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 responding to media advertisements)
Assess substance abuse behavior and give supportive 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
Precontemplation. The user is not considering change, is aware of few negative consequences, and is unlikely to take action soon.
A functional yet alcohol-dependent individual who drinks himself into a stupor every night but who goes to work every day, performs his job, has no substance abuse-related legal problems, has no health problems, and is still married.
This client needs information linking his problems and potential problems with his substance abuse. A brief intervention might be to educate him about the negative consequences of substance abuse. For example, if he is depressed, he might be told how his alcohol abuse may cause or exacerbate the depression.
Contemplation. The user is aware of some pros and cons of substance abuse but feels ambivalent about change. This user has not yet decided to commit to change.
An individual who has received a citation for driving while intoxicated and vows that next time she will not drive when drinking. She is aware of the consequences but makes no commitment to stop drinking, just to not drive after drinking.
This client should explore feelings of ambivalence and the conflicts between her substance abuse and personal values. The brief intervention might seek to increase the client's awareness of the consequences of continued abuse and the benefits of decreasing or stopping use.
Preparation. This stage begins once the user has decided to change and begins to plan steps toward recovery.
An individual who decides to stop abusing substances and plans to attend counseling, AA, NA, or a formal treatment program.
This client needs work on strengthening commitment. A brief intervention might give the client a list of options for treatment (e.g., inpatient treatment, outpatient 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 new behaviors, but these are not yet stable. This stage involves the first active steps toward change.
An individual who goes to counseling and attends meetings but often thinks of using again or may even relapse at times.
This client requires help executing an action plan and may have to work on skills to maintain sobriety. The clinician should acknowledge the client's feelings and experiences as a normal part of recovery. Brief interventions could be applied throughout this stage to prevent relapse.
Maintenance. The user establishes new behaviors on a long-term basis.
An individual who attends counseling regularly, is actively involved in AA or NA, has a sponsor, may be taking disulfiram (Antabuse), has made new sober friends, and has found new substance-free recreational activities.
This client needs help with relapse prevention. A brief intervention could reassure, evaluate present actions, and redefine long-term sobriety maintenance plans.
Source: Adapted from Prochaska and DiClemente, 1984.
Script in the emergency department, primary care office, or other setting where consultations will be performed
Script in the substance abuse treatment unit
Introducing the Issue
"I'm from the substance abuse disorder unit. Your doctor asked me to stop by to tell you about what we do on that unit. Would you be willing to talk to me briefly about it? Whatever we talk about will remain 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?"
"Would it be OK with you if we discuss some of the difficulties you've had in getting homework done for the group meetings and how we can work together to help you take advantage of the treatment process?"
Screening, Evaluating, and Assