated on a case-by-case
than large-scale or pervasive change.
basis. (2) Some criteria for considering the
Research concerning relative effectiveness of
appropriateness of brief therapy for clients
brief versus longer term therapies for a variety
include
of presenting complaints is mixed. However,
there is evidence suggesting that brief therapies Dual diagnosis issues
are often as effective as lengthier treatments for The range and severity of presenting
certain populations. problems
The duration of substance dependence
The best outcomes for brief therapy may
Availability of familial and community
depend on clinician skills, comprehensive
supports
assessments, and selective criteria for
The level and type of influence from peers,
eligibility. Using selective criteria in
family, and community
prescribing brief therapy is critical, since
Previous treatment or attempts at recovery
many clients will not meet its eligibility
The level of client motivation
requirements. (2)
xviii
Executive Summary and Recommendations
brief therapy do not differ significantly from Therapists should identify and discuss the
those used for lengthier treatments. goals of brief therapy with the client early in
treatment, preferably in the first session. (2)
Clinicians can use a variety of brief
Although abstinence is an optimal clinical
assessment instruments, many of which are
goal, it still must be negotiated with the
free. These instruments should be
client (at least in outpatient treatment
supplemented in the first session by a clinical
settings). Abstinence as a goal is not
assessment interview that covers current use
necessarily the sole admission requirement
patterns, history of substance use,
for treatment, and the therapist may have to
consequences of substance abuse, coexisting
accept an alternative goal, such as decreased
psychiatric disorders, major medical
substance use, in order to engage the client
problems and health status, education and
effectively. (2)
employment status, support mechanisms,
The provider of brief therapy must
client strengths and situational advantages,
accomplish certain critical tasks during the
and family history. (2)
first session (2), including
The screening and assessment process
i Producing rapid engagement
should determine whether the client’s
i Identifying, focusing, and prioritizing
substance abuse problem is suitable for a
problems
brief therapy approach. (2)
i Working with the client to develop a
Assessment is critical not only before
treatment plan and possible solutions for
beginning brief therapy but also as an
substance abuse problems
ongoing part of the process. (2)
i Negotiating the approach toward change
Therapists who primarily provide brief
with the client (which may involve a
therapy should be adept at determining early
contract between client and therapist)
in the assessment process which client needs
i Eliciting client concerns about problems
or goals are appropriate to address. Related
and solutions
to this, and equally important, the therapist
i Understanding client expectations
must establish relationships that facilitate the
i Explaining the structural framework of
client’s referral when her needs or goals
brief therapy, including the process and its
cannot be met through brief therapy. (2)
limits (i.e., those items not within the
The first session scope of that treatment segment or the
In the first session, the main goals for the agency’s work)
therapist are to gain a broad understanding of i Making referrals for critical needs that
the client’s presenting problems, begin to have been identified but cannot be met
establish rapport and an effective working within the treatment setting
relationship, and implement an initial
intervention, however small.
Maintenance strategies,
termination of therapy, and
Counselors should gather as much followup
information as possible about a client before Maintenance strategies must be built into the
the first counseling session. However, when treatment design from the beginning. A
gathering information about a client from practitioner of brief therapy must continue to
other sources, counselors must be sensitive to provide support, feedback, and assistance in
confidentiality and client consent issues. (2) setting realistic goals. Also, the therapist should
xx
Executive Summary and Recommendations
help the client identify relapse triggers and therapies depends on administration of the
situations that could endanger continued entire regimen.
sobriety. (2)
The therapist must use caution in combining
Strategies to help clients maintain the
and mingling certain techniques and must be
progress made during brief therapy include the
sensitive to the cultural context within which
following (2):
therapies are integrated. (2)
Educating the client about the chronic, Therapists should be sufficiently trained in
relapsing nature of substance abuse the therapies they are using and should not
Considering which circumstances might rely solely on a manual such as this to learn
cause a client to return to treatment and those therapies. (2)
planning how to address them Training for brief therapies, in contrast to the
Reviewing problems that emerged but were training necessary to conduct brief
not addressed in treatment and helping the interventions, requires months to years and
client develop a plan for addressing them in usually results in a specialist degree or
the future certification. The Consensus Panel
Developing strategies for identifying and recommends that anyone seeking to practice
coping with high-risk situations or the the therapies outlined here should receive
reemergence of substance abuse behaviors more thorough training appropriate to the
Teaching the client how to capitalize on type of therapy being delivered. (Appendix
personal strengths B of the TIP provides contact information for
Emphasizing client self-sufficiency and some organizations that may be able to
teaching self-reinforcement techniques provide such training.) (2)
Developing a plan for future support, Providers of brief therapy should be able to
including mutual help groups, family focus effectively on identifying and adhering
support, and community support to specific therapeutic goals in treatment. (2)
Providers who practice brief therapy should
Termination of therapy should always be
be able to distill approaches from longer
planned in advance. (2) When the client has
term therapies and apply them within the
made the agreed-upon behavior changes and
parameters of brief therapy. (2)
has resolved some problems, the therapist
should prepare to end the brief therapy. If a Cognitive–Behavioral Therapy
client progresses more quickly than anticipated,
CBT represents the integration of principles
it is not necessary to complete the full number of
derived from behavioral theory, cognitive social
sessions.
learning theory, and cognitive therapy, and it
Therapist characteristics provides the basis for a more inclusive and
Therapists will benefit from a firm grounding in comprehensive approach to treating substance
theory and a broad technical knowledge of the abuse disorders.
many different approaches to brief therapy that CBT can be used by properly licensed and
are available. (2) When appropriate, elements of trained mental health practitioners even if they
different brief therapies may be combined to have limited experience with this type of
provide successful outcomes. However, it is therapy—either as a cost-effective primary
important to remember that the effectiveness of approach or in conjunction with other therapies
highly defined interventions (e.g., workbook- or a 12-Step program. CBT can be also used
driven interventions) used in some behavioral early in and throughout the treatment process
xxi
Executive Summary and Recommendations
Define the situation that contributes to resources, and establish the client as the person
substance abuse in terms meaningful to the responsible for recovery. Thus, clients may be
client (2) more likely to see beyond the limitations of
Identify steps needed to control or end short-term treatment and envision recovery as a
substance abuse (2) lifelong process of working to reach their full
Heal the family system so it can better potential. (2)
support change (2)
Using humanistic and
Maintain behaviors that will help control
existential therapies
substance abuse (2)
Many aspects of humanistic and existential
Respond to situations in which the client has
approaches (including empathy, encouragement
returned to substance use after a period of
of affect, reflective listening, and acceptance of
abstinence (2)
the client’s subjective experience) can be useful
Strategic/interactional approaches are most in any type of brief therapy. They help establish
useful in rapport and provide grounds for meaningful
Learning how the client’s relationships deter engagement with all aspects of the treatment
or contribute to substance abuse (2) process. (2)
Shifting power relationships (2) Humanistic and existential approaches can
Addressing fears (2) be used at all stages of recovery in creating a
foundation of respect for clients and mutual
Most forms of strategic/interactional acceptance of the significance of their
therapies are brief by the definition used in this experiences. (2) There are, however, some
TIP. Strategic/interactional therapies normally therapeutic moments that lend themselves more
require 6 to 10 sessions, with 6 being most readily to one or more specific approaches.
common.
Client-centered therapy can be used
Humanistic and immediately to establish rapport and to
Existential Therapies clarify issues throughout the session. (2)
Humanistic and existential psychotherapies use Existential therapy may be used most
a wide range of approaches to the planning and effectively when a client has access to
treatment of substance abuse disorders. They emotional experiences or when obstacles
are, however, united by an emphasis on must be overcome to facilitate a client’s entry
understanding human experience and a focus into or continuation of recovery (e.g., to get
on the client rather than the symptom. someone who insists on remaining helpless
Humanistic and existential approaches share a to accept responsibility for her actions). (2)
belief that people have the capacity for self- Narrative therapy can be used to help the
awareness and choice. However, the two client conceptualize treatment as an
schools come to this belief through different opportunity to assume authorship and begin
theories. a “new chapter” in life. (2)
Humanistic and existential therapeutic Gestalt approaches can be used throughout
approaches may be particularly appropriate for therapy to facilitate a genuine encounter with
short-term substance abuse treatment because the therapist and the client’s own
they tend to facilitate therapeutic rapport, experience. (2)
increase self-awareness, focus on potential inner
xxiii
Executive Summary and Recommendations
Transpersonal therapy can enhance spiritual Although there is some disagreement in the
development by focusing on the intangible details, psychodynamic brief therapy is
aspects of human experience and awareness generally thought more suitable for (2)
of unrealized spiritual capacity. (2)
Those who have coexisting psychopathology
Using a humanistic or existential therapy with their substance abuse disorder
framework, the therapist can offer episodic Those who do not need or who have
treatment, with a treatment plan that focuses on completed inpatient hospitalization or
the client’s tasks and experiences between detoxification
sessions. (2) Those whose recovery is stable
For many clients, momentary circumstances Those who do not have organic brain
and other problems surrounding substance damage or other limitations to their mental
abuse may seem more pressing than notions of capacity
integration, spirituality, and existential growth,
Integrating psychodynamic concepts
which may be too remote from their immediate
into substance abuse treatment
situation to be effective. In such instances,
Most therapists agree that people with substance
humanistic and existential approaches can help
abuse disorders comprise a special population,
clients focus on the fact that they do indeed
one that often requires more than one approach
make decisions about substance abuse and are
if treatment is to be successful. Therapists
responsible for their own recovery. (2)
whose orientations are not necessarily
Psychodynamic Therapies psychodynamic may still find these techniques
and approaches useful, and therapists whose
Psychodynamic therapy focuses on unconscious
approaches are psychodynamic may be more
processes as they are manifested in the client’s
effective if they conduct psychotherapy in a way
present behavior. The goals of psychodynamic
that complements the full range of services for
therapy are client self-awareness and
clients with substance abuse disorders. (2)
understanding of the past’s influence on present
behavior. In its brief form, a psychodynamic Family Therapy
approach enables the client to examine
For many individuals with substance abuse
unresolved conflicts and symptoms that arise
disorders, interactions with their family of
from past dysfunctional relationships and
origin, as well as their current family, set the
manifest themselves in the need and/or desire
patterns and dynamics for their problems with
to abuse substances.
substances. Furthermore, family member
Several of the brief forms of psychodynamic
interactions with the substance abuser can either
therapy are less appropriate for use with
perpetuate and aggravate the problem or
persons with substance abuse disorders, partly
substantially assist in resolving it. Family
because their altered perceptions make it
therapy is particularly appropriate when the
difficult to achieve insight and problem
client exhibits signs that his substance abuse is
resolution. However, many psychodynamic
strongly influenced by family members’
therapists use forms of brief psychodynamic
behaviors or communications with them. (2)
therapy with substance-abusing clients in
Family involvement is often critical to
conjunction with traditional substance abuse
success in treating many substance abuse
treatment programs or as the sole therapy for
clients with coexisting disorders. (2)
xxiv
Executive Summary and Recommendations
disorders—most obviously in cases where the Therapists can “create” a family by drawing
family is part of the problem. (2) on the client’s network of significant contacts.
Family therapy can be used to (2) A more important question than whether the
client is living with a family is, “Can the client’s
Focus on the expectation of change within
problem be seen as having a relational
the family (which may involve multiple
(involving two or more people) component?”
adjustments)
Test new patterns of behavior Using brief family therapies
Teach how a family system works—how the In order to promote change successfully within
family supports symptoms and maintains a family system, the therapist will need the
needed roles family’s permission to enter the family space
Elicit the strengths of every family member and share their closely held confidences. The
Explore the meaning of the substance abuse therapy, however, will work best if it varies
disorder within the family according to the cultural background of the
family. (1)
Appropriateness of brief
Most family therapy is conducted on a short-
family therapy
term basis. Sessions are typically 90 minutes to
Long-term family therapy is not usually
2 hours in length. The preferred timeline for
necessary for the treatment of substance abuse
family therapy is not more than 2 sessions per
disorders. While family therapy may be very
week (except in residential settings), to allow
helpful in the initial stages of treatment, it is
time to practice new behaviors and experience
often easier to continue to help an individual
change. Therapy may consist of as few as 6 or as
work within the family system through
many as 10 sessions, depending on the purpose
subsequent individual therapy. (2)
and goals of the intervention.
Short-term family therapy is an option that
could be used in the following circumstances (2): Group Therapy
When resolving a specific problem in the Group psychotherapy is one of the most
family and working toward a solution common modalities for treatment of substance
When the therapeutic goals do not require in- abuse disorders. Group therapy is defined as a
depth, multigenerational family history, but meeting of two or more people for a common
rather a focus on present interactions therapeutic purpose or to achieve a common
When the family as a whole can benefit from goal. It differs from family therapy in that the
teaching and communication to better therapist creates open- and closed-ended groups
understand some aspect of the substance of people previously unknown to each other.
abuse disorder
Appropriateness of group therapy
Definitions of “family” Group psychotherapy can be extremely
Family therapy can involve a network that beneficial to individuals with substance abuse
extends beyond the immediate family, involves problems. (2) It gives them the opportunity to
only a few members of the family system, or see the progression of abuse and dependency in
even deals with several families at once. (2) The themselves and others; it also provides an
definition of “family” varies in different cultures opportunity to experience personal success and
and situations and should be defined by the the success of other group members in an
client. atmosphere of support and hope.
xxv
Executive Summary and Recommendations
xxvi
1 Introduction to Brief
Interventions and Therapies
T
he use of brief intervention and brief specific family problems with a client and/or
therapy techniques has become an family members or deal with specific individual
increasingly important part of the problems such as personal finances and work
continuum of care in the treatment of substance attendance. The basic goal for a client regardless
abuse problems. With the health care system of setting is to reduce the risk of harm that may
changing to a managed model of care and with result from continued use of substances. The
changes in reimbursement policies for substance reduction of harm, in its broadest sense, pertains
abuse treatment, these short, problem-specific to the clients themselves, their families, and the
approaches can be valuable in the treatment of community.
substance abuse problems. They provide the The brief therapies discussed in this TIP are
opportunity for clinicians to increase positive brief cognitive–behavioral therapy, brief
outcomes by using these modalities strategic and interactional therapies, brief
independently as stand-alone interventions or humanistic and existential therapies, brief
treatments and as additions to other forms of psychodynamic therapy, short-term family
substance abuse and mental health treatment. therapy, and time-limited group therapy. The
They can be used in a variety of settings choice to include these therapeutic modalities
including opportunistic settings (e.g., primary was based on a combination of relevant research
care, home health care) and specialized and, in some instances where there is a smaller
substance abuse treatment settings (inpatient research base, the clinical knowledge and
and outpatient). expertise of the Consensus Panel. All of these
Used for a variety of substance abuse approaches are currently being used in the
problems from at-risk use to dependence, brief treatment of substance abuse disorders, and all
interventions can help clients reduce or stop of them can contribute something to the array of
abuse, act as a first step in the treatment process treatment techniques available to the eclectic
to determine if clients can stop or reduce on practitioner.
their own, and act as a method to change Brief interventions and brief therapies may
specific behaviors before or during treatment. be thought of as elements on a continuum of
For example, there are some issues associated care, but they can be distinguished from each
with treatment compliance that benefit from a other according to differences in outcome goals.
brief, systematic, well-planned intervention such Interventions are generally aimed at motivating
as attending group sessions or doing homework. a client to perform a particular action (e.g., to
In other instances, brief interventions address enter treatment, change a behavior, think
1
Chapter 1
differently about a situation), whereas therapies motivational enhancement therapy, which has a
are used to address larger concerns (such as clearly articulated theoretical rationale (for more
altering personality, maintaining abstinence, or on this topic, see TIP 35, Enhancing Motivation for
addressing long-standing problems that Change in Substance Abuse Treatment, which was
exacerbate substance abuse). This TIP presents conceived as a companion volume to this TIP
brief interventions as a way of improving client [Center for Substance Abuse Treatment (CSAT),
motivation for treatment. The brief therapies 1999c]).
considered here are ways of changing client For the purposes of this TIP, brief therapy
attitudes and behaviors. Other differences that involves a series of steps taken to treat a
help distinguish brief interventions from brief substance abuse problem, whereas brief
therapies include interventions are those practices that aim to
investigate a potential problem and motivate an
Length of the sessions (from 5 minutes for an
individual to begin to do something about his
intervention to more than six 1-hour therapy
substance abuse. Therapy involves movement
sessions)
(or an attempt at movement) toward change.
Extensiveness of assessment (which will be
Brief therapy concentrates particularly on
greater for therapies than for interventions)
investigating a problem in order to develop a
Setting (nontraditional treatment settings
solution in consultation with the client; brief
such as a social service or primary care
interventions generally involve a therapist
setting, which will use interventions
giving advice to the client.
exclusively, versus traditional substance
The increasing emphasis on brief approaches
abuse treatment settings where therapy or
is partly attributable to recent changes in the
counseling will be used in addition to
health care delivery system, in which clinicians
interventions)
are urged to reduce costs while maintaining
Personnel delivering the treatment (brief
treatment efficacy. Essentially, clinicians are
interventions can be administered by a wide
constrained by time and diminishing resources
range of professionals, but therapy requires
yet are treating an increasing number of
training in specific therapeutic modalities)
individuals with substance abuse problems.
Materials and media used (certain materials
Fortunately, there is a body of literature on
such as written booklets or computer
brief approaches in the treatment of substance
programs may be used in the delivery of
abuse disorders. Brief interventions and brief
interventions but not therapies)
therapies have the appeal not only of being brief
Although the theoretical bases for brief but also of having research backing that
therapy and brief intervention may be different, supports their use. Brief interventions have
this distinction is less obvious in practice. These been widely tested with both general clinical
two approaches to substance abuse problems and substance-abusing populations and have
and behavior change reflect a continuum rather shown great promise in changing client
than a clear dichotomy. The distinction may be behavior. Brief therapies, however, have been
further blurred as the change process associated unevenly researched. As indicated in the
with the success of brief interventions is better discussion of each type, in addition to the
understood or refined and as theories are empirical results reported in scientific journals,
developed to explain a brief intervention’s clinical and anecdotal evidence supports the
mechanism of action. Already, some forms of efficacy of brief therapies in the treatment of
brief intervention overlap with therapy, such as substance abuse. The brevity and lower
2
Introduction
delivery costs of these brief approaches make Brief interventions for alcohol problems, for
them ideal mechanisms for use in settings from example, have employed various approaches to
primary care to substance abuse treatment change drinking behaviors. These approaches
where cost often plays as much of a role as have ranged from relatively unstructured
efficacy in determining what treatments clients counseling and feedback to more formal
receive. structured therapy and have relied heavily on
Brief interventions and brief therapies are concepts and techniques from the behavioral
also well suited for clients who may not be self-control training (BSCT) literature (Miller
willing or able to expend the significant and Hester, 1986b; Miller and Munoz, 1982;
personal and financial resources necessary to Miller and Rollnick, 1991; Miller and Taylor,
complete more intensive, longer term 1980) (see Chapter 4 for more information on
treatments. Although much research supports BSCT). Usually, brief treatment interventions
the theory that longer time in treatment is have flexible goals, allowing the individual to
associated with better outcomes, research also choose moderation or abstinence. The typical
suggests that for some clients, there is no loss in counseling goal is to motivate the client to
effectiveness when length and intensity of change her behavior and not to assign self-
treatment are reduced. blame. While much of the research to date has
centered on clients with alcohol-related
An Overview of Brief problems, similar approaches can be taken with
3
Chapter 1
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4
Introduction
5
Chapter 1
Figure 1-2
Goal of Brief Interventions According to Setting
Setting Purpose
Opportunistic setting Facilitate referrals for additional specialized treatment
(e.g., a nurse identifying substance-abusing clients
through screening and advising them to seek further
assessment or treatment)
Affect substance abuse directly by recommending a
reduction in hazardous or at-risk consumption patterns
(e.g., a primary care physician advising hazardous or at-
risk drinkers to cut down, National Alcohol Screening
Day) or establishing a plan for abstinence
Neutral environments (e.g., individuals Assess substance abuse behavior and give supportive
responding to media advertisements) advice about harm reduction (e.g., a public health
initiative to screen people in shopping malls and provide
feedback and advice)
Health care setting Facilitate referrals for additional specialized treatment
Substance abuse treatment programs 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 center 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 behavior change related to substance abuse or
associated problems
Source: Adapted from Bien et al., 1993.
target goal and encouraged to take Brief interventions are typically conducted in
responsibility for selecting and working on face-to-face sessions, with or without the
behavioral change in a way that is most addition of written materials such as self-help
comfortable for him. Any followup visits will manuals, workbooks, or self-monitoring diaries.
provide an opportunity to monitor progress and A few have consisted primarily of mailed
to encourage the client’s motivation and ability materials, automated computer screening and
to make positive changes. The person advice, or telephone contacts.
delivering the brief intervention is usually Some interventions are aimed at specific
trained to be empathic, warm, and encouraging health problems that are affected by substance
rather than confrontational. abuse, rather than substance abuse itself.
6
Introduction
For example, an intervention may be conducted therapy may also be used if resources for more
to help a client reduce her chances of contracting extensive therapy are not available or if
human immunodeficiency syndrome (HIV) by standard treatment is inaccessible or unavailable
using clean needles; as a result, if the client only (e.g., remote communities, rural areas). Brief
has dirty needles, she might avoid using them in therapies often target a substance-abusing
order to reduce her risk of HIV and thus reduce population with more severe problems than
her use of heroin. By raising an individual’s those for whom brief interventions are
awareness of her substance abuse, a brief sufficient. Brief therapies can be useful for
intervention can act as a powerful catalyst for special populations if the therapist understands
changing a substance abuse pattern. that some client issues may be developmental or
The distress clients feel about their substance physiological in nature (see TIP 26, Substance
abuse behavior can act as an influence to Abuse Among Older Adults, and TIP 32, Treatment
encourage change as they recognize the negative of Adolescents With Substance Use Disorders
consequences of that behavior to themselves or [CSAT, 1998b, 1999b]).
others. Positive and negative external forces are Although brief therapies are typically shorter
also influences. Life events, such as a major than traditional versions of therapy, these
illness or the death of significant others, career therapies generally require at least six sessions
change, marriage, and divorce, can contribute to and are more intensive and longer than brief
the desire to change. Brief interventions can interventions. Brief therapy, however, is not
address these events and feelings that simply a shorter version of some form of
accompany them with the underlying goal of psychotherapy. Rather, it is the focused
changing clients’ substance abuse behaviors. application of therapeutic techniques specifically
targeted to a symptom or behavior and oriented
An Overview of Brief toward a limited length of treatment.
7
Chapter 1
The Demand for Brief similar efforts were made to curtail heroin use in
major cities by establishing methadone
Interventions and maintenance clinics and residential therapeutic
Therapies communities (IOM, 1990).
By the 1980s, direct Federal financial support
The impetus for shorter forms of interventions
for treatment had slowed, and although some
and treatments for a range of substance abuse
States continued to grant subsidies, the most
problems comes from several sources:
rapid growth in the field switched to the
Historical developments in the field that insurance-supported private sector and the
encourage a comprehensive, community- development of treatment programs targeted
based continuum of care—with treatment primarily to heavy consumers of alcohol,
and prevention components to serve clients cocaine, and marijuana (Gerstein and Harwood,
who have a wide range of substance abuse- 1990). The standardized approach used in most
related problems of these private, hospital-based programs
A growing body of evidence that consistently incorporated many aspects of the Minnesota
demonstrates the efficacy of brief model pioneered in the late 1950s, with a strong
interventions focus on the 12-Step philosophy developed in
An increasing demand for the most cost- Alcoholics Anonymous (AA), a fixed-length, 28-
effective types of treatment, especially in this day stay, and insistence on abstinence as the
era of health care inflation and cost major treatment goal (CSAT, 1995).
containment policies in the private and Initially, treatment programs in both the
public sectors public and private sectors tended to serve the
Client interest in shorter term treatments most seriously impaired populations; however,
providers gradually recognized the need for
The increasing demand for treatment of
treatment options for a wider range of clients
some sort—arising from the identification of
who had different types of substance abuse
more at-risk consumers of substances through
disorders. Providers realized that not all clients
EAPs, substance-testing programs, health
benefit from a single standardized treatment
screening efforts, and drunk driving arrests—
approach. Rather, treatment should be tailored
coupled with decreased public funding and cost
to individual needs determined by in-depth
containment policies of managed care leave only
assessments of the client’s problems and
two options: provide diluted treatment in
antecedents to her substance abuse disorder.
traditional models for a few or develop a system
Providers were also aware that interventions
in which different levels and types of
with less dysfunctional clients often had greater
interventions are provided to clients based on
success rates. In the interest of reducing drunk
their identified needs and characteristics (Miller,
driving, for example, educational efforts were
1993).
targeted at offenders charged with DWI as an
Expanding Treatment Options alternative to revoking their driving licenses. In
The development of public substance abuse such programs, more attention was given to
treatment programs subsidized by Federal, outcomes and factors in the treatment setting
State, and local monies dates to the late 1960s than to the client’s history; these seemed to
when public drunkenness was decriminalized affect success rates whether or not treatment
and detoxification centers were substituted for was completed.
drunk tanks in jails. At about the same time,
8
Introduction
9
Chapter 1
10
Introduction
11
Chapter 1
Programs should monitor client satisfaction substance abusers who are at risk for more
over time, and whenever possible counselors serious health, social, and emotional problems is
should be involved in quality improvement high, both from a public health and a clinical
activities. Identifying trends over time can perspective. As the health care system
indicate what improvements need to be made. undergoes changes, programs should take the
Implementation of substance abuse prevention opportunity to develop and advocate a
and brief intervention strategies in clinical comprehensive system of substance abuse
practice requires the development of interventions, combining the skills of clinicians
systematized protocols that can provide easier with the knowledge gained from the research
service delivery. The need to implement community.
effective and unified strategies for a variety of
12
2 Brief Interventions in Substance
Abuse Treatment
B
rief interventions for substance abuse discussed in this TIP are time limited,
problems have been used for many years structured, and directed toward a specific goal.
by alcohol and drug counselors, social They follow a specific plan (and in some cases a
workers, psychologists, physicians, and nurses, workbook) and have timelines for the adoption
and by social service agencies, hospital of specific behaviors.
emergency departments, court-ordered Several studies have attempted to identify
educational groups, and vocational factors that result in differential responses to
rehabilitation programs. Primary care providers brief intervention by varying client
find many brief intervention techniques effective characteristics or by conducting subgroup
in addressing the substance abuse issues of analyses. Most studies of brief interventions to
clients who are unable or unwilling to access date are limited by their lack of sufficient subject
specialty care. Examples of brief interventions assessments. Findings from the available
include asking clients to try nonuse to see if they research suggest that client characteristics are
can stop on their own, encouraging not good predictors of a person’s response to a
interventions directed toward attending a self- brief intervention and that brief interventions
help group (e.g., Alcoholics Anonymous [AA] or may be applicable to individuals from a wide
Narcotics Anonymous [NA]), and engaging in range of cultures and backgrounds (Babor, 1994;
brief, structured, time-limited efforts to help Babor and Grant, 1991).
pregnant clients stop using. This chapter provides theoretical and
Brief interventions are research-proven practical information on brief interventions,
procedures for working with individuals with both in opportunistic settings and in the
at-risk use and less severe abuse behaviors and substance abuse treatment setting. The stages-
can be successful when transported into of-change model is presented first because of its
specialist treatment settings and performed by usefulness in understanding the process of
alcohol and drug counselors. As presented in behavioral change. Next, the goals of brief
the literature, brief interventions to change intervention are described and applied to
substance abuse behaviors can involve a variety various levels of substance use. FRAMES
of approaches, ranging from unstructured elements critical to brief intervention are
counseling and feedback to formal structured detailed, and five essential steps are listed with
therapy (Chick et al., 1985; Fleming et al., 1997; scripts to use in various settings. The brief
Kristenson et al., 1983; Persson and Magnusson, intervention workbook, a practical tool for use
1989). Brief interventions, as defined and during a brief intervention, is explained.
13
Chapter 2
Essential clinician knowledge and skills for noncompliance could result. To consider
conducting a successful brief intervention are change, clients at the precontemplation stage
then described. Discussions of the use of brief must have their awareness raised. To resolve
intervention in substance abuse programs and their ambivalence, clients in the contemplation
nonspecialized settings follow. The final section stage must be helped to choose positive change
presents research findings on brief interventions over their current circumstances. Clients in the
for both at-risk users and dependent users. preparation stage need help in identifying
potential change strategies and choosing the
Stages-of-Change Model most appropriate ones. Clients in the action
stage need help to carry out and comply with
The work of Prochaska and DiClemente and the change strategies.
their “stages-of-change” model help clinicians The clinician can use brief interventions to
tailor brief interventions to clients’ needs motivate particular behavioral changes at each
(Prochaska and DiClemente, 1984, 1986). stage of this process. For example, in the
Prochaska and DiClemente examined several contemplation stage, a brief intervention could
theories concerning how change occurs and help the client weigh the costs and benefits of
applied their findings to substance abuse change. In the preparation stage, a similar brief
behavior modification. They devised a model intervention could address the costs and benefits
consisting of five stages of change that seemed of various change strategies (e.g., self-change,
to best represent the process people go through brief treatment, intensive treatment, self-help
when thinking about, beginning, and trying to group attendance). In the action stage, brief
maintain new behavior (see Figure 2-1). The interventions can help maintain motivation to
stages-of-change model is explained more fully continue on the course of change by reinforcing
in TIP 35, Enhancing Motivation for Change in personal decisions made at earlier stages.
Substance Abuse Treatment (CSAT, 1999c). Understanding these stages helps the
These stages have proven useful, for clinician to be patient, to accept the client’s
example, in predicting those most likely to quit current position, to avoid “getting too far
smoking and in targeting specific kinds of ahead” of the client and thereby provoking
interventions to smokers in different stages resistance, and, most important, to apply the
(DiClemente et al., 1991; Prochaska, 1999; correct counseling strategy for each stage of
Prochaska and DiClemente, 1986; Velicer et al., readiness. Effective brief interventionists
1992). Stages of change are being examined in quickly assess the client’s stage of readiness,
brief interventions with hazardous and harmful plan a corresponding strategy to assist her in
substance users as well, as a means of tailoring progressing to the next stage, and implement
interventions to the individual’s current stage of that strategy without succumbing to distraction.
change (Hodgson and Rollnick, 1992; Mudd et Indeed, clinician distraction can be a greater
al., 1995). obstacle to change in brief intervention than
Clients need motivational support time limitations. Regardless of the stage of
appropriate to their stage of change. If the readiness, brief interventions can help initiate
clinician does not use strategies appropriate to change, continue it, accelerate it, and prevent the
the stage the client is in, treatment resistance or client from regressing to previous behaviors.
14
Brief Interventions
Figure 2-1
The Stages of Change
Precontemplation. The A functional yet alcohol-dependent This client needs information linking his
user is not considering individual who drinks himself into problems and potential problems with his
change, is aware of few a stupor every night but who goes substance abuse. A brief intervention might
negative consequences, to work every day, performs his be to educate him about the negative
and is unlikely to take job, has no substance abuse-related consequences of substance abuse. For
action soon. legal problems, has no health example, if he is depressed, he might be told
problems, and is still married. how his alcohol abuse may cause or
exacerbate the depression.
Contemplation. The user An individual who has received a This client should explore feelings of
is aware of some pros citation for driving while ambivalence and the conflicts between her
and cons of substance intoxicated and vows that next time substance abuse and personal values. The
abuse but feels she will not drive when drinking. brief intervention might seek to increase the
ambivalent about She is aware of the consequences client’s awareness of the consequences of
change. This user has but makes no commitment to stop continued abuse and the benefits of
not yet decided to drinking, just to not drive after decreasing or stopping use.
commit to change. drinking.
Preparation. This stage An individual who decides to stop This client needs work on strengthening
begins once the user has abusing substances and plans to commitment. A brief intervention might
decided to change and attend counseling, AA, NA, or a give the client a list of options for treatment
begins to plan steps formal treatment program. (e.g., inpatient treatment, outpatient
toward recovery. treatment, 12-Step meetings) from which to
choose, then help the client plan how to go
about seeking the treatment that is best for
him.
Action. The user tries An individual who goes to This client requires help executing an action
new behaviors, but counseling and attends meetings plan and may have to work on skills to
these are not yet stable. but often thinks of using again or maintain sobriety. The clinician should
This stage involves the may even relapse at times. acknowledge the client’s feelings and
first active steps toward experiences as a normal part of recovery.
change. Brief interventions could be applied
throughout this stage to prevent relapse.
Maintenance. The user An individual who attends This client needs help with relapse
establishes new counseling regularly, is actively prevention. A brief intervention could
behaviors on a long- involved in AA or NA, has a reassure, evaluate present actions, and
term basis. sponsor, may be taking disulfiram redefine long-term sobriety maintenance
(Antabuse), has made new sober plans.
friends, and has found new
substance-free recreational
activities.
Source: Adapted from Prochaska and DiClemente, 1984.
15
Chapter 2
Figure 2-2
Sample Objectives
Learning to schedule and prioritize time
Expanding a sober support system
Socializing with recovering people or learning to have fun without substance abuse
Beginning skills exploration or training if unemployed
Attending an AA or NA meeting
Giving up resentments or choosing to forgive others and self
Staying in the “here and now”
16
Brief Interventions
the problem drinker to change his behavior, not and determines if the client needs any additional
to assign blame. Helping clients to recognize services.
the need for change is an essential step in this
process.
ASAM Criteria
Under ASAM criteria (see Figure 2-3), brief
Substance-Dependent User interventions are aimed at the nondependent
Intervention at this level of use may focus on user, at level 0.5 or possibly level I. Individuals
encouraging users to consider treatment, to at level II may be appropriate for a brief
contemplate abstinence, or to return to intervention if relapse potential and recovery
treatment after a relapse. The goal of environment are major problems for those with
intervention for dependent users is to relatively minor physiological and psychological
recommend the optimal behavior change and substance problems and high motivation to
level of care. In reality, however, the clinician change. ASAM criteria have been extremely
may be able to negotiate a change the client is useful for clinical management of persons with
willing to accept and work over time toward substance abuse disorders who require more
abstinence. For example, if a client resists care than is needed for at-risk drinkers. Brief
committing to prolonged abstinence, the interventions, whether directed at reducing at-
provider could negotiate a limited period risk use (often used in primary care settings) or
ending with a “checkup,” at which time the assisting in specific aspects of the treatment
client might consider extending abstinence process, can be helpful for clients at every
further. ASAM level and in many treatment settings.
It should be noted that some substance-
dependent clients may be in a life-threatening Components of Brief
stage in their addiction or risk serious
consequences such as losing their jobs, going to
Interventions
jail, or losing their families. For these clients, There is tremendous diversity in the process of
brief interventions should be linked to a referral recovery from a substance abuse disorder.
strategy in which the goal is a therapeutic Clients make changes for different reasons, and
alliance between the client and the referral an intervention that works well for one client
treatment team. Brief intervention in this may not work for another. Brief interventions
context is more like “case management,” in are components of the journey toward recovery
which the primary care provider tracks the and can be integral steps in the process. For
client’s progress with other service providers some clients, assistance with the decision to
Figure 2-3
American Society of Addiction Medicine (ASAM) Patient Placement Criteria
ASAM has developed client placement criteria for the treatment of substance-related disorders (1996).
ASAM delineates the following levels of service:
Level 0.5, early intervention
Level I, outpatient services
Level II, intensive outpatient/partial hospitalization services
Level III, residential inpatient services
Level IV, medically-managed intensive inpatient services
18
Brief Interventions
make the change will be enough to motivate 1. Introducing the issue in the context of the
them to start changing the behavior, whereas client’s health
others may need more intensive clinical 2. Screening, evaluating, and assessing
involvement throughout the change process. 3. Providing feedback
Brief interventions can be tailored to different 4. Talking about change and setting goals
populations, and many options are available to 5. Summarizing and reaching closure
augment interventions and treatments, such as
Providers may not have to use all five of
AA, NA, and medications. It should be noted,
these components in every session. It is more
however, that brief interventions are not a
important to use the components that reflect the
substitute for specialized care for clients with a
needs of the client and her personal style.
high level of dependency. They can be used to
Before eliminating steps in the brief intervention
engage clients in specific aspects of treatment
process, however, there should be a well-
programs, such as attending group and AA or
defined reason for doing so. Moreover, a vital
NA meetings. Brief interventions can also help
part of the intervention process is monitoring to
potential clients move toward seeking treatment
determine how the patient is progressing after
and can serve as a temporary measure for clients
the initial intervention has been completed.
on waiting lists for treatment programs. Even
Monitoring allows the clinician and client to
clinicians who advocate abstinence as a goal can
determine gains and challenges and to redirect
use brief interventions as tools to help clients
the longer term plan when necessary.
reach that goal.
Following are descriptions of the five basic
There are six elements critical to a brief
steps. Sample scenarios are provided where brief
intervention to change substance abuse behavior interventions might be initiated, with practical
(Miller and Sanchez, 1994). The acronym information about that particular step. For each
FRAMES was coined to summarize these active step, Figure 2-5 presents scripts for brief
ingredients, which are shown in Figure 2-4. The interventions that clinicians can use in substance
FRAMES components have been combined in abuse treatment units or other settings where
different ways and tested in diverse settings and interventions might occur. (For examples
cultural contexts. focused on at-risk drinkers, see TIP 24, A Guide to
A brief intervention consists of five basic Substance Abuse Services for Primary Care Clinicians
steps that incorporate FRAMES and remain [CSAT, 1997]. For detailed descriptions of more
consistent regardless of the number of sessions techniques, see TIP 35, Enhancing Motivation for
or the length of the intervention: Change in Substance Abuse Treatment [CSAT,
1999c]).
Figure 2-4
FRAMES
Feedback is given to the individual about personal risk or impairment.
Responsibility for change is placed on the participant.
Advice to change is given by the provider.
Menu of alternative self-help or treatment options is offered to the participant.
Empathic style is used in counseling.
Self-efficacy or optimistic empowerment is engendered in the participant.
19
Chapter 2
Figure 2-5
Scripts for Brief Intervention
Script in the emergency department, Script in the substance abuse
Component primary care office, or other setting treatment unit
where consultations will be
performed
Introducing “I’m from the substance abuse “Would it be OK with you if we
the Issue disorder unit. Your doctor asked me discuss some of the difficulties you’ve
to stop by to tell you about what we do had in getting homework done for the
on that unit. Would you be willing to group meetings and how we can work
talk to me briefly about it? Whatever together to help you take advantage of the
we talk about will remain treatment process?”
confidential.” Or, “This must be tough
for you. Would it be OK with you if
we take a few minutes to talk about
your drinking?”
Screening, “In reviewing the information “Given what you see as the additional
Evaluating, and you’ve given me, using a scale of ‘not stress in your family and your desire to
Assessing ready,’ ‘unsure,’ and ‘ready,’ how make the treatment work for you this
prepared do you feel you are to stop time, on a scale of 1 to 10, how ready do
drinking?” you feel to find a way to put time into
Client says “unsure.” your homework?”
“One of the factors that might tie Client says, “6.”
together your accident and your “I am pleased that you are willing to
problems with your wife is your consider trying this, even though it won’t
drinking.” be easy. Let’s come up with some
“I think it would be worth talking strategies that we can write down to help
more to some of the people at the you accomplish this goal.”
substance abuse disorder unit so that
your problems don’t get worse,” or, “I
think a 2-week trial when you don’t
drink alcohol at all would be helpful in
determining whether or not drinking
makes things worse and if stopping
use works for you. What do you
think?”
Providing “I’d like to get some confidential “I’d like to talk about what was going
Feedback information about your drinking to on when you decided not to do the
give me a better idea of your drinking homework assignment. Can you tell me a
style. Can you tell me how many days little about what you were thinking or
a week you drink? How many drinks feeling at the time? Why do you think it
a day?” was difficult to get your homework done?
20
Brief Interventions
21
Chapter 2
Figure 2-6
Screening for Brief Interventions for Alcoholism
Screen
At each visit, ask about alcohol use
Screen is positive if
Consumption is greater than 14 drinks per week or greater than 4 drinks per occasion (men)
Consumption is greater than 7 drinks per week or greater than 3 drinks per occasion (women)
CAGE score is greater than 1
Medical problems: blackouts, depression, hypertension, trauma, abdominal pain, liver dysfunction,
sexual problems, sleep disorders
Laboratory: elevated gamma-glutamyl transpeptidase or other liver function tests; elevated mean
corpuscular volume; positive blood alcohol concentrations
Behavioral problems: work, family, school, accidents
Alcohol dependence: a score of 3 or higher on CAGE or one or more of the following: compulsion to
drink, impaired control, withdrawal symptoms, increased tolerance, relief drinking
Other Drug Abuse and Infectious Diseases; TIP 24, during screening. It involves an interactive
A Guide to Substance Abuse Services for Primary dialog for discussing the assessment findings; it
Care Clinicians; and TIP 31, Screening and is not just clinician driven. Feedback should be
Assessing Adolescents for Substance Use Disorders given in small amounts. First, the clinician gives
(CSAT, 1994b, 1994c, 1994d, 1997, 1999a). a specific piece of feedback, then asks for a
Counseling tips: Before you begin the brief response from the client. Sometimes the
intervention, decide how much information you feedback is a brief, single sentence; at other
have time to obtain and whether you want to times it could last an hour or more. Figure 2-7
have the client answer any questionnaires. provides an example of giving feedback.
Watch for defensiveness or other resistance, and Counseling tips: Use active listening (see
avoid pushing too hard. “Active listening” later in this chapter). Be
aware of cultural, language, and literacy issues.
Providing Feedback Be nonjudgmental.
This component highlights certain aspects of the
client’s behavior using information gathered
22
Brief Interventions
Figure 2-7
Client Feedback and Plan of Action
Give specific feedback to the patient, then advise in a firm but empathic manner
If diagnosed as at risk: If diagnosed as alcohol dependent:
SUCCEEDS DOES NOT SUCCEED Involve family: refer for family treatment and
self-help (e.g., Al-Anon, etc.) (must have
CONTINUE FOLLOWUP patient permission and involvement)
Stress abstinence
Urge patient to attend self-help meetings (AA,
NA, Self-Management and Recovery Training
[SMART], etc.)
Consider referral to addiction medicine
specialist, and/or possible pharmacotherapy
with disulfiram (Antabuse) or naltrexone
(ReVia)
Source: ASAM, 1994; reprinted with permission.
Talking About Change client who is trying to stop using cocaine but
And Setting Goals wants to continue to drink alcohol.)
Talking about change involves talking about the In talking about change, the clinician often
possibility of changing behavior. It is used with suggests a course of action, then negotiates with
clients in all stages of change, but it differs the client to determine exactly what he is willing
profoundly depending on the stage the client to do. Sometimes, talking about change is
has reached. For example, in precontemplation, premature (i.e., before the assessment and
clients are helped to recognize and change their feedback have happened). In that case, it should
view of consequences; in contemplation, they be postponed until later in the intervention.
are helped to resolve ambivalence about change. Counseling tips: Offer change options that
In action, the focus is on planning, removing match client’s readiness for change. Be realistic:
barriers, and avoiding risky situations; in Recommend the ideal change, but accept less if
maintenance, the emphasis is on establishing the client is resistant.
new long-term behaviors. It is important that
Summarizing and
the clinician assess the client’s readiness to
Reaching Closure
change if it is not already known. (See Figure
2-8 for examples of discussing change with a This step involves a summary of the discussion
and a review of the agreed-upon changes.
23
Chapter 2
Figure 2-8
Talking About Change at Different Stages
In this example, a client who has come to treatment to stop using cocaine has her alcohol use brought
to her attention. At each stage of readiness, the counselor might use a different strategy. Following are
some of the possible scripts that might be used:
Precontemplation: “Some people find it helpful to ask others in a group if any of them tried to quit
cocaine but continued drinking. If you were to try that with your group, you might be surprised at
what you hear. What do you think?”
Contemplation: “One thing you might try is writing a list of the pros and cons of stopping drinking,
as you see them. Just write down all the ideas that come to you, no matter how silly or offbeat they
seem. This may help you get a clearer picture of your situation. Is that something you’d be willing
to try?”
Action: “You’ve said you want to try quitting alcohol, as well as cocaine. Can we talk about how
you might go about making that happen?”
Maintenance: “Things have improved in a lot of ways for you. I’d like to meet with you each month
for a while to talk about what things work for you and what things don’t work as well.” (Because
relapse can occur at any point in the change process, addressing this issue in a proactive, positive
manner is useful.)
24
Brief Interventions
in the workbook follow a script and may focus Essential Knowledge and
on the following:
Skills for Brief
Identification of future goals for health,
activities, hobbies, relationships, and
Interventions
financial stability
Providing effective brief interventions requires
Customized feedback on screening questions
knowledge, skills, and abilities. Studies have
relating to substance abuse patterns and
shown that applying the clinician’s skills listed
other health habits (also may include
below produces good outcomes, including
smoking, nutrition, etc.)
getting clients to enter treatment, work harder in
Discussion of where the client’s substance
treatment, stay longer in treatment, and have
abuse patterns fit into the population norms
better outcomes after treatment such as higher
for his age group
participation in aftercare and better sobriety
Identification of the pros and cons of
rates (Brown and Miller, 1993; Miller et al.,
substance abuse—this is particularly
1993).
important because the clinician must
understand the role of substance abuse in the Overall attitude of understanding and
context of the client’s life (given the acceptance
opportunity to discuss the positive aspects of Counseling skills such as active listening and
her substance abuse, the client may talk helping clients explore and resolve
about her concerns honestly instead of ambivalence
feeling she should say what she thinks the A focus on intermediate goals (see discussion
clinician wants to hear; this builds a better earlier in this chapter)
working relationship) Working knowledge of the stages-of-change
Consequences of continued substance use to model (see discussion earlier in this chapter)
encourage the client to decrease or stop
Attitude of Understanding
abusing substances and avoid longer term
And Acceptance
effects of continued substance abuse
Reasons to cut down or quit using Clinicians must assure their clients that they will
(maintaining family, work, independence, listen carefully and make every effort to
and physical health all may be important understand the client’s point of view during a
motivators) brief intervention. Brief interventions are by
Sensible use limits and strategies for cutting definition time limited, which increases the
down or quitting—useful strategies include difficulty of adopting such an attitude.
developing social opportunities that do not However, when clients experience this
involve abusing substances and becoming nonjudgmental, respectful interest and
reacquainted with hobbies and interests understanding from the clinician, they feel safe
A substance abuse agreement—agreed-upon to openly discuss their ambivalence about
use limits (or abstinence) signed by the client change—rather than resist pressure from the
and the clinician—can often be an effective clinician to change before they are ready to do
way to alter use patterns so. The sooner they address their ambivalence,
Coping with risky situations (e.g., socializing the sooner they progress toward lasting change
with substance users, isolation, boredom, (see also TIP 35, Enhancing Motivation for Change
and negative family interactions) in Substance Abuse Treatment [CSAT, 1999c]).
Summary of the session
25
Chapter 2
When clients feel they are being pushed ask open-ended questions to which the client
toward change—even if the clinician is not must respond with a statement, rather than a
pushingthey are likely to resist. Clients must simple yes or no. Instead of summarizing a
summon all of their attention and strength to situation and then asking, “Is this correct?” ask
resolve their ambivalence, and resisting the the client, “What do you think? How do you
clinician may cause them to lose track and argue feel about the situation?” Open-ended
against change. If the client and clinician begin questions are invitations to share and provide a
arguing or debating, the clinician should means to probe for important information that
immediately shift to a new strategy, otherwise emerges in the interview.
the brief intervention will fail. In other words,
Exploring and resolving ambivalence
resistance is a signal for the clinician to change
Another important skill is the ability to help
strategies and defuse the resistance.
clients explore and resolve ambivalence.
Counseling Skills Ambivalence is the hallmark of a person in the
contemplation stage of readiness. It is one of the
Active listening most prevalent clinical challenges encountered
One of the most important skills for brief in brief interventions. Whether it takes 1 minute
interventionists is “active listening” (see Figure or 40 minutes, the goal is to help clients become
2-9). Active listening is the ability to accurately more aware of their position and the discomfort
restate the content, feeling, and meaning of the that accompanies their ambivalence. Increasing
client’s statements. This is also called “reflective awareness of this discomfort within an
listening,” “reflecting,” or sometimes understanding and supporting relationship can
“paraphrasing.” Active listening is one of the inspire the client to progress to a stage of
most direct ways to rapidly form a therapeutic preparation or action. For example, a client
alliance. When done well, it is a powerful might be willing to go to counseling but not an
technique for understanding and facilitating AA meeting; in that case, the clinician should
change in clients. Active listening goes beyond work with the client’s motivation and focus on
nonverbal listening skills or responses such as, the positive step the client is willing to make.
“Hmmm,” “Uh-huh,” “I see,” “I hear you,” or “I One way to help a client recognize his
understand where you’re coming from.” None ambivalence is to ask him to identify the benefits
of these short statements demonstrates that the and costs of the targeted behavior (e.g., using
clinician understands. Counselors should also alcohol) and the benefits and costs of changing
Figure 2-9
Steps in Active Listening
1. Listen to what the client says.
2. Form a reflective statement. To reflect your understanding, repeat in your own words what the client
said.
3. Test the accuracy of your reflective statement. Watch, listen, and/or ask the client to verify the accuracy
of the content, feeling, and/or meaning of the statement.
Skilled active listeners perform these three steps automatically, naturally, smoothly, and quickly. Active
listening saves time by reducing or preventing resistance, focusing the client, focusing the clinician,
encouraging self-disclosure, and helping the client remember what was said during the intervention.
26
Brief Interventions
the behavior. The clinician listens and interventions can be used with clients before,
summarizes these benefits and costs, then asks during, and after substance abuse treatment.
the client if any of them is more important than To integrate the use of brief interventions
the others. This helps identify values that are into specialized treatment, counselors and
important to the client and can therefore providers should be trained to provide this
increase or decrease the chance of changing. service. The Consensus Panel recommends that
Clinicians might also ask if any of the pros and agencies consider allocating counselor training
cons is more or less accurate than others. This time and resources to these modalities. The
provides an opportunity for irrational thoughts Panel anticipates that brief interventions will
to be refuted, which can help remove barriers to help agencies meet the increasing demands of
change (see example in the text box below). the managed care industry and fill the gaps that
Another approach to raising awareness of have been left in client care. It is also extremely
ambivalence is to explore the client’s experience important for substance abuse treatment
of feeling caught between opposing desires. For personnel to collaborate with primary care
more specific techniques for resolving providers, employee assistance program (EAP)
ambivalence, see TIP 35, Enhancing Motivation for personnel, wellness clinic staff, and other
Change in Substance Abuse Treatment (CSAT, community-based service providers in
1999c). developing plans that include both brief
interventions and more intensive care to help
Brief Interventions in keep the client focused on treatment and
Substance abuse treatment programs frequently Reduce no-show rates for the start of
use brief interventions, although they might not treatment
be called by that name. Brief interventions can Reduce dropout rates after the first session of
be effectively integrated into more treatment
comprehensive treatment plans for clients with Increase treatment engagement after intake
substance abuse disorders. These approaches assessment
can be particularly useful in treatment settings Increase compliance for doing homework
when they are used to address specific targeted Increase group participation
client behaviors and issues in the treatment Address noncompliance with treatment rules
process that can be difficult to change using (e.g., smoking in undesignated places,
standard treatment approaches. Brief unauthorized visits, or phone calls)
27
Chapter 2
Reduce aggression and violence (e.g., verbal problems including substance abuse disorders
hostility toward staff and other clients) and merely to refer them for specialty care
Reduce isolation from other clients (Miller et al., 1994). Many clients do not use
Reduce no-show rates for continuing care alcohol, for example, at a level that requires
Increase mutual-help group attendance specialized treatment. Others who use at
Obtain a sponsor, if involved with a 12-Step moderate or severe levels may be unwilling or
program unable to participate in specialized, mainstream
Increase compliance with psychotropic substance abuse treatment programs. Moreover,
medication therapies some individuals may attach a stigma to
Increase compliance with outpatient mental attending treatment versus general health care
health referrals services. Older adults and women often do not
Serve as interim intervention for clients on seek or engage in treatment because of stigma.
treatment program waiting lists An individual’s level of substance use is
detected through screening instruments,
Brief Interventions medical tests (e.g., urine testing), observation, or
Figure 2-10
Professionals Outside of Substance Abuse Treatment Who Can
Administer Brief Interventions
Primary care physicians Lawyers
Substance abuse treatment providers Mental health workers
Emergency department staff members Teachers
Nurses EAP counselors
Social workers Crisis hotline workers, student counselors
Health educators Clergy
28
Brief Interventions
and advice to reduce or stop it. If the initial chart. For example, if a medical client in a
intervention does not result in substantial primary care clinic is also seen by an alcohol and
improvement, the professional may refer the drug counselor for treatment of a substance
individual for additional specialized substance abuse disorder, those medical records are
abuse treatment. strictly protected by Federal law and may not be
Treatment providers who work in settings put in the client’s chart. (For more information
other than substance abuse treatment must be on these Federal laws, see TIP 24, A Guide to
flexible when assessing, planning, and carrying Substance Abuse Services for Primary Care
out brief interventions. For example, they will Clinicians [CSAT, 1997].)
likely encounter more risky drinkers than Heather makes an important distinction
alcohol-dependent individuals (in the United between brief interventions that are delivered in
States there are four times as many risky opportunistic settings where patients are not
drinkers as dependent drinkers [Mangione et al., directly seeking help for a substance abuse
1999]). Some research indicates that the disorder and those conducted in treatment
potential for brief interventions to reduce the environments where patients are seeking the
harm, problems, and costs associated with help of specialists (Heather, 1995). Brief
moderate to heavy alcohol use by risky drinkers interventions conducted in opportunistic
significantly surpasses the effectiveness from settings tend to be shorter, rely less on theory
applications of brief interventions on substance- and more on an existing clinician–client
dependent individuals (Higgins-Biddle et al., relationship, and are less expensive because they
1997). Other research on brief interventions, as are offered as part of an existing service.
presented below, highlights some of the more
rigorous studies with positive outcomes. The
Conducting Brief Interventions
costs of alcohol abuse to society, as interpreted With Older Adults
by health care costs, lost productivity, and Older adults present unique challenges in
criminal activity, are enormous, and brief applying brief intervention strategies for
interventions are a cost-effective technique to reducing alcohol consumption. The level of
address such abuse. Typically these brief drinking necessary to be considered risky
interventions act as an early intervention before behavior is lower than for younger individuals
or close to the development of alcohol-related (Chermack et al., 1996). Intervention strategies
problems and primarily entail instructional and should be nonconfrontational and supportive
motivational components addressing drinking due to increased shame and guilt experienced
behavior. In substance abuse treatment, brief by many older problem drinkers. As a result,
interventions are used to assist in the treatment older adult problem drinkers find it particularly
engagement process and to deal with specific difficult to identify their own risky drinking. In
individual, family, or treatment-related issues. addition, chronic medical conditions may make
When delivering a brief intervention in any it more difficult for clinicians to recognize the
treatment setting, the provider should be role of alcohol in decreased functioning and
mindful of room conditions and interruptions quality of life. These issues present barriers to
because client confidentiality is of utmost conducting effective brief interventions for this
importance. Federal law requires that chart vulnerable population. For more on this topic,
notes or other records on substance abuse be refer to TIP 26, Substance Abuse Among Older
kept apart from the rest of the client’s main Adults (CSAT, 1998b).
29
Chapter 2
30
Brief Interventions
some outcome measures. They concluded that Brief Interventions for At-Risk
no evidence supports the inferiority of brief And Problem Use
interventions in comparison with more A study conducted in 1983 focused on males in
extensive treatment offered by treatment Malmo, Sweden, in the late 1970s (Kristenson et
specialists to patients who are seeking help for al., 1983). The subjects, advised to reduce their
their alcohol-related problems. Heather argues, alcohol use in a series of health education visits,
however, that the findings do not support the subsequently demonstrated significant
statement that the effectiveness of brief reductions in gamma-glutamyl transferase
interventions is equal to that of other studied levels and health care utilization up to 5 years
treatments for alcohol abuse (Heather, 1995). after the brief interventions. The Medical
Finally, Bien and colleagues concluded from Research Council (MRC) trial, conducted in 47
an analysis of three other studies that brief general practitioners’ offices in Great Britain
interventions enhanced the motivation of (Wallace et al., 1988), found significant
treatment-seeking problem drinkers to enter and reductions in alcohol use by the intervention
remain in outpatient or residential alcohol group compared to the control group 12 months
treatment compared with clients not receiving following the intervention.
such attention (Bien et al., 1993). Anderson and Scott identified men and
Although other reviewers of brief women from eight general practices in England
interventions have reported more qualified who consumed more than 15 standard drinks
reactions, all seem to agree that strong research (for men) or 9 standard drinks (for women) of
evidence supports the use of brief interventions alcohol per week (Anderson and Scott, 1992).
for heavy or excessive, nondependent drinkers, These individuals were randomly assigned to
particularly those identified in general medical receive either no intervention or feedback about
practice settings (Heather, 1995; Kahan et al., the findings from the screening and 10 minutes
1995; Mattick and Jarvis, 1994; Wilk et al., 1997). of advice from the physician to reduce their
Wilk and colleagues examined evidence from 12 consumption levels, accompanied by a
controlled clinical trials that randomized nearly pamphlet of self-help information. After 1 year,
4,000 heavy drinkers to brief intervention or no the males in the advice group had significantly
intervention (Wilk et al., 1997). They concluded reduced their mean weekly alcohol
that heavy drinkers who received interventions consumption by 2.8 ounces more than those
in a primary care setting were almost twice as who received no intervention. The females in
likely to moderate drinking than those who did both groups, however, showed significant
not receive an intervention. The National reductions in alcohol consumption at the same
Institute on Alcohol Abuse and Alcoholism followup point, with no between-group
(NIAAA) has also presented data on the efficacy differences.
and uses of brief interventions for dependent In a widely publicized evaluation of brief
drinkers (NIAAA, 1999). interventions conducted in health care settings
This TIP reviews the most methodologically in 10 nations sponsored by WHO, the
sound brief intervention studies and discusses investigators identified 1,490 nonalcoholic heavy
methodological limitations of previous and drinkers from eight core sites through a 20-
current research in this area. The research is minute health interview (Babor and Grant, 1991;
presented in two sections: (1) brief interventions Babor et al., 1994). These participants were
for at-risk and problem use and (2) brief randomly assigned to one of four groups: (1) no
interventions for substance abuse. further intervention, (2) 5 minutes of simple
31
Chapter 2
advice about the importance of sensible with a no-intervention control group, the
drinking or abstinence, (3) simple advice plus 15 patients who received two 10- to 15-minute
minutes of brief counseling and a self-help sessions of scripted advice (using a workbook
manual that encouraged the development of a that focused on advice, education, and
habit-breaking-plan, or (4) at five of the sites, contracting information) showed significantly
extended supportive counseling delivered in greater reductions in alcohol consumption at a
three extra sessions following the initial advice 12-month followup based on drinking levels
and 15-minute session. After 9 months, males during the previous week, episodes of binge
who received any intervention, including the 5 drinking over the past month, and frequency of
minutes of advice, reported approximately 25 excessive drinking in the previous 7 days.
percent less daily alcohol consumption—a Males in the study also had significantly fewer
greater change than was observed in the no- days of hospitalization than counterparts in the
intervention control group. Significantly, the control group. Females in the experimental
men who showed the greatest response to groups reduced their consumption significantly
simple advice had more severe alcohol problems more than males in the experimental group.
and higher consumption patterns. This research group (Fleming et al., 1999) also
Another interesting finding from the WHO conducted a similar trial with primary care
study was that female participants in all groups patients over 65 and found significant
had reduced their drinking at 9 months, differences in drinking after 12 months for the
regardless of whether they received any experimental group compared to the control
intervention. One explanation may be that the group.
female participants were only recruited from Miller and colleagues have developed a
two relatively affluent countries—Australia and special form of a brief intervention known as the
the United States—thus, the results cannot be Drinker’s Check-Up (Miller and Sovereign,
generalized to all women (Sanchez-Craig, 1994). 1989), designed to evaluate whether alcohol is
Furthermore, the 20-minute comprehensive harming an individual in any way. In the 1989
assessment was sufficiently intensive that some study, participants were recruited through
women may have responded to implicit media advertisements and were asked to come
messages of cutting down on consumption into a neutral setting for the assessment. As
without further overt advice, especially reported by Bien and colleagues, several trials of
considering that only 10 minutes of simple this approach have demonstrated encouraging
advice or 15 minutes of counseling were results from providing systematic feedback
additionally provided (Kristenson and about assessment results and some self-help
Osterling, 1994). options (Bien et al., 1993). Compared with a no-
One successful study demonstrated the intervention group of respondents who had to
efficacy of a brief alcohol intervention in a wait 6 weeks for assessment, the recipients of
community-based primary care setting (Fleming immediate feedback and brief, empathic
et al., 1997). Project TrEAT (Trial for Early assistance showed prompt and persistent
Alcohol Treatment) identified 723 men and reductions (of 29 to 57 percent) in consumption
women as problem drinkers from 17,695 patterns. More empathic counseling, an
patients who were screened in 17 community- important component of brief interventions (see
based primary care practices. The outcomes discussion on FRAMES earlier in this chapter), is
studied were reductions in alcohol consumption also associated with larger reductions than the
and health resource utilization. In comparison
32
Brief Interventions
use of the more traditional confrontational styles difficult and important clinical and public health
(Miller et al., 1993). issue.
While the types of brief interventions vary,
the basic design of most studies is a randomized
Brief Interventions for
controlled trial that assigns clients with Dependent Use
hazardous drinking patterns either to a brief Most studies of brief interventions for alcohol
intervention (ranging from one to ten sessions) use that had the goal of changing drinking
or to one or more control conditions (Anderson behavior have included only subjects who did
and Scott, 1992; Babor, 1992; Babor and Grant, not meet criteria for alcohol dependence and
1991; Chick et al., 1985; Fleming et al., 1997; explicitly excluded dependent drinkers with
Harris and Miller, 1990; Heather et al., 1987; significant withdrawal symptoms. The rationale
Kristenson et al., 1983; Persson and Magnusson, for this practice was that alcohol-dependent
1989; Wallace et al., 1988). Overall, the majority individuals or those affected most severely by
of brief alcohol intervention studies have found alcohol should be referred to formal specialized
significantly greater improvements in drinking alcoholism treatment programs because their
outcomes for the experimental group compared conditions are not likely to be affected by low
to the control group; however, most also found intensity interventions (Babor et al, 1986;
significant changes in drinking over time for Institute of Medicine [IOM], 1990). However,
both the control and brief intervention there have been positive trials that address this
conditions. Meta-analyses found an effect size issue specifically.
of 20 to 30 percent in studies conducted in NIAAA reviewed the studies focused on
health care settings (Bien et al., 1993; Kahan, alcohol-dependent drinkers (NIAAA, 1999).
1985). Trials conducted since 1995 have Some of these studies focused on the
garnered similar effect sizes with one trial effectiveness of motivating alcohol-dependent
finding a greater effect size for women (35 patients to enter specialized alcohol treatment.
percent) (Fleming et al., 1997). Women were not As long ago as 1962, a nonrandomized study
always included in earlier trials, but later trials was conducted of alcohol-dependent patients,
that did include women found that they were identified in the emergency department
more likely than men to decrease their drinking (Chafetz et al., 1962). Of those receiving brief
based on brief targeted advice. counseling, 65 percent followed through in
Because of the success of brief alcohol keeping a subsequent appointment in a
interventions with adults in opportunistic specialized alcohol treatment setting. Only 5
settings, new trials with special populations percent in the control group followed through
(e.g., older adults, injured patients in emergency with an appointment.
departments, pregnant women) are now being Brief interventions have also been compared
proposed and conducted. In addition, new to more intensive and extensive treatment
technologies are being studied, including approaches used in traditional treatment
computerized real-time tailored booklets for at- settings with positive results (Edwards et al.,
risk drinkers, and the use of Interactive Voice 1977; Project MATCH Research Group, 1997,
Recognition (IVR) for interventions and 1998). In a small study, the effectiveness of a
followup. These and other technologies, if one-session brief advice protocol plus monthly
efficacious and effective, will provide clinicians followup telephone calls, focused on the
with new tools to assist them in working with a patient’s personal responsibility to stop
33
Chapter 2
34
Brief Interventions
35
Chapter 2
could be seeking additional treatment during no published studies that definitively address
the course of the research (Bien et al., 1993; this issue.
Kahan et al., 1995; Mattick and Jarvis, 1994). There is strong evidence supporting the
Also, randomization of samples has not always efficacy of alcohol screening and brief
been conducted (Wilk et al., 1997), and some interventions, in particular (Fleming et al., 1997).
early studies did not have control groups or did However, few studies to date have tested the
not have an adequate comparison group (Bien et implementation of brief intervention strategies
al., 1993). Some of the newer brief intervention in community-based medical and treatment
studies have addressed many of these concerns settings. Several new initiatives address this
(Fleming et al., 1997, 1999). These, however, critical next step in the process. Higgins-Biddle
remain issues that must be addressed by new and colleagues identified the research base and
studies of brief intervention techniques with current applications of screening and brief
special populations and with new technology. interventions (Higgins-Biddle et al., 1997). The
findings on the effectiveness from clinical trials
Future Issues in Research and on screening and brief interventions were found
Practice to be encouraging, with risky drinkers reducing
The background research in this TIP is based on their alcohol consumption by 20 percent, on
the most rigorous trials from the 1960s through average. Individual study results varied from
the 1990s. As study designs have become more 15 to 40 percent depending on the population
sophisticated, many of the earlier and methodology used. In the next few years,
methodological issues are being addressed. focused work in these areas will inform
Questions remain regarding specific levels of clinicians regarding optimal brief intervention
abuse and dependence after which brief implementation strategies and provide a bridge
intervention approaches are less effective and from research efficacy to practical application in
more intensive treatment is required. It is real world clinical settings.
possible that factors such as social stability and There is evidence that a variety of brief
support (as indicated in Edwards and Orford, interventions are effective with at-risk and
1977) play a role in improved responses to hazardous substance users, and emerging
briefer treatments and that these factors may be evidence suggests that brief interventions can be
more important than the level of substance used to motivate patients to seek specialized
abuse or dependence. substance abuse treatment and to treat some
As secondary analyses are conducted from alcohol-dependent persons. Clinical evidence
more recent clinical trials, some of the strongest also suggests that brief interventions can be
covariates will emerge. Further research used in specialized treatment programs to
focused specifically on the myriad of issues that address specific targeted issues.
could affect outcomes is needed to determine In sum, the Consensus Panel believes it is
whether brief interventions can be useful for critical for policymakers and providers of
clients with dual diagnoses or whether they managed care to understand that brief
always require more intensive treatments interventions should never be thought of as the
because of the complexity of their illnesses. only treatment option for persons with
Although there is ongoing research testing the substance abuse problems but as one of a
effectiveness of brief interventions with patients continuum of techniques for use with a
who have serious psychiatric illnesses and population of clients with substance abuse
coexisting substance abuse disorders, there are problems ranging from at-risk to dependent use.
36
3 Brief Therapy in Substance
Abuse Treatment
B
rief therapy is a systematic, focused to change basic attitudes and handle a variety of
process that relies on assessment, client underlying problems. Compared with brief
engagement, and rapid implementation therapies, brief interventions are more
of change strategies. Brief therapy providers motivational, seeking to motivate the client to
can effect important changes in client behavior make a specific change (in thought or action).
within a relatively short period. The brief (See Chapter 1 for more on how this TIP
therapies presented in this TIP should be seen as distinguishes brief therapies from brief
contained modalities of treatment, not episodic interventions.)
forms of long-term therapy. Brief therapy differs from longer term
However, in the literature and in practice, the therapy in that it focuses more on the present,
term “brief therapy” covers a wide range of downplays psychic causality, emphasizes using
approaches to treatment of varying lengths and effective therapeutic tools in a shorter time, and
with a variety of goals. Brief therapies usually focuses on a specific behavioral change rather
consist of more (as well as longer) sessions than than large-scale or pervasive change. A number
brief interventions. The duration of brief of specific types of therapy are designed to be
therapies is reported to be anywhere from 1 carried out in a brief period (e.g., cognitive–
session (Bloom, 1997) to 40 sessions (Sifneos, behavioral approaches are often designed to
1987), with the typical therapy lasting between 6 require fewer than 20 sessions). Many longer
and 20 sessions. Twenty sessions usually is the approaches have been or can be adapted; even
maximum because of limitations placed by lengthy psychodynamic approaches have been
many managed care organizations. Any therapy adapted for brief therapy with clear guidelines
may be brief by accident or circumstance, but for their use (Davanloo, 1980; Luborsky, 1984;
the focus of this TIP is on planned brief therapy. Mann, 1973; Sifneos, 1972; Strupp and Binder,
The therapies described here may involve a set 1984).
number of sessions or a set range (e.g., from 6 to This chapter provides an overview of brief
10 sessions), but they always work within a time therapy in substance abuse treatment. First, the
limitation that is clear to both therapist and evidence for the efficacy of this approach is
client. In the following pages, all therapies presented. The appropriateness of brief therapy
described should be understood as planned or is discussed next, and criteria are provided for
time limited. determining duration of therapy. The
Brief therapies differ from brief interventions components of all brief therapies are then
in that their goal is to provide clients with tools discussed, including common characteristics
37
Chapter 3
and steps in treatment. Finally, essential specific research evaluating different types of
therapist knowledge and skills for conducting brief therapy is given in Chapters 4 to 9.)
successful brief therapies are described. There is, however, promising evidence that
The chapters following this present a cross- brief therapies as a treatment for substance
section of the approaches that are and have been abuse disorders are often as effective as
used in brief therapy. No one approach is lengthier treatments (Bien et al., 1993; Gottheil et
endorsed as the best or only approach for use al., 1998; McLellan et al., 1993; Miller and
with the range of persons with substance abuse Hester, 1986a; Miller and Rollnick, 1991). These
disorders, nor are all of them considered by the studies are positive but are primarily limited to
Consensus Panel to be equally valid. Rather, the program effectiveness studies with smaller
therapies in Chapters 4 through 9 were chosen sample sizes. Future research should both
because they either represent the most widely replicate previous work and use more rigorous
used brief therapies or they represent models designs that include experimental designs with
that have good potential, are recommended by randomization. Many of the fundamental
national experts, and will be of interest and questions about brief therapies—the optimum
assistance to providers who treat persons across conditions under which they should be used, the
the range of substance abuse disorders. Some of economic cost-benefits, and level and type of
these approaches can be used with the whole provider, the most suitable types of clients—
range of people with substance abuse disorders; have yet to be studied.
others are useful only for a smaller subset of that The majority of clients in therapy (regardless
population. Each of the chapters that follows of the modality) remain in treatment for
discusses a particular type of the individual between 6 and 22 sessions; 90 percent end
therapies. However, each of the approaches treatment before completing 20 visits (Friedberg,
described in Chapters 4 to 9 will provide useful 1999). The fact that many clients stay in therapy
techniques for the eclectic practitioner. for relatively short periods of time suggests that
brief therapy techniques should be much more
Research Findings common than they are in current clinical
practice (Pekarik and Wierzbicki, 1986; Phillips,
Research concerning the relative effectiveness of 1987). Many therapists trained in long-term
brief versus longer term therapies for a variety treatment modalities choose not to use planned
of presenting complaints is mixed. Some studies short-term therapies (Bloom, 1997). Alcohol and
have found that planned, short-term therapies drug counselors often have to work with clients
are as effective as lengthier (or unlimited) in a limited period of time, however, and could
therapy (Koss and Shiang, 1993; Smyrnios and apply brief therapy techniques even when they
Kirkby, 1993). Other studies, such as the are designed for treatment of different types of
Consumer Reports mental health study (Seligman, disorders and problems.
1995) and the National Institute of Mental Because brief therapy is more effective than
Health (NIMH) Treatment of Depression being on a waiting list, it could benefit many
Research Program (Blatt et al., 1995; Elkin, 1994), clients. Wolberg suggested that all clients
have found that longer term treatments seeking treatment be given brief therapy
generally lead to better outcomes as perceived initially, before moving on to long-term
by clients. Much depends on the modality being treatments (Wolberg, 1980). Such an approach
evaluated and the goals of the treatment. (More would help to reserve longer treatments for
38
Brief Therapy in Substance Abuse Treatment
clients with a greater need for them. However, brief therapy. Therefore, client needs and the
there are clearly exceptions to this rule, such as suitability of brief therapy must be evaluated on
clients who have a history of severe and a case-by-case basis. Some criteria for
persistent mental illness. Other criteria for considering the appropriateness of brief therapy
assigning a client to longer term rather than are presented in Figure 3-2. The American
brief therapy are presented in Figure 3-1. Society of Addiction Medicine (ASAM) client
Planned brief therapy can be adapted as part placement criteria for substance abuse treatment
of a course of serial or intermittent therapy (ASAM, 1996) may also be useful for
(Budman and Gurman, 1988; Cummings, 1990). determining who could benefit from brief
When doing this, the therapist conceives a long- therapy (see discussion in Chapter 2).
term treatment as a number of shorter Brief therapy may be appropriate for a
treatments, which requires that the client’s moderate to heavy drinker such as a college
problems be addressed serially rather than student but inappropriate as the sole treatment
concurrently. Because of insurance constraints, for a commercial airline pilot who is alcohol
many therapists are now billing by episode and dependent, no matter what the motivation is for
treating one problem at a time. treatment. Therapists must consider
Brief therapy may prove to be a useful tool extenuating circumstances when recommending
for reconceiving how therapy is delivered. For a particular course of treatment. In some
the treatment provider working with clients programs, duration of therapy is determined
with substance abuse disorders, this means that mutually by the client and therapist; brief
a particular type of therapy could be applied to therapy may be the best option if the client
a specific problem associated with a client’s objects to longer term treatment or if expense is
substance abuse. By treating these allied an issue.
problems, long-term goals, such as continued Research is needed to identify specific
abstinence, may be more likely to be reached populations for which brief therapy would serve
(Iguchi et al., 1997; McLellan et al., 1993). as the catalyst for resolution of substance abuse-
related problems. The impact of brief therapy
When To Use Brief on chronically relapsing, substance-abusing
Figure 3-1
Criteria for Longer Term Treatment
The following criteria can help identify clients who could benefit from longer term treatment:
39
Chapter 3
Figure 3-2
Selected Criteria for Providing Brief Therapy
Dual diagnosis issues such as a coexisting psychiatric disorder or developmental disability
The range and severity of presenting problems
The duration of abuse
Availability of familial and community supports
The level and type of influence from peers, family, and community
Previous treatment or attempts at recovery
The level of client motivation (brief therapy may require more work on the part of the client but a
less extensive time commitment)
The 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
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
client and what kind of modality would be most therapeutic communities, psychotherapy,
effective. methadone maintenance therapy, and extended
The best outcomes for brief therapy may detoxification (Hubbard et al., 1997). Therefore,
depend on the therapist’s skills, comprehensive although brief therapy is a useful tool in a
assessments, and selective criteria for eligibility. portfolio of interventions, its use should be
Using selection criteria in prescribing brief targeted to those clients who are most likely to
therapy is critical, since many clients will not benefit.
meet eligibility. The Consensus Panel hopes Determining when to use a particular type of
that brief therapy will be adequately brief therapy is also an important consideration
investigated before managed care and third- for counselors and therapists. Counselors
party payors decide it is the only modality for recognize that not all clients are at the same
which they will pay. stage in their readiness for treatment. Currently,
Brief therapy for substance abuse treatment the most widely used model for understanding
is a valuable but limited approach, and it should clients’ readiness for change is Prochaska and
not be considered a standard of care for all DiClemente’s stages-of-change model, which is
populations. In fact, time in treatment has been discussed in Chapter 2. (For more information
found to be directly related to better outcomes about this model, see also TIP 35, Enhancing
within a range of modalities, including Motivation for Change in Substance Abuse
40
Brief Therapy in Substance Abuse Treatment
Treatment [CSAT, 1999c].) Counselors who use the messages she gives herself and help her
this model will have to determine which therapy correct problematic thinking patterns and
is compatible with the client’s stage of readiness dysfunctional beliefs (Kendall and Turk, 1984).
for change and the tasks needed to move Often, dysfunctional beliefs lead to low levels of
forward in the change process and develop an perceived self-efficacy and subsequent inability
overall understanding of the course of change to adopt or maintain the desired behavior
(DiClemente and Scott, 1997). (Bandura, 1986). It is important to note that self-
Clinical interventions should be targeted to efficacy shifts in a predictable way across the
the client’s stage of readiness for change to stages of behavior change, with clients
increase his motivation to change behaviors and progressively becoming more efficacious as they
to augment a sense of empowerment in move through the stages (Marcus et al., 1992;
recovery. Therapies that work with experiential Prochaska et al., 1994).
processes (such as consciousness raising, self-
reevaluation, and a cognitive restructuring) are Approaches to
more important for understanding and
predicting transition from preparation to action
Brief Therapy
and from action to maintenance (Prochaska et Brief therapy uses a selected process to change a
al., 1994). Seeking and processing information, specific problem based on an underlying theory
observing others, and gathering useful about the cause of the problem or the best way
information in light of the client’s situation are to encourage positive change. Figure 3-3 lists
the primary activities reported most frequently several therapeutic approaches that are
during the contemplation stage (Prochaska et al., applicable to brief therapy. These approaches
1992). Especially during this early stage the can be used with clients with different types of
client should be provided with information problems and varying degrees of substance
regarding addiction as well as confronted with abuse severity.
the short- and long-term consequences of
continued use. Asking the client to perform a Components of Effective
risk appraisal of continued use as well as a
benefit/risk-reduction appraisal of achieving
Brief Therapy
abstinence can facilitate sound decisionmaking Although different models of brief therapy may
that involves a comparison of all potential gains stress certain goals and activities more than
and losses (Janis and Mann, 1977). others, all brief therapies have common
Finally, it will be essential to learn the client’s characteristics (see Figure 3-4). In addition, brief
perceived obstacles to engaging in treatment as therapies should incorporate several stages,
well as to identify any dysfunctional beliefs that including screening and assessment, an opening
could sabotage the engagement process. The session that includes the establishment of
basic assumption behind this approach is that treatment goals, subsequent sessions,
the way individuals evaluate a situation and maintenance strategies, ending treatment, and
cope with it determines their emotional reaction followup. These stages are discussed below.
to it (Ellis and Grieger, 1977). The critical factor
in determining an individual’s response is the Screening and Assessment
client’s self-perception and associated emotions. Screening and assessment are critical initial
The therapist should help the client recognize steps in brief therapy. Screening is a process in
41
Chapter 3
Figure 3-3
Approaches to Brief Therapy
Approaches Description
Cognitive This therapy posits that substance abuse disorders reflect habitual, automatic,
therapy negative thoughts and beliefs that must be identified and modified to change
erroneous ways of thinking and associated behaviors. The desire to use
substances is typically activated in specific, often predictable high-risk situations,
such as upon seeing drug paraphernalia or experiencing boredom, depression, or
anxiety. This approach helps clients examine their negative thoughts and replace
them with more positive beliefs and actions. Many relapse prevention strategies
use cognitive processes to identify triggering events or emotional states that
reactivate substance use and replace these with more healthful responses. (See
Chapter 4 for more information.)
Behavioral Using this approach, which is based on learning theories, the therapist teaches the
therapy client specific skills to improve identified deficiencies in social functioning, self-
control, or other behaviors that contribute to substance use disorder. Some of the
techniques that are used 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. (See Chapter 4 for more general information on behavioral therapy
and Chapter 8 for more information on CRAFT and other behavioral family
therapies.)
Cognitive This approach combines elements of cognitive and behavioral therapies, but in
behavioral most substance abuse treatment settings it is considered a separate therapy. This
therapy approach focuses on learning and practicing a variety of coping skills. The
emphasis is placed on developing coping strategies, especially early in the
therapy. Cognitivebehavioral therapy is thought to work by changing what the
client does and thinks rather than just focusing on changing how the client thinks.
(See Chapter 4.)
Strategic/ These approaches seek to understand a client’s viewpoint on a problem, what
interactional meaning is attributed to events, and what ineffective interpersonal interactions
therapies and coping strategies are being applied. By shifting the focus to competencies,
not weaknesses and pathology, the therapist helps clients change their perception
of the problem and apply existing personal strengths to finding and applying a
more effective solution. (See Chapter 5.)
Solution- Using this approach, the therapist helps a client with a substance abuse disorder
focused therapy recognize the exceptions to use as a means to reinforce and change behavior.
Future behavior is based on finding solutions to problem behaviors. Little or no
time is spent talking about the problem; rather, therapy is focused on solutions
that have already worked for the client in the past. (See Chapter 5.)
42
Brief Therapy in Substance Abuse Treatment
43
Chapter 3
Figure 3-4
Characteristics of All Brief Therapies
They are either problem focused or solution focused; they target the symptom and not what is
behind it.
They clearly define goals related to a specific change or behavior.
They should be understandable to both client and clinician.
They should produce immediate results.
They can be easily influenced by the personality and counseling style of the therapist.
They rely on rapid establishment of a strong working relationship between client and therapist.
The therapeutic style is highly active, empathic, and sometimes directive.
Responsibility for change is placed clearly on the client.
Early in the process, the focus is to help the client have experiences that enhance self-efficacy and
confidence that change is possible.
Termination is discussed from the beginning.
Outcomes are measurable.
which clients are identified according to of brief therapy. For example, if a client lacks
characteristics that indicate that they are the financial means to participate in a longer
possibly abusing substances. Screening does not treatment process, a brief therapy approach is
inform the therapist of the severity of the imperative. Some treatment is almost always
individual client’s substance abuse, only its better than no treatment. In addition, brief
presence and, in some cases, broad indications therapy may be indicated for clients who resist
of risk. Screening identifies the need for more longer treatment, rather than risk the loss of an
in-depth assessment and is not a substitute for otherwise motivated client. (Technical
an assessment. Assistance Publication [TAP] 21, Addiction
Assessment is a thorough, extensive process Counseling Competencies: The Knowledge, Skills,
that involves a broad analysis of the factors and Attitudes of Professional Practice [CSAT,
contributing to and maintaining a client’s 1998a] contains further guidance on screening
substance abuse, the severity of the problem, and assessment for brief therapy.)
and the variety of consequences associated with Therapists should gather as much
it. Screening and assessment procedures for information as possible about a client before the
brief therapy do not differ significantly from first counseling session. One way to do this is to
those used for lengthier treatments. obtain copies of any notes taken by an intake
The assessment should determine whether worker or the referral source. However, when
the client’s substance abuse problem is suitable gathering information about a client from other
for a brief therapy approach. The criteria for sources, therapists should be sensitive to
determining the appropriateness of brief confidentiality and client consent issues (for
therapy, presented in Figures 3-1 and 3-2, are more information see the section entitled
first applied during the assessment stage. “Confidentiality of Information About Clients”
It is reasonable to assume that brief therapies in Chapter 9 of the forthcoming TIP, Substance
are most effective with clients whose problems Abuse Treatment for Persons With HIV/AIDS
are of short duration and who have strong ties [CSAT, in press]). Other options include asking
to family, work, and community. However, intake workers to administer questionnaires,
limited client resources may also dictate the use using computerized assessments, or asking the
44
Brief Therapy in Substance Abuse Treatment
client to complete an assessment form before the the following section. For sample screening
first session. The assessment instrument can be instruments and additional information on
brief and informal, generating critical screening procedures see also TIP 24, A Guide to
information in a short time. Although initial Substance Abuse Services for Primary Care
screening and assessment ideally should be Clinicians; TIP 26, Substance Abuse Among Older
conducted before the first therapy session, the Adults; TIP 31, Screening and Assessing
process of assessment should continue Adolescents for Substance Use Disorders; and TIP
throughout treatment. 35, Enhancing Motivation for Change in Substance
A variety of brief assessment instruments, Abuse Treatment (CSAT, 1997, 1998b, 1999a,
many of which are free, are available to 1999c).
clinicians. Assessing Alcohol Problems (National For brief therapy, the setting in which
Institute on Alcohol Abuse and Alcoholism, treatment will occur frequently dictates the kind
1995) is a useful source of research-validated of assessment that can be conducted. Clients
instruments. Figure 3-5 provides a sample seek treatment in the type of agency they feel
battery of brief assessment instruments that will best meet their needs (e.g., those who need
might be used in a brief therapy setting, ideally to continue working while seeking treatment
before the first counseling session. These will likely enter an outpatient program).
instruments can provide the therapist with a Constraints may be placed by insurance
quick assessment of the most critical domains companies or other outside forces. For example,
about which clinical decisions should be made. managed care environments generate their own
In general, most clients can complete these assessment criteria. Assessment often must be
instruments in less than 1 hour. These conducted outside the treatment facility and
instruments should be supplemented in the first may not qualify as a reimbursable visit. In
counseling session by a clinical assessment addition, private practitioners often do not have
interview that covers the core areas outlined in easy access to background information
Figure 3-5
Sample Battery of Brief Assessment Instruments
Assessment Domain Example 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
Readiness to change Commitment to Change Algorithm, 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.
45
Chapter 3
regarding a potential client. In a primary care accomplish certain critical tasks during the first
office, screening and assessment consist only of session, including
taking a client’s history and conducting a
physical examination.
Producing rapid engagement
Core assessment areas Identifying, focusing, and prioritizing
Before proceeding with brief therapy for problems
substance abuse disorders, a number of areas Working with the client to develop possible
should be assessed, including the following: solutions to substance abuse problems and a
treatment plan that requires the client’s
Current use patterns
active participation
History of substance abuse
Negotiating the route toward change with
Consequences of substance abuse (especially
the client (which may involve a contract
external pressures that are bringing the client
between client and therapist)
into treatment at this time, such as family or
Eliciting client concerns about problems and
legal pressures)
solutions
Coexisting psychiatric disorders
Understanding client expectations
Information about major medical problems
Explaining the structural framework of brief
and health status
therapy, including the process and its limits
Information about education and
(i.e., those items not within the scope of that
employment
treatment segment or the agency’s work)
Support mechanisms
Making referrals for critical needs that have
Client strengths and situational advantages
been identified but can not be met within the
Previous treatment
treatment setting
Family history of substance abuse disorders
and psychological disorders Goals of treatment
Therapists should identify and discuss the goals
As mentioned earlier, assessment is critical
of brief therapy with the client early in
not only before beginning brief therapy but also
treatment, preferably in the first session. The
as an ongoing part of the process. Only by
client has a critical role in determining the goals
continually assessing the client’s progress and
of therapy, and the therapist might have to be
problems can the therapist accomplish the goals
flexible. The therapist can recommend
of brief therapy in the limited timeframe. In
treatment goals, but ultimately they are
addition, ongoing assessment can function as a
established through interaction and negotiation
therapeutic tool because it helps clients identify
with the client. If a client has certain
when they are at risk of using substances as well
expectations of therapy that make it difficult for
as other negative behaviors.
her to commit to the goals and procedures of
The Opening Session brief therapy or to a particular therapeutic
In the first session, the main goals for the approach, other approaches should be
therapist are to gain a broad understanding of considered or a referral made.
the client’s presenting problems, begin to Treatment goals should focus on the central
establish rapport and an effective working problem of substance abuse and may include the
relationship, and implement an initial following:
intervention, however small. The therapist must
46
Brief Therapy in Substance Abuse Treatment
Teaching the client how to capitalize on Leave the door open for possible future
personal strengths sessions dealing with the client’s other
Emphasizing client self-sufficiency problems
(encouraging the client to work through his Elicit commitment from the client to try to
own problems and stay focused on the goals follow through on what has been learned or
that have been set in therapy) and teaching achieved
self-reinforcement techniques Review what positive outcomes the client can
Developing a plan for future support, expect
including mutual help groups, family Review possible pitfalls the client may
support, and community support (e.g., encounter (e.g., social situations, old friends,
religious or social service organizations), relationship issues) and talk about the
which can be done much earlier than in long- likelihood of a good outcome and indicators
term therapy of a poor outcome
Review the early indicators of relapse (e.g.,
In addition to routine progress assessments
depression, stress, anger)
that are conducted throughout the therapy,
midway through the agreed-upon number of In brief therapy, issues regarding referral and
sessions the therapist should formally review followup are often different from those of longer
the client’s progress. Particularly because of the term therapy because clients will not necessarily
time limitations of brief therapy, continuing remain in contact with the therapist. If the goals
assessments are essential to ensure that of therapy have not been met, more intensive
problems are addressed and that the client can therapy may be suggested.
recognize when she is most at risk of slipping During continual assessment of the progress
into substance abuse or other negative of the therapy, the therapist may decide that
behaviors. Assessments will also take into referral is appropriate before treatment ends. It
account the level of the client’s progress. When is important to remember that referrals can be
the client has made agreed-upon behavior made at any time during treatment, not just at
changes and has resolved some problems, the the end of the treatment process. Reasons for
therapist should prepare to end the brief initiating referrals during or at the end of
therapy. If a client progresses more quickly than treatment include the following:
anticipated, it is not necessary to complete the
The client needs ancillary services for other
full number of sessions.
problems that have been recognized during
Ending Treatment therapy (e.g., medical or psychiatric
problems).
Termination of therapy should always be
The client requires more intensive therapy.
planned in advance. In many types of brief
The client may benefit from involvement
therapy, the end of therapy will be an explicit
with a support group, such as Alcoholics
focus of discussion in which the therapist should
Anonymous, Self-Management and Recovery
Leave the client on good terms, with an Training (SMART), or Moderation
enhanced sense of hope for continued change Management (which may also be a part of
and maintenance of changes already the brief therapy process).
accomplished
48
Brief Therapy in Substance Abuse Treatment
49
Chapter 3
Brief therapy is amenable to the use of a wide Brief therapy for substance abuse disorders is
range of techniques from which the therapist often helpful, but should not be considered a
can choose. It is therefore helpful for therapists standard of care for all persons or populations.
to be aware of the broad range of therapeutic Brief therapy, as presented in this TIP, can be a
techniques available. Exposure to several contained modality of treatment and not an
psychotherapeutic approaches (many described episodic form of long-term therapy. In fact,
in the following chapters) allows therapists to successful brief therapy may be the only
understand how other clinicians might approach treatment some clients will require.
the situation, what a client might have
experienced in previous treatments, and how to
build on these experiences.
50
4 Brief Cognitive–Behavioral
Therapy
A
n approach that has gained widespread abuse treatment. Both behavioral and cognitive
application in the treatment of theories have led to interventions that
substance abuse is cognitive–behavioral individually have been proven effective in
therapy (CBT). Its origins are in behavioral treating substance abuse. Several of these are
theory, focusing on both classical conditioning reviewed, as they have been successfully
and operant learning; cognitive social learning incorporated into an integrated cognitive–
theory, from which are taken ideas concerning behavioral model of addictive behaviors and
observational learning, the influence of their treatment.
modeling, and the role of cognitive expectancies
in determining behavior; and cognitive theory Behavioral Theory
and therapy, which focus on the thoughts,
cognitive schema, beliefs, attitudes, and In contrast to many other methods, behavioral
attributions that influence one’s feelings and approaches to the treatment of substance abuse
mediate the relationship between antecedents have substantial research evidence in support of
and behavior. Although there are a number of their effectiveness. Two recent comprehensive
similarities across these three seminal reviews of the treatment research literature offer
perspectives (see Carroll, 1998), each has strong evidence for their effectiveness (Holder et
contributed unique ideas consistent with its al., 1991; Miller et al., 1995). However, some
theoretical underpinnings. However, in most critics argue that this is because behavioral
substance abuse treatment settings, the approaches have been developed under
prominent features of these three theoretical controlled conditions and that in “real” therapy
approaches are merged into a cognitive– there are many more variables at work than can
behavioral model. be measured in controlled experiments.
Before focusing more specifically on the Providers should take advantage of the wide
cognitive–behavioral model, this chapter range of behavioral therapy techniques that are
examines the behavioral and cognitive theories available. These techniques can be conducted
and therapies that serve as the foundations of successfully in individual, group, and family
and have contributed significantly to the settings, among others, to help clients change
cognitive–behavioral approach to substance their substance abuse behaviors.
51
Chapter 4
Behavioral approaches assume that substance learning. A major tenet of behavioral therapy is
abuse disorders are developed and maintained that because substance abuse is a learned
through the general principles of learning and behavior pattern, changing the reinforcement
reinforcement. The early behavioral models of contingencies that govern this behavior can
substance abuse were influenced primarily by modify it. This goal can be achieved by focusing
the principles of both Pavlovian classical on either the classically conditioned craving
conditioning and Skinnerian operant learning responses or on the operant reinforcement
(O’Brien and Childress, 1992; Stasiewicz and patterns that are assessed as maintaining the
Maisto, 1993). (See Figure 4-1 for definitions of substance abuse. More specifically, the
classical conditioning and operant learning.) classically conditioned response can be
Today, behavioral therapy for the treatment addressed either through extinction or
of substance abuse disorders is based primarily, counterconditioning procedures; the operant
though not exclusively, on methods derived responses can be targeted through contingency
from both operant and classical theories of management or coping skills training. (More
Figure 4-1
Classical Conditioning and Operant Learning
According to the theory of classical conditioning, an originally neutral stimulus comes to elicit a
response as a result of being paired with an unconditioned stimulus (an event that elicits a response
without any prior learning history) or with a conditioned stimulus. As applied to substance abuse,
repeated pairings between the emotional, environmental, and subjective cues associated with the use of
substances and the actual physiological and phenomenological effects produced by specific substances
lead to the development of a classically conditioned response. Subsequently, when the substance abuser
is in the presence of such cues, a classically conditioned withdrawal state or craving is elicited. Cocaine-
and opiate-dependent individuals, for example, experience marked physiological arousal and report
strong craving when they see their drug works and other drug paraphernalia or when they experience
negative emotions such as depression—even after prolonged drug-free periods (Childress et al., 1994,
1988; Ehrman et al., 1992). Alcohol-dependent clients experience similar physiological reactivity to
alcohol-related cues such as being in a bar or watching others drink (Rohsenow et al., 1991). These cues
can become “triggers” or high-risk situations that can lead to substance use and relapse.
Operant learning refers to those behaviors that are increased in frequency by reinforcement. Behaviors
that result either in rewarding or positive outcomes or that allow the individual either to avoid or escape
from negative consequences are likely to increase in frequency. Substance abuse in the presence of
classically conditioned cues is instrumental in reducing or eliminating the arousal associated with a state
of craving, thus serving to reinforce the substance abuse behavior. That is, the behavior serves a basic
rewarding function for the individual. This represents the second form of learning, operant conditioning.
An alcohol-dependent person who drinks to feel more social and less anxious or a cocaine abuser who
gets high to overcome depression is using substances in an instrumental way. To the extent that they
experience the effects they seek, the greater the likelihood they will use substances under similar
circumstances in the future. Presumably, people continue to abuse substances even in the face of
negative consequences (e.g., legal, marital, or health problems) because these consequences are quite
removed in time from the point of use; also, the more immediate positively reinforcing effects of the
substance typically override consideration of such consequences.
52
Brief Cognitive–Behavioral Therapy
information about the basic assumptions of therapy. Decisions about the length of treatment
behavioral theories concerning substance abuse are made on the basis of these assessments,
disorders is contained in Figure 4-2.) rather than according to a formula or theoretical
According to behavioral theory, changes in assumption about how long therapy should take.
behavior come about through learning new Each individual is approached as a unique case,
behaviors. Because substance abuse behavior is albeit one to which broad principles can be
learned, it can be changed by teaching the client applied.
more adaptive, alternative behaviors aimed at
achieving the same rewards. Figure 4-3 provides Behavioral Therapy
an overview of some of the advantages of
Techniques Based on
behavioral theories of substance abuse and
dependence and their treatment. Classical Conditioning
By its very design, most behavioral therapy is Models
brief. The aim is not to remake personality, but
rather to help the client address specific,
Extinction and Cue Exposure
identifiable problems in such a way that the
Procedures
client is able to apply the basic techniques and
A principal of classical conditioning is that if a
skills learned in therapy to the real world,
behavior occurs repeatedly across time but is not
without the assistance of the therapist.
reinforced, the strength of both the cue for the
Behavioral therapy focuses more on identifying
behavior and the behavior itself will diminish and
and changing observable, measurable behaviors
the behavior will extinguish. This principal has
than other therapeutic approaches and hence
been the foundation of behavioral treatments
lends itself to brief work. Treatment is linked to
known as “cue exposure” (O’Brien et al., 1990;
altering the behavior, and success is the change,
Rohsenow et al., 1991; Rohsenow and Monti, 1995).
elimination, or enhancement of particular
Even after relatively long periods of abstinence
behaviors.
from substances, being placed in situations that
Regular assessment and measurement of
have physical–environmental, social, or emotional
progress are integral to effective behavioral
cues associated with past
Figure 4-2
Basic Assumptions of Behavioral Theories of
Substance Abuse and Its Treatment
Human behavior is largely learned, rather than determined by genetic factors.
The same learning processes that create problem behaviors can be used to change them.
Behavior is largely determined by contextual and environmental factors.
Covert behavior such as thoughts and feelings is subject to change through the application of learning
principals.
Actually engaging in new behavior in the contexts in which they are to be performed is a critical part
of behavior change.
Each client is unique and must be assessed as an individual in a particular context.
The cornerstone of adequate treatment is a thorough behavioral assessment.
53
Chapter 4
Figure 4-3
Advantages of Behavioral Theories in Treating
Substance Abuse Disorders
Flexible in meeting specific client needs
Readily accepted by clients due to high level of client involvement in treatment planning and goal
selection
Soundly grounded in established psychological theory
Derived from scientific knowledge and applied to treatment practice
Structured in its guidelines for assessing treatment progress
Empowering clients to make their own behavior change
Effective, according to strong empirical and scientific evidence
Source: Rotgers, 1996.
54
Brief Cognitive–Behavioral Therapy
posters, a bar with bottles of a large number and independent, free-standing treatments (O’Brien,
wide range of alcoholic beverages, and other et al., 1990; Smith and Frawley, 1993). In this
drinking-related cues. The room is meant to context, Smith and colleagues reported positive
highlight and make more salient the cues outcomes for dependent users of both alcohol
associated with drinking. The client is asked to and cocaine who received chemical aversion
identify her favorite type and brand of alcohol. procedures as part of their treatment in
After pouring a drink, she is asked to swirl the comparison to those who did not receive similar
alcohol around in the glass, to smell the alcohol, treatment (Frawley and Smith, 1990; Smith et al.,
to place the glass to her lips and taste, and then to 1997). Rimmele and colleagues also
begin to take a sip of the drink. At that point, as recommended covert sensitization as a highly
she is about to take a drink, the effects of the effective and portable treatment component
emetic drug “kick in” and the client becomes which, unlike chemical or electric aversion
nauseated and vomits. Over repeated sessions, therapies, can be used at any time and in any
which occur every other day for a 10-day period, setting as a self-control strategy (Rimmele et al.,
the alcohol-related sight, smell, and taste cues not 1995).
only do not elicit craving and positive feelings
about drinking, but rather they now elicit Behavioral Therapy
conditioned nausea.
Techniques Based on
Therapies based on counterconditioning
theory typically use chemically induced aversion Operant Learning Models
or electric shock as negative consequences to be
A number of substance abuse treatment
paired with the substance-related cues. Visual
strategies have derived from operant learning
imagery can also be used in a technique called
principles. While they are often incorporated
covert sensitization. In this procedure, the client is
into broad-spectrum cognitive–behavioral
asked to imagine as vividly as possible a
approaches, they have also been used as
sequence of events that begin by seeing his
independent forms of treatment. Common
favorite bar; this is typically accompanied by
elements of behavioral treatments based on
increased craving. As the person proceeds
theories of operant learning include contingency
further in imagining entering the bar, sitting
management, behavior contracting, community
down, ordering a drink, and so on, the initial
reinforcement, and behavioral self-control
sense of craving shifts to mild discomfort. As he
training. The following sections describe some
visualizes beginning to take a drink and tastes
of the elements used in brief behavioral therapies
the alcohol, he is then asked to imagine
based on the operant learning model.
becoming violently sick and vomiting (Rimmele
et al., 1995). Contingency Management and
While aversive conditioning procedures have Behavior Contracting
most often been used in the treatment of alcohol In contingency management approaches, an
dependence, they have also been applied to the active attempt is made to change those
treatment of marijuana and cocaine use (Frawley environmental contingencies that can influence
and Smith, 1990; Smith et al., 1988). It should be substance abuse behavior (Higgins et al., 1998).
noted that these aversive conditioning The goal is to decrease or stop substance use and
techniques, as well as cue exposure approaches, to increase behaviors that are incompatible with
are best viewed as components of a more use. In particular, those contingencies that are
comprehensive treatment program rather than as found through a functional analysis (see Figure
55
Chapter 4
4-4) to prompt as well as reinforce substance the criterion for marked reduction in drug use
abuse are weakened by associating evidence of and also were significantly more likely to
substance use (e.g., a drug-positive urine screen) achieve the criterion of having 4 consecutive
with some form of negative consequence or weeks of drug-free urine samples. None of the
punishment. Contingencies that prompt and clients in a control condition (no take-home
reinforce behaviors that are incompatible with privileges) met these criteria. Whereas only 2
substance abuse and that promote abstinence are percent of the control group evidenced a
strengthened by associating them with positive decrease in the frequency of drug-positive
reinforcers. urines, clients in the incentive program
One recent study evaluated the effects of a decreased use between 14 and 18 percent.
voucher program in the treatment of methadone- In addition to increasing drug abstinence,
maintained opiate addicts with a history of similar voucher systems have been effective in
cocaine use (Silverman et al., 1998). Clients who maintaining attendance of methadone clients at a
provided cocaine-free urine samples received job-skills training program (Silverman et al.,
vouchers that had monetary value. The value of 1996). However, in contrast to drug treatment,
the vouchers increased as the number of less evidence is available concerning the
consecutive cocaine-free urine samples effectiveness of such contingency management
increased. Clients in the contingent voucher approaches in the treatment of alcohol problems
condition, compared to those who received (Higgins et al., 1998).
vouchers on a noncontingent basis, reported Attempts to incorporate real-world
decreased craving for cocaine and significantly contingencies into treatment programs are
increased cocaine abstinence. A more general increasing (Higgins, 1999). Clearly, programs
positive treatment effect was also noted, with can build contingencies such as take-home
clients in the contingent voucher condition also medication privileges into the structure of their
demonstrating an increased abstinence from programs. Milby and colleagues provide an
opiates. example of a contingency management system
Chutuape and colleagues have also shown incorporated into treatment that is more relevant
that providing methadone take-home privileges to real-life situations of users (Milby et al., 1996).
contingent on drug-free urine samples among In this study, homeless substance abusers were
methadone clients with persistent multiple drug enrolled in an intensive day treatment program.
abuse resulted in marked reductions in drug use A subgroup of these clients was also involved in
(Chutuape et al., 1999). Nearly 25 percent of a contingent work therapy and housing
clients in the take-home incentive program met program. As long as the clients remained
Figure 4-4
Functional Analysis
A functional analysis probes the situations surrounding the client’s substance abuse. Specifically, it
examines the relationships among stimuli that trigger use and the consequences that follow. This type
of analysis provides important clues regarding the meaning of the behavior to the client, as well as
possible motivators and barriers to change. In behavioral therapy, this is the first step in providing the
client with tools to manage or avoid situations that trigger substance use. Functional analysis yields a
roadmap of a client’s interpersonal, intrapersonal, and environmental catalysts and reactions to
substance use, thereby identifying likely precursors to substance use. (For more information on this
topic, see the section below under the heading “Cognitive–Behavioral Therapy.”)
56
Brief Cognitive–Behavioral Therapy
substance free, they were able to remain in the program. Contracts targeting goals supportive
work program and remain in the therapeutic of recovery (e.g., improving vocational behavior,
housing; if they were found to be drinking or saving money, being prompt for counseling,
using drugs, they became ineligible for both the regularly taking medication) are generally more
job training/work program and housing. Clients likely to be achieved and lead to better outcomes
involved in the abstinence-contingent program than those more directly related to substance use
had fewer cocaine-positive urine samples, fewer (e.g., clean urine samples) (Anker and Crowley,
days of drinking, fewer days of homelessness, 1982; Iguchi et al., 1997; Magura et al., 1987,
and more days of employment during the 1988). For instance, research found that
followup period than those in the standard receiving vouchers contingent on completing
treatment. objective, individually tailored goals related to
Naturalistic contingencies may also be useful one’s overall treatment plan was more effective
in treatment. These contingencies include in reducing substance abuse than either a
threatened loss of job, spouse, or driver’s license voucher system specifically targeting drug-free
and were positively related to treatment urine samples or a standard treatment without
outcome among alcohol users (Krampen, 1989). either of these contingency contracts added
However, the prognosis was less favorable in (Iguchi et al., 1997). The effectiveness of such
those patients who had already experienced a contracts also appears to be linked to the severity
loss in one of those areas because the of the consequences that might result from a
contingency no longer existed for them. broken contract (Magura et al., 1987).
Higgins and colleagues noted that written Behavioral contracting and contingency
contracts may be used to help implement a management are often found as elements in a
contingency management program (Higgins et number of more comprehensive approaches such
al., 1998). The contract should specify clearly, as community reinforcement and behavioral self-
using the client’s own words, the target behavior control training.
to be changed, the contingencies surrounding
either changing behavior or not, and the
Community Reinforcement
timeframe in which the desired behavior change Approach
is to occur. The act of composing and signing a The community reinforcement approach (CRA)
contract is a small but potentially important was developed as a treatment for alcohol abuse
ritual signifying the client’s commitment to the disorders (Azrin, 1976; Hunt and Azrin, 1973).
proposed change. In the contract, the client may After a period during which it appears to have
include contingencies, especially rewards or been little used, it has received increased
positive incentives that will reinforce target interest as a behavioral approach to substance
behaviors (e.g., attending treatment sessions, abuse (Higgins et al., 1998; Meyers and Smith,
getting to 12-Step meetings, avoiding stimuli 1995; Smith and Meyers, 1995). CRA is a
associated with substance use). Goals should be broad-spectrum approach based on the
clearly defined, broken into small steps that principles of operant learning, the goal of
occur frequently, and revised as treatment which is to increase the likelihood of continued
progresses; contingencies should occur quickly abstinence from alcohol or drugs by
after success or failure. reorganizing the client’s environment. In
Most often, behavioral contracts and particular, CRA attempts to weaken the
contingency management procedures are influence of reinforcement received by
embedded in a more comprehensive treatment substance abuse and its related activities by
57
Chapter 4
increasing the availability and frequency of among those interventions having the greatest
reinforcement derived from alternative empirical support (Miller et al., 1995). CRA’s
activities, particularly those vocational, family, application to substances other than alcohol also
social, and recreational activities that are appears to have been successful (Higgins et al.,
incompatible with substance abuse (Higgins et 1998). This extension is exemplified by the
al., 1998). recent publication of a detailed CRA therapy
A goal of CRA is to make these alternative manual for the treatment of cocaine dependence
interpersonal and social sources of reinforcement by the National Institute on Drug Abuse
available when the person is sober or drug-free, (Budney and Higgins, 1998). This manual relies
but to make them unavailable if the person heavily on the early work of Higgins and
drinks or uses. The program consists of a colleagues in evaluating the effectiveness of
number of components, and it can be tailored to combining CRA with contingency management
the specific circumstances of a client. Vocational approaches (e.g., use of vouchers for drug-free
counseling and job clubs can improve clients’ urine samples) in the treatment of cocaine
basic skills as well as job-seeking skills (e.g., dependence (Higgins et al., 1991, 1993). In
résumé development, application completion, comparison to standard outpatient treatment,
job interview skills). Social and recreational clients in the CRA-plus-vouchers condition
counseling is provided to help clients learn about remained in treatment longer, had more
and sample a number of substance-free continuous weeks of drug-free urine samples,
recreational pursuits and social activities. In and had greater amounts of cocaine abstinence
some cases, social clubs have been established to even at a 12-month followup. A similar pattern
provide clients with a substance-free of findings has been obtained with methadone-
environment where they can gather and have maintained opiate addicts (Abbott et al., 1998).
fun. The CRA model has been modified into the
For those clients who are married or in a Community Reinforcement and Family Training
relationship, marital counseling and procedure (CRAFT) (Meyers et al., 1996). The
communication skills training are provided to client’s significant others and family members,
enhance the quality of the relationship and who are an integral part of this approach, receive
reduce the stress of substance-related training in behavior modification and enhancing
arguments. Couples are trained to give each motivation. CRAFT seeks to reduce or stop
other positive attention through compliments, substance abuse by working through nonusing
appreciation, affection, and offers to help. A family and friends. While CRA involves family
focus is placed on clarifying expectations that or significant others in treatment, CRAFT is more
each partner has about the behavior of the of a form of family therapy (rather than
other. For those with a problem with alcohol, individual therapy) and therefore is discussed in
medication (e.g., disulfiram [Antabuse]) Chapter 8 of this TIP.
monitored by the spouse may be used. The
client also receives training in problemsolving
Behavioral Self-Control Training
and in ways to refuse requests to drink or use In contrast to CRA, which incorporates a wide
drugs. array of individuals in the treatment process, the
CRA has been described as a promising but behavioral self-control training approach
underutilized treatment for alcohol abuse focuses on the substance abuser and his
(McCrady, 1991). A review of the alcohol attempts to reduce or stop substance abuse
treatment outcome literature identifies CRA either on his own or with the aid of a therapist
58
Brief Cognitive–Behavioral Therapy
(Hester, 1995; Hester and Miller, 1989). The goal Rather than involvement with a therapist, the
of this approach is either moderation and harm person may be guided instead by self-help
reduction or abstinence. As applied to alcohol manuals (Miller and Munoz, 1982; Sanchez-
problems, the approach consists of the eight Craig, 1995), intervention via correspondence
sequential steps listed below (Hester, 1995): (Sitharthan et al., 1996), or even a computer
program (Hester and Delaney, 1997).
1. The client establishes an upper limit on the
McCrady also included behavioral self-
number of drinks per day and the peak
control training as another promising but
blood alcohol level on any one drinking
underutilized treatment approach (McCrady,
occasion.
1991). Hester indicated that there is good
2. The client begins to self-monitor both the
empirical support for behavioral self-control
number of drinks taken and the drinking
training in achieving the goal of moderate,
setting (e.g., when, where, with whom, how
nonproblematic drinking (Hester, 1995). In
he is feeling). This provides the basis of a
randomized clinical trials, problem drinkers
functional analysis.
assigned to behavioral self-control with a goal of
3. The client begins to modify the rate at which
either moderation or abstinence typically have
alcohol is consumed. This might be done by
comparable long-term outcomes. Although
switching from the individual’s standard
behavioral self-control approaches have been
alcoholic beverage to one containing less
used primarily with alcohol problems, they have
alcohol, by sipping a drink over a longer
also been used with other substances such as
period of time, or by spacing the number of
opiates (van Bilsen and Whitehead, 1994).
drinks consumed across time.
4. The client must develop and practice being Application of Behavioral
able to refuse drinks assertively when Techniques
offered them.
Behavioral therapies are often delivered using a
5. The client establishes a reinforcement system
specific manual, but they are also adaptable to
to reward the achievement of these drinking-
the individual client. A number of the
related goals.
behavioral techniques described here are also
6. Through the process of self-monitoring, the
used by therapists using cognitive–behavioral
client is able to determine those social,
therapy. The following sections describe how
emotional, and environmental antecedents
brief behavioral therapy might be applied at
that prompt overdrinking.
different stages of treatment. Some of the
7. The client learns new coping skills to use
techniques developed for brief behavioral
rather than relying on drinking as a means of
therapy are also presented.
coping.
8. The client attempts to learn ways to avoid Initial session
relapsing back to heavy drinking. The initial session in brief behavioral therapy
involves an exploration of the reasons the client
Although a therapist may guide the
is seeking treatment at this particular time; the
individual in a behavioral self-control model, the
extent to which this motivation for treatment is
substance abuser maintains primary
intrinsic, rather than influenced by external
responsibility for changing his behavior. During
sources; the areas of concern that the client and
the course of therapy, the client and therapist
significant others may have about his substance
meet in brief sessions to go over homework and
abuse; the situations in which she drinks or uses
ensure that the client is following through.
59
Chapter 4
excessively; and the consequences she determine those problems to target, their
experiences (both positive and negative, as well relative priority, and ways to resolve them.
as proximal and removed from the actual Near the end of the initial session the
substance abuse). This involves an abbreviated therapist reviews with the client the procedure
functional analysis. (See the section with that for filling out the self-monitoring records. In
name later in this chapter.) addition, the therapist might provide the client
The information gained in the session will with self-help manuals that outline the specific
assist the counselor in determining the steps in the behavioral self-control process. Self-
antecedents that prompt substance abuse and monitoring of substance abuse behavior is one
the reinforcers that appear to maintain it. Based form of written homework common in
on the information obtained, the counselor can behavioral approaches; other types of homework
begin to formulate a treatment plan with respect might also be used. Homework assignments can
to the specific target behaviors to address, the include such things as keeping a journal of
behavioral interventions that address these behaviors, activities, and feelings when using
target behaviors most effectively, and behaviors substances or at risk of doing so. In the brief
incompatible with heavy drinking that should behavioral model designed by Phillips and
be reinforced and targeted for an increase in Weiner, techniques such as programmed therapy
frequency. and writing therapy (see Figure 4-6) make what
During the initial session, the therapist is typically thought of as “homework” the
should note the most salient problems identified central concern of the therapy session (Phillips
by the client and intervene with them first. The and Weiner, 1966).
therapist also should assess the client’s
Later sessions
readiness to change and then develop initial
Based on a review of the information collected
behavioral goals in collaboration with the client.
through self-monitoring, subsequent sessions
For substance abuse disorders, these goals will,
involve negotiation about treatment goals.
of course, involve a reduction in or cessation of
While many problem drinkers, for example,
substance use. In addition to targeting
choose a moderation goal, across time those with
substance abuse as the primary focus, other
more severe problems shift to a goal of
goals will be developed to assist the client in
abstinence (Hodgins et al., 1997). Later sessions
improving daily functioning (e.g., by reducing
might also consider the introduction of cue
stress, as described in Figure 4-5). The focus of
exposure training or relapse prevention targeted
the therapy might be to negotiate with the client
at substance abuse above a particular level.
to accomplish these other goals by reducing use.
These behavioral techniques have been
The therapist will continue to engage the client
incorporated into more comprehensive
in a collaborative process in which they
Figure 4-5
Teaching Stress Management
The client learns methods that will help her reduce stress, including relaxation techniques, systematic
desensitization, planning in advance for a potentially stressful event, and cognitive strategies. These
techniques can help in resisting the temptation to abuse substances in otherwise stressful situations.
While it does not seem that all clients with substance abuse disorders face increased stress (Cappell,
1987), for those who do, stress management techniques (such as those described by Stockwell, 1995) can
prove useful.
60
Brief Cognitive–Behavioral Therapy
Figure 4-6
Programmed Therapy and Writing Therapy
These techniques lend themselves to brief therapy because they reduce the role of the therapist and
increase the amount of work required from the client. Phillips and Weiner developed these techniques
as stand-alone approaches to treatment (Phillips and Weiner, 1966). However, they can also be used as
adjuncts to other forms of treatment and may be incorporated into the homework assignments that
many therapists already are using. In programmed therapy, the client interacts with written or
computerized instructions and tests that work to teach the client new behaviors, much in the way
students might learn a subject from a textbook. Writing therapy involves having the client come in at a
designated time each week to write for 1 hour in a notebook which the therapist then reads and
responds to in writing. No one but the therapist and the client should have access to the notebook.
Writing therapy is a technique that may be particularly useful for clients who have difficulty talking
about their thoughts and feelings.
behavioral self-control approaches, even those et al., 1988). The diagram in Figure 4-7 illustrates
with an abstinence goal (Larimer and Marlatt, the three bidirectional components of this theory:
1990; Sitharthan et al., 1997). The decision to (1) cognitions or thoughts, (2) affect or feelings,
implement such interventions will be guided by and (3) behavior. While cognitive theory owes a
the client’s continued self-monitoring, which the debt to the behavioral model, the differences are
client and counselor review at each session. apparent. Unlike behavioral models that focus
Brief behavioral therapy might also involve primarily on observable behaviors, cognitive
the client’s spouse or significant others, who may theory views antecedent events, cognitions, and
attend several of the therapy sessions. In behavior as interactive and dynamic, as
addition to serving as a corroborator of the indicated by the double-headed arrows
client’s self-reported substance use, a significant (depicted in Figure 4-7). Each of these
other may be involved in behavioral contracting components is capable of affecting the others,
and community reinforcement interventions. but the primary emphasis is placed on cognition.
The significant other could be taught to The way we act and feel is most often affected by
positively reinforce a client’s reduced drinking our beliefs, attitudes, perceptions, cognitive
or abstinence and not to argue with her drinking schema, and attributions. These cognitive factors
when she is intoxicated, but rather to approach serve as a template through which events are
her when she is sober and provide positive filtered and appraised. To the extent that our
feedback. The client and the significant other thinking processes are faulty and biased, our
may develop a contingency contract that will emotional and behavioral responses to what goes
encourage reinforcement of her positive on in our life will be problematic. According to
behaviors. this theory, changing the way a client thinks can
change the way he feels and behaves.
Cognitive Theory Cognitive theory was developed by A.T. Beck
as a way of understanding and treating
Cognitive theory assumes that most depression but has since been applied to
psychological problems derive from faulty numerous other mental health issues including
thinking processes (Beck and Wright, 1992; Beck substance abuse disorders. Beck believed that
et al., 1993; Beck and Liese, 1998; Ellis, 1982; Ellis
61
Chapter 4
Figure 4-7
The Relationship Among Factors Maintaining Behavior in Behavioral and
Cognitive Models
Antecedents are activating situations or life events (something happens or is about to happen—
situations about which the individual has strong feelings). Cognitions represent the individual’s
opinions, thoughts, or attitudes that serve to filter and distort the perception of the antecedents.
Behavior is the individual’s observable actions and emotional reactions that result from his beliefs and
emotions (how someone thinks or feels and the behavior resulting from those thoughts).
depressed clients held negative views of of individuals with emotional and behavioral
themselves, the world, and their future, and that problems, including substance abuse disorders.
these negative views were the real causes of An overview of the nature and content of
their depression. He found that their distorted thinking more specifically associated
psychological difficulties were due to automatic with substance abuse is provided in Figure 4-9
thoughts, dysfunctional assumptions, and (Ellis et al., 1988). These thoughts are
negative self-statements. Automatic thoughts presumably automatic, overlearned, rigid and
often precede emotions but occur quite rapidly inflexible, overgeneralized and illogical,
with little awareness; consequently, individuals dichotomous, and not based on fact. They also
do not value them highly. For example, tend to reflect reliance on substances as a means
depressed people address themselves in highly of coping with boredom and negative emotions,
critical tones, blaming themselves for everything a negative view of the self as a person with a
that happens. Figure 4-8 is a list of 15 common substance abuse problem, and a tendency to
cognitive errors found in the thinking processes facilitate continued substance use.
62
Brief Cognitive–Behavioral Therapy
Figure 4-8
Fifteen Common Cognitive Errors
1. Filtering—taking negative details and magnifying them, while filtering out all positive aspects of a
situation
2. Polarized thinking—thinking of things as black or white, good or bad, perfect or failures, with no
middle ground
3. Overgeneralization—jumping to a general conclusion based on a single incident or piece of evidence;
expecting something bad to happen over and over again if one bad thing occurs
4. Mind reading—thinking that you know, without any external proof, what people are feeling and why
they act the way they do; believing yourself able to discern how people are feeling about you
5. Catastrophizing—expecting disaster; hearing about a problem and then automatically considering the
possible negative consequences (e.g., “What if tragedy strikes?” “What if it happens to me?”)
6. Personalization—thinking that everything people do or say is some kind of reaction to you; comparing
yourself to others, trying to determine who’s smarter or better looking
7. Control fallacies—feeling externally controlled as helpless or a victim of fate or feeling internally
controlled, responsible for the pain and happiness of everyone around
8. Fallacy of fairness—feeling resentful because you think you know what is fair, even though other
people do not agree
9. Blaming—holding other people responsible for your pain or blaming yourself for every problem
10. Shoulds—having a list of ironclad rules about how you and other people “should” act; becoming
angry at people who break the rules and feeling guilty if you violate the rules
11. Emotional reasoning—believing that what you feel must be true, automatically (e.g., if you feel stupid
and boring, then you must be stupid and boring)
12. Fallacy of change—expecting that other people will change to suit you if you pressure them enough;
having to change people because your hopes for happiness seem to depend on them
13. Global labeling—generalizing one or two qualities into a negative global judgment
14. Being right—proving that your opinions and actions are correct on a continual basis; thinking that
being wrong is unthinkable; going to any lengths to prove that you are correct
15. Heaven’s reward fallacy—expecting all sacrifice and self-denial to pay off, as if there were someone
keeping score, and feeling disappointed and even bitter when the reward does not come
Source: Beck, 1976.
Such negative thoughts and irrational beliefs particularly feeling doomed about the past—
have been found to be associated with substance were predictive of both the frequency of
abuse disorders. Problem avoidance, dwelling drinking and the average quantity of alcohol
on negative events, holding a negative outlook consumed following substance abuse treatment
on the world and on one’s future, and avoidance (Rohsenow et al., 1989).
of responsibility have been associated with the
development of patterns of substance abuse and Cognitive Therapy
urges to drink among individuals with alcohol
problems (Butterfield and Leclair, 1988; Denoff, Given the view that dysfunctional behavior,
1988; Rohsenow et al., 1989). Rohsenow and including substance abuse, is determined in
associates found that irrational beliefs— large part by faulty cognitions, the role of
63
Chapter 4
Figure 4-9
Characteristic Thinking of People With Substance Abuse Disorders
Qualitative Descriptors
Automatic, nonconscious
Rigid, inflexible
Overlearned and often practiced
Dichotomous, all-or-none
Overgeneralized and illogical
Nonempirical and absolute
therapy is to modify the negative or self- Once a specific faulty thought is identified,
defeating automatic thought processes or the therapist will challenge a client to look at
perceptions that seem to perpetuate the alternative ways of seeing the same event.
symptoms of emotional disorders. Clients can Whenever a client has difficulty changing a
be taught to notice these thoughts and to change perception, the therapist can give him
them, but this is difficult at first. Cognitive homework to test the truth of his cognitions. If,
therapy techniques challenge the clients’ for example, a client insists that his boss hates
understanding of themselves and their situation. him, the therapist can ask him to verify this with
The therapist helps clients become more an assignment: “Ask your coworkers if your
objective about their thinking and distance boss treats them the same way he treats you.”
themselves from it when recognizing cognitive Figure 4-11 gives an example of how a thought
errors or faulty logic brought about by leads to a feeling and then to a behavior.
automatic thinking. Once the maladaptive thoughts are
Treatment, therefore, is directed primarily at discovered in a person’s habitual, automatic
changing distorted or maladaptive thoughts and thinking, it becomes possible to modify them by
related behavioral dysfunction. Cognitive substituting rational, realistic ideas for the
restructuring is the general term given to the distorted ones to create a happier and healthier
process of changing the client’s thought life without substance abuse.
patterns. Figure 4-10 shows a number of The approach developed by Beck and
distorted addictive thoughts and more rational colleagues to achieve the goal of a substance-free
alternatives that the therapist might help life is referred to as cognitive therapy (Beck et
develop and practice over the course of al., 1993; Beck and Liese, 1998), while Ellis’
cognitive restructuring. approach is known as rational-emotive therapy
64
Brief Cognitive–Behavioral Therapy
Figure 4-10
Common Irrational Beliefs About Alcohol and Drugs
With More Rational Alternatives
Irrational Belief Rational Alternative or Dispute
Drinking is never a problem for me, even if I Losing control can be the first sign of a problem, and if
do lose control once in a while. It’s other my drinking is a significant problem for others, sooner
people who have a problem with the way I or later it will be for me.
drink.
I need to use drugs to relax. I want to use drugs but don’t have to use them just
because I want to.
I can’t stand not having what I want; it is just I may not like it, but I have stood it in the past and can
too hard to tolerate. do so now.
The only time I feel comfortable is when I’m It’s hard to learn to be comfortable socially without
high. drugs but people do so all the time.
It would be too hard to stop drinking. I’d lose While stopping drinking and doing drugs might cost
all my friends, be bored, and never be me some things and take time and effort, if I don’t, the
comfortable without it. consequences will be far worse.
People who can’t or don’t drink are doomed to Where’s the evidence of that? I’ll try going to an
frustration and unhappiness. Alcoholics Anonymous meeting and do some research
on how frustrated and miserable these nondrinkers
actually are.
Once you’ve stopped using and you see it’s all A slip is only a new learning experience toward
over, you’re right back to where you started, recovery. It is not a failure, only a setback that can tell
and all your efforts only lead you to total me what direction I need to go in now. It’s my choice.
failure. Once an addict, always an addict.
Source: Adapted from Rotgers, 1996.
(Ellis et al., 1988). Generally, the therapist takes beliefs that all people are prone to. Beck, on the
a more active role in cognitive therapy than in other hand, believes that the cognitive therapist,
other types of therapy, depending on the stage using a supportive Socratic method, should
of treatment, severity of the substance abuse, enlist the client in carefully examining the
and degree of the client’s cognitive capability. accuracy of her beliefs. Thus, Beck places more
While Ellis and Beck have similar views importance on the client’s own discovery of
about the prominent role that cognitions play in faulty and unproductive thinking, while Ellis
the development and maintenance of substance believes that the client should simply be told
abuse disorders, their theories differ in that these exist and what they are. Nevertheless,
considering how the therapist should treat there is substantial overlap in both the theory
irrational or maladaptive cognitions. Rational- and practice of these two therapies. Clearly,
emotive therapy is often more challenging and different clients will have different responses to
confrontative, with the therapist informing the these qualitatively different approaches to
client of the irrationality of certain types of modifying their thoughts and beliefs.
65
Chapter 4
Figure 4-11
Thoughts, Feelings, and Behaviors
Thought Feeling Behavior
“There’s only one way to feel Desire to feel good Drink alcohol, snort cocaine
really good”
The maladaptive thought in this triad should be replaced in order to avoid the consequent behavior.
Therapeutic work in cognitive therapy is behaviors and attitudes that do not involve the
devoted primarily, although not exclusively, to use of substances. In addition, cognitive therapy
addressing specific problems or issues in the can help the client develop healthier ways of
client’s present life, rather than global themes or viewing both his history of substance abuse and
long-standing issues. At times, however, it is the meaning of a recent “slip” or relapse so that
important to understand the connection it does not inevitably lead to more substance
between the origins of a set of cognitions and abuse.
the client’s current behavior. Such an
understanding of how the individual got to the
Initial Session
present emotional and behavioral state is often Cognitive therapy works under the assumption
essential to understanding the mechanism of that a client can be educated to approach his
change. The client’s attention to current problems rationally. Because of this emphasis
problems is intended to promote her on rational understanding, the cognitive
development of a plan of action that can reverse therapist will typically begin therapy by
dysfunctional thought processes, emotions, and explaining the nature of her approach (see
behavior—such as avoidance of problems or Figure 4-12 for a sample opening script).
feelings of helplessness. Clients are enlisted as In the opening session of cognitive therapy,
coinvestigators or scientists who study their the therapist will assess the client’s view of his
own thought patterns and associated problems and their causes. The therapist pays
consequences. careful attention to the meaning the client
Cognitive therapy can be useful in the assigns to significant events and how that
treatment of substance abuse disorders in meaning is related to subsequent feelings and
several ways. When distorted or unproductive unwanted behavior. In the middle to late
ways of thinking about daily life events lead to phases of the first session, the therapist will
negative emotional states that then promote emphasize the collaborative aspect of the
substance use, cognitive therapy can be used to therapy process and introduces the cognitive
alter the sequence by targeting and modifying model to the client. There are three major steps
the client’s thoughts. When clients limit their in this process:
options for coping with stress by rigid or all-or- 1. The therapist establishes rapport by
nothing thinking (e.g., “nothing will help me listening carefully to the client, using
deal with this problem but a drink”), cognitive questions and reflective listening to try to
therapy can help them explore alternative understand how the client thinks about his
66
Brief Cognitive–Behavioral Therapy
Figure 4-12
Introducing Cognitive Therapy: A Sample Script
“I want to spend a few minutes telling you about my approach. Basically, it comes from the
observation by many people that our feelings and behaviors in particular situations follow directly from
how we think about these situations. My goal in working with you is to focus on trying to understand
how you see things—the important things in your life that are related to substance use—and to help you
look at them objectively and honestly. We may find that you are seeing them correctly, and we’ll have
to address these realities. Sometimes, though, people get into automatic ways of thinking about
themselves and their situation without examining them more carefully. Let’s look at these possibilities
and see if they can be changed to help you. How does that sound to you?”
life circumstances and how those thoughts 5. Socratic questioning—to encourage the client
relate to problematic feelings and behavior. to contemplate, evaluate, and synthesize
The client educates the therapist about diverse sources of information; also known
himself and his problems. as “guided discovery”
2. The therapist educates the client about the 6. Capsule summaries—to maintain focus and a
cognitive model of therapy and determines connection to the goals of the therapy
if he is satisfied with the model. 7. Homework assignments—to serve as a bridge
3. The therapist asks the client to describe a between sessions and to ensure that the
recent event that has triggered some recent client continues to work on problems by
negative feelings, as a way of illustrating the collecting information, testing beliefs, and
cognitive therapy process. trying new behaviors
8. Feedback in the therapy sessions—to ensure
Later Sessions that the client and therapist are
Cognitive therapy tends to follow a standard communicating
within-session structure to make the maximum
use of time, to focus on the most important Duration of Therapy and
current problems, to set the tone for a working Frequency of Sessions
atmosphere, and to maintain continuity between Cognitive therapy adheres to the basic goals of
sessions. Beck structures sessions into eight planned brief therapy, but treatment times can
elements, listed below, which he describes in vary. It typically lasts from 12 to 20 weeks, with
greater detail (Beck et al., 1993): the client and therapist meeting once per week.
(Freeman et al., 1990). However, it can be
1. Setting the agenda—to focus on primary goals
conducted in less time—for instance, once per
for treatment
week for six to eight sessions. The number of
2. Mood check—to monitor the feelings of the
sessions will depend on the nature of the
client, especially changes
problem.
3. Bridge from last session—to maintain
Because cognitive therapy is usually planned
continuity between sessions
for comparatively short treatment times, there
4. Discussion of today’s agenda—to prioritize
has not been much research to study the relative
topics, avoid irrelevant tangents, determine
effectiveness of longer term cognitive therapy.
the best possible use of time, and solicit the
However, Lyons and Woods in their meta-
client’s topics for discussion
analysis of 70 different rational-emotive therapy
67
Chapter 4
studies found that increased effects correlated fall back into old, automatic ways of thinking
with longer treatment times (Lyons and Wood, that may require a return to therapy. The
1991). More research needs to be conducted therapist can productively build on what was
looking at the effect of treatment duration on the learned in previous sessions, help the client see
efficacy of these therapies. how she slipped into old patterns, and further
In a brief version of this therapy, there is less reinforce the process of catching oneself in the
time to understand and restructure all of the process of thinking negative automatic
cognitions that may be influencing substance thoughts. The therapist must be prepared to
abuse. The therapist must use the early sessions move from topic to topic while always adhering
to determine the most productive focus of the to the major theme—that how the client thinks
therapy, given the short timeframe. If the client determines how the client feels and acts,
used substances primarily to cope with negative including whether the client abuses substances.
mood states, then therapy may focus on Cognitive therapy can be quite successful as
understanding how the client’s interpretation of an option for brief therapy for several other
events led to the negative moods. Restructuring reasons (Carroll, 1996a):
these thought processes may help decrease
It is designed to be a short-term approach
reasons for substance abuse. Alternatively, if
suited to the resource capabilities of many
the client drinks largely to party and have a
delivery systems.
good time with friends, a focus on expected
It focuses on immediate problems and is
effects may lead to the client’s gaining greater
structured and goal oriented.
awareness of negative consequences and,
It is a flexible, individualized approach that
perhaps, a reduced association of the substance
can be adapted to a wide range of clients,
with positive experiences. If the client is
settings (both inpatient and outpatient), and
returning to therapy after a period of sobriety
formats, including groups.
that ended in relapse, a focus on the
circumstances leading to relapse and other
resulting consequences may shape the therapy.
Cognitive–Behavioral
A number of specific cognitive therapy Theory
techniques may be appropriate for use,
Early behavioral theories of substance abuse
depending on the phase of treatment and the
were nonmediational in nature (Donovan and
issues raised by the client. Cognitive
Marlatt, 1993). They focused almost exclusively
interventions can be introduced at any point
on overt, observable behaviors, and it was
throughout the treatment process, whenever the
believed that understanding the antecedents and
therapist feels it is important to examine a
reinforcement contingencies was sufficient to
client’s inaccurate or unproductive thinking that
explain behavior and to modify it. Over time,
may lead to the risk of substance abuse. They
however, these behavioral theories began to
also can be used episodically with clients who
incorporate cognitive factors into their
leave and then return to treatment or during
conceptualizations of substance abuse disorders.
aftercare or continuing care following a more
These more recent models are mediational in
intensive treatment episode.
nature; that is, a greater role is attributed to the
Periods without therapy sessions allow
interaction among a variety of individual
clients time to practice the new skills of
difference variables such as beliefs, values,
identifying and challenging unproductive
perceptions, expectations, and attributional
thinking on their own. However, it is easy to
processes in mediating the development and
68
Brief Cognitive–Behavioral Therapy
continuation of substance abuse disorders 1978). The basic attributional dimensions are
(Abrams and Niaura, 1987; Mackay and internal/external, stable/unstable, and
Donovan, 1991; Marlatt et al., 1988; Marlatt and global/specific. For instance, clinically
Donovan, 1981). This expanded, mediational depressed persons tend to blame themselves for
model has been described as cognitive social adverse life events (internal), believe that the
learning or cognitive–behavioral theory. This causes of negative situations will last
theory postulates that cognitive factors mediate indefinitely (stable), and overgeneralize the
all interactions between the individual, causes of discrete occurrences (global).
situational demands, and the person’s attempts Healthier individuals, on the other hand, view
to cope effectively. negative events as due to external forces (fate,
Cognitive–behavioral theory represents the luck, environment), as having isolated meaning
integration of principles derived from both (limited only to specific events), and as being
behavioral and cognitive theories, and it transient or changeable (lasting only a short
provides the basis for a more inclusive and time). Figure 4-14 lists and further defines the
comprehensive approach to treating substance three dimensions of attribution that make up an
abuse disorders. However, a broader range of “attributional style.”
cognitions is included in cognitive–behavioral Attributional styles play a major role in the
theory than had been involved in earlier cognitive–behavioral theory of substance abuse
versions of cognitive theory. These include disorders (Davies, 1992; Marlatt and Gordon,
attributions, appraisals, self-efficacy 1985). The nature of substance abusers’
expectancies, and substance-related effect attributional styles is thought to have
expectancies. Each of these will be reviewed considerable bearing on their perception of their
briefly below. Common elements of brief substance abuse problem and their approach to
cognitive–behavioral therapy are listed in recovery. An alcohol-dependent client, for
Figure 4-13. instance, may believe that he drank because he
was weak (an internal attribution) or because he
Attributions was surrounded by people encouraging him to
An attribution is an individual’s explanation of have a beer (an external attribution). He may
why an event occurred. Abramson and believe that his failure to maintain abstinence
colleagues proposed that individuals develop shows that he is a weak person who can never
attributional styles (i.e., individual ways of succeed at anything (a global attribution) or that
explaining events in their lives that can play a a drinking episode does not represent a general
role in the development of emotional problems weakness, but was instead due to the specific
and dysfunctional behaviors) (Abramson et al., circumstances of the moment (a specific
Figure 4-13
Common Elements of Brief Cognitive–Behavioral Therapies
The therapist focuses on current problems.
She establishes attainable and contracted goals.
She seeks to obtain quick results for the most pressing problems.
She relies on a variety of empirically based techniques to increase the client’s ability to handle his own
problems.
Source: Adapted from Bloom, 1997; Peake et al., 1988.
69
Chapter 4
Figure 4-14
Attributional Styles
Internal/External: Do you attribute events and their causes to yourself or to others?
Stable/Unstable: Will this cause continue to affect your future or can it change or stop?
Global/Specific: Does the cause of one bad circumstance affect all areas of your life or just one?
attribution). He may believe that the cause of dependent on alcohol, marijuana, opiates, and
his slip is something he cannot change (a stable other illicit drugs, provides empirical support
attribution) or that the next time, he will catch for the attributional style hypothesized to
himself and exert better coping responses (an mediate the AVE (Birke et al., 1990; Bradley et
unstable attribution). Whereas the internal, al., 1992; Reich and Gutierres, 1987; Stephens et
global, and stable attribution for the use of al., 1994; Walton et al., 1994).
alcohol is likely to lead to feelings of
hopelessness and a return to drinking, the
Cognitive Appraisal
external, specific, unstable attribution is likely to For the cognitive–behavioral therapist, an
lead to greater efforts to cope with similar individual’s appraisal of stressful situations and
situations in the future. his ability to cope with the demands of these
Marlatt and Gordon described a negative situations are important influences on the
attributional process that can occur after a slip initiation and maintenance of substance abuse,
(the first use of a substance after a period of as well as relapse after cessation of use
abstinence) and that may lead to continued use (Hawkins, 1992; Marlatt and Gordon, 1985;
in a full-blown relapse (Marlatt and Gordon, Shiffman, 1987, 1989; Wills and Hirky, 1996).
1985). This process, known as the abstinence Folkman and Lazarus described two
violation effect (AVE), involves the attribution of different levels of cognitive appraisal (Folkman
the cause of an initial slip to internal, stable, and and Lazarus, 1988, 1991). The first level is a
global factors. These clients may believe that primary appraisal. This represents the
they are hopeless addicts and failures, that they individual’s perception of a situation and an
will never be able to achieve and maintain estimation of the potential level of stress,
sobriety, and that there is no use in trying to personal challenge, or threat involved with the
change because they think that they cannot situation. Secondary appraisal represents the
succeed. individual’s evaluation of her ability to meet the
AVE also has an emotional component challenges and demands specific to the
associated with it. Substance abusers who have situation. This secondary appraisal, which will
slipped and have internal, stable, and be influenced by the extent, nature, and
generalized attributions will feel depressed, availability of the individual’s coping skills,
worthless, helpless, and hopeless. This further mediates the individual’s perception of
attributional style tends to be associated with a stress and the person’s emotional response.
form of “learned helplessness” that is To the extent that the individual senses that
perpetuated by the substance users’ distorted she has the necessary behavioral, cognitive, or
perceptions. Together, the sense of helplessness emotional coping skills to meet the challenges of
and the negative emotional state increase the the situation, it will be appraised as less
likelihood that the initial lapse will develop into threatening or stressful. Conversely, if the
a full-blown relapse. Research with individuals person judges that the necessary coping skills
70
Brief Cognitive–Behavioral Therapy
are lacking, the situation is viewed as more (1) basic avoidance of situations that have been
threatening and stressful, and the person is previously associated with substance abuse and
likely to be frightened, anxious, depressed, or (2) seeking social support when confronted with
helpless. The results of Smith and colleagues the temptation to drink or use drugs.
suggest that such cognitive appraisals may play The cognitive domain also includes two
a more prominent role than attributions in general categories of coping: (1) negative
mediating emotional responses to potentially thinking, or thinking about all the negative
threatening situations (Smith et al., 1993). consequences that have resulted from substance
abuse and a desire to no longer experience these,
Coping behaviors
and (2) positive thinking, or thinking about all
In substance use-related situations, coping
the benefits that are accrued by being clean and
“refers to what an individual does or thinks in a
sober and not wanting to lose these. Litman
relapse crisis situation so as to handle the risk
suggests that these coping strategies operate in a
for renewed substance use” (Moser and Annis,
somewhat sequential manner (Litman, 1986).
1996, p. 1101). Cognitive–behavioral theory
Initially, when clients are attempting to initiate
posits that substance users are deficient in their
and stabilize abstinence from substances, they
ability to cope with interpersonal, social,
appear to rely more heavily on the behavioral
emotional, and personal problems. In the
strategies. As the period of abstinence increases,
absence of these skills, such problems are
there appears to be a transition from
viewed as threatening, stressful, and potentially
predominantly behavioral strategies toward a
unsolvable. Based on the individual’s
greater reliance on cognitive methods of coping.
observation of both family members’ and peers’
Coping strategies have a number of other
responses to similar situations and from their
dimensions. They can be emotion focused,
own initial experimental use of alcohol or drugs,
problem focused, or avoidant. A distinction is
the individual uses substances as a means of
also made between those that are general coping
trying to deal with these problems and the
strategies and those that are expressly
emotional reactions they create. From this
attempting to cope with urges, craving, and
perspective, substance abuse is viewed as a
temptation to use in settings associated with
learned behavior having functional utility for
past substance abuse. Another important
the individual—the individual uses substances
dimension of coping strategies is the stage at
in response to problematic situations as an
which they are used in response to a potentially
attempt to cope in the absence of more
difficult substance-related situation (Shiffman,
appropriate behavioral, cognitive, and
1989). Anticipatory coping is employed as one
emotional coping skills.
anticipates and attempts to plan how to deal
A number of dimensions are involved in the
with upcoming situations. They take the form
coping process as it relates to substance abuse
of “What can I do if.…” There are also coping
(Donovan, 1996; Hawkins, 1992; Lazarus, 1993;
strategies that are employed in the moment that
Shiffman, 1987; Wills and Hirky, 1996). The first
one is having to deal with the difficult
is the general domain in which the coping
substance-related situations. They take the form
response occurs. Coping responses can occur
of “What can I do now.…” Finally, there are
within the affective, behavioral, and cognitive
restorative coping strategies that can be
domains. Litman identified a number of
employed if one fails to cope and finds himself
behavioral and cognitive strategies that are
using in the situation. These take the form of
protective against relapse (Litman, 1986). There
“What can I do now that I’ve…” It is these
are two behavioral classes of coping behavior:
71
Chapter 4
restorative coping strategies that play a role in considerable degree of situational specificity in
determining whether an initial drink or use of the coping process. That is, different types of
drugs will escalate into a full-blown relapse. substance-related situations seem to require
Research on coping behavior as it relates to different types of coping responses rather than a
substance abuse disorders has generally general coping strategy’s being equally effective
supported the basic tenet of cognitive– across situations. Second, strategies used to
behavioral approaches, namely that these clients cope with nonspecific stress appear to be
are deficient in their coping skills, that these somewhat different from those used to cope
deficiencies contribute to their continued with temptation. These findings suggest that
substance abuse, and that those whose deficits treatment not only should rectify deficiencies in
are not remedied are at a greater risk of relapse coping abilities, but that it may be necessary to
than those who increase their coping through focus on skills to deal with both general stress
treatment (Wills and Hirky, 1996). Another and substance-related temptation. Furthermore,
study found that the number of coping attempts it may be necessary to develop coping skills
and the type of coping will influence both specific to several possible situations in which
relapse and the return to abstinence (Moser and the client may use substances.
Annis, 1996). Attempting to cope with a relapse
crisis led to higher rates of abstinence than not
Self-Efficacy Expectancies
trying to cope, and the greater the number of The apparent lack of coping skills among
coping strategies employed, the less likely the substance users is an important contributor to
person was to use. If one coping response was another key construct in cognitive–behavioral
performed, the probability of abstinence was 40 approaches, namely self-efficacy expectancies
percent; the probability rose to 80 percent if two (Bandura, 1977). These expectancies refer to an
coping attempts were made. Similarly, the individual’s beliefs about his ability to
greater the number of coping strategies used by successfully execute an appropriate response in
an individual following a relapse, the greater the order to cope with a given situation. Self-
likelihood of returning to abstinence. Exclusive efficacy expectancies are determined in part by
use of active coping strategies (e.g., engaging in the individual’s repertoire of coping skills and
alternative activities that are incompatible with an appraisal of their relative effectiveness in
drinking, problemsolving, seeking support from relation to the specific demands of the situation.
others, thinking of consequences of using, using Bandura has hypothesized that expectations of
positive/negative self-talk) was associated with personal efficacy determine whether coping
maintaining abstinence in contrast to exclusive behavior will be initiated or not, the amount of
reliance on avoidant strategies (e.g., ignoring the effort that will be expended in attempting to
situation, dealing with it indirectly by eating, or cope, and how long a coping attempt will
relying on willpower). continue in the face of obstacles and aversive
Neidigh and colleagues investigated the experiences (Bandura, 1977). He also suggested
strategies employed to cope with stress and the that self-efficacy exerts an influence on the
temptation to drink among individuals individual’s behavior through cognitive,
attempting to control their drinking (Neidigh et motivational, and emotional systems (Bandura,
al., 1988). They found that both cognitive and 1994). If a person has low self-efficacy due to a
behavioral coping strategies were effective in lack of necessary coping skills, she might be
resisting a drink. Two other important findings expected to have negative or distorted thoughts
were obtained. First, there appears to be a and beliefs about herself and her situation, have
72
Brief Cognitive–Behavioral Therapy
reduced motivation to even try to cope, and may represent the individual’s expectation that
be depressed and perceive herself as helpless. certain effects will predictably result from
Cognitive–behavioral approaches to substance use. Although there has been more
substance abuse disorders postulate that low research on alcohol-related effect expectancies
levels of self-efficacy are related to substance use (Goldman, 1994), there has been an increased
and an increased likelihood of relapse after interest in drug-related expectancies (Brown,
having achieved abstinence (Annis and Davis, 1993). Given that drugs have differing effects, it
1988b, 1989b; DiClemente and Fairhurst, 1995; has been necessary to develop measures specific
Marlatt and Gordon, 1985). A model of relapse to the effects anticipated from these different
that is based on the role of self-efficacy and drugs, such as marijuana (Schafer and Brown,
coping is depicted in Figure 4-15. 1991) and cocaine (Jaffe and Kilbey, 1994;
Self-efficacy has been thought of as both the Schafer and Brown, 1991).
degree of a client’s temptation to use in The initial focus in studying alcohol-related
substance-related settings and his degree of expectancies was on the positive effects that
confidence in his ability to refrain from using in individuals anticipated from alcohol (Goldman
those settings (Annis and Davis, 1988b; and Brown, 1987). Drinkers anticipated that
DiClemente et al., 1994; Sklar et al., 1997). The alcohol would serve as a global elixir, having
role of self-efficacy has been examined for positive effects on mood, social and
alcohol (Evans and Dunn, 1995; Solomon and interpersonal behavior, sexual behavior,
Annis, 1990), cocaine (Coon et al., 1998; Rounds- assertiveness, and tension reduction. Positive
Bryant et al., 1997), marijuana (Stephens et al., effect expectancies for marijuana include
1993), opiates (Reilly et al., 1995), and across all relaxation and tension reduction, social and
of these substances of abuse (Sklar et al., 1997). sexual facilitation, and perceptual and cognitive
This research generally supports the hypothesis enhancement (Schafer and Brown, 1991).
that those with lower levels of self-efficacy are Positive cocaine-related expectancies include
more likely to abuse substances. global positive effects, generalized arousal,
euphoria, enhanced abilities, and relaxation and
Substance-Related Effect tension reduction (Jaffe and Kilbey, 1994;
Expectancies Schafer and Brown, 1991).
As substance use is reinforced by the positive More recently, there has been an increased
effects of the substance being taken, it is also interest in the expectations of negative outcomes
likely that the individual will develop a set of that individuals hold about substances.
cognitive expectancies about these anticipated Negative expectancies about alcohol include
effects on her feelings and behavior. They cognitive and behavioral impairment, risk and
Figure 4-15
Relapse Prevention Model Based on Self-Efficacy Theory
73
Chapter 4
aggression, and negative self-perception conditioned cues that can elicit a strong craving
(Fromme et al., 1993). Negative consequences or desire to use. To the extent that substance
expected from cocaine include global negative abuse allows the individual to avoid or escape
effects, anxiety, depression, and paranoia (Jaffe such problem situations or their resultant
and Kilbey, 1994; Schafer and Brown, 1991). It is emotional reactions, the use of substances will
thought that the anticipated positive effects of be reinforced through operant learning. Thus
substances serve as an incentive or motivation to the likelihood is increased that substances will
use. Conversely, negative expectancies are be abused and will come to be relied on in the
thought to act as a disincentive and contribute to future when the individual encounters similar
reduced drinking or drug use (McMahon and situations.
Jones, 1993; Michalec et al., 1996). Marlatt and colleagues have characterized a
Research supports these hypothesized number of situations in which substances are
actions of positive and negative expectancies abused (Chaney et al., 1982; Cummings and
(Jaffe and Kilbey, 1994; Jones and McMahon, Gordon, 1980; Marlatt and Gordon, 1980, 1985).
1994b; Rounds-Bryant et al., 1997). Positive While the original taxonomy of these situations
alcohol- and cocaine-related expectancies are focused on settings in which relapse occurred
associated with a greater likelihood of relapse following a period of abstinence from a
and poorer substance-related outcomes (Brown substance, the settings appear to represent
et al., 1998; Rounds-Bryant et al., 1997), whereas situations in which substance use in general will
negative alcohol effect expectancies are related be more likely to occur (Annis and Davis, 1988a;
to decreased likelihood of relapse and less Marlatt, 1996). The situations as originally
alcohol consumption (Jones and McMahon, categorized are found in Figure 4-16.
1994a; McMahon and Jones, 1996). These situations have been classified into
Research also indicates that alcohol-related categories. At the broadest level, they are
effect expectancies were negatively correlated considered either interpersonal (i.e., involving a
with clients’ ratings of self-efficacy at the present or recent interaction with someone else)
beginning of treatment (Brown et al., 1998); that or intrapersonal–environmental (i.e., factors that
is, the lower the perceived self-efficacy, the are either internal to the individual or reactions
greater the level of anticipated positive effects of to nonpersonal environmental events). There
alcohol. Both these sets of expectancies changed are a number of more specific situations within
over the 4-week course of treatment, with self- each of these broader categories. These
efficacy increasing and alcohol effect situations include many emotional,
expectancies decreasing. Lower self-efficacy interpersonal, and environmental settings in
judgments, positive alcohol expectancies, and which people commonly abuse substances and
reliance on avoidant, emotion-focused coping where they are likely to relapse. Therefore,
strategies were significantly associated with these are called “high-risk” situations. These
increased alcohol consumption and alcohol- situations also serve as the foundation from
related problems among heavy drinking college which a number of measures of substance-
students (Evans and Dunn, 1995). related self-efficacy have been developed (Annis
and Davis, 1988b; DiClemente et al., 1994; Sklar
High-Risk Situations et al., 1997).
Over time, with repeated exposure, aspects of a While there appears to be considerable
situational context (e.g., the people, places, overlap in high-risk situations across substances
feelings, activities) can come to serve as (Cummings and Gordon, 1980), there are also a
74
Brief Cognitive–Behavioral Therapy
Figure 4-16
Taxonomy of High-Risk Situations Based on
Marlatt’s Original Categorization System
Intrapersonal–Environmental Determinants
Coping with negative emotional states
i Coping with frustration and anger
i Coping with other negative emotional states (e.g., fear, anxiety, tension, depression, loneliness,
sadness, boredom, grief, loss, guilt)
Coping with negative physical/physiological states
i Coping with physical states associated with prior substance use (e.g., withdrawal distress)
i Coping with other negative physical states (e.g., pain, illness, injury, fatigue)
Enhancement of positive emotional states (e.g., using substances to enhance pleasure, for celebration)
Testing personal control (e.g., using to test “willpower” to see if treatment worked, to see if one can
drink or use in a moderate way)
Giving in to temptations or urges
i In the presence of substance-related cues
i In the absence of substance-related cues
Interpersonal Determinants
Coping with interpersonal conflict
i Coping with frustration and anger
i Coping with other interpersonal conflict
Social pressure to drink or use
i Direct social pressure
i Indirect social pressure
Enhancement of positive emotional states
75
Chapter 4
Figure 4-17
A Cognitive–Behavioral Model of the Relapse Process
Client
Experiences a sense of
mastery and an ability to
These perceptions and expectancies
cope with the situation lead to initial use of alcohol
These perceptions
decrease the likelihood of These feelings increase the probability
relapse of relapse
76
Brief Cognitive–Behavioral Therapy
skills, choose not to use those they have, or are abstinence or moderation and for those who
inhibited from doing so (Monti et al., 1994, have maintained such goals longer. These
1995). It also assumes that over the course of negative emotions represent yet another high-
time, substance abusers develop a particular set risk situation. If the individual does not have
of effect expectancies based on their the necessary restorative coping skills to deal
observations of peers and significant others with them and to counteract the impact of a
abusing substances to try to cope with difficult negative attributional style, it is more likely that
situations and through their own experiences of an initial slip will continue on as a full-blown
the positive effects of substances. They have relapse (Stephens et al., 1994).
come to believe that substances have positive
benefits that are more immediate and prominent Cognitive–Behavioral
than their negative consequences. They also
come to rely on substances as a means of trying
Therapy
to cope with these situations. Cognitive–behavioral therapy (CBT) derives, in
To the extent that the individual is lacking in part, from both behavioral and cognitive
the coping skills necessary to deal with the theories. While sharing a number of procedures
demands of high-risk substance abuse or relapse in common, CBT is also distinct in many ways
situations, his sense of self-efficacy decreases. from these other therapies (Carroll, 1998). In
As personal efficacy decreases, the anticipated comparison to cognitive therapy, CBT places
positive effects of substance abuse increase and less emphasis on identifying, understanding,
become more salient (Brown et al., 1998). Under and changing underlying beliefs about the self
such conditions, the individual is likely to use and the self in relationship to substance abuse.
(Moser and Annis, 1996). When confronted by It focuses instead on learning and practicing a
similar situations in the future, the likelihood of variety of coping skills, only some of which are
using continues to be quite high, unless new cognitive. A greater emphasis is also placed on
coping skills have been learned. Given the using behavioral coping strategies, especially
interaction of self-efficacy, substance-related early in therapy. CBT tries to change what the
effects expectancies, and high-risk situations, client both does and thinks.
“the decision to drink or exercise restraint (self- In comparison to behavioral treatments such
control) is ultimately determined by self-efficacy as the community reinforcement approach, CBT
and outcome expectations formulated around a focuses more on cognitions, beliefs, and
current situational context” (Abrams and expectancies. Also, CBT generally does not
Niaura, 1987, p. 152). incorporate contingency management
Attributional processes and emotional approaches such as the use of vouchers to
responses also play a role in an individual’s reinforce desired behaviors. CBT is usually
decision to use (Marlatt and Gordon, 1985). confined to the treatment session (although
Should the client attribute her substance abuse therapists often give homework to clients to be
to internal, stable, and global characteristics completed outside the therapy session), whereas
(e.g., “I’m nothing but an addict; there’s nothing the community reinforcement approach stresses
that I can do to stop using”), then it is likely that the importance of incorporating interventions
she will feel angry, depressed, hopeless, and into real world settings and taking advantage of
helpless. These reactions are less likely to occur community resources. Figure 4-18 lists a
and to be less pronounced for individuals who number of features thought to be unique to
are more firmly committed to the goal of cognitive–behavioral interventions.
77
Chapter 4
Figure 4-18
Essential and Unique Elements of Cognitive–Behavioral Interventions
The key ingredients that distinguish CBT from other some other therapies and that must be included in a
CBT treatment include the following:
CBT uses learning processes to help and effectiveness of the individual’s coping
individuals reduce their drug use. It works by skills. While a major emphasis in cognitive–
helping clients recognize the situations in which behavioral therapy is on identifying and
they are likely to use, find ways of avoiding remediating deficits in coping skills, it is also
those situations, and cope more effectively with important to assess the client’s strengths and
situations, feelings, and behaviors related to adaptive skills (DeNelsky and Boat, 1986).
their substance abuse (Carroll, 1998). To achieve The functional analysis will also assess
these therapeutic goals, cognitive–behavioral features in the client’s emotional states and
therapies incorporate three core elements: (1) thoughts and in her environment that are highly
functional analysis, (2) coping skills training, associated with substance abuse. This allows
and (3) relapse prevention (Rotgers, 1996). the identification of situations that are
particularly high risk for the individual. In
Functional Analysis addition, it is important to determine what the
Behavioral, cognitive, and cognitive–behavioral person thought, felt, and did both during and
treatments all rely heavily on an awareness of after high-risk situations. Gaining information
the antecedents and consequences of substance about high-risk situations in which the person
abuse. In all of these therapeutic approaches, drank or used drugs and those in which a
the client and therapist typically begin therapy relapse crisis was encountered but averted is
by conducting a thorough functional analysis of helpful in assessing coping abilities, self-efficacy
substance abuse behavior (Carroll, 1998; Monti perceptions, substance-related effect
et al., 1994; Rotgers, 1996). This analysis expectancies, and attributional processes.
attempts to identify the antecedents and Without such a thorough assessment, CBT
consequences of substance abuse behavior, treatment cannot proceed and is likely to fail
which serve as triggering and maintaining (Rotgers, 1996). This detailed analysis serves to
factors. Antecedents of use can come from inform the treatment process and individualize
emotional, social, cognitive, situational/ the specific interventions and treatment plan for
environmental, and physiological domains the client. The therapist and client can then use
(Miller and Mastria, 1977). The functional the results of the functional analysis to
analysis should also focus on the number, range,
78
Brief Cognitive–Behavioral Therapy
79
Chapter 4
Figure 4-19
Intrapersonal and Interpersonal Skills Training Elements
Managing thoughts about substance abuse Refusing offers to drink or use drugs
Problemsolving Starting conversations
Decisionmaking Using body language
Relaxation training and stress management Giving and receiving compliments
Becoming aware of anger Assertiveness training
Managing anger Refusing requests
Becoming aware of negative thinking Communicating emotions
Managing negative thinking Communicating in intimate relationships
Increasing pleasant activities Giving criticism
Planning for emergencies Receiving criticism
Coping with persistent problems Receiving criticism about substance abuse
Enhancing social support networks
drink in a social situation (which might include involved in the session, the therapist models the
some form of assertiveness training, as effective coping skill for the particular topic.
described in Figure 4-20). Learning how to The therapist then asks the client to participate
develop new social contacts with people who in a role-playing scenario in which he can
are not substance abusers is another example. rehearse the new coping behaviors. The
Skills training sessions follow a relatively therapist provides feedback and guidance while
standardized format. The client is given an the client continues in the behavioral rehearsal.
overview of the session, describing the area to Between sessions, therapists often give
be addressed and the rationale for the specific homework assignments that provide the client
intervention to be used. This is facilitated by with an opportunity to try behaviors learned in
skill guidelines that focus attention on the most sessions in real-life settings. The next session
important aspects of the approach as it applies usually begins with a review of this homework
to substance abuse. After discussing the issues and the client’s reactions to it.
Figure 4-20
Assertiveness Training
The client is encouraged to disclose and express emotions and needs, to stand up for his rights, to do
what is best for himself, and to express negative emotions constructively. This is useful for clients with
substance abuse disorders because being unable to express their emotions and needs may lead to relapse.
As a client becomes more assertive, he will be better able to control his impulsive behavior as well as the
environmental factors that may lead to relapse. Assertiveness training is usually combined with other
psychotherapy because it requires a change in attitude as well as in behavior.
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Brief Cognitive–Behavioral Therapy
Skills training approaches have been It is often necessary to help the client change the
evaluated more than many other approaches to passivity and sense of helplessness that often
substance abuse disorders. Monti and accompany low self-efficacy. Bandura noted
colleagues evaluated a coping skills training that there are a number of ways to increase self-
intervention for cocaine-dependent clients efficacy (Bandura, 1977). However, the model
(Monti et al., 1997). A cocaine-specific skills that appears to have the greatest impact and
training intervention, administered as lasting influence uses the idea of performance
individual counseling, was added to a more accomplishments to enhance client self-efficacy.
comprehensive treatment program along with a In this model, the client is coached to do
placebo control. The approach involved the something that she previously was unable to do.
identification of high-risk situations based on a Annis and Davis use graduated homework
functional analysis and the teaching of coping assignments to help in this process (Annis and
skills to deal with these situations. In Davis, 1988b). The client gradually exposes
comparison to the control condition, clients who herself to increasingly difficult situations with
received individualized coping skills training greater relapse risk but does so without using.
had significantly fewer days of cocaine use and The rate of the exposure is calculated to be at a
significantly shorter periods of binge use of level that can be handled by the client. The
cocaine over a 3-month followup period. accomplishment of these homework tasks serves
Although the two groups did not differ in their as a point of discussion to reinforce the client’s
rates of relapse, the pattern of use and the harm growing sense of self-efficacy.
associated with it clearly favored the skills The therapist practicing CBT will also
training condition. challenge the attributional process and
emotional aftermath of a relapse. If a slip
Relapse Prevention occurs, the therapist should try to bring the
The third core element of CBT is relapse more negative attributions for relapse (internal,
prevention. While there are a number of stable, and generalized) to the client’s attention
different models of relapse (Donovan and so that he can identify these tendencies and
Chaney, 1985), the two best articulated within learn how to change them. Clients can be
the cognitive–behavioral model are those helped to see the relapse as caused by a lack of
presented by Annis and Davis and Marlatt and appropriate coping skills for the particular
Gordon (Annis and Davis, 1988b; Marlatt and situation (i.e., external), alterable with training
Gordon, 1985). Relapse prevention approaches or practice (i.e., unstable), and not implying that
rely heavily on functional analyses, everything the person does is wrong (i.e.,
identification of high-risk relapse situations, and specific). This change in perspective will help
coping skills training, but also incorporate reduce the client’s sense of helplessness and loss
additional features. These approaches attempt of control. Addressing the attributional process
to deal directly with a number of the cognitions should be done in the broader context of
involved in the relapse process and focus on educating the client about the relapse process.
helping the individual gain a more positive self- Research has consistently shown that people
efficacy. who expect more positive effects from
Although self-efficacy is related to the substances are more likely to abuse them
availability of coping skills and would be (Brown, 1993; Goldman and Rather, 1993). It
expected to increase as the client learns new has also become clear more recently that
skills, this does not always occur spontaneously. individuals who are aware of and concerned
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Chapter 4
about the more negative consequences alcohol. Challenging social beliefs about the
associated with substance abuse are less likely to effects of a substance may alter its use.
use (Jones and McMahon, 1996). There are also Another way to use substance expectancy
significant differences in the way men and information in therapy is to have the client
women react to expectancies concerning consider both the positive and negative effects
substances; males are more affected by positive of the substance. Many clients have automatic
expectancies, whereas the positive expectancies scripts like “I’ll feel more relaxed if I drink”
of females are more balanced by negative without considering other scenarios, like: “I’ll
expectancies (Romach and Sellers, 1998). drink too much. I’ll have a fight with my
The therapist can work to challenge a client’s girlfriend, and then I’ll sleep in and not go to
positive expectancies about the effects of class.” The therapist helps the client
substances. There are two strategies that the acknowledge that the other consequences exist
therapist can use concerning expectancies in and are not being attended to. It is possible to
order to decrease substance abuse: change the use a decisional balance procedure in this
client’s belief in the positive effects of the process, wherein the client is asked to list all the
substance or get her to pay more attention to her positive and negative things associated with
knowledge and experience of its negative drug use. By acknowledging the substance’s
effects. positive effects, the therapist gains credibility
For a long time, researchers did not believe and reduces resistance from the client. The
that positive expectancies concerning substance client can more easily acknowledge the negative
effects could be changed, but a study on heavy- aspects of substance abuse and make those
drinking college students showed that beliefs more salient. This technique is a
expectations regarding alcohol effects could be mainstay of motivation enhancement therapies
altered (Darkes and Goldman, 1993). In group that are largely cognitive in nature (Miller and
sessions, several techniques were used to make Rollnick, 1991). (TIP 35, Enhancing Motivation for
the students aware that some of their alcohol- Change in Substance Abuse Treatment [CSAT,
related expectancies were false. For example, 1999c], gives more detailed information on these
the heavy-drinking college students were told approaches.)
that the beverages they were drinking contained Relapse prevention also stresses the
alcohol, but they were actually given importance of preparing for the possibility of a
nonalcoholic drinks, disguised to look, smell, relapse and planning ways to avoid it or, failing
and even taste like alcohol. They then engaged this, stop the process quickly and with minimal
in group party games, in which most displayed harm when it does occur. Clients are sometimes
the uninhibited behavior that is associated with apprehensive about talking so directly about the
alcohol intoxication. Later, when they were told possibility of relapse. The therapist can help
that their beverages were actually placebos, they dispel these concerns by using an analogy of fire
were surprised. Group discussion and other drills. Having a drill and being prepared for a
information on placebo effects altered their fire does not necessarily mean that a fire will
perceptions of the positive effects of alcohol. A occur. However, if one does, it will be possible
significant decrease in alcohol consumption was to get out of the situation without getting
noted in this group after the intervention, burned. It is helpful to have very concrete
compared to a control group that received emergency plans, including the phone numbers
conventional information on the effects of of individuals supportive of the client’s recovery
82
Brief Cognitive–Behavioral Therapy
process. Including family members in the When I look at my track record, I don’t
planning process is important because they are see much of a future.
often better able than the client to see the Therapist: I wouldn’t give up hope yet. We’ll work
warning signs of an impending relapse. together to help you get a better look at
Relapse prevention also stresses the your cocaine use, some of the things
development of a more balanced and healthier that trigger it, and some of the benefits
lifestyle. Marlatt and Gordon posit that one you think you get from it. Sometimes
source of possible relapse risk has to do with the by looking at your use from a different
degree of stress or daily hassles that the client perspective, you can help put it into
experiences (Marlatt and Gordon, 1985). They context and things don’t seem so
suggest that when the demands and obligations hopeless. Now why don’t you tell me
a client feels (“shoulds”) outweigh the pleasures about how you slipped and started
the individual can engage in (“wants”), then his using after your last time in treatment.
life is out of balance. This often results in What was going on in your life? What
feelings of deprivation and resentment. In were you feeling? What were you
response to these feelings, the individual could thinking about yourself and your life?
begin making decisions that gradually lead Client: Well, when I got out I still had some
toward possible relapse. The goal is to help the doubts about whether I would make it
individual find a better balance, increasing or not. I mean I felt better about myself,
involvement in pleasant and rewarding but there was still a lot of crap going on
activities while reducing the level and sources of in my life. I had bills to pay. My
stress. relationship was falling apart. I was
still being hassled by my probation
A Case Study Using CBT officer. I was feeling kind of
The following case study involves a young male overwhelmed. Here I thought I would
cocaine user who has sought outpatient walk out of there a new man, but I
treatment. It reflects interactions early in the walked out with all the same problems.
course of the session and is meant to depict Therapist: Was there any time after treatment
some of the questions the therapist could ask to when you felt you could handle all the
gain information about the antecedents, problems facing you?
consequences, and cognitive mediators involved Client: Well, for a while, then I started to feel
in his use. depressed. I mean you go through
Therapist: So, can you tell me about your cocaine treatment, and this stuff shouldn’t be
use and why you are coming to happening.
treatment now? Therapist: What did you try to do to deal with it
Client: Well, I finally came to the end of my all?
rope. I kept using even though I didn’t Client: At first I thought I would get myself
want to, and I felt that I was nothing organized and get a plan. But it didn’t
but a junkie who had no future. It’s work. As much as I tried, I couldn’t
just hopeless. figure out a way to put all this stuff in
Therapist: What makes you say that? its place and handle it. So I just threw
Client: Well, I just can’t stop using. Even up my hands and said, “Screw it!” I
when I’ve gone through treatment in felt like the best thing to do was to pull
the past, I end up using in no time.
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Chapter 4
the blankets over my head and hope that everything that had happened to me and
it would all blow over. was not sure what I was going to do.
Therapist: So, did it blow over? My friend pulled out some coke and
Client: No. Things just kept getting worse. I asked if I’d like some. I just kept
couldn’t pay my bills. My relationship thinking of how lousy I felt and how
was gone, and I got booted out of my good I would feel if I used. So I said
apartment. yeah, why not.
Therapist: As all this was happening, did you
In this case study, it is clear that the client has
think about using cocaine?
a low sense of self-efficacy predicated in part by
Client: You bet I did! I kept thinking, “Damn,
his past treatment failures and his inability to
it sure would feel good to get all this off
cope with difficult situations. As a result, he
my mind.” And I knew that if I used
feels depressed and helpless. He makes a half-
coke it would all go away—at least for a
hearted attempt at problemsolving but fails in
while.
this attempt. Then he switches to passive-
Therapist: So, as you thought about the cocaine,
avoidant approaches in order to cope (e.g.,
what positive things did you think you
pulling the blanket over his head and hoping it
would feel if you used?
will all blow away). His depression continues
Client: I knew I’d feel a rush, I’d feel damn
unabated as the daily hassles mount. The
good—and I’d just forget. I could get
positive expectancies he has about cocaine as the
out of the depression and funk I’d been
“magic elixir” are quite strong and seem to
in. I was just looking to feel better.
outweigh potential negative consequences. His
Therapist: Did you think of any negative things
situational context contains two high-risk
about using?
situations. The first is the negative mood states
Client: Yeah. I always seem to crash after
that he experiences, when he has abused
using. So I lose the high and find
substances in the past. The second is the
myself sometimes even more depressed
indirect social pressure involved in returning to
than before. But that didn’t seem to
a setting that had been associated with
bother me. I’m willing to put up with it
substance abuse in his past. There is also the
for a while. I’ll take the high any day.
proximal influence of the direct social pressure
It lets me get away from all this crap—
to use from his friend. The likelihood of relapse
at least for a while.
was high, and, in fact, relapse occurred.
Therapist: So what were the circumstances of your
The therapist in this case might consider
starting to use again?
using skills training that focuses on
Client: Well, like I said, I got booted from my
problemsolving, stress management to alleviate
apartment. And I couldn’t go stay with
his depression, developing communication
my girlfriend since she booted me too.
skills, practicing substance refusal skills, and
So I had to find a place to stay. I called
developing a social support network. The
an old friend who said I could stay at
therapist should target both this client’s low self-
his place for a while. We used to do a lot
efficacy and his positive cocaine-effect
of drugs together. I knew he might not
expectancies. Clearly the full intervention plan
be the best person to be staying with,
would require further assessment and a
but he was the only one I felt would put
functional analysis; however, a direction for
up with me. So, I moved in. I was
further treatment can already be seen in this
feeling pretty low, thinking about
brief interchange.
84
Brief Cognitive–Behavioral Therapy
Duration of Therapy and though these criteria were derived from cocaine
Frequency of Sessions users, they appear to be applicable to clients
Two advantages of CBT are that it is relatively using other substances.
brief in duration and quite flexible in While reliance on the results of the functional
implementation. CBT typically has been offered analysis makes skills training particularly well
in 12 to 16 sessions, usually over 12 weeks suited for individual therapy, these
(Carroll, 1998). The form of CBT used in interventions can easily be adapted for use in
NIAAA’s Project MATCH (Kadden et al., 1992) group settings (Monti et al., 1989). Similarly,
consisted of 12 sessions, administered as they can be used with inpatients or outpatients
individual therapy, meeting once per week. The and can be administered as part of an intensive
sessions included eight “core” sessions that phase of treatment or as part of less intensive
dealt with alcohol-related issues (e.g., coping aftercare or continuing care. CBT is also
with craving, drink refusal, relapse emergency compatible with a number of other elements in
planning) and general problem-solving skills treatment and recovery, ranging from
that all clients were expected to receive, and four involvement in self-help groups to
“elective” topic areas chosen from a menu of pharmacotherapy (Carroll, 1998).
more general social and interpersonal issues
Efficacy for Treating Substance
based on individually assessed problem areas.
Abuse Disorders
A 12-session CBT for cocaine addicts suggested
that this length of treatment is sufficient to In contrast to many other therapies, cognitive–
achieve and stabilize abstinence from cocaine behavioral therapy for the treatment of
(Carroll, 1998). However, not all clients will substance abuse disorders has substantial
respond in that amount of time. In such cases, research evidence in support of its effectiveness.
an initial trial CBT can serve as preparatory to a The research findings on the use of coping
more intensive treatment experience. skills training with alcohol- and cocaine-
dependent clients indicate that this strategy has
When To Use Cognitive– strong empirical support. A review of outcome
Behavioral Therapy studies evaluating the efficacy of relapse
Varieties of cognitive–behavioral therapy are prevention interventions indicates that the
applicable to a wide range of substance abusers. support for relapse prevention is more equivocal
The outpatient CBT program developed by (Carroll, 1996b). Relapse prevention was found
Carroll for cocaine users excluded a number of to be superior to no treatment, but the results
different clients as inappropriate for that form of have been less consistent when it is compared to
treatment (see Figure 4-21). However, even various control conditions or to other active
Figure 4-21
Types of Clients for Whom Outpatient CBT Is Generally Not Appropriate
Those who have psychotic or bipolar disorders and are not stabilized on medication
Those who have no stable living arrangements
Those who are not medically stable (as assessed by a pretreatment physical examination)
Those who have concurrent substance dependence disorders, with the possible exception of alcohol or
marijuana dependence
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Chapter 4
treatments. There are some outcomes on which Overall, behavioral, cognitive, and cognitive–
relapse prevention may have considerable behavioral interventions are effective, can be
impact (Carroll, 1996b); for instance, although used with a wide range of substance abusers,
not necessarily reducing the rate of relapse, and can be conducted within the timeframe of
clients treated in relapse prevention appear to brief therapies.
have less severe relapses when they occur.
86
5 Brief Strategic/Interactional
Therapies
S
trategic/interactional therapies attempt to All of these models stem in part from the
identify the client’s strengths and actively work of Milton Erikson. He coined the term
create personal and environmental strategic therapy to describe an approach in
situations where success can be achieved. In which the therapist takes responsibility for
these therapies, the focus is on the individual’s finding new and effective strategies to help
strengths rather than on pathology, the clients in distress. Jay Haley, John Weakland,
relationship to the therapist is essential, and and other theorists of the Mental Research
interventions are based on client self- Institute (MRI) consulted with Erikson as they
determination with the community serving as a expanded on his theoretical approach.
resource rather than an obstacle. This model has More recently, Steve De Shazer and his
been widely used and successfully tested on colleagues, who were influenced by the MRI
persons with serious and persistent mental approach, shifted the focus of treatment from
illnesses (Rapp and Wintersteen, 1989; Saleebey, problems to solutions, calling their modality
1996; Solomon, 1992). It has also been used with solution-focused therapy. Their approach,
persons who have problems related to substance originally developed to work in brief marriage
abuse (Juhnke and Coker, 1997; Miller and Berg, and family therapy, has since been used in a
1991; Ratner and Yandoli, 1996; Watzlawick et variety of situations for a variety of presenting
al., 1967). Although the research to date on problems, including substance abuse disorders.
these therapies (using nonexperimental designs) (See Chapter 8 for more information on the
has not focused exclusively on substance abuse application of all these therapies to the
disorders, the use of these therapies in treating treatment of families.)
substance abuse disorders is growing. Interactional therapy is based on the
Many different theoretical approaches have assumption that problems can best be
strategic or interactional roots. They can be understood by examining clients’ (often
distinguished from each other primarily by the dysfunctional) interactions with others and
different emphasis and value they place on their resulting problems. Strategic therapy is a
components of the change process. Therapists form of interactional therapy because it does not
rarely follow a single theoretical approach focus on the root causes of the client’s problems
strictly; therapists today influence and learn but instead tries to increase competency and
from each other, incorporating what they find develop problem-solving skills that will help the
useful into their own work. client in her interactions with others. For the
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Chapter 5
purpose of this discussion, however, the focused therapists (Iguchi et al., 1997). The
combined term strategic/interactional therapy is solution-focused therapist believes that helping
used. This broader term allows solution- clients with substance abuse disorders to
focused therapy, which is certainly interactional, address any life problems they find significant
to be included in this section. Although it has a will help them to reduce their substance use.
strong kinship with strategic approaches, not all What is important is finding a solution to the
practitioners consider solution-focused therapy problems the client identifies as significant, then
to be “strategic.” reinforcing the client’s success in solving those
The significance of these different problems. This procedure helps the client to
approaches can be found in their presentation of recognize her own ability to solve her problems.
an alternative approach to understanding how The study by Iguchi and colleagues compared
substance abuse disorders evolve and how new the role of urine testing, traditional substance
innovative solutions could be generated to assist abuse counseling services, and the
with the resolution of these problems. reinforcement of nonsubstance–use-related
The Consensus Panel believes that these positive life changes and found that the latter
therapeutic approaches are potentially useful for resulted in the most significant reduction in
clients with substance abuse disorders and substance use even after reinforcement
should be introduced to offer new knowledge contingencies ended.
and techniques for treatment providers to The solution-focused therapy model has been
consider. This chapter presents one used to respond to a range of problems and
strategic/interactional approach, solution- complaints. Researchers Berg and Miller were
focused therapy, which has been used in the first to apply the model specifically to the
substance abuse treatment. Information on treatment of alcohol-related problems, but
when to use solution-focused brief therapy with others also have used these techniques for
substance abuse clients, a case study using treating substance abuse disorders (Berg, 1995;
strategic/interactional approaches with a Berg and Miller, 1992; Berg and Reuss, 1998;
substance-abusing client, and the general Ratner and Yandoli, 1996). This treatment
theories that provide the basis for model is not necessarily a useful treatment
strategic/interactional therapies are strategy for all clients with substance abuse
discussed below. disorders; no one model is. However, this
model is a “complex and varied package of
Solution-Focused strategies that can be applied in an
direct the client’s attention to periods when he her substance abuse affects those significant
was substance free. To identify these periods, areas of concern. The therapist helps the client
the therapist must listen carefully to the client’s solve those significant problems while strongly
responses, then ask the client to discuss those reinforcing the client’s success. After the initial
periods. The purpose is to help the client realize session, the therapist keeps the client focused on
that he can maintain sobriety and has, in fact, how her situation is improving by asking,
done so in the past. The idea of focusing on the “What’s better this time?”
exception to any presenting problem is an aspect
of strategic therapy that has particular relevance Compatibility of
to the substance abuser because, as Berg notes,
Strategic/Interactional
almost every substance abuser has had some
period of abstinence—in many cases this period Therapies and 12-Step
may have lasted months or years (Berg, 1995). Programs
Exceptions to presenting problems may fall
into two categories, deliberate exceptions and Strategic/interactional approaches can be used
random exceptions (see Figure 5-1 for definitions). in conjunction with other treatments, even those
The more deliberate the behavior on the part of that require a longer term commitment.
the client, the easier it will be for her to repeat it. Strategic/interactional therapies are guided by
But even substance-free periods that seemed to an intent to generate a unique set of techniques,
result from outside influences (i.e., random approaches, or modalities that are effective for a
exceptions) can be used to help the client realize particular client. For some clients, a
her own ability to stay sober. combination of brief therapy with longer term
As discussed above, a therapist using a participation in another treatment program,
solution-focused approach works closely with such as a self-help group, will be most effective.
the client to understand the client’s own In spite of some theoretical differences,
perspective on her problems. By focusing on strategic/interactional approaches can be used
those areas the client considers significant (e.g., successfully in conjunction with 12-Step
relationships, work, financial security), the programs. These approaches, especially
therapist assists the client in understanding how identifying triggers that can lead to relapse or
Figure 5-1
Deliberate and Random Exceptions to Substance Abuse Behaviors
Deliberate exceptions are situations in which a client has intentionally maintained a period of sobriety or
reduced use for whatever reason. For example, a client who did not use substances for a month in order
to pass a drug test for a new job has made a deliberate exception to his typical pattern of daily substance
use. If he is reminded that he did do this in the past it will demonstrate that he can repeat the behavior.
Random exceptions are occasions when a client reduces use or abstains because of circumstances that
are apparently beyond her control. The client may say, for example, that she was just “feeling good” and
did not feel the urge to use at a particular time but cannot point to any intentional behaviors on her part
that enabled her to stay sober. This type of exception is more difficult for the therapist to work with but
can also be used to help the client perceive her own efficacy. In such instances the therapist can ask the
client to try to predict when such a period of “feeling good” might occur again, which will force her to
begin thinking about the behaviors that may have had an effect on creating the random exception.
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Chapter 5
exploring barriers that can prevent the client Heal the family system so it can better
from going to Alcoholics Anonymous (AA) support change
meetings or calling his sponsor, can be applied Maintain behaviors that will help control
to critical points in maintaining sobriety. For substance use
example, the therapist can help the client Respond to situations in which the client has
identify the “payoff” for not attending the returned to substance use after a period of
meeting and the key players in the system that abstinence
maintains the client’s substance abuse. Even a
More specifically, strategic/interactional
client who feels he is powerless over substance
approaches are useful in
abuse without the help of a higher power can
recognize he has some control over the choices Learning how the client’s relationships deter
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Brief Strategic/Interactional Therapies
who knows the way.” The therapist using this the Eriksonian model, a therapist might ask the
strategic/interactional approach should convey client to project herself into the future and
a sense of hope that bridges the chasm between describe what it will be like when the changes
what is and what could be and support the just discussed have been made, or talk about a
client through the change process with respect. “future self” who has resolved current problems
The strategic/interactional approach can also and for whom current fears are no longer an
help break through a stalemate in a relationship issue. Such strategies are useful in confronting
that blocks healing, particularly if there has been common fears and helping clients see beyond
a power struggle that has left both parties them.
exhausted and with an apparently restricted
range of options. In a power struggle, each
Duration of Therapy and
person says she is right and the other is wrong; Frequency of Sessions
one of them must give in. When the Most forms of strategic/interactional therapies
strategic/interactional approach is applied to are brief by the definition used in this TIP.
power struggles it can help to “open up the Strategic/interactional therapies normally
system,” working to change the clients’ require 6 to 10 sessions, with 6 considered
perceptions of each other and their relationship typical. Sessions are usually weekly, and it is
and enable them to see a broad range of options. not advisable to have more than two sessions
Both parties are assisted in seeing themselves as per week. This type of therapy often involves
strong, capable, and in control. Because the assigning “homework” for the client to observe
substance abuser typically feels helpless, how specific changes in behavior affect the
inadequate, and condescended toward, the problem, and time is needed to determine how a
therapist often has to rebalance the power new strategy is working and see how the system
structure to promote more effective interactions. is affected by the change.
For example, in a situation where one In solution-focused brief therapy, the client is
partner pushes the other to stop drinking, the encouraged to determine the length of time
partner who has been drinking may feel needed between sessions. This approach helps
controlled and demeaned and therefore may the client take ownership of the process and
withdraw in a passive manner or react with an recognize his power to control change (realizing
explosive temper. He then gets drunk to further that one has the power to choose often is the
express his anger or to get even. The partners’ solution itself).
respective behaviors maintain the problem. The
Applicability to Different
therapist works to help each partner perceive
Types of Clients
the other more positively. As this is
accomplished, each person becomes more In strategic/interactional approaches, clients are
receptive to new solutions. The therapist then traditionally defined as customers, complainers,
helps the partners identify specific changes they or visitors. Customers are clients who state that
can make, thus dismantling the old system and they have a problem, they can not cope with the
laying the foundation for a new one that can problem on their own, and they need the
support different behavioral choices. therapist’s help. Strategic/interactional
The strategic/interactional approach is also approaches are particularly helpful for the latter
an appropriate way to address a client’s fear of two types of clients—those who think someone
change. Often, clients feel that “something else should change to resolve the presenting
worse” may happen when they quit using. In problem (complainers) and those who see their
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presence in treatment as involuntary (visitors). when it is difficult to use this approach directly
Strategic/interactional therapies offer these with the client, it may still be an effective
kinds of clients a way to make effective changes modality to use with family members to help
within their own frames of reference. them change behaviors that support the client’s
For example, consider a client who feels her substance abuse (Fisch et al., 1982).
boss overreacted to her substance abuse and For other populations, the approach may
believes she should not have been forced to have to be adapted to work effectively. The
enter treatment to retain her job. Instead of therapist may have to use supportive props such
working to try to convince the client she really as handouts of the agreed-upon plan of action
does have a problem, the therapist can make and a list of goals to help keep the client on
progress working within her view of the track. Strategic/interactional strategies can be
situation, perhaps by saying, “So your boss simplified for people who have a cognitive
thinks you have a problem. What would it take impairment. Because this approach works with
to get him off your back?“ The assumption that the client’s language and functional level, a
the client wants to be free of the problems client with a cognitive disability may be able to
caused by this other person gives the therapist identify and meet goals appropriate to her skills
something to focus on without challenging the and abilities. Many therapists believe that the
client’s view of the situation. solution-focused approach is useful with clients
Most clients with substance abuse disorders who have schizophrenia, and research supports
can be viewed as “hidden customers” who its effectiveness with some clients who have
desire some sort of change in their behavior, serious mental illnesses (Saleebey, 1996;
even if they are not willing to articulate that fact Solomon, 1992).
(Berg, 1995). Given that, the therapist’s task is to
make the “complainer” or “visitor” aware that Case Study
he is in fact a “customer” of the therapist’s
services. Figure 5-2 presents a portion of a dialog
between a counselor and a client, a 45-year-old
When Might a Strategic/ real estate agent who was treated 4 years ago in
Interactional Approach Not an inpatient treatment program and thereafter
Be the Best? attended a 12-Step group to help him stop his
Eriksonian approaches may be contraindicated polysubstance abuse (cocaine and alcohol).
for clients with severe disorders. Clients who After experiencing 3 clean and sober years, he
have personality disorders (Axis II) may jump began to use again. The client started gambling,
quickly from one suggestion to another without then using cocaine and alcohol while gambling.
a clear sense of how to make use of therapeutic His real estate license is now in jeopardy
suggestions. Because they feel a need to stay in because of customer complaints and reports to
therapy they may resist solutions that would the State Licensing Board. He was recently
bring an end (albeit a successful one) to their convicted for a second time for driving under
relationship with the therapist. Clients with the influence (DUI), and his wife and family
impaired brain function as a result of substance moved out. The client tells the therapist that his
abuse may not be good candidates for this renewed abuse of substances was the result of
approach either. (For these clients, a more the gambling. Unlike the negative feedback
directive approach is helpful.) However, even from family, colleagues, and other professionals,
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Figure 5-2
Strategic/Interactional Therapy in Practice: A Case Study
Conversation Observations
Client: Things were going great. I was going to a lot
of meetings. I felt life was getting better. I was
getting along with my kids. Getting in touch with
the spiritual part of the problem. I don’t know what
happened.
Client: I guess I’d been gambling for a few months The first trigger (boredom) has been identified; this
before I got high. I was bored. will have to be reframed as treatment progresses.
Client: I spent too much money on gambling, and my An important interactional element surfaces.
wife yelled at me the same way she used to when I Sometimes the things that spouses or significant
got high on cocaine. I won a whole lot, really. It others do or say can either reinforce the client’s
wasn’t fair. substance abuse or help him out of the problem.
Therapist: Sounds like when you were gambling, you Nonjudgmental language is used to enter the client’s
were excited. So I don’t get it—what went wrong? frame of reference/world-view. It is best if the client is
Why did you need the cocaine, too? Is it possible able to define the substance abuse as a problem he
gambling wasn’t enough? wants to overcome rather than have the therapist
define this for the client.
Client: I guess I just needed more of the high, you
know. My wife and I were fighting more. The
pressure was getting to me. I guess that’s when I
started on the cocaine.
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Client: I got scared. I was up for 3 days. The alcohol Here the therapist gets some understanding of the
helped me come down and sleep. sequence of the client’s substance abuse.
Therapist: Sounds scary to me. How did you get The therapist validates the client’s experience, rather
through that scared period? You tolerated it than criticizing the client’s behavior.
somehow for 3 days.
Therapist: I hear that you realized something needed The therapist is pointing out that the client’s action
to be done, and you knew you needed something to was an attempt at regulation, though not a long-term
slow you down, and you took action. solution. The statement reminds the client that he is
in control and making choices. It reaffirms the
client’s strength and coping skills—the client made an
adaptive response to a difficult situation and may
make a different choice next time.
Therapist: So how is this a problem for you now? This question brings the client back to defining the
problem for himself, rather than letting the therapist
or someone else (spouse, boss, probation officer, etc.)
define it for him.
Client: Well, I lost my family, almost lost my This “hopeless and helpless” stance should be shifted.
business, and I’m facing another DUI. Solution-focused and MRI approaches would try to
promote effective strategies and eliminate ineffective
ones. An Eriksonian might challenge the client to
compare his positive and negative self-image (i.e., the
way it feels to go to AA and stay sober versus how it
feels after getting high).
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Therapist: It sounds to me like you have incredible Here is a “make it or break it” point in treatment.
inner strength. What keeps you going? The therapist is seeking a key that will move the client
to action (e.g., his love of his children, his desire to get
Client: I don’t want to die. his wife back, his concern about his job). In this case,
the therapist has just learned that the client fears he
will die as a result of his use.
Therapist: It sounds like you have a very strong, Some therapists would call the competent self the
competent side that wants the best for you and wants “recovery self.”
to live. Let’s use that competent part of you to get
back on track and rebuild your life. What do you
think?
Therapist: Let’s begin by figuring out where you are The “readiness ruler” is an effective way to determine
now. On a scale of 1 to 10, on which “1” is the worst the client’s readiness to change and identify next
you could feel and “10” is “clean, sober, and steps. The therapist is using this technique to identify
successful,” where are you now? a baseline to measure progress and focus the client in
the direction of change and progress.
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Therapist: That’s good because slow change is more At this point, the therapist is ready to define some
important than fast change. You really can’t count on kind of action and seek commitment to change. The
fast change to last. So if you did slip back to a “2,” response is also intended to encourage the client by
what would it take to move you to a “3”? identifying small, feasible steps
Therapist: Sounds good. You said now you go to AA The therapist is looking for exceptions: times when
meetings and get high afterward. What did you do something the client did worked and he experienced
afterwards when you didn’t do that, when you success.
stayed sober?
Therapist: So when you don’t have things to The therapist is reframing the problem to open the
do, you get antsy. door to a solution.
Therapist: Yes, it is difficult to go home to an empty The therapist is acknowledging the difficulty, but also
place. But it sounds like you have not given up on pointing out the positive direction implicit in the
people. People are still important to you. You want client’s statement. The therapist empathizes with the
human contact—to care about people and have them client, validating his experiences and feelings, but also
care about you. pointing out the positive direction implicit in the
client’s statement.
Client: If nobody’s around, I feel empty. I get bored.
Then I want to use. I want to make something
happen.
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Therapist: That’s interesting. Despite the fact that The therapist is framing the client’s self-image
you feel empty, you can still function. I think there positively, suggesting a change in the way the client
is something internally powerful in you that has not now sees himself.
come out. For some reason, it has been suppressed.
My guess is that the boredom comes when you
suppress that side of you.
Client: You keep talking about this powerful side. I A natural response from a client who is mostly
don’t get it. I lost everything. Where’s this great focusing on negative perceptions and experiences. The
power I’m supposed to have? therapist’s focus continues to be on shifting the client’s
perception to positive strengths and constructive
Therapist: I think it’s right here—let’s see if we can action.
bring it out a bit. Tell me about a time when you felt
tremendous pleasure and control, but you were
sober.
Therapist: Some time this week if you’re willing to At this point, the therapist might encourage the client
try something, and only if you’re willing, try to to feel that vibration and run across the bases in his
bring back that experience. Take note of what it was mind or ask whether the activity mentioned is one the
like and how difficult it was to get there. client could do in his present life. The therapist could
suggest here that a local recreation center, or another
Client: Okay. Maybe I’ll try that. way of being physically active, would be an option for
restoring the sense of power and control as well as
connecting with people.
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Client: It’s going to be good to sit there and know Part of what’s happening is that the external and
I’m not hiding. internal pressure resulting from the shame is being
reduced; consequently, the feeling about going is
changing.
the therapist, using strategic/interactional This case study is an example of how a brief
approaches, praises the client for coming back to strategic/interactional therapist might work
treatment: “Look at what you have done! with a client who has previously been successful
You’re in this chair instead of still out there.” at controlling his substance abuse problem but
The therapist assures the client that relapse is has relapsed. The approach described is a
part of the recovery process and suggests that generic strategic/interactional approach and
the experience can be seen as educational. In does not represent a pure model of any one type
contrast to emphasizing the client’s failure, the of strategic/interactional therapy. Because the
therapist sends the message, “You’re a survivor, client has relapsed, an important guiding
not a victim.” The therapist affirms the client’s principal is to discover what has caused him to
ability to stay sober and begins to seek ways to deviate from those behaviors, thoughts, and
emphasize and draw on the client’s strengths. activities that had previously been effective in
The therapist seeks to understand the events controlling his substance abuse. The therapist
that led up to renewed use but also searches for must then assist the client either to return to
the behaviors that previously helped the client those things that have been working before or to
stay abstinent for 3 years. add or replace them with strategies that are
more effective.
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However, different models (discussed later in The therapist could continue to develop
this section) use different tactics to explore the effective strategies and increase their use.
nature of the problem, as follows: She could use affirmations, continue to use
scaling questions, and “join” with the client
The therapist using Eriksonian therapy seeks
by acknowledging how difficult it is to
to define the client’s problem in the client’s
change and rebuild his life.
terms and probe the way she understands
The therapist should also be aware of the
the problem (i.e., the “frame”). Compared to
client’s motivation to change and continue to
other strategic interactional models, the
ask the client what he thinks will happen if
Eriksonian approach moves more quickly to
changes take place. This technique
action, seeks to effect change more quickly,
demonstrates respect for the client’s values.
and places greater emphasis on the
The therapist could continue to gather
unconscious processes underlying change.
information about the stressors that trigger
The therapist using solution-focused brief
the client’s substance abuse and help him to
therapy spends most of the first session
determine how he can handle them
defining goals. Throughout the session, the
differently. The therapist should ask the
word “problem” is avoided.
client about ways he has successfully
The therapist using the MRI model seeks to
handled stressors in the past and expand on
define the problem in the client’s terms and
those successes.
understand the “frame” in a manner similar
The therapist could use images and symbols
to the Eriksonian approach. However, this
to help the client see the problem in a helpful
modality focuses on modifying ineffective
way. For example, the client might find a
solutions that have been previously
new job and throw himself completely into it.
attempted.
The therapist could tell him that he is a
The therapist using Haley’s problem-solving
shining star: “You’re shining bright right
therapy pays special attention to gaining an
now. What can you do to keep shining?”
understanding of power issues in
This starts a discussion about how to last
relationship to the problem (e.g., who
longer, work smarter, achieve more, and use
controls key decisions).
restraint.
Later Sessions The therapist might also focus on assisting
Once the therapist has encouraged a person the client to improve other aspects of his life.
with a substance abuse disorder to take further The client’s continued belief in his own
steps toward change, the subsequent sessions strength and basic goodness should be
will focus on identifying and supporting supported. The therapist should help him
additional steps in the same direction. The see himself as an individual who wants
following are examples of techniques that might what’s best for both himself and his family.
be used in the remaining sessions with the client One effective strategy is to encourage the
in this case study. client to adopt a “helper” role in some area of
his life. This shifts the focus further from his
Set up a termination point. The therapist
view of himself as a helpless, incompetent
could ask the client to describe the signs that addict to a strong, caring, competent person
things are getting better for him, or ask, who can help others. This client’s
“What things will you be doing differently?”
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participation in AA might give him the emphasize unconscious factors in change and
opportunity to help others in this manner. the importance of indirect ways to shift
meanings and behavior. His approach is active,
As the end of the therapeutic process nears,
building on clients’ resources to help them attain
the therapist helps the client prepare for the
their goals. The therapist and client cooperate in
future. Following are suggestions for how the
building an awareness of the client’s experience
therapist can do this.
and an understanding of its meaning. Together,
Prepare the client to maintain positive change they build a context for change.
through difficult times. It is useful to convey Erikson’s interventions emphasize the
the idea that the learning curve is never a following:
straight slope; rather, it is a curvy line, with
Suggestion as a means of bypassing an
peaks and dips. There will be slips. It is
impasse, reframing the problem, and taking a
unrealistic to expect perfection. Life will
first step toward solving it
continuously have “ups and downs”—the
Metaphor as indirect intervention—a way to
goal is not to make things even but to cope
help the client retrieve resources and create a
effectively with these ups and downs.
unique response that builds a bridge for
Identify what the potential next stressors and
learning; the therapist uses the client’s
challenges will be. Work through the
metaphors (e.g., if the client sees recovery as
following question with the client: “Given
a road, then the therapist can speak of
what we’ve learned, how would you cope
bridges or of smoothing the way, thus
with the next stressor/challenge?”
activating the client’s imagination in the
Devote some time to preparing the client for
service of the change process)
changes to the environment. For example, how
The symptom as a communication that
will significant people in his life react to his
conveys information about developmental
change in behavior?
needs
Ask the client to look into the future at the end of
An orientation toward the future (e.g.,
the treatment period and tell the therapist where
depression is seen as the result of focusing on
he intends to be at a certain time (this is an
past associations; as the client works toward
Eriksonian approach). The therapist could ask
change and begins to accomplish goals, she
for a specific date when the client expects to
lets go of depression)
get there and ask the client to call the
Acquiring new skills to meet the
therapist on that date. This process sets up
requirements of new situations (such as the
an expectation of progress and
different ways of socializing associated with
accountability.
abstinence) and to handle developmental
Ericksonian Therapy tasks
All forms of strategic/interactional therapies The cure conceptualized as the loss of the
have their roots in the work of Milton Erikson, symptom and as the development of new
an innovative psychotherapist who was one of relational patterns that allow a creative
the first theorists to suggest the importance of response to the environment
working within the client’s “frame.” With his While Erikson was able to work with
unique use of hypnotherapy he fostered rapid virtually all clients using these techniques, his
changes in his clients, often in an indirect work has been especially useful in helping
fashion. Through this work he came to people let go of trauma, break through a
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resistance to change, and alter obsessive– Berg and Miller relate the “central
compulsive, phobic, or addictive behavior. philosophy” of solution-focused therapy in the
following three rules (Berg and Miller 1992,
Solution-Focused Brief Therapy p. 17):
Solution-focused brief therapy was developed
1. “If it ain’t broke, don’t fix it!”
by Steve De Shazer and his colleagues at the
2. Once you know what works, do more of it!
Brief Family Therapy Center in Milwaukee,
3. If it doesn’t work, then don’t do it again—do
Wisconsin. In solution-focused brief therapy,
something different!
the emphasis is placed on building exceptions to
the presenting problem and making rapid Solution-focused interviewing strategies
transitions to identifying and developing include the following (based on Giorlando and
solutions intrinsic to the client or problem Schilling, 1996), presented in a typical sequence.
(Cooper, 1995). Basic tenets of this approach These strategies can be applied at different
include the following: points in the therapeutic process as appropriate.
Focusing on competence rather than Ask the “miracle question” (i.e., “If a miracle
pathology happened and [your condition] were
Finding a unique solution for each person suddenly not a problem for you, how would
Using exceptions to the problem to open the your life be different?”).
door to optimism Ask about exceptions (e.g., “Are there ever
Using past successes to foster confidence times you see pieces of the miracle?”).
Looking to the client as the expert Explore differences between current status
Using goal-setting to chart a path toward and the desired problem-free state (e.g.,
change “What is the difference between the times
Sharing the responsibility for change with when you can see pieces of the miracle and
the client the times when you can see only the
problem?”).
The basic tenets of the solution-focused
Use scaling to determine how well the client
model are fairly simple; they are the same when
thinks things are going, how willing she is to
used for treating substance abuse disorders as
work toward the “miracle,” her confidence in
they are for treating other mental health
her ability to change, and the steps needed to
concerns. A therapist uses these same principles
improve the situation from one rating on the
for an individual client, family, or group. The
scale to the next highest.
therapist emphasizes finding solutions to a
Try taking “time-outs” and suggest to the
problem, not on discovering the cause or origins
client “While I step out, I want you to think
of the problem. According to Giorlando and
of the next smallest step you could take that
Schilling,
would bring you to the next number on the
The innovative perspective of solution-focused scale.”
therapy shifts the emphasis from problems to
solutions, empowering the client to access her
Affirm client competencies (e.g., tell the
internal resources, strengths, and past client, “I am impressed you are sitting in that
successes, with therapist and client working chair again after what you just went
collaboratively to achieve change in a shorter through”). Many of these clients have never
time than that required by traditional schools
of psychotherapy (Giorlando and Schilling,
had this success acknowledged before.
1996).
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Brief Strategic/Interactional Therapies
Suggest tasks that the client can perform to work. However, the therapist notes that she
improve her situation (e.g., ask her to do began using after the death of her spouse and
something achievable that would provide therefore hypothesizes that the substance
useful information or move her closer to the abuse is related to her deep grief. The
“miracle” she has chosen). challenge for the therapist is to work with the
client’s position in a way that allows for a
The MRI Therapeutic Model more useful understanding of the problem,
The Mental Research Institute’s brief therapy and therefore for new, more effective
model is based on the belief that problems solutions.
develop from, and are maintained by, the way State goals. What behaviors are to be changed
that normal life difficulties are perceived and and what would be the signs of change?
handled (Fisch et al., 1982). Normal difficulties Review attempted solutions. What has the
become problems when an individual client done to try to solve the problem?
continually mishandles a situation, using the What has worked, and what has not worked?
same ineffective approach each time. A client’s Reframe the situation. Help the client change
belief system can cause him to develop his perception of himself, others involved, or
ineffective approaches to problems that result in the problem situation so that new options
maintaining or even exacerbating the difficulty. can appear.
The more the client uses an ineffective solution Develop second order change. Help the client
to solve a problem, the more the problem is generate more effective solutions that lead in
reinforced and maintained. The solution lies in a different direction from the ineffective
helping the client change his perception of the ones—either by modifying attempted
problem, then either modify the attempted solutions or by developing new ones. In the
solution so it has a greater chance of success or case of a client who has tried to control her
devise a more effective solution. These new drinking by obsessing over her need to stop
solutions (generally referred to as second order drinking, the therapist might perceive that
change) work best if they are sufficiently every time she thinks about controlling her
different from the ineffective, previously drinking she activates her fears that she is
attempted solutions. weak and out of control. The more she
In each session, practitioners using the MRI obsesses over controlling her drinking the
brief therapy model should try to do the more overwhelmed she becomes about the
following: impossibility of the task. The therapist
Define the problem in behavioral terms. For would try to help this client to stop obsessing
example, a client may say, “I feel compelled over this task and instead view the situation
to join the others at work in drinking, as manageable and changeable in a step-wise
although as a result I have such a ‘short fuse’ fashion. The therapist would help her see
that I get in fights and even hurt my wife.” that she has been strong and capable in other
Determine how the client understands the aspects of her life and that she can make use
problem. What is her “frame of reference” or of these strengths and competencies to
“position”? It is important to understand handle his drinking problem.
how the client views her problem and what Plan for maintenance of the new behaviors.
attitudes she has toward the problem. For Support continued improvement by
example, a client might insist that her preparing the client to meet future challenges
substance abuse is the result of pressures at and crises.
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The speed with which a therapist is able to sequences—who talks to whom, and in what
move through these steps will depend on the order. The therapist should try to answer
client’s particular problem, overall questions such as, “What function does the
development, cognitive capacities, and his stage symptom serve in stabilizing the family?” and,
of readiness to change. “What is the central theme around which the
problem is organized?”
Haley’s Problem-Solving Therapy Haley’s approach assumes that substance
Jay Haley wrote that “therapy can be called abuse by a family member is a symptom of a
strategic if the therapist initiates what happens family’s desire to avoid confronting
during the therapy and designs a particular dysfunctional family dynamics. The individual
approach for each problem” (Haley, 1973, p. 17). is not necessarily responsible for having created
To do this the therapist will have to identify the symptom (which would fit in well with a
solvable problems, design interventions to disease concept addiction). According to
resolve them, correct those interventions based Haley’s model, a wife may drink to avoid
on responses from the client, and evaluate the expressing her rage at her husband for having
effectiveness of the therapy. an affair. The husband implicitly understands
Haley’s problem-solving therapy emphasizes that by confronting his wife’s drinking, a
obtaining a clear statement of the problem and confrontation might ensue over his infidelity
an accurate picture of the interactional and that could destroy the marriage. This
sequences that maintain it. Moreover, approach recommends negotiating a path to
symptoms (i.e., presenting dysfunctions) or change by changing the family pattern that
problem behaviors serve a function in families militates against it. The therapist could work
and carry metaphorical information about with the family to set goals and design a
hierarchical dysfunction (Haley, 1987). Through strategic series of directives to meet these goals,
observing the client’s symptomatic behavior, the usually involving a change in the sequences of
therapist can often understand the underlying interaction that maintain the problem. In the
problem metaphorically. For example, if a child above example, the wife’s drinking serves to
runs away it can indicate that the family is stabilize the family and avoid the real issues of
“running away” from confronting an issue. This the wife’s anger and the husband’s infidelity.
behavior often signals a solution as well, calling The therapist would work with the wife to
attention to what needs to be changed. express her anger in a way other than drinking,
To map out a family’s organization, the and define the issue as one of trust in the
therapist should observe communication marriage.
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6 Brief Humanistic and
Existential Therapies
H
umanistic and existential human nature as basically good, with an
psychotherapies use a wide range of inherent potential to maintain healthy,
approaches to case conceptualization, meaningful relationships and to make choices
therapeutic goals, intervention strategies, and that are in the interest of oneself and others. The
research methodologies. They are united by an humanistic therapist focuses on helping people
emphasis on understanding human experience free themselves from disabling assumptions and
and a focus on the client rather than the attitudes so they can live fuller lives. The
symptom. Psychological problems (including therapist emphasizes growth and self-
substance abuse disorders) are viewed as the actualization rather than curing diseases or
result of inhibited ability to make authentic, alleviating disorders. This perspective targets
meaningful, and self-directed choices about how present conscious processes rather than
to live. Consequently, interventions are aimed unconscious processes and past causes, but like
at increasing client self-awareness and self- the existential approach, it holds that people
understanding. have an inherent capacity for responsible self-
Whereas the key words for humanistic direction. For the humanistic therapist, not
therapy are acceptance and growth, the major being one’s true self is the source of problems.
themes of existential therapy are client The therapeutic relationship serves as a vehicle
responsibility and freedom. This chapter broadly or context in which the process of psychological
defines some of the major concepts of these two growth is fostered. The humanistic therapist
therapeutic approaches and describes how they tries to create a therapeutic relationship that is
can be applied to brief therapy in the treatment warm and accepting and that trusts that the
of substance abuse disorders. A short case client’s inner drive is to actualize in a healthy
illustrates how each theory would approach the direction.
client’s issues. Many of the characteristics of The existentialist, on the other hand, is more
these therapies have been incorporated into interested in helping the client find
other therapeutic approaches such as narrative philosophical meaning in the face of anxiety by
therapy. choosing to think and act authentically and
Humanistic and existential approaches share responsibly. According to existential therapy,
a belief that people have the capacity for self- the central problems people face are embedded
awareness and choice. However, the two in anxiety over loneliness, isolation, despair,
schools come to this belief through different and, ultimately, death. Creativity, love,
theories. The humanistic perspective views authenticity, and free will are recognized as
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which our experiences assume meaning as continuation of recovery (e.g., to get someone
apperception (Schor, 1998). Becoming aware of who insists on remaining helpless to accept
this process yields insight and facilitates the responsibility). Narrative therapy may be used
ability to choose new ways of being and acting. to help the client conceptualize treatment as an
For many clients, momentary circumstances opportunity to assume authorship and begin a
and problems surrounding substance abuse may “new chapter” in life. Gestalt approaches can
seem more pressing, and notions of integration, also be used throughout therapy to facilitate a
spirituality, and existential growth may be too genuine encounter with the therapist and the
remote from their immediate experience to be client’s own experience. Transpersonal therapy
effective. In such instances, humanistic and can enhance spiritual development by focusing
existential approaches can help clients focus on on the intangible aspects of human experience
the fact that they do, indeed, make decisions and awareness of unrealized spiritual capacity.
about substance abuse and are responsible for These approaches increase self-awareness,
their own recovery. which promotes self-esteem and allows for more
client responsibility, thus giving the client a
Essential Skills sense of control and the opportunity to make
By their very nature, these models do not rely choices. All of these approaches can be used to
on a comprehensive set of techniques or support the goals of therapy for substance abuse
procedures. Rather, the personal philosophy of disorders.
the therapist must be congruent with the
theoretical underpinnings associated with these Duration of Therapy and
approaches. The therapist must be willing and Frequency of Sessions
able to engage the client in a genuine and Although many aspects of these approaches are
authentic fashion in order to help the client found in other therapeutic orientations, concepts
make meaningful change. Sensitivity to like empathy, meaning, and choice lie at the
“teachable” or “therapeutic” moments is very heart of humanistic and existential
essential. therapies. They are particularly valuable for
brief treatment of substance abuse disorders
When To Use Brief Humanistic and because they increase therapeutic rapport and
Existential Therapies enhance conscious experience and acceptance of
These approaches can be useful at all stages of responsibility. Episodic treatment could be
recovery in creating a foundation of respect for designed within this framework, with the
clients and mutual acceptance of the significance treatment plan focusing on the client’s tasks and
of their experiences. There are, however, some experience between sessions. Humanistic and
therapeutic moments that lend themselves more existential therapies assume that much growth
readily to one or more specific approaches. The and change occur outside the meetings. When
details of the specific approaches are laid out focused on broader problems, these therapies
later in this chapter. Client-centered therapy, for can be lifelong journeys of growth and
example, can be used immediately to establish transformation. At the same time, focusing on
rapport and to clarify issues throughout the specific substance abuse issues can provide a
session. Existential therapy may be used most framework for change and more discrete goals.
effectively when a client is able to access These techniques will also work well in
emotional experiences or when obstacles must conjunction with other types of therapy.
be overcome to facilitate a client’s entry into or
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Brief Humanistic and Existential Therapies
Figure 6-1
A Case Study
This case study will be referred to throughout this chapter. It will provide an example to which each type of
humanistic or existential therapy will be applied.
Sandra is a 38-year-old African-American woman who has abused a number of substances, including
cocaine, heroine, alcohol, and marijuana over the past 15 years. She left high school and was a
prostitute for 5 years. Later she found a job as a sales clerk at a home furnishings store. Sandra had
two children in her early twenties, a daughter who is now 15, and a son, aged 18. Because of her
substance abuse problems, they live with other relatives who agreed to raise them. Sandra has been in
treatment repeatedly and has remained substance free for the last 5 years, with several minor relapses.
She has been married for 2 years, to Steve, a carpenter; he is substance free and supports her attempts
to stay away from substances.
Last month she became symptomatic with AIDS. She has been HIV-positive for 5 years but had not
developed any illnesses related to the disease. Sandra has practiced safe sex with her husband who
knew of her HIV status. Recently, after learning from the physician at her clinic about her HIV
symptoms, she began to “shoot up,” which led her back into treatment. Out of fear, she came to the
treatment center and asked to see a counselor at the clinic one day after work. She is worried about her
marriage and that her husband will be devastated by this news. She is afraid she is no longer strong
enough to stay away from drugs since discovering the onset of AIDS. She is also concerned about her
children and her job. Uncertain of how she will keep on living, she is also terrified of dying.
Each individual exists in a private world of acceptance. This type of therapy aims not to
experience in which the individual is the interpret the client’s unconscious motivation or
center. conflicts but to reflect what the client feels, to
The most basic striving of an individual is overcome resistance through consistent
toward the maintenance, enhancement, and acceptance, and to help replace negative
actualization of the self. attitudes with positive ones.
An individual reacts to situations in terms of Rogers’ techniques are particularly useful for
the way he perceives them, in ways the therapist who is trying to address a
consistent with his self-concept and view of substance-abusing client’s denial and motivate
the world. her for further treatment. For example, the
An individual’s inner tendencies are toward techniques of motivational interviewing draw
health and wholeness; under normal heavily on Rogerian principles (see TIP 35,
conditions, a person behaves in rational and Enhancing Motivation for Change in Substance
constructive ways and chooses pathways Abuse Treatment [CSAT, 1999c], for more
toward personal growth and self- information on motivational interviewing).
actualization (Carson, 1992).
Response to the case study
A client-centered therapist focuses on the A client-centered therapist would engage in
client’s self-actualizing core and the positive
reflective listening, accepting the client and her
forces of the client (i.e., the skills the client has
past, and clarifying her current situation and
used in the past to deal with certain problems).
feelings. As Sandra developed trust in the
The client should also understand the
therapist, he would begin to emphasize her
unconditional nature of the therapist’s
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Chapter 6
positive characteristics and her potential to storytelling and mythology to enhance self-
make meaningful choices to become the person awareness (see Campbell, 1968; Feinstein and
she wants to (and can) become. Another goal of Krippner, 1997; Middelkoop, 1989).
therapy would be to help her develop sufficient Parker and Horton argue that “Studies in a
insight so that she can make choices that reflect variety of disciplines…have suggested that all
more closely the values and principles to which cognition is inherently metaphorical” and note
she aspires. For example, she may want to tell “the vital role that symbolism plays in
her husband about her symptoms and try to perception” (Parker and Horton, 1996, p. 83).
strengthen her marriage. The authors offer the “perspective that the
If Sandra began to feel guilt about her past as universe is made up of stories rather than
a prostitute, the therapist would demonstrate atoms” and suggest, “Myth and ritual are
appreciation of her struggle to accept that aspect vehicles through which the value-impregnated
of herself, highlighting the fact that she did beliefs and ideas that we live by, and for, are
eventually choose to leave it. He may note that preserved and transmitted” (p. 82). From this
she did the best she could at that time and perspective, narratives reveal a deeper truth
underscore her current commitment to choose a about the meanings of our experience than a
better life. Sandra would be supported and factual account of the events themselves. As
accepted, not criticized. She would be Feinstein and Krippner note, “Personal
encouraged to express her fear of death and the mythologies give meaning to the past,
effect this fear has on her. This might be the first understanding to the present, and direction to
time in her life that someone has been the future” (Feinstein and Krippner, 1997, p.
unconditionally accepting of her or focused on 138).
her strengths rather than her failings. She When people tell and retell their life stories
apparently has the ability to solve problems, (with the help of a therapist), the stories evolve
which is reflected by her return to therapy and into increasingly meaningful and healing
her insight about needing help. By being constructions. As narrative therapists listen to
understood and accepted, her self-esteem and the stories clients tell, they assist them by
sense of hope would increase and her shame identifying alternative ways of understanding
would decrease. She would feel supported in events in their lives. Thus, they help clients to
making critical choices in her life and more assume authorship of their lives in order to
confident to resume her recovery. rewrite their stories by breaking patterns and
developing new solutions. Narrative therapy
Narrative Therapy helps clients resolve their problems by
Narrative therapy emerges from social
Helping them become aware of how events
constructivism, which assumes that events in
in their lives have assumed significance
life are inherently ambiguous, and the ways in
Allowing them to distance themselves from
which people construct meaning are largely
impoverishing stories by giving new
influenced by family, culture, and society.
meaning to their past
Narrative therapy assumes that people’s lives,
Helping them to see the problem of
including their relationships, are shaped by
substance abuse as a separate, influential
language and the knowledge and meaning
entity rather than an inseparable part of who
contained in the stories they hear and tell about
they are (note the discrepancy between this
their lives. Recent approaches to understanding
and the AA member’s statement, “My name
psychological growth have emphasized using
is Jane, and I am an alcoholic”)
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The focus of therapeutic dialog could then other shifts in consciousness. Although
shift toward developing alternatives to hopeless grounded in psychological theory, transpersonal
aspects of personal and cultural expectations. It practitioners also tend to incorporate
would be helpful to remind her that recent perspectives from ancient wisdom traditions.
advances in medical treatments mean that AIDS The practice of transpersonal therapy is
may not be the death sentence it was once defined more by its orientation and scope rather
thought to be. Other important questions can than by a particular set of techniques or
help her to begin to create an alternative story: methods (Boorstein, 1980). Wittine suggests five
“As you begin to understand the positive and postulates for a transpersonal psychotherapy
negative influences in your life, what qualities (Wittine, 1989):
must you possess in order to remain sober and
1. Transpersonal psychotherapy is an
develop better relationships with your husband
approach to healing and growth that
and children?” She may need help replacing
recognizes the centrality of the self in the
these stories with more positive narratives about
therapeutic process.
herself. As Sandra talks about the people and
2. Transpersonal psychotherapy values
events in her life, such as her childhood and her
wholeness of being and self-realization on
children, she can discover some of her feelings,
all levels of the spectrum of identity (i.e.,
as well as the personal meaning in her story.
egoic, existential, transpersonal).
She can experience a great deal of healing
3. Transpersonal psychotherapy is a process of
through the therapist’s feedback and questions
awakening from a limited personal identity
that uncover the desires and emotions beneath
to expanded universal knowledge of self.
her story. A continued focus on identifying,
4. Transpersonal psychotherapy makes use of
practicing, or even imagining changes in her
the healing restorative nature of subjective
story can begin the process of developing new
awareness and intuition in the process of
ways of living.
awakening.
Transpersonal Therapy 5. In transpersonal psychotherapy, the
therapeutic relationship is a vehicle for the
Transpersonal psychology emerged as a “fourth
process of awakening in both client and
force” in psychology in the late 1960s and has
therapist.
strong roots in humanistic and existential
psychologies, Jungian analysis, the East–West Integrating insights and practices in
dialog, and ancient wisdom traditions. everyday life is the goal of every therapy.
Transpersonal therapy may be thought of as a Bringing the transpersonal dimension to the
bridge between psychological and spiritual forefront may involve the following:
practice. Exploration of “inner voices” including those
A transpersonal approach emphasizes of a higher self that provides guidance for
development of the individual beyond, but growth of the individual (Rowan, 1993)
including, the ego. It acknowledges the human Refinement of intuition or nonrational
spiritual quest and recognizes the human knowing
striving for unity, ultimate truth, and profound Practice of creativity in “formal” (art) or
freedom. It cultivates intuitive ways of knowing informal (personal relationships) encounters
that complement rational and sensory modes.
This approach also recognizes the potential for
growth inherent in “peak” experiences and
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a clear and symbolic expression of unresolved How is more important than why (i.e., causes
issues. The use of rituals or rites-of-passage are not as important as results).
inspired by the wisdom traditions can provide The individual’s inner experience is central.
some catalyst for shifting her consciousness
For Gestalt therapists the “power is in the
through forgiveness and release.
present” (Polster and Polster, 1973). This means
The therapist may engage in a wide variety
that the “now” is the only place where
of methods (e.g., imagery, art, or dream work,
awareness, responsibility, and change can occur.
meditation, rituals), but the heart of the work is
Therefore, the process of therapy is to help the
in the simple and humane spirituality that is
client make contact with the present moment.
embodied by the therapist’s loving presence
Rather than seeking detailed intellectual
along with the therapist’s openness to explore
analysis, the Gestalt therapist looks to create a
the full range of human experience directly. For
“safe emergency” in the therapeutic encounter.
Sandra, this experience may be seen as an
Perls’ invocation to “lose your mind and come
opportunity for practicing love and forgiveness,
to your senses” implies that a feeling-level,
moving out from behind rigid self-separateness,
“here and now” experience is the optimal
facing fears, and transforming her self-
condition for therapeutic work. This may be
definition.
accomplished in a fairly short amount of time by
Gestalt Therapy explicitly asking clients to pay attention (e.g.,
“What are you aware of now? How does your
Gestalt theory holds that the analysis of parts
fear feel to you?”). The therapist may point out
can never provide an understanding of the
how the client could be avoiding the present
whole. In a therapeutic setting, this approach
moment through inauthentic “games” or ways
opposes the notion that human beings can be
of relating such as “talking about” feelings
understood entirely through a rational,
rather than experiencing them directly. Clients
mechanistic, scientific process. The proponents
may be asked to exaggerate certain expressions
of Gestalt therapy insist that the experiential
(e.g., pounding a fist) or role-play certain
world of a client can be understood only
internal dialogs (e.g., through an empty chair
through that individual’s direct experience and
technique). These may all serve the goal of
description. Gestalt therapists seek to help their
helping clients move into the immediacy of their
clients gain awareness of themselves and the
experience rather than remaining distant from it
world. Discomfort arises from leaving elements
through intellectualization or substance abuse.
and experiences of the psyche incomplete—
The term contact in Gestalt refers to meeting
primarily past relationships and intrapsychic
oneself and what is other than oneself. Without
conflicts that are unresolved, which Perls calls
appropriate contact and contact boundaries
“unfinished business” (Perls, 1969). According
there is no real meeting of the world. Instead,
to Gestalt theory
one remains either engulfed by the world on one
The organism should be seen as a whole hand or, on the other hand, distant from the
(physical behavior is an important world and people.
component, as is a client’s mental and Substance abuse interrupts the flow of what
emotional life). Perls called “organismic self-regulation.” The
Being in the “here and now” (i.e., being result is that individuals do not achieve
aware of present experience) is of primary satisfaction of their needs and can remain
importance. unaware of what their needs are. The substance
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Brief Humanistic and Existential Therapies
abuser may distort or thwart the natural cycle at contact now? What is the sensation in your
any of the following points: body at this moment?”).
Sandra may also identify certain issues such
Experiencing the need
as substance abuse, relationship difficulties, and
Mobilization of energy
the threat of death from AIDS that seem to
Contact
dominate her life. The therapist might invite her
Satisfaction
to name and explore the sensation that the
Withdrawal
thought of death, for example, brings; perhaps
Rest
this involves a sense of a void, or feeling cold
Treatment involves bringing awareness to and dark, or a feeling of engulfment. She then
each of these dimensions and the client’s may be asked to become these sensations—for
strategies of avoidance. example, the therapist may ask her to be “the
Substance abuse may also be understood as void” and encourage her to speak as if she were
“introjection” in which the client attempts to that void. This may then open possibilities for a
“swallow whole” or “drink in” his environment dialog with the void through acting out the
without contact and discrimination. This type of opposite polarity: separateness and choice. This
client bypasses and blocks other experiences might involve using an empty chair technique in
that might enable contact and the development which the client would literally move into the
of discrimination. Perls maintains that such a chair of the “void,” speak as if she were that,
client seeks immediate confluence without and then move into an opposite chair and
preparatory contact. This pattern of interaction respond in a dialog. A therapist could also
extends to other relationships (besides the explore her introjection through questions such
substance) as well. as, “How is this void different or the same as
In order for this work to proceed, the from the feeling of alcohol or in relationships
therapist must maintain a fine-tuned, present- with your children or husband?” She might also
moment immediacy, even serving as a use this same technique to dialog with family
“resonance chamber” (Polster and Polster, 1973) members, or certain aspects of herself.
for the client’s experience. They, too, must be Sandra seems to have a great deal of
able to make and sustain contact with the client “unfinished business” that involves
and with their own reactions. unexpressed feelings (e.g., anger, longing, hurt).
Response to the case study Experimentation with these sensations may
The Gestalt therapist begins with Sandra’s begin to free her to express and meet these
current experience of the world, starting with feelings more directly. All of this work
awareness and attention. The therapist may encourages Sandra’s experimentation with new
simply help her become aware of basic sights, ways of relating both during and outside of the
sounds, somatic reactions, feelings, and session in order to move into the “here and
thoughts as well as what her attention drifts to. now” and work toward the resolution of
The immediate contact between therapist and “unfinished business.”
client is a component of the “now” where these
sensations are explored directly. The therapist The Existential Approach
might notice and ask about her style of eye To Therapy
contact, or her fidgeting body, or stream of
thoughts (e.g., “What is it like to make eye The existential approach to therapy emphasizes
the following six propositions:
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Chapter 6
1. All persons have the capacity for self- humanistic approaches and techniques. Yalom,
awareness. for example, perceives the therapist as a “fellow
2. As free beings, everyone must accept the traveler” through life, and he uses empathy and
responsibility that comes with freedom. support to elicit insight and choices. He
3. Each person has a unique identity that can strongly believes that because people exist in the
only be known through relationships with presence of others, the relational context of
others. group therapy is an effective approach (Yalom,
4. Each person must continually recreate 1980).
himself. The meaning of life and of Preliminary observations and research
existence is never fixed; rather, it constantly indicate individuals with low levels of perceived
changes. meaning in life may be prone to substance abuse
5. Anxiety is part of the human condition. as a coping mechanism. Frankl first observed
6. Death is a basic human condition that gives this possibility among inpatient drug abusers in
significance to life. Germany during the 1930s (Frankl, 1959).
Nicholson and colleagues found inpatient drug
The core question addressed in existential
therapy is “How do I exist?” in the face of abusers had significantly lower levels of
uncertainty, conflict, or death. An individual meaning in life when compared to a group of
achieves authenticity through courage and is matched, nonabusing control subjects
thus able to define and discover his own (Nicholson et al., 1994). Shedler and Block
meaning in the present and the future. There performed a longitudinal study and found that
are important choices to be made (e.g., to have lower levels of perceived life meaning among
true freedom and to take responsibility for one’s young children preceded substance abuse
life, one must face uncertainty and give up a patterns in adolescence (Shedler and Block,
false sense of security). 1990).
A core characteristic of the existential view is In the context of treating substance abuse
that an individual is a “being in the world” who disorders, the existential therapist often serves
has biological, social, and psychological needs. as a coach helping the client confront the anxiety
Being in the world involves the physical world, that tempts him to abuse substances. The client
the world of relationships with others, and one’s is then focused on taking responsibility and
own relationship to self (May and Yalom, 1995, making his own choices to remain substance
p. 265). The “authentic” individual values free. If he chooses to avoid the anxiety through
symbolization, imagination, and judgment and substances, he cannot move forward to find
is able to use these tools to continually create truth and authenticity. The challenge for the
personal meaning. existential therapist is to help the client make
Existential therapy focuses on specific personal decisions about how to live, drawing
concerns rooted in the individual’s existence. upon creativity and love, instead of letting
The contemporary existential psychotherapist, outside events determine behavior.
Irvin Yalom, identifies these concerns as death,
isolation, freedom, and emptiness. Existential
Time and Existential Therapy
therapy focuses on the anxiety that occurs when Although existential therapy may not have been
a client confronts the conflict inherent in life. designed for practice in a time-limited fashion,
The role of the therapist is to help the client its underlying principles relating to the client’s
focus on personal responsibility for making struggle for meaning in the face of death can be
decisions, and the therapist may integrate some applied to a time-limited setting. Brief therapy
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Brief Humanistic and Existential Therapies
(no matter what the modality) must be and ways of dealing (or not dealing) with
concerned with the “here and now.” Both choices about substance abuse. The focus in her
existential and brief therapies are also concerned therapy would be on choosing the life she wants
with the limitations of time. Hoyt suggests that to live. The therapist would assist her in dealing
in brief therapy time should always be an issue constructively with anxiety so that she can find
for discussion, and the therapist should make a meaning in the rest of her life. This could be
point of reminding the client of his use of time accomplished by engaging her in the struggle to
and the time scheduled for terminating therapy assume authorship of her choices. She may be
(Hoyt, 1995). encouraged to “play out” scenarios of choices
Mann’s model of time-limited psychotherapy she faces and acknowledge the accompanying
(Mann, 1973; Mann and Goldman, 1994), fears and anxieties. She might be asked, “What
although based in part on psychodynamic keeps you from sharing your fears with your
theory, also uses an existential approach to the husband, and accepting the possibility of his
primacy of time. In Mann’s approach, the time support?” or “Imagine yourself expressing your
limitation of brief therapy is emphasized to help love for your children and regret for the
the client confront issues of separateness and mistakes you have made.” Thus, the therapist
isolation. This facilitates the client’s becoming would help her understand that making difficult
engaged in and responsible for the process of choices in the face of death is actually a way to
recovery. find integrity, wholeness, and meaning.
The teachings of the existential therapist,
Response to the case study
Yalom, can be a useful resource in dealing with
An existential therapist may help Sandra
issues related to death, since he has worked with
understand that her diagnosis of AIDS forces
terminally ill cancer patients for many years,
her to confront the possibility of death and,
helping them to use their crisis and their danger
consequently, face the responsibilities thrust
as an opportunity for change (Yalom, 1998).
upon her by life. The therapist could accomplish
Yalom explains that although death is a primary
this by helping her understand that her life (like
source of anxiety for a client, incorporating
everyone else’s) is finite. Therefore, she is
death into life can enrich life and allow one to
challenged to forge meaning from her life and
live more purposefully.
make difficult decisions about her relationships
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7 Brief Psychodynamic Therapy
P
sychodynamic therapy focuses on moderate severity of substance abuse. It is also
unconscious processes as they are important that the psychodynamic therapist
manifested in the client’s present know about the pharmacology of abused drugs,
behavior. The goals of psychodynamic therapy the subculture of substance abuse, and 12-Step
are client self-awareness and understanding of programs.
the influence of the past on present behavior. In Psychodynamic therapy is the oldest of the
its brief form, a psychodynamic approach modern therapies. As such, it is based in a
enables the client to examine unresolved highly developed and multifaceted theory of
conflicts and symptoms that arise from past human development and interaction. This
dysfunctional relationships and manifest chapter demonstrates how rich it is for
themselves in the need and desire to abuse adaptation and further evolution by
substances. contemporary therapists for specific purposes.
Several different approaches to brief The material presented in this chapter provides
psychodynamic psychotherapy have evolved a quick glance at the usefulness and the complex
from psychoanalytic theory and have been nature of this type of therapy.
clinically applied to a wide range of
psychological disorders. A growing body of Background
research supports the efficacy of these
approaches (Crits-Christoph, 1992; Messer and The theory supporting psychodynamic therapy
Warren, 1995). originated in and is informed by psychoanalytic
Short-term psychodynamic therapies can theory. There are four major schools of
contribute to the armamentarium of treatments psychoanalytic theory, each of which has
for substance abuse disorders. Brief influenced psychodynamic therapy. The four
psychodynamic therapies probably have the schools are: Freudian, Ego Psychology, Object
best chance to be effective when they are Relations, and Self Psychology.
integrated into a relatively comprehensive Freudian psychology is based on the theories
substance abuse treatment program that first formulated by Sigmund Freud in the early
includes drug-focused interventions such as part of this century and is sometimes referred to
regular urinalysis, drug counseling, and, for as the drive or structural model. The essence of
opioid-dependents, methadone maintenance Freud’s theory is that sexual and aggressive
pharmacotherapy. Brief psychodynamic energies originating in the id (or unconscious)
therapies are perhaps more helpful after are modulated by the ego, which is a set of
abstinence is well established. They may be functions that moderates between the id and
more beneficial for clients with no greater than external reality. Defense mechanisms are
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Chapter 7
constructions of the ego that operate to appear to the user to be capable of curing the
minimize pain and to maintain psychic central defect in the self.
equilibrium. The superego, formed during [T]he ingestion of the drug provides him with
latency (between age 5 and puberty), operates to the self-esteem which he does not possess.
control id drives through guilt (Messer and Through the incorporation of the drug, he
supplies for himself the feeling of being
Warren, 1995).
accepted and thus of being self-confident; or
Ego Psychology derives from Freudian he creates the experience of being merged with
psychology. Its proponents focus their work on the source of power that gives him the feeling
enhancing and maintaining ego function in of being strong and worthwhile (Blaine and
Julius, 1977, pp. viiviii).
accordance with the demands of reality. Ego
Psychology stresses the individual’s capacity for Each of the four schools of psychoanalytic
defense, adaptation, and reality testing (Pine, theory presents discrete theories of personality
1990). formation, psychopathology formation, and
Object Relations psychology was first change; techniques by which to conduct
articulated by several British analysts, among therapy; and indications and contraindications
them Melanie Klein, W.R.D. Fairbairn, D.W. for therapy. Psychodynamic therapy is
Winnicott, and Harry Guntrip. According to distinguished from psychoanalysis in several
this theory, human beings are always shaped in particulars, including the fact that
relation to the significant others surrounding psychodynamic therapy need not include all
them. Our struggles and goals in life focus on analytic techniques and is not conducted by
maintaining relations with others, while at the psychoanalytically trained analysts.
same time differentiating ourselves from others. Psychodynamic therapy is also conducted over a
The internal representations of self and others shorter period of time and with less frequency
acquired in childhood are later played out in than psychoanalysis.
adult relations. Individuals repeat old object Several of the brief forms of psychodynamic
relationships in an effort to master them and therapy are considered less appropriate for use
become freed from them (Messer and Warren, with persons with substance abuse disorders,
1995). partly because their altered perceptions make it
Self Psychology was founded by Heinz difficult to achieve insight and problem
Kohut, M.D., in Chicago during the 1950s. resolution. However, many psychodynamic
Kohut observed that the self refers to a person’s therapists work with substance-abusing clients,
perception of his experience of his self, in conjunction with traditional drug and alcohol
including the presence or lack of a sense of self- treatment programs or as the sole therapist for
esteem. The self is perceived in relation to the clients with coexisting disorders, using forms of
establishment of boundaries and the brief psychodynamic therapy described in more
differentiations of self from others (or the lack of detail below.
boundaries and differentiations). “The
explanatory power of the new psychology of the Introduction to Brief
self is nowhere as evident as with regard to…the
addictions” (Blaine and Julius, 1977, p. vii).
Psychodynamic Therapy
Kohut postulated that persons suffering from The healing and change process envisioned in
substance abuse disorders also suffer from a long-term psychodynamic therapy typically
weakness in the core of their personalities—a requires at least 2 years of sessions. This is
defect in the formation of the “self.” Substances because the goal of therapy is often to change an
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Brief Psychodynamic Therapy
aspect of one’s identity or personality or to Barber, 1991). For example, some brief
integrate key developmental learning missed psychodynamic models focus mainly on
while the client was stuck at an earlier stage of symptom reduction (Horowitz, 1991), while
emotional development. others target the resolution of the Oedipal
Practitioners of brief psychodynamic therapy conflict (Davanloo, as interpreted by Laikin et
believe that some changes can happen through a al., 1991). The length of therapy is usually
more rapid process or that an initial short related to the ambitiousness of the therapy
intervention will start an ongoing process of goals. Most therapists are flexible in terms of
change that does not need the constant the number of sessions they recommend for
involvement of the therapist. A central concept clinical practice. Often the number of sessions
in brief therapy is that there should be one major depends on a client’s characteristics, goals, and
focus for the therapy rather than the more the issues deemed central by the therapist.
traditional psychoanalytic practice of allowing
the client to associate freely and discuss Psychodynamic
unconnected issues (Malan, 1976). In brief
Psychotherapy for
therapy, the central focus is developed during
the initial evaluation process, occurring during Substance Abuse
the first session or two. This focus must be
Supportive-expressive (SE) psychotherapy
agreed on by the client and therapist. The
(Luborsky, 1984) is one brief psychodynamic
central focus singles out the most important
approach that has been adapted for use with
issues and thus creates a structure and identifies
people with substance abuse disorders. It has
a goal for the treatment. In brief therapy, the
been modified for use with opiate dependence
therapist is expected to be fairly active in
in conjunction with methadone maintenance
keeping the session focused on the main issue.
treatment (Luborsky et al., 1977) and for cocaine
Having a clear focus makes it possible to do
use disorders (Mark and Faude, 1995; Mark and
interpretive work in a relatively short time
Luborsky, 1992). There have been many studies
because the therapist only addresses the
of the use of SE therapy for substance abuse
circumscribed problem area. When using brief
disorders, resulting in a significant body of
psychodynamic approaches to therapy for the
empirical data on its effectiveness in treating
treatment of substance abuse disorders, the
these problems (see below).
central focus will always be the substance abuse
Mark and Faude asserted that although their
in association with the core conflict. Further, the
therapeutic approach was devised specifically
substance abuse and the core conflict will
for cocaine-dependent clients, these people often
always be conceptualized within an
have multiple dependencies, and this approach
interpersonal framework.
can be used to treat a variety of substance abuse
The number of sessions varies from one
disorders. However, clients should be
approach to another, but brief psychodynamic
reasonably stable in terms of their substance
therapy is typically considered to be no more
abuse before beginning this type of therapy
than 25 sessions (Bauer and Kobos, 1987). Crits-
(Mark and Faude, 1995).
Christoph and Barber included models allowing
Mark and Faude theorized that substances of
up to 40 sessions in their review of short-term
abuse substitute a “chemical reaction” in place
dynamic psychotherapies because of the
of experiences and that these chemically
divergence in the scope of treatment and the
induced experiences can block the impact of
types of goals addressed (Crits-Christoph and
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Chapter 7
other external events. The person with a “They’re just waiting for me to make a fool of
substance abuse disorder will therefore have a myself.”
“tremendously impoverished and impaired
For many people with substance abuse
capacity to experience,” and traditional
disorders, alcohol or drug use is a way of self-
psychotherapy might have to be augmented
medicating against feelings of low self-worth
with techniques that focus on increasing a
and low self-esteem that reflect the client’s RS.
client’s ability to experience (Mark and Faude,
A negative RO reinforces a negative RS and can
1995, p. 297).
lead to the deceptive and manipulative behavior
Effective SE therapy depends on appropriate
that is sometimes observed in this population.
use of what is termed the core conflictual
The client’s RS is based on the individual’s
relationship theme (CCRT), a concept first
somatic experiences, actions, and perceived
introduced by Lester Luborsky. According to
needs. Following are examples of statements
Luborsky, a CCRT is at the center of a person’s
that could reflect a client’s core RS:
problems. The CCRT develops from early
childhood experiences, but the client is unaware “I’m so stupid and gullible.”
the client will have better control over behavior “If I didn’t use drugs, I would lose my
experiences (Bohart and Todd, 1988). The CCRT A third component of CCRT is a person’s
develops out of a core response from others (RO), wish; it reflects what the client yearns for, wishes
which represents a person’s predominant for, or desires. The client’s “wish” is largely
expectations or experiences of others’ internal based on individual personality style. Those
and external reactions to herself, and a core with substance abuse disorders often have a
response of the self (RS), which refers to a more or wish to continue using the substance without
less coherent combination of somatic having to endure the consequences. Put another
experiences, affects, actions, cognitive style, self- way, they would like to be accepted (or loved or
esteem, and self-representations. appreciated) as they are, without having to give
Most people with substance abuse disorders up the pleasure they get from their use
have particularly negative expectations of (Levenson et al., 1997). Many people who have
others’ attitudes toward them (that is, the RO), substance abuse disorders have much invested
although it remains unclear which came first— in denying that they really have a problem, in
this response or the substance abuse disorder. portraying themselves as helpless victims, and
Either way, the two become mutually in disclaiming their role in the behavior that has
reinforcing. Following are examples of brought them into treatment.
statements that reflect the core RO of a person Once therapy has been initiated, the therapist
with a substance abuse disorder: and client can work together to put the client’s
“Everybody hates me.” goals into the CCRT framework and explore the
“I am just being used.” meaning, function, and consequence of her
“People laugh at me.” substance abuse, looking in particular at how
“No one understands how I feel.” the RO and RS have contributed to the problem.
“Everybody wants me to be something I’m The CCRT framework also can be used to
not.” identify potential obstacles in the recovery
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Brief Psychodynamic Therapy
process as the therapist and client explore the months ago. At the beginning of treatment, she
client’s anticipated responses from others and told Christopher that she was going to request
from herself and discuss how these perceptions medication from her physician for her back pain.
will change when she stops abusing substances. After her eighth session, with her reluctant
The CCRT concept also can help clients deal agreement, Christopher informed the physician
with relapse, which is regarded by virtually all that she was in treatment for cocaine
experts in the field as an integral and natural dependence. Christopher asked the physician to
part of recovery. Relapse offers the client and find a medication other than diazepam (Valium)
the SE therapist the opportunity to examine how for Stella’s back pain.
the RO and RS can serve as triggers and to Stella began the 19th session complaining
devise strategies to avoid these triggers in the that ever since the physician found out she was
future. Finally, SE therapy is conducive to client a drug user, he has treated her differently. “He
participation in a self-help group such as thinks I’m a scumbag drug addict,” she said.
Alcoholics Anonymous, or it can be used as a Christopher acted uncharacteristically: he
mechanism to examine a client’s unwillingness offered some advice. He suggested that Stella
to participate in these groups. consider telling her physician how she feels
about his treatment. The intervention strikingly
Stella and Christopher: altered the mood and productivity of the
A Case Study session. After a brief expression of sympathy for
The case study in this section came from the her position, he focused on her extreme distress
NIDA Collaborative Cocaine Study (Mark and over the physician’s treatment. He attempted to
Faude, 1997; adapted with permission). SE is explain the intensity of her reaction in terms of
the therapeutic approach used. projection: that she responded so strongly
While dependent and impulsive, Stella, a 28- because of her negative view of herself.
year-old cocaine-dependent woman, would be Matters got worse as the session continued.
seen under many circumstances as warm and Stella related a second negative incident when
open. She appears to be the kind of person who she described her treatment by the physician in
wears her heart on her sleeve, but it is a big a group therapy session. The group therapist
heart nonetheless, capable of caring for others responded, “Well, you manipulate doctors!”
with loyalty and compassion. In addition, she Stella had been furious.
has a tenacity of spirit; despite a horrific Christopher encouraged her to say more.
personal history she completed her training as a Stella became frustrated at Christopher’s lack of
medical technician and has worked in that understanding and explained that again, she felt
capacity for much of the last 4 years. Her she was being treated like a “scumbag,” this
therapist, Christopher, is a well-trained time by the group therapist. Christopher
psychodynamically oriented therapist. He is an suggested that Stella might tell both the
intelligent, serious, and measured person, physician and the group therapist how she felt.
whose well-meaning nature comes through The tension in the session disappeared, and
under most circumstances despite his natural Stella remarked that she has always had trouble
reserve. sticking up for herself.
Stella has a history of polysubstance abuse, In supervision, Christopher realized
including the abuse of prescription drugs, both immediately that he was indirectly letting Stella
anxiolytics and opioids. She worked as a know that he understood and agreed with her.
medical technician until she injured her back 3
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Chapter 7
Diagnostically speaking, Stella has a Stella’s drug use became a part of the therapy
borderline personality disorder as defined by in two ways. In the first session, Stella told
the Diagnostic and Statistical Manual of Mental Christopher that she had taken
Disorders, 4th Edition [DSM-IV] (American chlordiazepoxide for several days before their
Psychiatric Association, 1994). When she was appointment, to relieve her anxiety. She pointed
between 6 and 8 years old, Stella’s maternal out that it had been prescribed by a doctor.
grandfather sexually abused her. Her parents Presumably, Christopher would have known
divorced when she was 10, and she lived with the results of her drug screen, which was part of
her mother, who was often drunk and the program. She thus confessed before being
physically abusive. Stella said she was closer to confronted by drug screen results. Her claim
her father, whom she described as gentle. He that the prescription was legitimate facilitated
appeared to others as weak and ineffectual. her denial that she has anything to be concerned
At age 15, Stella ran off with a boyfriend who about.
was also her pimp. After 2 weeks she returned Second, Stella announced her intention to ask
home, was unable to leave her mother, and was her physician for diazepam, a commonly abused
diagnosed as having agoraphobia, for which she medication. By contacting her physician,
took chlordiazepoxide (Librium). Two years Christopher replayed a common scenario in her
later she ran away with another man, a life: she signals that someone should take
particularly sadistic pimp. For 5 years she was control or care for her, then resents it when they
too terrified to leave him. It was during this do, feeling that she is being treated like a
period that she started using cocaine. “scumbag drug addict.” She can create the
The cocaine both “disclaims action” and largely illusory sense of being cared for when
affirms her “badness.” Her cocaine use enabled someone treats her as a helpless incompetent.
her to avoid examining why she stayed with her Was this how Christopher was treating her
boyfriend and simultaneously affirmed her when he called her physician?
badness. So, she deserves her fate. She would When Christopher suggested that she tell the
use the cocaine to clear her painful feelings and physician and the group therapist how she felt
feel “strong and independent,” then “feel like a about the way they had treated her, his words
big baby for having to use the drugs.” She may have given advice, but his communication
thought of herself as a “big baby,” for returning actually conveyed agreement with Stella’s
to her mother at age 15 and for being unable to position that she had been unfairly treated.
leave her current boyfriend. Her reactions to Stella experienced Christopher’s agreement
cocaine are typical; a brief surge or a “high,” and support through his intervention.
followed by a crash. However, these typical However, what could have made this a more
reactions also fit her core theme: she wants to be powerful therapeutic interaction would have
loved and cared for but believes she will be been either for Christopher to directly
thwarted and exploited by others because of this acknowledge his misgivings about having taken
wish. Her response then is to use drugs, which charge and contacted the physician or to explore
makes her feel strong and independent for a how Stella came to hear his initial obliqueness as
brief time and also makes her see herself as giving her what she wanted—his care and
deserving of being thwarted and exploited, support.
which has happened repeatedly in interpersonal
contexts in her life.
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Brief Psychodynamic Therapy
127
Chapter 7
optimal approach for providing treatment for Although there is some disagreement in the
substance abuse disorders (Strean, 1994). details, this type of brief therapy is generally
What this means for practitioners of thought more suitable for the following types of
psychodynamically oriented treatments is that clients:
in addition to providing the more dynamic
Those who have coexisting psychopathology
interventions, it is important to also incorporate
with their substance abuse disorder
direct, drug-focused interventions. This can be
Those who do not need or who have
accomplished by one therapist combining both
completed inpatient hospitalization or
models or, in a comprehensive treatment
detoxification
program for substance users, one therapist
Those whose recovery is stable
providing dynamic therapy and an alcohol and
Those who do not have organic brain
drug counselor providing direct, drug-focused
damage or other limitations due to their
counseling. It can be argued that this is why SE
mental capacity
therapy was so helpful in the methadone
studies. In those studies, psychodynamic
therapy was well integrated into a
Psychodynamic Concepts
comprehensive methadone maintenance Useful in Substance
program. In other words, in addition to the Abuse Treatment
dynamic therapy, clients received substance
abuse disorder counseling along with Psychodynamic theories endeavor to provide
methadone (Woody et al, 1998). coherent explanations for intrapsychic and
One study conducted a small, controlled trial interpersonal workings. Because of the
comparing SE therapy to a brief (one-session) importance of this approach in the development
intervention for marijuana dependence. The SE of modern therapy, the techniques that stem
approach was adapted for use in treatment of from these theories are inevitably used in any
cannabis dependence (Grenyer et al., 1995) and type of psychotherapy, whether or not it is
was offered once a week for 16 weeks. Results identified as “psychodynamic.” For example,
showed that both interventions were helpful but people who have worked with those who have
SE therapy produced significantly larger substance abuse disorders are familiar with
reductions in cannabis use, depression, and “denial,” even if they are not aware that this
anxiety, and increases in psychological health process is one of the psychodynamic defense
(Grenyer et al., 1996). The authors concluded mechanisms. Counselors whose clients have an
that SE therapy could be an effective treatment immediate and strong negative reaction to them
for cannabis dependence. often benefit from an understanding of the
concept of “transference.” It also is helpful for
Clients Most Suitable for an alcohol and drug counselor who is left feeling
Psychodynamic Therapy hopeless and confused after a session to
Brief psychodynamic therapy is more understand how “countertransference” could be
appropriate for some types of clients with at work. Therefore, counselors who treat clients
substance abuse disorders than others. For with substance abuse disorders can benefit from
some, psychodynamic therapy is best understanding the basic concepts of general
undertaken when they are well along in psychodynamic theory discussed in this section,
recovery and receptive to a higher level of self- even if they do not use a strictly psychodynamic
knowledge. intervention.
128
Brief Psychodynamic Therapy
129
Chapter 7
very focused and active uncovering of the These options include learning to separate his
unconscious. reactions to the supervisor from his feelings
Contemporary analytic theorists who about his father, working through his feelings
concern themselves with substance abuse about his father (of which he may not have been
disorders typically do not focus on the idea that previously aware), actively choosing alternative
addiction is linked to a developmentally behaviors to drinking when he feels bad (e.g.,
primitive level of ego functioning, although they attending a 12-Step meeting), and accepting
may endorse it. One reason is that this idea greater responsibility for his feelings and
leads to a rather pessimistic belief regarding the behaviors.
outcome of analytic treatments for substance A broader definition of insight, also
abuse disorders. Another reason is that it does promoted by brief psychodynamic therapies, is
not contribute helpful information to the simply any realization about oneself, one’s inner
therapeutic approach, and it can impede the workings, or one’s behavior. For example, a
development of an empathic and respectful client who says, “the only emotion I really feel is
therapeutic alliance. Furthermore, there is anger,” has opened the door to understanding
increasing empirical evidence for the idea that the effect others have on her, and vice versa.
severe substance abuse is largely driven by She can then begin to develop alternative
biobehavioral forces and that individual behaviors to those that previously followed
psychological factors are of lesser importance automatically from her anger (such as drinking),
(Babor, 1991). Although analytic theories have as well as to understand why her emotional
tended to ignore this (Leeds and Morgenstern, repertoire is so limited.
1996), it has become increasingly a part of the Insight involves both thoughts and feelings.
knowledge base in understanding substance A purely intellectual exercise will not lead to
abuse disorders. behavior change. True insight involves a
powerful emotional experience as well as a
Insight cognitive component and leads to a greater
Another critical underlying concept of acceptance of responsibility for feelings and
psychodynamic theory—and one that can be of behavior. In treating substance abuse disorders,
great benefit to all therapists—is the concept of it is important to recognize that insight alone is
insight. Psychodynamic approaches regard often not sufficient to create change. Substances
insight as a particular kind of self-realization or of abuse are powerful behavioral reinforcers and
self-knowledge, especially regarding the the therapist needs to help the client counter the
connections of experiences and conflicts in the strong compulsive desire for them. Thus, in
past with present perceptions and behavior and addition to insight, it could be helpful to offer
the recognition of feelings or motivations that psychoeducation and make behavioral
have been repressed. Insight can come through interventions, which might include encouraging
a sudden flash of understanding or from attendance and participation in self-help
gradual acquisition of self-knowledge. So, for programs and requiring regular testing by
example, a client who feels depressed and angry urinalysis and/or Breathalyzer™. Many
and subsequently drinks comes to realize that therapists who conduct substance abuse
his feelings toward his father are stimulated by treatment from a psychodynamic perspective
an emotionally abusive supervisor at work. This are comfortable combining insight-oriented
type of realization gives the client new options. therapy with concrete, behavioral interventions.
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Brief Psychodynamic Therapy
Figure 7-1
Defense Mechanisms
Denial. Pretending that a threatening situation does not exist because the situation is too distressing
to cope with. A child comes home, and no one is there. He says to himself, “They are here. I’ll find
them soon.”
Displacement. Feelings and thoughts directed toward one person or object are directed toward
another person. For example, an employee has feelings of anger toward his boss but is unaware of
these feelings because of his internal conflict over acknowledging them. Instead he becomes
disproportionately angry at his wife over a minor problem at home.
Grandiosity. Although not one of the originally identified analytic defenses, grandiosity is frequently
employed by substance abusers (Mark and Luborsky, 1992). Grandiosity defends against
unconscious low self-esteem by invoking self-deceptive, overly positive opinions about oneself. An
example of grandiosity in a substance-abusing client is the client who insists that he can maintain
control of drug use despite the fact that he was using an increasingly large amount of drugs with
increasing frequency. This example can be seen as denial as well because denial involves denying or
minimizing the consequences of the addiction. However, the grandiosity is evident in the user’s
unrealistic belief that he is in control of his drug use when it would seem that his use is compulsive
and clearly out of control at this point.
Identification with the aggressor. The activity of doing unto someone else what aroused anxiety when
it was done to oneself. A child has a tonsillectomy. She then puts on a toy stethoscope and goes
around pretending to take out the tonsils of her playmates.
Introjection. The individual “takes inside” himself what is threatening. For example, a child feels
strong anxiety about losing a parent’s love when the latter admonishes her for not cleaning her
room. To cope with the anxiety she tells herself, “You are a bad girl.”
Isolation. Painful ideas are separated from feelings associated with them. To face the full impact of
sexual or aggressive thoughts and feelings, the ideas and affects are kept apart. For example, the
thought of shouting obscenities in a church is kept separate from all the rage about being in church.
Thus, in isolation the individual may have fleeting thoughts of an aggressive or sexual nature
without any emotional accompaniment.
Projection. This is the opposite of introjection; an intolerable idea or feeling is ascribed to someone
else. For example, it could be hypothesized that because the late Senator Joseph McCarthy could not
tolerate his own homosexual wishes, he spent much time compiling lists of men in the State
Department who, according to McCarthy, were hiding their homosexuality.
132
Brief Psychodynamic Therapy
Khantzian theorizes that deficits, rather than continues to be a popular theory although most
conflicts, underlie the problems of those with researchers and therapists now would say that
substance abuse disorders. That is, weakness or this can offer only partial answers to the
inadequacies in the ego or self are at the root of questions of how abusers develop drug
the problem. Khantzian and colleagues preferences and what the meaning is of such
developed Modified Dynamic Group Therapy preferences. It is important to consider the
(MDGT) to address these issues in a group social and physical environmental context of
therapy format, and this approach has some substance abuse as well. That is, whatever
empirical support. Khantzian put forth the self- drugs are most readily available in a person’s
medication hypothesis, which essentially states community and what his peers and associates
that substance abusers will use substances in an are using also have a strong influence on a
attempt to medicate specific distressing user’s drug preference.
psychiatric symptoms (Khantzian, 1985). It Krystal offers two possible theories of the
follows, then, that substance-dependent persons etiology of substance abuse disorders. One is
will express a strong preference for a particular based on an object-relations conceptualization.
drug of choice to medicate their particular set of In this theory, the substance abuser experiences
symptoms. For example, those dependent on the substance as the primary maternal object.
opioids are thought to be medicating intense The substance abuser relates to the substance in
anger and aggression that their egos are unable the same maladaptive relationship patterns that
to contain. Cocaine-dependent people are she experienced developmentally with the
believed to be seeking relief from intense mother. The second theory focuses on the
depression or emotional lability (as in bipolar substance abuser’s disturbed affective functions,
disorders) or attention deficit disorder. This known as alexithymia. It is thought that
133
Chapter 7
individuals with alexithymia do not recognize urge” to abuse substances—an urge that can
the cognitive aspects of feeling states. Instead, take precedence over every other aspect of life.
they experience an uncomfortable, global state Furthermore, the symptom (substance abuse) is
of tension in response to all affective stimuli. often considered pleasurable by the client, in
Thus they seek to relieve this discomfort with contrast to the symptoms of other psychological
substances. disorders (such as anxiety or depression). Thus,
McDougall views substance abuse as a “[psychodynamic] therapy should be considered
psychosomatic disorder. It is a way of dealing as part of an overall treatment plan that includes
with distress that involves externalizing and some kind of drug counseling and possibly
making physical what is essentially a other interventions as well, such as medications
psychological disturbance. Substance abuse and family therapy” (Levenson et al., 1997,
then is the habitual use of an externalizing p. 125).
defense against painful or dangerous affects.
McDougall suggests that these painful affects
Integrating Psychodynamic
are the response to deep uncertainty about one’s Concepts Into Substance Abuse
right to exist, one’s right to a separate identity, Treatment
and one’s right to have control over one’s body Many of the concepts and principles used in
limits and behavior. The abuse of drugs is part psychodynamic therapy with clients who have
of a “false self” that the individual creates to substance abuse disorders are similar to those
ward off these painful feelings. used with clients who have other psychiatric
Some critics have argued that a major disorders. However, most therapists agree that
limitation of those psychoanalytic theories is people with substance abuse disorders comprise
that they do not make allowances for the a special population—one that often requires
biological bases of substance abuse disorders more structure and a combined treatment
(Babor, 1991). However, contemporary approach if treatment is to be successful. To
psychoanalytic theorists acknowledge that effectively treat these clients, it is important to
biology plays a role in behaviors related to combine skill in the provision of the model of
substance abuse. But the unanswered question therapy with knowledge of the general factors in
remains whether biological or psychological the treatment of substance abuse disorders.
factors come first: Why does a person start using These include knowledge of the pharmacology
substances? Analytic concepts are useful here, and the intoxication and withdrawal effects of
in that they can be said to facilitate the drugs, familiarity with the subculture of
resolution of problems that contribute to substance abuse and with substance-dependent
emotional distress and to help explore the lifestyles, and knowledge of self-help programs.
connection among interpersonal patterns, It also helps to feel comfortable working with
emotions, and substance abuse. substance abusers and for one’s therapeutic style
Levenson and colleagues offer such a theory to express acceptance of and empathy for the
(Levenson et al., 1997). They describe a client. In modifying SE psychotherapy for use
biopsychosocial conceptualization of substance with clients with substance abuse disorders,
abuse disorders that can, in part, be addressed Luborsky and colleagues identified certain
by brief psychodynamic therapy. In this model, emphases that are particularly important
substance abuse disorders are particularly (Luborsky et al., 1977, 1989). These emphases,
difficult to treat because, unlike other listed below, are relevant for applying other
psychological disorders, there is a “primary
134
Brief Psychodynamic Therapy
135
Chapter 7
Figure 7-2
Brief Psychodynamic Therapy
Therapy Length of Focus Major Techniques
(Theorist) Treatment
Time-Limited 12 sessions Central issue related to Formulation, presentation, and
Psychotherapy conflict about loss interpretations of the central issue
(Mann) (lifelong source of pain, Interpretation around earlier
attempts to master it, losses
and conclusions drawn Termination
from it regarding the
client’s self-image)
Short-Term Usually 12 Unresolved conflict Early transference interpretation
Anxiety-Provoking to 15 defined during the Confrontation/clarification/inter-
Psychotherapy sessions evaluation pretations
(Nielsen and Barth)
Intensive Short- 5 to 30 ses- Experiencing and Relentless confrontation of
Term Dynamic sions; up to linking interpersonal defenses
Psychotherapy 40 sessions conflicts with impulses, Early transference interpretation
(Laikin, Winston, for severe feelings, defenses, and Analysis of character defenses
and McCullough) personality anxiety
disorders
SE Therapy 16 for major Focus on the core Supportive: creating therapeutic
(Luborsky and depression, conflictual relationship alliance through sympathetic
Mark) 36 for theme listening
cocaine Expressive: formulating and inter-
dependence preting the CCRT; relating sym-
ptoms to the CCRT and explaining
them as coping attempts
136
Brief Psychodynamic Therapy
Sources: Crits-Christoph and Barber, 1991; Klerman and Weissman, 1993; Rounsaville and Carroll, 1993.
137
Chapter 7
the client’s consciousness so that they can then “cyclical maladaptive pattern,” which includes
be explored and resolved. four categories of information:
138
Brief Psychodynamic Therapy
139
Chapter 7
Strategies for dealing with the interpersonal efficacy of 12 sessions of weekly individual
context emerge and are tried by the client psychotherapy, without adjunctive
(problemsolving). pharmacotherapy, as the sole treatment for 42
subjects who were randomly assigned to either
Other Research IPT or RP. Rates of attrition were significantly
higher for IPT than for RP, with only 38 percent
In addition to Supportive-Expressive of those in IPT compared to 66 percent of those
psychotherapy, both IPT and MGDT have been in RP completing the 12-week course of
studied as therapies for use in the treatment of treatment (Rounsaville and Carroll, 1993). On
substance abuse disorders. most outcome measures there were no
IPT has been evaluated as an adjunctive significant differences between the two
treatment for a full-service methadone clinic treatment conditions; both were associated with
(Rounsaville et al., 1983). This was a favorable outcomes. However, for clients with
collaborative research project that paralleled a more severe psychiatric symptoms or more
study by Woody and colleagues (Woody et al., severe drug use, those who received RP were
1983). Seventy-two methadone-maintained, more likely to become abstinent than those who
opiate-dependent subjects who were diagnosed received IPT. Clients with more severe
with a psychiatric disorder (e.g., depression) substance abuse disorders may require the
were randomly assigned to one of two treatment greater structure and direction offered by the
conditions, each lasting 6 months. The relapse prevention approach (Rounsaville and
treatments were IPT offered once a week and Carroll, 1993). This is entirely consistent with
low contact, consisting of one 20-minute the observation that substance-focused
meeting per month, when symptoms and social interventions are perhaps the optimal approach
functioning were reviewed. Both groups also for treating substance abuse disorders (Strain,
received treatment as usual in the methadone- 1999). Based on the rather modest empirical
maintenance program that included a weekly support, Rounsaville and Carroll suggested that
90-minute session of group counseling. The the role of IPT in the treatment of substance
main findings were that it was extremely abuse disorders might be the following:
difficult to recruit and retain clients in the
To introduce clients into treatment
program and that although both treatments
To treat clients with lower levels of substance
were associated with significant clinical
improvements during the 6-month period, there abuse
To treat clients who did not benefit from
was essentially no advantage to IPT over low
contact. This study was done in a program in other modalities
To complement other ongoing treatment
which clients were suspended after 3 months if
they continued to use illicit drugs, thus modalities
To help clients maintain and solidify gains
providing a potent behavioral intervention. For
the control group, clients were forced to do well following the establishment of stable
or leave the program. abstinence
A second study (Carroll et al., 1991) Khantzian and colleagues developed MGDT
compared IPT with Relapse Prevention (RP), a to address the characterological underpinnings
cognitive–behavioral therapy (Marlatt and of substance abuse disorders (Khantzian et al.,
Gordon, 1985) for the treatment of ambulatory 1990). The group has four main goals:
cocaine-using clients. This study evaluated the
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Brief Psychodynamic Therapy
1. The development of affect tolerance This approach has shown efficacy for abuse
2. The building of self-esteem in research, but the research was not
3. The discussion and improvement of comparative, so it is not known how effective
interpersonal relationships this approach is in contrast to other approaches.
4. The development of appropriate self-care
strategies
141
8 Brief Family Therapy
S
ubstance abuse disorders do not develop Family involvement is often critical for
in isolation. For many individuals with success in treating many substance abuse
substance abuse disorders, interactions disorders—most obviously in cases where
with the family of origin, as well as the current elements of the family are inadvertently
family, set the patterns and dynamics for their reinforcing or supporting the problem. In some
problems with substances. Furthermore, family cases, another family member has a different
member interactions with the substance abuser agenda from the rest of the family. For example,
can either perpetuate and aggravate the problem the husband of a recovering substance abuser
or substantially assist in resolving it. Family may have taken on additional roles in the family
therapy is suggested when the client exhibits as a result of the vacuum left when his wife was
signs that substance abuse is strongly influenced abusing substances. The husband may be
by family members’ behaviors or unwilling to let her resume her place in the
communications with them. Family therapy family or share control of the family budget, for
might be contraindicated if other family example. Unless family therapy can shift his
members are active substance abusers, violent, position, the client’s recovery is likely to be
deny that the client’s substance abuse is impeded. When the whole family is involved in
problematic, or remain excessively angry. therapy, changes are faster and easier to
Family therapy is often used to examine maintain. In addition, the client gains a built-in
factors that maintain a client’s substance abuse support system.
behavior. To understand these factors, the Complex interactions between family
therapist considers the family’s various dynamics and substance abuse have long been
structural elements and how they contribute to recognized (Lewis, 1937). Whalen suggested
the substance abuse. These elements might spousal psychopathology was a contributing
include the power hierarchy, roles, rules, factor in the onset and maintenance of substance
alignments, and communication patterns within abuse (Whalen, 1953). Jackson argued on the
the family. Through family therapy, the basis of interviews with members of Al-Anon
clinician can help the family identify that the depression, anxiety, and distress seen so
dysfunctional areas, adjust its hierarchy, change often in family members of substance abusers
various roles that members play, change stem from, rather than cause substance abuse
dysfunctional rules, alter dysfunctional disorders (Jackson, 1954).
alignments between family members, and Contrary to what had long been the popular
replace dysfunctional communications with opinion, most individuals with substance abuse
clear, direct, and effective communication. disorders maintain close ties with their families.
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Chapter 8
Research has consistently shown that people If possible, an appropriately trained family
with substance abuse disorders are in closer therapist should be available to conduct sessions
contact with their families of origin than the involving a client’s family.
members of the general population of
comparable age (Bekir et al., 1993; Douglas, Appropriateness of Brief
1987).
A number of reviews have found strong
Family Therapy
support for the use of family therapy methods Long-term family therapy is not usually
for substance abuse treatment. Recent research necessary within the context of treatment for
even suggests that family and marital treatment substance abuse disorders. An exception is
produces better marital and drinking outcomes long-term residential treatment, during which
than nonfamily methods (Lowinson et al., 1997). the involvement of the client’s family is highly
At least one study that compared long-term and recommended and often is an integral part of
short-term family therapy (16 and 8 casework the therapeutic process. Making real progress
interventions over an 8- and a 4-month period, with a family over a long period is challenging.
respectively) found that shorter services were Stumbling blocks, barriers, and pathology seem
often more beneficial (Garvin et al., 1976). to emerge. Family members drop out and
However, comparable studies specifically on reenter the therapeutic process, and it becomes
family therapy as applied to substance abuse increasingly difficult for the therapist to avoid
disorders are lacking. making decisions. The family may try to
The Harvard Medical School Department of incorporate the therapist into the family system,
Psychiatry successfully used couples counseling routinely seeking direction in a crisis. Boundary
in the context of treatment for alcohol- and projection issues must be addressed. In
dependent clients. Studies of participants in the short-term family therapy, the boundary
Harvard Counseling for Alcoholics’ Marriages between the therapist and the family is more
Project (Project CALM) showed that more than clear. In general, it is easier to continue to help
50 percent of husbands with alcohol abuse an individual work within the family system
disorders who participated remained alcohol through subsequent individual therapy.
free in the first year after treatment, compared Some traditional approaches encourage
with less than 30 percent of husbands treated in clients to work on themselves in isolation from
individual therapy. Participants in the program others, but there are very few instances in which
also had fewer marital separations. With the the opportunity to work with a client’s family—
addition of a relapse prevention program, the for at least one or a few sessions—is not
results improved even further (Rotunda and beneficial. Obviously, one such exception is
O’Farrell, 1997). when the client is unwilling to pursue this
Family therapy should be conducted by a approach. Another instance best dealt with
clinician with a good understanding of family individually is when the client’s situation
systems, dysfunctional family patterns, power involves issues of separation and individuation
struggles, and communication. Alcohol and although conjoint family work often helps
drug counselors can learn to work with families, complete this process. Physical, emotional, or
especially if they do not hold the family sexual abuse of the client by a family member
responsible for the substance abuse. may also rule out family therapy. Short-term
144
Brief Family Therapy
family therapy is an option that could be used in community members, including healers or
the following circumstances: others who can help promote or block change.
Young children, although not the most powerful
When resolving a specific problem in the
members of the family, often have helpful
family and working toward a solution
perceptions to contribute to the therapy process.
When the therapeutic goals do not require in-
In determining how and when to include
depth, multigenerational family history, but
children, it is important to consider their age
rather a focus on present interactions
and the nature of the subject matter the family
When the family as a whole can benefit from
will address. Parental sexual relations,
teaching and communication to better
obviously, should be discussed by the parents
understand some aspect of the substance
alone.
abuse disorder
Family therapy approaches have been
Family therapy offers an opportunity to employed with a variety of specific substance-
Focus on the expectation of change within abusing subpopulations, including those who
the family (which may involve multiple are dually diagnosed (Read et al., 1993; Reilly,
adjustments) 1991; Ryglewicz, 1991), Vietnam veterans with
Test new patterns of behavior substance abuse disorders and posttraumatic
Teach how a family system works, and how stress disorder (Fahnestock, 1993; Moyer, 1988),
the family supports symptoms and maintains older adults with substance abuse disorders
needed roles (Amodeo, 1990; Crawley, 1993; Rathbone-
Elicit the strengths of every family member McCuan and Hedlund, 1989), cocaine abusers
Explore the meaning of substance abuse (O’Malley and Kosten, 1988; Rice-Licare and
within the family Delaney-McLoughlin, 1990; Smokowski and
Wodarski, 1996), HIV-positive clients with
An obvious prerequisite for family therapy
substance abuse disorders (Barth et al., 1993),
would seem to be the existence of a family.
and substance-abusing perpetrators of domestic
However, some therapists, including Haley,
violence (Flanzer, 1989; O'Sullivan, 1989).
believe it is possible to “create” a family by
drawing on the client’s network of significant
contacts. A more important question than
Definitions of “Family”
whether the client is living with a family is, The term “family therapy” evokes images of
“Can the client’s problem be seen as having a parents and children. However, as mentioned
relational component (that is, involving two or above, family therapy can involve a network
more people)?” Rather than simply trying to beyond the immediate family, may involve only
identify existent family members, therapists can one family member in treatment or a few
begin by conducting an assessment of the members of the family system, or may even
client’s social network that would include include several families at once.
significant others, friends, employers, and Network therapy views substance abuse
coworkers. These people are significant and disorders from a cognitive–behavioral
helpful in the client’s life and can be important perspective (Galanter, 1993; Galanter et al., 1997;
elements of a client’s recovery program. Keller et al., 1997). In network therapy,
The definition of “family” also varies in significant nonfamily members, such as friends,
different cultures and situations. For example, extended family members, cousins, and
for a substance abuser in a Native American grandparents, as well as family members, are
group, the notion of family may extend to
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Chapter 8
regarded as useful resources available to assist would occur in single-family therapy. Typically,
the client. four or five families participate, often achieving
In contrast, some types of family systems meaningful results rapidly (Kaufman and
therapy regard substance abuse as a symptom of Kaufman, 1979).
an underlying pathology at work in the family. This approach helps with boundary setting
This approach seeks to restructure the family and reestablishment of the parent–child
and the maladaptive behaviors which contribute hierarchy. If a parent is the substance abuser, a
to (or encourage) the client’s substance abuse family role reversal may have occurred in which
(Keller et al., 1997). the children have taken the parental role and
Conjoint couples therapy addresses couples become caretakers. In therapy and recovery, it
issues within the family (Epstein and McCrady, is important that these boundaries be reclarified
1998; Zweben et al., 1988). Typically, couples and that the correct parent–child hierarchy be
carry out assignments in dealing with key reestablished. Not communicating is typical in
therapeutic themes, such as listing the factors families undergoing substance abuse treatment.
that attracted each partner to the other, One of the goals must be to reestablish lines of
discussing how the relationship could regain communication.
that attraction, and looking at expectations of The disadvantage of this approach is that the
each partner, needs from the other partner, and families involved may not have much common
resentments. Couples may need to explore their experience; also, some families feel ashamed in
ideas about gender roles within the relationship, this sort of encounter and are not willing to
or they may have to explore their views on share their experiences. At times, this approach
parenting, especially in regard to the can lead client families simply to complain to
disciplining of children. They may also be asked one another, without being motivated to find
to share ways in which they communicate new solutions. One of the responsibilities of the
dissatisfaction or negative feelings about the therapist leading the group is to guide the
ongoing substance abuse. family in exploring alternatives and choosing
Multifamily groups are often used in among them.
substance abuse treatment for educational Multiple family therapy offers an
purposes and as support groups. They can opportunity to deal with four concerns for
explore ways to attain strategic objectives families in which substance abuse has been a
relevant to each family, offer an opportunity for problem (Brill, 1981):
sharing knowledge, address boundary and
1. Inadequate internal family development
communication issues, and expose participants
2. Family systems and role imbalance
to new ways of managing challenges.
3. Selected socialization variances within the
Participants realize they are not alone and are
family (i.e., differences in the desire and
helped to maintain their substance-free lifestyle
ability of family members to socialize)
through learning new coping techniques and
4. Dysfunctional, ineffective family behaviors
ways to stop enabling substance abuse. The
that maintain the problem
therapist can apply the experiences of one
family to help another. After one family Some researchers believe that multiple
describes a solution, the therapist may ask family therapy is especially useful for families
another, “Would that work in your family?” dealing with substance abuse disorders
This approach can promote accountability for (Kaufman and Kaufman, 1979). In families
maintaining agreements with less stress than where one or more members have a substance
146
Brief Family Therapy
abuse disorder, deterioration in the family involvement with the substance user (Al-Anon,
system is usually seen. Multiple family therapy 1979; Bepko, 1985). As a result, treatment often
allows a quick assessment of the deterioration consists of a referral to Al-Anon and (less
and stimulates a confrontation and strategy to frequently) separate therapy groups for family
reverse this process. members that exclude the substance user
Furthermore, it is most useful in residential (Frankel, 1992; Friedman, 1990; McCrady, 1989;
settings where the family is easily accessible, Regan et al., 1983).
although it has also been successfully used in Family systems models, on the other hand,
outpatient settings. Kaufman and Kaufman also instead of focusing on individual personality
found that it works best with highly motivated disorders, generally regard substance abuse and
and involved clients and dependence as symptoms of dysfunctional
[R]educes the incidence of premature interpersonal dynamics within the family
dropouts, acts as a preventive measure for (Bowen, 1974; Gorad et al., 1971). From this
other family members, builds a subculture that perspective, the substance abuse meets a need
acts as an extended ‘good family,’ and creates
on some level for the family as a whole and
and supports structural family changes that
interdict the return of drug abuse (Kaufman inadvertently reinforces the substance abuse
and Kaufman, 1979, p. 84). (Davis et al., 1974; Stanton, 1977). Chafetz and
colleagues, for example, cite a family who
Theoretical Approaches laughed and joked together while the father was
intoxicated during an experimental session in
Many therapists are unfamiliar with effective contrast to the same family’s rather flat affect
ways to utilize supportive family members and during a session when the father was sober
significant others when treating substance abuse (Chafetz et al., 1974). The father’s alcohol abuse
disorders (Bale, 1993; French, 1987; McCrady, was seen as having become necessary for this
1991). This may stem in part from reliance on family to express their positive emotions. Based
popular concepts drawn from the traditional on similar anecdotal evidence, many family
“family disease” model, in which family treatment approaches have evolved that seek to
members of the substance user are seen as identify the specific role or family-level
suffering from the disease of “codependency” “adaptive function” served by substance abuse,
(Beattie, 1987; Coudert, 1972). Cermak even with the goal of bolstering interpersonal
defines codependency using criteria similar to functioning in this area in order to reduce these
those used in the Diagnostic and Statistical secondary gains from substance abuse for the
Manual for Mental Disorders, 4th Edition [DSM- individual and the family (Bepko, 1985; Stanton
IV] (Cermak, 1986). According to Schutt, and Todd, 1982; Steinglass et al., 1977). Several
family treatment models are described below.
[T]he woman who lives with an alcoholic
develops an enabling illness. She constantly Strategic family therapy (Haley, 1976) and the
stands between the alcoholic and his crises, related Milan school of family therapy (Selvini-
thus enabling and condoning the further usage Palazzoli et al., 1978) target the positive
of the drug (Schutt, 1985, p. 5).
interpersonal aspects of substance abuse
From this perspective, family members of the specifically, acknowledging directly its benefits
person with a substance abuse disorder “enable” to the family (e.g., “With your husband
the substance abuse to continue and so are unemployed as a result of his drinking, he can
thought to need help “detaching” or be home when the children get out of school”),
disengaging from their overresponsible as well as the negative consequences the family
147
Chapter 8
might face if the substance abuse were to end authority and define clearer intergenerational
(Fisch et al., 1982; Haley, 1987). Together with boundaries, especially between these men and
such paradoxical interventions as suggesting the their mothers (Stanton and Todd, 1982).
family may not yet be ready to change, these Bowenian family therapy (Bowen, 1978) also
interventions often provoke “spontaneous” focuses on family-of-origin emotional
growth on the part of the family (Weeks and attachment patterns and unresolved separation
L’Abate, 1979; Winn, 1995). See Chapter 5 in issues to make sense of substance abuse
this TIP for more information on strategic and disorders. Instead of working through the
interactional therapies, which often involve the parental generation, however, adults and
family directly. adolescents are helped to differentiate and
Structural family therapy looks beyond the define themselves as individuals by
specific family dynamics around substance acknowledging and curtailing their residual
abuse disorders to more general imbalances in emotional entanglements. As a result, substance
family relationships that might maintain abuse is no longer needed as a way to deny their
substance abuse, such as extreme family-of-origin attachments (Bowen, 1974).
disengagements and inappropriate coalitions Contextual family therapy (Boszormenyi-Nagy
between family members, especially across and Spark, 1973) is another transgenerational
generational lines (Minuchin, 1974). Salvadore family model that has been applied in work
Minuchin has had an enormous impact on both with families affected by substance abuse
the theory and practice of structural family (Flores-Ortiz and Bernal, 1989). This approach
therapy, although many of his concepts have emphasizes ethical legacies and unconscious
been modified as they have been incorporated loyalties passed along from one generation to
into the spectrum of modalities. Minuchin the next. For example, the adolescent substance
stressed the importance of the hierarchy of abuser loyally provides her parents the
power within the family and identifying opportunity to vent unresolved anger left from
dysfunctional uses of power (e.g., their own upbringing. Treatment helps clarify
“scapegoating”). It is important to understand the ways these unconscious “ledgers” are
both healthy and dysfunctional roles within the passed down from generation to generation, and
family: alignments, collusions, and parents are encouraged to deal with their
communication patterns. These key points are childhood issues directly instead of acting them
routinely explored in family therapy, although out through their own children.
many therapists would not feel comfortable Other family therapy models deemphasize
“imposing” their own model of health on a the systemic “function” of the substance abuse
family—an issue that did not trouble Minuchin. or family pathology and concentrate instead on
Structural therapists explore current family utilizing family strengths and enlisting family
organization, especially hierarchy and intimacy, members as agents of change to motivate the
while encouraging the family to loosen rules substance user and provide support for ongoing
and expectations that might be locking the recovery (Liddle et al., 1992; Meyers et al., 1998;
substance abuser into a dysfunctional role Noel and McCrady, 1993; Sisson and Azrin,
(Minuchin and Fishman, 1981; Stanton, 1977). In 1993). This is particularly the case with multiple
one of the earliest applications of family therapy family therapy models and family
for substance abuse disorders, Stanton and Todd psychoeducational groups (Kaufman and
worked successfully with families of young Kaufman, 1979; Kymissis et al., 1995; O’Farrell et
male heroin addicts to reestablish parental al, 1985). Frankel described conducting separate
148
Brief Family Therapy
groups for parents and adolescents (Frankel, using a modified version (Noel and McCrady,
1992). Szapocznik and colleagues also extended 1993) of the Spouse Behavior Questionnaire
the family group model to prevention with (Orford et al., 1975). Spouses were trained using
families of adolescents at high risk of role-playing and rehearsals to reinforce
developing a substance abuse disorder abstinence and decrease any of their behaviors
(Szapocznik et al., 1989). that could trigger renewed alcohol
Behavioral marital therapy (BMT) models consumption. Spouses were also instructed to
concentrate on teaching and practicing let the drinker experience negative
guidelines for clear communication and conflict consequences from drinking and to be more
resolution, marital enhancement, and substance assertive regarding the impact of the alcohol
abuse-specific coping skills such as ways to use.
handle relapse productively. The BMT The third type of treatment included all of
component was developed as part of the the training above, plus a BMT component
Program for Alcoholic Couples Treatment, a (McCrady et al., 1986). Each couple’s
research study that received good empirical interactional behaviors were initially assessed
support after controlled trials (McCrady, 1989). using the Locke-Wallace Marital Adjustment
Forty-five people with alcohol abuse disorders Test (Locke and Wallace, 1959) and Areas of
and their spouses were randomly assigned to Change Questionnaire (Birchler and Webb,
one of three types of spouse involvement during 1977). Couples in the BMT group were taught
outpatient treatment (approximately 15 ways to enrich their relationship by planning
sessions) and then followed over a 2-year and carrying out shared fun activities,
period. designating special “love days” to demonstrate
The first type of treatment was Minimal their affection, and practicing good
Spouse Involvement (MSI), where the spouse communications skills with planned family
attended all sessions but only as an observer. discussions, as well as techniques for
Client and clinician worked together to prepare problemsolving and negotiation. Finally, to
an inventory of the substance abuser’s offset the abstinence violation effect (a description
incentives to change and a functional analysis of of which is in Chapter 4) (Marlatt, 1978), couples
the substance abuse behavior utilizing the Time- were coached to regard any relapse that might
Line Follow-Back Interview (Sobell et al., 1980) occur as an opportunity to sharpen their efforts
and a Drinking Patterns Questionnaire (Zitter rather than give up. Booster sessions were
and McCrady, 1993). Drinking-specific sometimes scheduled up to 6 months
interventions geared to the client were then posttreatment (Noel and McCrady, 1993).
taught, including alcohol refusal skills, learning Based on followup assessments at 6 months,
to self-monitor drinking urges and consumption couples in the BMT group reported better
rates on a daily basis, rearranging contingencies marital satisfaction and relapsed more slowly
to support abstinence, restructuring irrational after treatment than the other two groups.
cognitions, plus developing alternative Clients with partners in the BMT group were
relaxation and assertiveness skills (McCrady et also more likely than those with “Minimal
al., 1986). Spouse Involvement” to complete treatment
The second of the three treatment types, (McCrady et al., 1986). Eighteen months after
Alcohol-Focused Spouse Involvement (AFSI), treatment, couples who had received BMT
included the same drinking-specific assessments reported enjoying greater relationship
and interventions but also assessed the couple satisfaction with fewer marital separations.
149
Chapter 8
In addition, the rate of abstinence among the systems available in the community such as
BMT couples had gradually continued to churches and schools (Piazza and DelValle,
improve after treatment ended rather than 1992).
dropping off, as occurred with the other two The community reinforcement approach (CRA)
groups in this study and most other substance is a brief systemic/family intervention and
abuse treatment programs (McCrady et al., therapy model that has shown good results
1991). In support of this particular finding, through training the significant others, generally
Stout and colleagues reported the same pattern spouses, of treatment-resistant clients with
of improvement 2 years after a similar BMT trial alcohol abuse disorders (Hunt and Azrin, 1973;
with a different sample of 229 clients with Sisson and Azrin, 1986, 1989). CRA participants
alcohol use disorders (O’Farrell and Cowles, learn to encourage sobriety by reinforcing
1989). abstinence while allowing the drinker to
According to Noel and McCrady, this long- experience negative consequences from
term effectiveness suggests that marital therapy intoxication. Significant others also learn to
may prevent relapse during early recovery by identify a time when the drinker might be
stabilizing the substance user’s interpersonal willing to enter treatment, in contrast to the
context (Noel and McCrady, 1993). Similar BMT confrontational methods advocated by the
approaches have recently been successfully Johnson Institute (Johnson, 1986) and Unilateral
employed with male substance abusers and Family Therapy models (Thomas and Ager,
their partners (Fals-Stewart et al., 1996) and 1993). CRA participants are prepared to
applied in relapse prevention (McCrady, 1993) contribute to the treatment process when and if
with booster sessions spread out over the the drinker agrees to this. Because domestic
following year (O’Farrell et al., 1993). A BMT violence remains a significant risk throughout
approach specifically for female substance this process, spouses and significant others are
abusers is also being studied (Wetchler et al., helped to recognize and respond to warning
1993). signs by de-escalating conflict and ensuring
Network therapy approaches (Favazza and their own safety.
Thompson, 1984; Galanter, 1993) recognize the Once the drinker agrees to enter treatment,
potential support from those outside the the significant other attends all further sessions
immediate family, especially in terms of and participates in communication-skills
conducting effective substance abuse training and “reciprocity marriage counseling”
interventions. Gathering together those who to develop mutually reinforcing behaviors
genuinely care about the welfare of the (Sisson and Azrin, 1989). The significant other is
substance abuser, especially friends and also asked to monitor the drinker’s disulfiram
extended family members, helps encourage the use (Antabuse) on a daily basis and to respond
substance abuser to stop using and remain appropriately if the disulfiram is not taken
abstinent. Galanter also points to the (Sisson and Azrin, 1993). Besides disulfiram and
importance of the involvement of Alcoholics marital counseling, drinkers in the CRA
Anonymous (AA) in network therapy (Galanter, programs receive job and social skills counseling
1993). Similarly, Selekman has involved peer as needed. It is worth noting that some CRA
group members in family therapy with sessions have been held in the family’s home
adolescent substance users (Selekman, 1991). (Hunt and Azrin, 1973), recognizing the
Piazza and DelValle have developed therapeutic potential for home-based treatments (Henggeler
interventions that actively incorporate larger et al., 1996).
150
Brief Family Therapy
In a study utilizing the CRA approach, 12 were randomly assigned to either the CRAFT
significant others of treatment-resistant clients program, an Al–Anon-only group, or a Johnson
with alcohol abuse disorders were randomly Institute intervention group (Johnson, 1973,
divided to form a CRA group of seven and a 1986). Of the CRAFT participants with alcohol
control group of five who were referred to Al- abuse disorders, 67 percent went into treatment,
Anon. Of the CRA group, six of the seven whereas only 13 percent of the Al-Anon group
resistant spouses entered treatment, compared and 23 percent of the Johnson Institute
with none of the Al-Anon group partners. The intervention group entered treatment (Meyers et
partners of CRA participants reduced their al., 1998).
drinking days from 24 per month to 11 before CRAFT also works with significant others to
entering treatment, and this rate dropped to 2 improve their social and emotional welfare.
drinking days per month once the couple started Significant others are encouraged to decrease
joint treatment (Sisson and Azrin, 1986). (More stress by taking care of themselves and making
information on the CRA model can be found in changes to enhance their own well-being and
Chapter 4 of this TIP.) positive social supports. Participants in the
The CRA has been modified into the CRAFT program have reported reductions in
community reinforcement and family training anger, anxiety, and depression, regardless of the
(CRAFT) procedure (Meyers et al., 1996) with substance user’s treatment status. Although
clinical trials under way (Meyers et al., 1998). much of the focus of the CRA and CRAFT
This brief systemic intervention and therapy models centers on getting the substance abuser
model also works through the concerned other into treatment, both programs emphasize the
to analyze behavior patterns surrounding importance of ongoing family or couples
substance abuse. Substance abuse triggers and sessions employing communication skills
consequences are sought, as well as training and marital reciprocity counseling
interpersonal cues and positive consequences (Meyers et al., 1998; Sisson and Azrin, 1986).
that support more adaptive, sober behaviors. Family therapy is often applied in the
This analysis can include the Spouse Enabling treatment of adolescents with substance abuse
Inventory or the Spouse Sobriety Influence disorders, and many specific family therapy
Inventory (Thomas et al., 1994). The risk of models have been developed for this
domestic violence is assessed using the Conflict population. These often weave together
Tactics Scale (Straus, 1979), and strategies, concepts and techniques from different schools
including a safety plan, are developed. of family therapy. Multidimensional family
Communication skills are an important aspect of therapy (MDFT) (Liddle et al., 1992) is a brief
this model. The basic rules taught are to be family therapy model that has demonstrated
brief, be positive, be specific and clear, label significant long-term clinical effectiveness in
feelings, express understanding for the other’s treating adolescent substance abuse and conduct
perspective, accept partial responsibility when disorders during controlled trials (Schmidt et al.,
indicated, and offer to help (Meyers et al., 1998). 1996). MDFT integrates structural/strategic
A treatment setting is also lined up in family therapy (Stanton, 1981; Todd, 1986) with
anticipation that the substance abuser will agree research findings on adolescent development
to accept further help at some point. (Liddle et al., 1992). The MDFT model is
In one preliminary study of the CRAFT designed to enhance a family’s ability to buffer
model, 130 significant others of treatment- adolescents against destructive peer and social
resistant clients with alcohol abuse disorders influences by nurturing healthy teen
151
Chapter 8
development through supportive rather than was also a reduction in related conduct
strictly authoritarian parent–child relationships. disorders among 68 percent of the teens with
Individual sessions with the adolescent are significant improvements seen in school
interspersed with family sessions to allow the performance (Schmidt et al., 1996). Most
therapist an opportunity to form a supportive remarkably, these positive outcomes remained
relationship with the teen and act as an at followup 1 year later (Liddle and Dakof,
intermediary between parent(s) and child. 1995). Based on nonparticipant raters who
Besides relationship issues, the MDFT model assessed family therapy videotapes, the
recognizes the developmental tasks faced by the reductions in substance use were significantly
adolescent, such as learning to manage emotions associated with improvements in the parent–
and impulses, and tries to specifically address adolescent relationship (Schmidt et al., 1996), a
them. Therapy sometimes includes primary goal of MDFT (Liddle et al., 1992).
representatives of extrafamilial systems such as Unfortunately, dropout rates using the MDFT
school and probationary personnel as well as treatment model reached 28 percent, and only 69
peers. percent of the parents were assessed as making
Recognizing that most substance-abusing progress in modifying their parenting styles
teens and their parents are locked in conflict, the (Liddle and Dakof, 1994).
MDFT therapist works to find a common The Institute of Medicine (IOM)
ground and create a context where a more recommended that brief couples therapy be
trusting relationship can emerge. Adolescents included as a treatment option for all alcohol-
are challenged to identify and articulate their abusing clients, especially for those still
own issues and goals for therapy and to take experiencing only mild to moderate problems
steps to achieve these. Parents are challenged to (IOM, 1990). Based on their review of the
listen to their teens and let the parent–child treatment outcome literature, Edwards and
relationship evolve into one of mutual respect, Steinglass reached a similar conclusion:
balancing the parental tasks of guidance with The weight of the evidence...seems so strong at
support. This involves charging both the this point as to support a recommendation that
adolescent and the parents with responsibility family involvement, especially inclusion of
non-alcoholic family members in the
for change while conveying the clear expectation
assessment phase of treatment, be built in as a
that the family can arrive at this point of routine component of alcoholism treatment
reconciliation (Liddle et al., 1992). See TIP 32, programs (Edwards and Steinglass, 1995, p.
Treatment of Adolescents With Substance Use 485).
Disorders (CSAT, 1999b), for more information The brief family therapy approaches
on family therapy for adolescent substance reviewed above have all shown positive long-
users. term outcomes in controlled clinical trials.
In a diverse sample of families Together these approaches demonstrate the
(approximately 45 percent African-American or potential for brief family therapy in substance
Hispanic), 16 sessions of MDFT led 79 percent of abuse treatment.
the adolescents to reduce their average alcohol
and marijuana use from a daily to a weekly Using Brief Family
basis. In addition, harder substance use
dropped from every other month to zero. Of
Therapies
those who reduced their substance use, 30 Involving family members or concerned others
percent decided on complete abstinence. There in family therapy can have a number of benefits.
152
Brief Family Therapy
The dynamics of the family are already a factor written out. Permanent changes often resulted
in the client’s substance-abusing behavior in a with motivated families. Wegscheider-Cruse’s
complex and unique relationship. In the same work has been replicated in several residential
manner, the family can participate in the settings and training institutes (e.g., the On-Site
positive experience of treatment and recovery. and the Sierra Tucson Treatment Centers in
Tucson, Arizona).
Duration of Therapy and
Frequency of Sessions Opening Session
The majority of family therapy is conducted on a A typical opening session for a family in which a
short-term basis, with some exceptions (Object member has a substance abuse disorder might
Relations therapy may take years). Sessions involve the following:
may be 1½ to 2 hours in length. The preferred
The therapist seeks to clarify the nature of
timeline for family therapy is not more than two
the problem and to identify the family’s
sessions per week (except in residential settings)
goals. The therapist asks each family
to allow time to practice new behaviors and
member the same sort of open-ended
experience change. Duration of therapy could
questions typically used in individual
be 6 to 10 sessions, depending on the purpose
therapy. For example:
and goals of the intervention.
i “What you would like to see happen
In a residential treatment program, family
here?”
therapy can take place in a variety of ways
i “What would you like to work on?”
depending on program design and length of
i “What is your goal in coming here?”
stay. Some programs have “family weeks” in
i “How did you get here?”
conjunction with individual treatment. Others
The therapist educates the family in what is
may require clients to bring in a significant other
needed to participate effectively in the
one to two nights weekly to work together on
therapeutic process and to understand key
recovery issues. Adolescent treatment programs
biosocial issues related to substance abuse.
sometimes involve the family continuously
The therapist provides feedback to the family
throughout treatment.
on what was said, demonstrating whose
Certain forms of family therapy have been
goals are similar or different.
developed to achieve a high impact in a shorter
The therapist can then move on to
period of time. One noted derivative of
prioritizing directions for change or, if the
multifamily therapy is the Multiple Impact
direction is sufficiently clear, start work.
Model developed by Wegscheider-Cruse (1989),
Some therapists ask the family to engage in a
who brought together groups of four or five
“contract” that identifies the direction of
sober individuals who were previously
therapy and delineates each member’s
substance dependent and their families for a
commitment to the process.
concentrated, extended weekend of work. The
purpose was to enable the families to support Early on, practitioners of different theoretical
the continued sobriety of their formerly models will make choices about what they will
substance-dependent members. Family roles focus on and how to proceed, for example:
were recast so that each family member could Therapists who practice solution-focused
take on a different role, such as who would therapy would devote more time to
make family financial decisions. New gathering information and affirming family
agreements between family members were members at the first session, which would
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Chapter 8
probably conclude with the assignment of who want to attend on a voluntary, as-needed
tasks designed to test the possibility of basis. Some practitioners ask the client and
change in areas where change seems feasible. family members to call them after 6 months or 1
Therapists applying Eriksonian therapy, after year for a followup conversation. Depending on
asking family members what they want, the family’s needs, the therapist may be able to
might ask, “How will you know when you provide reinforcement without further meetings,
get there?” A followup question would be, or may suggest one or two followup sessions to
“Is there any reason you can think of why it address emerging issues.
would not be okay to get there?” This At a minimum, clients should be assured that
question tests for resistance and any they can call the therapist when necessary.
constraints, such as the possibility of family
violence, which could prevent open and Cultural Issues
honest communication. The therapist would
then try to do something about that It is important that a family therapist
constraint in order to create safety (an action understand the family’s ethnic and cultural
referred to as an “ecological check”). background. (See the example in the text box
Therapists using the Mental Research below.) Failure to do so may be partially
Institute (MRI) strategic model would responsible for the large dropout rate by ethnic
examine solutions that have already been minorities after the first therapy session
attempted because most families with a (Soo-Hoo, 1999). To successfully promote
member struggling with a substance abuse change within a family system, the therapist will
disorder try a variety of solutions that have need the family’s permission to share their
not worked before formal treatment. The closely held secrets. The therapist’s approach,
family’s solution may be seen as the problem. however, must vary according to the cultural
background of the family. Working with a
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Brief Family Therapy
positive change. In another example, a therapist Ablon (with middle-class Catholic families)
working with a client who belonged to the and Kaufman and Borders have drawn attention
Southern Baptist fundamentalist movement to the importance of ethnic and cultural
found that the client was immobilized by the differences to understand and treat families with
shame that surrounded drinking in her family substance abuse problems (Ablon, 1980;
and the difficulty of talking about it. The client Kaufman and Borders, 1988). Many substance
approached the family’s minister to help frame abuse treatment programs have developed
the situation so that the family could face the culturally specific family therapy
problem together and find a solution. (For more models for Latino families (Flores-Ortiz and
information on family therapy for those from Bernal, 1989; Laureano and Poliandro, 1991;
unfamiliar cultures, see McGoldrick et al., 1996; Panitz et al., 1983; Szapocznik et al., 1991),
Sue and Sue, 1990.) African-American families (Aktan et al., 1996;
The language used to describe dynamics Ziter, 1987), and Native American families (Hill,
within the family system is charged with 1989), among others.
specific cultural meaning. For example, if a A family therapy approach that has been
client belongs to a culture that values lifelong successful with substance-using Hispanic
interdependence among family members, the adolescents combines elements from structural,
therapist would be ill advised to encourage strategic, and Milan therapies (Szapocznik and
greater independence from the family. Kurtines, 1989; Szapocznik et al., 1988, 1991).
However, the therapist might encourage the This approach focuses considerable effort on
client to become more effective within his family overcoming initial resistance to treatment
and explain ways that would allow some because the process embodies the family’s issues
freedom within the cultural parameters of the around the adolescent’s substance use
family. (Santisteban and Szapocznik, 1994; Szapocznik
and Kurtines, 1989).
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9 Time-Limited Group Therapy
G
roup psychotherapy is one of the most (Yalom, 1995). For many years, Alcoholics
common modalities for treatment of Anonymous (AA) and Narcotics Anonymous
substance abuse disorders. Group (NA) have recognized the importance of
therapy is defined as a meeting of two or more breaking the isolation associated with substance
people for a common therapeutic purpose or to abuse, while at the same time connecting
achieve a common goal. It differs from family individuals with others whose common purpose
therapy in that the therapist creates open- and is to dramatically change their lives through
closed-ended groups of people previously connection and community. From these
unknown to each other. The lessons learned in perspectives, time-limited group psychotherapy
therapy are practiced in the normal social offers potent opportunities to maximize the
network. Although efficacy research on group treatment energies of both therapist and client.
therapy for substance abuse disorder clients has Research suggests that most client
been limited, there is substantial anecdotal and improvement as a result of group therapy occurs
clinical evidence that it can have a dramatic within a brief span of time—typically, 2 or 3
impact on participating clients. In TIP 8, months (Garvin et al., 1976). This research
Intensive Outpatient Treatment for Alcohol and implies that short-term therapy can be as
Other Drug Abuse (CSAT, 1994a), group therapy successful as long-term therapy in promoting
is cited as the treatment modality of choice for a change. Short-term group therapy should be
variety of reasons. In clinical practice, group more goal-oriented, more structured, and more
psychotherapy offers individuals suffering from directive than long-term group therapy. Some
substance abuse disorders the opportunity to see therapists also believe the experience should be
the progression of abuse and dependency in intensified through the use of high-impact
themselves and in others; it also gives them an techniques such as psychodrama (see discussion
opportunity to experience their success and the later in this chapter).
success of other group members in an
atmosphere of support and hopefulness. The Appropriateness of
curative factors associated with group
psychotherapy, defined by Yalom, specifically
Group Therapy
address such issues as the instillation of hope, Groups can be extremely beneficial to
the universality experienced by group members individuals with substance abuse problems.
as they see themselves in others, the opportunity Levine and Gallogly have noted that groups for
to develop insight through relationships, and a alcohol-dependent clients
variety of other concerns specific to the support
Help reduce denial, process ambivalence,
of substance-abusing clients and their recovery
and facilitate acceptance of alcohol abuse
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Group Effects
One Consensus Panelist recalls a therapy session in which a member arrived, furious and hostile,
shouting, “How much longer do I have to do this stupid program? None of it works anyway!”
Another group member immediately asked, “So, how does the anger keep things going for you?” In
the ensuing conversation, the group learned that the angry member’s ex-wife had just sent him a bottle
of expensive whiskey with the following note: “Dying to get together again.” This revelation, and the
supportive group listening that followed, occurred largely without verbal involvement from the
therapist.
Increase motivation for sobriety and other sensitive approach and the directive approach.
changes The process-sensitive group approach finds its
Treat the emotional conditions that often direction in the traditions of analytical theory
accompany drinking (e.g., anxiety, and has a significant range of expression.
depression, hostility) Depending on the theoretical base and
Increase the capacity to recognize, anticipate, leadership style of the facilitator, a process-
and cope with situations that may precipitate sensitive group can examine the unconscious
drinking behavior processes of the group as a whole, utilizing
Meet the intense needs of alcohol-dependent these energies to help individuals see
clients for social acceptance and support themselves more clearly and therefore open up
(Levine and Gallogly, 1985) the opportunity for change. This “group-as-a-
whole” approach is best exemplified by the
Many beneficial effects happen more easily
work of Bion, who sees healing as an extension
in groups than in one-on-one therapy. Group
of the individuals within the group as the group
members confront each other, do “reality
comes to terms with a commonly shared anxiety
checks,” practice reflective listening, mirror each
(Bion, 1961).
other, and help each other reframe key issues.
Yalom offers a significant contrast to these
Individuals in earlier stages of dependence can
group-as-a-whole interventions through his
witness what later stage experiences are like
interactional group process model (Yalom,
(and by inference where they could progress if
1995). By attending to the relationships within
they do not reduce their use). Often, group
the group and helping individuals understand
members can be more effective than the
themselves within the relational framework, an
therapist in confronting a participant who is not
interactional group process provides individuals
facing an important issue (e.g., the client who
with significant information about how their
believes she can quit drinking and still smoke
behavior affects others and how they are in turn
marijuana).
affected by other members. In addition,
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Time-Limited Group Therapy
The second approach, and one better known It is important to note that in any kind of
to alcohol and drug counselors, is a dramatically group therapy, relationships are formed and
different form of group therapy, often referred process issues experienced. Even within the
to as a directive approach. It offers structured context of a cognitive–behavioral approach such
goals and therapist-directed interventions to as RBT, which is more educational than
enable individuals to change in desired ways. A therapeutic, issues of process invariably arise.
short-term directed group may be used to The experienced therapist can use the
address major issues of concern for clients with relationships within the group even in a
substance abuse disorders and to facilitate self- psychoeducational framework to support and
discovery and growth through appropriately enhance the treatment experience. Whenever
sequential activities. Because the therapist is the opportunity arises, the group facilitator
“central” and in charge, this type of group should help connect members to members.
depends less for success on group members and When shared histories are acknowledged, the
their ability to create a cohesive sense of sense of belonging is increased, and greater
belonging. cohesion takes place. Cohesion may seem less
Compared with the process-sensitive group, important in a directive psychoeducational
which sees the cohesive power of the group as a group. However, because of the very nature of
primary curative factor, the directive approach substance abuse disorders, a feeling of
addresses specific agenda items in a logical belonging to a group committed to its own
order with greater emphasis on content as the health rather than its own destruction is an
primary source of effective change. The important motivator for many clients.
directive approach, therefore, is perhaps more There has been significant debate within the
likely to be effective with those in early field regarding the pros and cons of
recovery. A potent example of directive, time- heterogeneous and homogeneous groups. The
limited group experience, developed by heterogeneous group, in which members have a
Maultsby and Ellis, is known as Rational variety of diagnoses, offers greater complexity
Behavioral Training (RBT) (Maultsby, 1976). and more opportunities for a wide range of
This cognitive–behavioral therapy takes place relationships, which can be extremely helpful to
over 13 weeks, one session per week. It uses many clients. However, the homogeneous
fundamental cognitive–behavioral interventions group, particularly when composed of clients
and the clients’ growing awareness of their with substance abuse disorders, tends to lend
ability to control their own belief systems and itself more quickly to issues of cohesion and
self-talk and thus control their affective states. safety. For this reason, homogeneity has
Clients are asked to share homework particular utility in the time-limited group
assignments and bring real-life situations into intervention.
the group for exploration and examination. An important issue within the context of the
There is little effort in this group modality to homogeneous substance abuse disorder group,
analyze or direct energy to the relationships whether time limited or not, is the group’s
within the room. RBT affords a short-term tendency to bond around its history of substance
intervention to develop the client’s skill in abuse rather than its commitment to recovery.
controlling emotions. The inference is that Although the general focus of substance abuse
individuals who experience their emotional treatment is on the abuse itself, the focus also
world as controllable will no longer need to use must include issues of living within the context
substances to exert “external” control. of the group. Through modeling and gentle
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Chapter 9
persuasion, the group facilitator can broaden the Brief Cognitive Group Therapy
scope of a substance abuse treatment group to Cognitive techniques work well in group
include relationships, concerns about daily therapy. The group is taught the basics of the
living, and newly discovered personal integrity. cognitive approach, then individual members
Such are the struggles of all people in all take turns presenting an event or situation that
circumstances. The movement from “what is tempted them to abuse substances. Other
wrong with us” to “how do we build better members assist the therapist in asking for more
lives?” is an important transition in the time- information about the client’s thoughts on the
limited group, whether psychoeducational or event and how it did or did not lead to
process sensitive. substance abuse (or to negative feelings that
Group therapy can be conducted within the might have led to use). Finally, the group
context of almost any theoretical framework members provide the client with alternative
familiar to the therapist and appropriate to ways of viewing the situation. Chapter 4
group goals. Often the therapist will work with discusses brief cognitive therapy in more depth.
two or more models at the same time. The
theoretical bases supporting both process- Cognitive–Behavioral
sensitive groups and a more directive style can Group Therapy
be combined effectively to address substance- The cognitive–behavioral approach focuses the
abusing clients. group’s attention on self-defeating beliefs,
relying on group members to identify such
Theories of Group beliefs in each other. The therapist encourages
Therapy group members to apply behavioral techniques
such as homework and visualization to help
The following group therapy models are participants think, feel, and behave differently.
discussed in this section: Chapter 4 discusses brief cognitive–behavioral
therapy in more depth.
Brief cognitive group therapy
Cognitive–behavioral group therapy Strategic/Interactional Therapies
Strategic/interactional therapy
The strategic therapist uses techniques similar to
Brief group humanistic and existential
those used in family therapy to challenge each
therapies
group member to examine ineffective attempted
Group psychodynamic therapy
solutions. The therapist encourages group
Modified dynamic group therapy (MDGT)
members to evaluate and process these
Modified interactional group process (MIGP)
attempted solutions and recognize when they
The first five are summarized below and are not working, then engages the group in
discussed at greater length in Chapters 4 though generating alternative solutions. The therapist
7 of this TIP. MIGP, considered a highly also works, where appropriate, to change group
effective type of brief group treatment for members’ perceptions of problems and help
substance abusers, is discussed in detail in this them understand what is happening to them.
section. The 11 therapeutic factors identified by Typically, the therapist guides the process, while
Yalom as the basis of successful group therapy members offer suggestions and encouragement
are presented at the end of this section (Yalom, to each other as they identify and implement
1995).
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Time-Limited Group Therapy
effective solutions. To address the problem of Role-playing and dream analysis in groups are
substance abuse, the group will often be practical and relevant exercises that can help
directed to examine problems that might result clients come to terms with themselves.
in substance abuse and reframe their One of the most influential contemporary
perceptions of these problems. experts on group therapy, Irvin D. Yalom,
The principles of solution-focused therapy considers himself an existentialist because he is
are the same for group treatment as for not concerned with past behavior except as it
individual therapy. These include client goal- influences the “here and now.” A summary of
setting through the use of the “miracle” his existential approach is presented in The
question, use of scaling questions to monitor Yalom Reader (Yalom, 1997) and consists of three
progress, and identification of successful sections: (1) therapeutic factors in group
strategies that work for each client. (These therapy, (2) a description of the “here and now”
techniques are defined in Chapter 5 of this TIP.) core concept, and (3) therapy with specialized
The therapist works to create a group culture groups, including a chapter on group therapy
and dynamic that encourages and supports and alcoholism. This last chapter details specific
group members by affirming their successes. At techniques to diminish anxiety but still permit
the same time, the therapist works to restrain the group to maintain an interactional focus—
client digressions (“war stories”) and personal for example, writing a candid summary of the
attacks. The therapist tries to challenge group session and mailing it to members before the
members—all of whom, unlike in family next meeting. Yalom has worked closely with
therapy, are seen as “customers”—to take action the National Institute on Alcohol Abuse and
to create positive change. Chapter 5 discusses Alcoholism to apply basic principles of group
brief strategic/interactional therapies in more therapy to alcohol abusers, and his ideas are
depth. applicable to those with other substance abuse
disorders as well. See Chapter 6 for more
Brief Group Humanistic and discussion of humanistic and existential
Existential Therapies therapies.
Several approaches fall within this category.
The transpersonal approach is useful in Group Psychodynamic Therapy
meditation, stress reduction, and relaxation Group psychodynamic therapy enables the
therapy groups and can be adapted for clients group itself to become both the context and
who have substance abuse disorders. In dealing means of change through which its members
with issues of religion or spirituality, it is helpful stimulate each other to support, strengthen, or
to have other people talk about their change attitudes, feelings, relationships,
perspectives. In this way, past degrading or thinking, and behavior—with the assistance of
punitive experiences related to organized the therapist.
religion can be redefined in a more meaningful The context sought is one in which the group
and useful context. becomes an influential reference group for the
Gestalt therapy in groups allows for more individual. Participation of members
according to their abilities leads to some
comprehensive integration in that each group
degree of involvement of each in pursuing
member can provide a piece of shared personal individual and group goals. The process of
experience. Each group member plays a role in goal-setting and clarification for expectation
creating the group, and all of their perceptions provides an agreed upon framework for
meeting of mutual needs. This, in turn,
must be taken into account in making a change.
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Time-Limited Group Therapy
reinforcement of these agreements throughout them from dominating the group is another
the group process. The importance of hallmark of MIGP.
confidentiality, the group’s accepting
General issues in MIGP
responsibility for itself, and self-disclosure are
Following the insights of Flores and Mahon,
all supported by the facilitator. Procedural
MIGP focuses special attention in four areas of
agreements, including beginning and ending the
the client’s life: gratification and support,
group session on time and ensuring that each
vulnerability of self, regulation of affect, and
member has a place within the circle, with any
self-care (Flores and Mahon, 1993). These four
absences addressed, are part of the development
areas receive particular attention because they
of the safe environment.
represent areas of vulnerability within the
In this process, the therapist helps the clients
substance-abusing client that can easily lead to
recognize that they are the primary change
relapse and undermine recovery.
agents. The group becomes a safe place both to
give and to receive support. Although Gratification and support
traditionally substance abuse groups tend to be Many clients come to treatment with profound
confrontative, MIGP is far more supportive. issues of guilt and shame. Therefore, they lack
This stems from the belief that denial and other the ability to give themselves gratification and
defense mechanisms become more rigid when a support in the face of change. The active
person is attacked. Consequently, group leadership style of MIGP allows group members
members are encouraged to support one another to openly support one another and at the same
and look for areas of commonality rather than time provides each group member with
use more shame-based interactive styles that attention from the leader that leads to higher
attempt to “break through denial.” levels of gratification. Affirming group
members’ willingness to share and support one
Intellectualization and MIGP
another is an essential ingredient in time-limited
Many therapists are told that clients should get
group work. It creates a positive atmosphere
in touch with their feelings and experience
and increases levels of safety and cohesiveness,
“what is in their gut.” Although awareness of
which further supports the change process.
the affective life is important to everyone, it is
precisely the regulation of emotions that many Vulnerability of self
substance-abusing clients have difficulty Substance-abusing clients often enter treatment
addressing. Consequently, although emotional with shattered self-esteem. Defending against
exploration is encouraged within the context of this internal vulnerability can become
MIGP, the facilitator is constantly monitoring damaging, because clients project their fears
the affective energy within the group, taking onto others. They may try to hide internal
steps to break emotional contagion should it vulnerability by appearing hostile and overly
begin. In a particularly intense group self-confident. An atmosphere of safety and
experience, the therapist may ask the group as a empathy enables clients with profound
whole to take a step back and look at what just vulnerabilities to enter the process of self-
took place. In this way, the group not only disclosure, through which they become
learns from its shared life but also experiences accessible not only to the group but also to
its ability to control intense emotional responses. themselves. The group facilitator actively
This consistent effort to reduce high levels of encourages such self-disclosure but at the same
anxiety or emotional catharsis and to prevent time emphasizes that individual members need
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not disclose any issue they are not yet ready to Use of Psychodrama
discuss. Clear boundaries and clear group
agreements further support the possibility for
Techniques in a
self-disclosure. Group Setting
Regulation of affect Psychodrama has long been effectively used
Substance abuse disorders can be perceived as with the substance-abusing client population in
the consequences of trying to control one’s a group setting. Wegscheider-Cruse effectively
emotional life with external substances. This integrated psychodrama as a means to heal
points to a failure of internal regulation that family-of-origin issues within the context of
makes the client uncomfortable when feeling addictive behaviors (Wegscheider-Cruse, 1989).
emotions that others might consider The utility of such an intervention seems to be
commonplace. Issues of grief, loss, sadness, and clinically well established. The techniques can
joy can be so affectively charged and linked to help the group move more quickly in terms of
the client’s past alcohol and drug use that they self-understanding and relational awareness.
threaten the client’s continued recovery. As The insights gained from the experience of
mentioned above, the leader’s sensitivity to the family sculpting (illustrated below) can be
levels of affective energy in the group is worthwhile and potent. However, it is
particularly important. Supporting group important to stress that psychodrama and other
members to both feel what they are experiencing similar expressive therapeutic interventions
and at the same time move to a safer and more bring with them a clinical potency that needs to
objective viewpoint regarding those feelings is be understood. These interventions can raise
inherent in MIGP. anxiety and shame to the point where some
clients may be pushed toward relapse or even
Self-care
feel the need to leave treatment to escape the
Substance-abusing clients often present to
internal conflicts encountered. As with any
treatment unaware of internal stresses and pain,
therapeutic technique, therapists should not
having lost sensitivity to physical cues that lead
utilize such techniques unless they are
others to the normal self-care functions of daily
thoroughly trained and well supervised. Any
living. These functions may be as simple as
intervention that has a powerful potential for
basic hygiene or more complex in terms of
growth almost always has an equal potential for
boundary setting and relational definitions.
damage if poorly conducted. Training and
Setting boundaries within the group and
appropriate supervision are particularly
encouraging heightened sensitivity to self-care
important with expressive techniques because of
are ways in which MIGP addresses this issue.
their clinical potency.
Clients must hear a consistent message that they
Psychodrama can be used with different
are worthy of the group’s support and,
models of group therapy. It offers persons with
therefore, worthy of their own attention in
substance abuse disorders an opportunity to
regard to self-care. All of the above can
better understand past and present
comfortably be addressed within the context of
experiences—and how past experiences
MIGP, with the leader actively connecting
influence their present lives. This approach
members to members, who support one another
encourages clients to relearn forgotten skills,
on the importance of self-monitoring and care.
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Time-Limited Group Therapy
imaginatively change apparent problems that themselves as isolated sit in the corner or under
block progress, rehearse new behaviors, practice a table with a “sponsor.” The therapist gives
empathy, and expand their emotional range by them sentences to complete, such as, “I like this
confronting feelings that have never been corner because….“ or “The first time I remember
properly dealt with. As clients act, important isolating is.…” Finally, they are asked to
concepts become real, internalized, and complete the sentence, “I have to get out of this
operational that might otherwise be purely corner because….” The sponsors then gather in
theoretical. Changes experienced through a circle and invite the persons they have been
acting become accessible to the psyche as part of supporting to join them, saying, “I want you to
the lived history of the individual. join this circle because….” This experience of
Some therapists use psychodrama to help connection often enhances participants’
transform internal dynamics that maintain old motivation and ability to change.
patterns relevant to substance abuse. For A common use of psychodrama in treatment
example, one therapist invites group members for substance abuse disorders is “sculpting”
to list “rules” in their family of origin. These family members in typical roles and enacting
rules may be related to substance abuse (e.g., significant situations related to substance abuse
“Don’t ever say that Mother is drunk. She is patterns. In this process, developed by Papp,
taking a nap.”). After a client describes a family members enact a scene to graphically
situation in which the rule would be invoked, he depict the problem (Papp, 1977, 1983). The
assigns family roles to other participants, giving physical arrangement of the family members
them instructions for how they would behave in illustrates emotional relationships and conflicts
this situation. The client is encouraged to break within the family. For example, a family may
the rule—in the case of the “napping” mother, naturally break up into a triad of the mother,
by insisting on bringing the truth into the sister, and brother, and a dyad of the father and
open—with the verbal encouragement of all another sibling. In that case, the therapist might
remaining group members who are not playing highlight the fact that the mother and father
assigned roles. The client’s victory—which can communicate through one of their children and
be a transformative, powerful experience—is never talk to each other directly.
celebrated as the achievement it is. In this In yet another form of psychodrama, one
example, the individual experiences himself as a person in the group may be asked to give voice
powerful truth-speaker rather than the to different aspects of her own self that either
powerless and voiceless participant he help maintain dependency or speak for change
perceived himself to be in the past. This new (sometimes called the “disease” and “recovery”
experience can enhance his sense of self-efficacy selves). The client might speak from a different
and help foster change in his own pattern of chair or position for each of these voices. The
substance abuse. intensity of psychodrama often helps
In another example of psychodrama, group compensate for the shorter time span now
participants explore “character defects” such as commonly funded for treatment. Although
grandiosity or isolation associated with their many participants express concern about acting,
pattern of substance abuse. The defects are the barrier of shyness often drops completely as
dramatized, with half the group engaged in the they enter the process with the assistance of a
dramatization and half sitting as an audience. dynamic and committed facilitator.
For example, persons who experience
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Time-Limited Group Therapy
and insight to one another. Particularly within and use the energy of the relationships to
the model of MIGP, the facilitator pays great facilitate change. As participants engage in
attention to altruistic moves on the part of relationships, they learn new social skills that
members. They are celebrated and can help them break through their isolation and
acknowledged. As individuals recognize that connect with others in more meaningful ways.
they have something of value to give their They also learn how to disconnect, which is
fellow group members, their self-esteem rises as equally important given the anxieties often
change and self-efficacy are supported. associated with relational loss and grief. The
group facilitator may at times deliberately focus
Corrective Recapitulation of the on these social skills through role-playing or
Primary Family Group modeling exercises within the context of the
This therapeutic factor pertains to the group itself. The healing takes place as the
importance of relationships within the client’s clients take what they have learned and
family of origin, which invariably finds experienced in group and actively generalize it
expression within the group experience. in their lives outside of the group.
“Recapitulation of the family group” happens
when a client—both consciously and Imitative Behaviors
unconsciously—relates to another group Imitative behaviors are an important source of
member as if that person is a member of his learning in group therapy. The process of
family of origin with whom he has struggled in modeling can be particularly important as
the past. This occurrence is clearly a projection, clients learn new ways to handle difficult
but it can be identified by the leader, and both emotions without resorting to violence or drug
group members involved can benefit as they use. Therapists must be acutely sensitive to the
investigate new ways of relating that break the important role they play within this context;
old dysfunctional patterns of the family of clients often look to the therapist to model new
origin. In a way, the group begins to serve as a behaviors as they encounter new situations
substitute family. The group members are the within the group context. Group members can
siblings, and the group facilitator is in a parental also learn by imitating other members who are
role. Even in a time-limited group, issues of successfully dealing with difficult relational
transference and countertransference may issues. It is helpful for a new group member to
require attention. However, MIGP tends to witness an ongoing group where people are
dilute the transference by “spreading it confronting their problems appropriately,
throughout the group” rather than moving beyond old dysfunctional patterns, and
concentrating it within the dyadic counseling forming new relationships that support change.
relationship. The group becomes a living demonstration of
these new behaviors, which facilitates and
Development of Socializing supports insight and change.
Techniques
Many substance abusers are “field-sensitive” or Interpersonal Learning
“field-dependent” individuals who are keenly Groups provide an opportunity for members to
conscious of the network of specific learn about relationships and intimacy. The
relationships as opposed to principles or group itself is a laboratory where group
generalizations that apply regardless of context. members can, perhaps for the first time,
Group therapy can take advantage of this trait honestly communicate with individuals who
167
Chapter 9
168
Time-Limited Group Therapy
the group is relationships. A brief explanation and the personal style of the therapist. In
of a “here and now” encounter is helpful—the homogeneous, problem-focused groups, for
group can become a place where feedback takes example, less time is needed to define what
place in the “here and now,” as members learn group members have in common. Opening
how they are affected by the others and how sessions typically include the following:
they in turn affect other members. This “here
New group members introduce themselves
and now” focus brings clients into the present
at the opening session, responding to a
and allows them to deal with real issues within
simple request such as, “Tell us what led you
the group that they can then apply in their daily
here.” Research suggests that if groups do
lives. It also distinguishes MIGP from self-help
not explicitly address the reason for each
support groups, which traditionally discourage
member’s participation, more members will
relational “here and now” interactions.
drop out (Levine, 1967). In the context of
If time permits, it is particularly effective for
substance abuse treatment, the therapist
group members as they are being assessed and
should therefore initially discuss with group
prepared for group to either watch or participate
members how substance abuse issues will be
in a practice group as a trial experience. A
addressed so as to ensure that focus is
variety of group tapes are available; however,
maintained.
any program can videotape one of its own
The “locus of control” for the group is
groups, with appropriate releases for client
clarified. Clients explore whether they
permission, to use for instructional purposes.
believe they have the ability to choose
This enables new clients to see what will happen
effective actions or if they think of
in the group session and lowers anxiety. This
themselves as helpless victims of
intentional effort to make the group safe and
circumstance. For directive groups, in which
reduce its inherent anxiety distinguishes MIGP
the therapist exercises greater control, this
from a more traditionally interactive process
process will be shorter than for group
group. Introductions to group can also be
process groups, in which group members
provided in a psychoeducational format.
take turns as leaders.
Clients learn not only what is going to take place
Goals for the group (and often for
in the group but also why and how the group
individuals) are clarified.
process brings about healing. The importance of
The therapist seeks to establish a safe, warm,
relationships and open communications through
supportive environment. There may be a
self-disclosure and support can be explained.
need to establish rules to increase safety—for
It is important to recognize that although a
example, that members will not engage in
significant amount of client preparation takes
physical contact, will not discuss what was
place before the client ever enters a group, client
said outside the room, and will give feedback
preparation itself is also a process and not an
to each other in an agreed-upon manner.
event. Through continual references to the
The therapist helps group members establish
group agreements and group contracts, the
connections with each other, pointing out
therapist continues to prepare clients as they
common concerns and problems.
move into the experience.
Some therapists ask the group to evaluate the
Initial Session opening session. This may be done orally or in
Opening sessions for group therapy differ writing. The group’s success can be measured
according to the type of group, its specific goals, through the following questions:
169
Chapter 9
170
Time-Limited Group Therapy
sexual preference will help clients in group may pose logistical difficulties. However, there
therapy share difficulties they may have is growing consensus among therapists that,
encountered because of that common whenever possible, women need to have their
background. own groups, particularly during early recovery
Participation in group therapy may be less (Byington, 1997). This does not suggest that
effective for women than men, perhaps because women should be fully segregated from men.
groups are often dominated by men and reflect Participation in mutually shared
their issues and style of interaction (Jarvis, 1992). psychoeducational experiences and multifamily
At this time, however, little research is available groups is a therapeutic way of addressing
on the relative efficacy of women-only rather gender issues (Byington, 1997).
than mixed-gender groups. Weitz argues that Concerns of ethnicity and race should be
women may have to be empowered in order to handled with sensitivity. This is not to suggest
remain abstinent (Weitz, 1982). Group that in a time-limited group, the potency of
cognitive–behavioral therapy has been found to homogeneity is such that each and every ethnic
be an effective treatment for women with or racial subgroup should be segregated in order
posttraumatic stress disorder and a substance to reap the benefits of this intervention.
abuse disorder (Najavits et al., 1996) as well as However, cultural issues need to be addressed
for women with both a substance abuse disorder openly and with sensitivity.
and a history of physical or sexual abuse
(Manisses Communication Group, 1997).
Cost-Effectiveness
Covington has written extensively about the The clinical utility of time-limited groups has
importance of women-specific groups, clearly been demonstrated, but the cost factor is
particularly in early recovery. She accurately not irrelevant to a consideration of the value of
pointed out that the powerful role definitions these groups. Although individual work and
within our culture tend to be played out in family work will likely always remain a part of
group and are often oppressive to women even the briefest time-limited treatment
(Covington, 1997). In a mixed group, the experience, acceptance and use of group
women quickly become the “emotional interventions are slowly growing. From a cost-
containers” for the group and take care of the management perspective, the benefits are
men. Although such activity is not defined as obvious. Not only can the therapist use the
pathological, it expresses cultural norms power of the group to support change within all
wherein women’s needs become secondary to group members, but one well-trained group
those of men, with the women primarily defined therapist can meet the clinical needs of 8 to 12
as caretakers. They are uncomfortable about clients in roughly the same amount of time as an
bringing up issues of sexuality, particularly individual session. When these numbers are
sexual abuse, given that men have generally enlarged to include more directive approaches
been the abusers (Covington, 1997). such as cognitive–behavioral or
The creation of gender-specific groups, psychoeducational groups, the cost–benefit ratio
particularly in small agencies or private practice, increases.
171
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207
Appendix A
208
Appendix B
Information and Training
Resources
Cognitive–Behavioral
General Brief Therapy Therapy
American Psychological Association Aaron T. Beck Institute for
(APA)—Division 29: Psychotherapy Cognitive Studies
Division of Psychotherapy Edmund F. O’Reilly, Ph.D.
P.O. Box 638 Founders Hall, Room 319
Niwot, CO 80544-0638 Assumption College
Phone: (303) 652-9154 500 Salisbury Street
Fax: (303) 652-2723 P.O. Box 15005
Web site: http://www.divisionofpsychotherapy.org/ Worcester, MA 01615-0005
E-mail: lpete@indra.com Phone: (508) 767-7000, x 7554
APA, headquarted in Washington, DC, is the Web site: http://graduate.assumption.edu/
world’s largest association of psychologists. counseling-psychology/aaron-t-beck-institute-
APA’s membership includes more than 159,000 cognitive-studies
researchers, educators, clinicians, consultants, E-mail: eoreill@eve.assumption.edu
and students. Through its divisions in 50 The Aaron T. Beck Institute for Cognitive
subfields of psychology and affiliations with 59 Studies provides information that highlights the
State, territorial, and Canadian provincial contributions of cognitive factors to the
associations, APA works to advance psychology resolution of problems in living. The Institute
as a science, as a profession, and as a means of hosts annual speakers and conferences that
promoting human welfare. address research and therapeutic development
Division 29 promotes education, research, in cognitive therapy as well as ethical and moral
high standards of practice, and the exchange of issues. It also sponsors education and training
information among psychologists interested in projects in cognitive therapeutic skills to
psychotherapy. students and to postgraduate professionals.
209
Appendix B
211
Appendix B
212
Information and Training Resources
213
Appendix B
abroad. The association facilitates research, group psychotherapy. Current projects include
theory development, and education. AAMFT developing national guidelines for doctoral and
hosts an annual national training conference postdoctoral training in group psychotherapy.
each fall as well as a week-long series of
continuing education workshops in the summer.
Association for Specialists in Group
Work (ASGW)
Group Therapy Jeremiah Donigian, President
Department of Counselor Education
SUNY College at Brockport
American Psychological Association
Brockport, NY 14420
(APA)—Division 49: Group
Phone: (800) 347-6647
Psychology and Group
Web site: http://www.asgw.org/
Psychotherapy
E-mail: jdonigia@po.brockport.edu
Alan M. Orenstein, Ph.D.
9712 DePaul Drive ASGW was founded to promote quality in
Bethesda, MD 20817 group work training, practice, and research,
Phone: (202) 373-7083 both nationally and internationally. A division
Web site: http://www.apa.org/about/division/ of the American Counseling Association (ACA),
div49.aspx ASGW numbers among its members more than
E-mail: alano@erols.com 5,800 group workers and group work educators.
The ASGW Web site provides a resource base
Division 49 of the APA (see above) provides a for teachers, students, and practitioners of group
forum for psychologists interested in research, work and includes both organizational
teaching, and practice in group psychology and information and professional resources.
214
Appendix C
Glossary
present moment rather than seeking detailed affects, actions, cognitive style, self-esteem,
intellectual analysis. and self-representations.
Contingency management: A contingency Counterconditioning: A method that uses
management approach attempts to change classical conditioning principles to make
those environmental contingencies that may behaviors previously associated with
influence substance abuse behavior. The positive outcomes less appealing by more
goal is to increase behaviors that are closely associating them with negative
incompatible with use. In particular, consequences. By repeatedly pairing those
contingencies that are found through a cues that formerly elicited a particular
functional analysis to prompt as well as behavior with negative rather than positive
reinforce substance use are weakened by outcomes, the cues lose their ability to elicit
associating evidence of substance abuse (e.g., the original classically conditioned response;
a drug-positive urine screen) with some form instead, they elicit a negative outcome. This
of negative consequence or punishment. is also called an aversive or counterconditioning
Contingencies that prompt and reinforce treatment approach.
behaviors that are incompatible with Countertransference: The phenomenon in
substance abuse and that promote abstinence which the therapist transfers his emotional
are strengthened by associating them with needs and feelings onto his client. This can
positive reinforcers. occur to a degree of personal involvement
Core conflictual relationship theme (CCRT): that seriously harms the therapeutic
Used in Supportive-Expressive (SE) Therapy, relationship.
this concept refers to the way in which the Covert sensitization: A technique used in
client interacts with others and with herself. counterconditioning therapy that pairs
The CCRT is considered to be the center of a negative consequences with substance-
client’s problems. It develops from early related cues through visual imagery.
childhood experiences, but the client is Cue exposure: This principle of classical
unaware of it and of how it developed. SE conditioning holds that if a behavior occurs
therapy posits that the client will have better repeatedly across time but is not reinforced,
control over behavior if she knows more the strength of both the cue for the behavior
about what she is doing on an unconscious and the behavior itself will diminish, and the
level. behavior will eventually vanish. Using cue
Core response from others (RO): A term used exposure, a client is presented with physical,
in SE therapy to explain one way in which environmental, social, or emotional cues
the core conflictual relationship theme is associated with past substance abuse (e.g., by
unconsciously developed. The RO accompanying her into an often-frequented
represents an individual’s predominant bar). The client then is prevented from
expectations or experiences of others’ drinking or taking drugs. This process, over
internal and external reactions to himself. time, leads to decreased reactivity to such
Core response of the self (RS): A term used in cues.
SE therapy that helps to develop an Defense mechanisms: The measures taken by
individual’s core conflictual relationship an individual’s ego to relieve excessive
theme. The RS refers to a more or less anxiety. When the environment causes
coherent combination of somatic experiences, excessive stress, the client’s ego will operate
216
Glossary
unconsciously to deny, distort, or falsify up into a triad of the mother, sister, and
reality. Defense mechanisms include denial, brother, and a dyad of the father and another
displacement, grandiosity, introjection, sibling. In that case, the therapist might
isolation, projection, repression, regression, highlight the fact that the mother and father
undoing, and identification with the communicate through one of their children
aggressor. and never talk to each other directly.
Deliberate exception: A situation in which a Functional analysis: A process used in
client has intentionally maintained a period behavioral and cognitive– behavioral therapy
of sobriety or reduced use for any reason. that probes the situations surrounding the
For example, a client who did not use client’s substance abuse. A functional
substances for a month in order to pass a analysis examines the relationships among
drug test for a new job has made a deliberate stimuli that trigger use and the consequences
exception to his typical pattern of daily that follow. This can provide important
substance use. If he is reminded that he did clues regarding the meaning of the substance
this in the past, it will demonstrate that he use behavior to the client, as well as possible
can do so in the future. motivators and barriers to change. In these
Directive approach: This form of group therapy forms of therapy, this is a first step in
offers structured goals and therapist-directed providing the client with tools to manage or
interventions to enable individuals to change avoid situations that trigger substance use.
in desired ways. It is a contrast to the Functional analysis yields a roadmap of a
process-sensitive approach. The directive client’s interpersonal, intrapersonal, and
approach addresses specific agenda items in environmental catalysts and reactions to
a logical order with greater emphasis on substance use, thereby identifying likely
content as the primary source of effective precursors to substance use.
change. Insight: A particular kind of self-realization or
Effect expectancies: A set of cognitive self-knowledge, usually regarding the
expectancies that the client develops connections of experiences and conflicts in
concerning anticipated effects on her feelings the past with present perceptions and
and behavior as drinking and drug use are behavior, and the recognition of feelings or
reinforced by the positive effects of the motivations that have been repressed.
substance being taken. These represent the Miracle question: A solution-focused
expectation she holds that certain effects will interviewing strategy in which the therapist
predictably result from drinking or using asks the client the question, “If a miracle
specific drugs. happened and your condition were suddenly
Family sculpting: A technique used in family not a problem for you, how would your life
therapy. The therapist “sculpts” family be different?” This forces the client to
members in typical roles and presents consider a life without substance use and to
significant situations related to substance imagine himself enjoying that life.
abuse patterns. In this process, family Operant learning: Operant learning refers to the
members enact a scene to graphically depict process by which behaviors that are
the problem. The physical arrangement of reinforced increase in frequency. Behaviors
the family members can illustrate emotional that result in positive outcomes or that allow
relationships and conflicts within the family. the client to avoid negative consequences are
For example, a family may naturally break likely to increase in frequency. Substance
217
Appendix C
use in the presence of classically conditioned because of circumstances that are apparently
cues is instrumental in reducing or beyond his control. The client may say, for
eliminating the arousal associated with a example, that he was just “feeling good” and
state of craving, thus serving to reinforce the did not feel the urge to use at a particular
substance abuse behavior. That is, the time but cannot point to any intentional
behavior serves a basic rewarding function behaviors on his part that enabled him to
for the individual. For example, an alcohol stay sober. In such instances, the therapist
abuser who drinks to feel more social and can ask the client to try to predict when such
less anxious is using substances in an a period of “feeling good” might occur again,
instrumental way. To the extent that she which will force him to begin thinking about
experiences the effects she seeks, the greater the behaviors that may have had an effect on
the likelihood she will use alcohol under creating the random exception.
similar circumstances in the future. Selfobject: A term used in self psychology that
Process-sensitive approach: This term consists refers to something or someone else that is
of two, somewhat different, contrasting types experienced and used as if it were part of
of group psychotherapy. The process- one’s own self. For example, a child is
sensitive group approach examines the dependent on her parent’s love and praise in
unconscious processes of the group as a order to develop a sense of self-worth and
whole, using these energies to help self-esteem. In that way, the child
individuals see themselves more clearly and internalizes a part of the parent as the
therefore open up the opportunity for selfobject.
change. The first type of process-sensitive Therapeutic alliance: The relationship between
approach may be termed the “group-as-a- the therapist and client. In all
whole” approach and sees healing as an psychodynamic therapies, the first goal is to
extension of the individuals within the group establish a “therapeutic alliance” between
as the group comes to terms with a therapist and client, because this association
commonly shared anxiety. The second type functions as the vehicle through which
of process-sensitive approach uses an change occurs. A therapeutic alliance
interactional group process model. By requires intimate self-disclosure on the part
attending to the relationships within the of the client and an empathic and
group and helping individuals understand appropriate response on the part of the
themselves within the relational framework, therapist. In brief psychodynamic therapy,
an interactional group process provides this alliance must be established as soon as
individuals with significant information possible, and the therapist must be able to
about how their behavior affects others and establish a trusting relationship with his
how they are in turn affected by other client in a short time.
members. Transference: The process, basic to all
Psychodrama: A method of psychotherapy in psychodynamic therapies, of the client’s
which clients act out their personal problems transference of salient characteristics of
by spontaneously enacting specific roles in unresolved conflicted relationships with
dramatic performances performed before significant others onto the therapist. For
fellow clients. example, a client whose relationship with her
Random exception: An occasion upon which a father is deeply conflicted may find herself
client reduces substance use or abstains reacting to the therapist as if he were her
218
Glossary
219
Appendix D
Health Promotion Workbook
Reprinted with permission from Barry, K.L., and Blow, F.C., 1998.
Exercise
Days per week you participated in vigorous activity none
seldom
1–2 days per week
3–5 days per week
6–7 days per week
Nutrition
Weight change in last 6 months no change in weight
gained more than 10 pounds
lost more than 10 pounds
don’t know
221
Appendix D
Tobacco Use
Tobacco used in last 6 months no
yes
If yes, which ones?
cigarettes
chewing tobacco
pipe
Alcohol Use
Drinking days per week 1–2 days per week
3–4 days per week
5–6 days per week
7 days per week
222
Health Promotion Workbook
Abstainers and light Drink no alcohol or fewer than 3 drinks per month
drinkers Alcohol use does not affect health or result in negative consequences
Pregnant and breastfeeding women are advised to drink NO alcohol
At-risk drinkers Drink over 12 (women) and 15 (men) standard drinks per week
At risk for negative health and social consequences
Alcoholics Heavy drinking has led to physical need for alcohol and to other
problems
Alcoholics (10%)
223
Appendix D
The following are some of the negative consequences that may result from drinking.
The following list identifies some of the reasons why people decide to cut down or quit drinking. Check
each box by the three most important reasons why YOU want to quit or cut down on your drinking.
Perhaps you can think of other reasons that are not on this list.
Write down the three most important reasons you chose to cut down or quit drinking.
1. _______________________________________________________________
2. _______________________________________________________________
3. _______________________________________________________________
224
Health Promotion Workbook
Think about the consequences of continuing to drink heavily. Now think about how your life might
improve if you change your drinking habits by cutting down or quitting. What improvements do you
anticipate?
Physical health:
Mental health:
Family:
Other relationships:
Work/school:
Financial:
Legal:
DRINKING AGREEMENT
Date: ________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
225
Appendix D
The drinks shown below in normal measure contain roughly the same amount of pure alcohol. You can
think of each one as a standard drink.
:KDW¶VDVWDQGDUGGULQN"
VWDQGDUGGULQN
FDQRI $VPDOO
RUGLQDU\ $JODVVRI JODVVRI
EHHURUDOH ZLQH VKHUU\
R] DVLQJOHVKRW R] R]
DVPDOOJODVV
RIVSLULWV
RIOLTXHXURU
R]
DSHULWLI
R]
Diary Card
226
Health Promotion Workbook
Here are examples of risky situations. The following list may help you remember situations that can
result in at-risk drinking.
What are some situations that make you want to drink at a risky level? Please write them down.
1. ____________________________________________________________________________
2. ____________________________________________________________________________
Some of these ideas may not work for you, but other methods of dealing with risky situations may work.
Identify ways in which you could cope with the specific risky situations you listed above.
1. For the first risky situation or feeling, write down different ways of coping.
________________________________________________________________________
________________________________________________________________________
227
Appendix D
2. For the second risky situation or feeling, write down different ways of coping.
________________________________________________________________________
________________________________________________________________________
Think about other situations and ways in which you could cope without using alcohol.
Visit Summary
We have covered a great deal of information today. Changing one’s behavior, especially drinking
patterns, can be a difficult challenge. The following pointers may help you stick with your new behavior
and maintain the drinking limit agreement, especially during the first few weeks when it is most difficult.
Remember that you are changing a habit and that it can be hard work. It becomes easier with time.
Every time you are tempted to drink above limits and are able to resist, congratulate yourself because
you are breaking an old habit.
Whenever you feel very uncomfortable, tell yourself that the feeling will pass.
At the end of each week, think about how many days you have been abstinent (have consumed no
alcohol) or have been a light or moderate drinker.
Some people have days during which they drink too much. If that happens to you, DON’T GIVE UP.
Just start again the next day.
228
Appendix E
Resource Panel
229
Appendix F
Field Reviewers
231
Appendix F
232
Field Reviewers
233
Appendix F
234
The TIPs Series
Other TIPs may be ordered by calling 1-877-SAMHSA-7 (1-877-726-4727) (English and Español)
or visiting http://store.samhsa.gov.
HHS Publication No. (SMA) 12-3952
Substance Abuse and Mental Health Services Administration
First Printed 1999
Revised 2002, 2003, 2004, 2007, 2009, 2011, and 2012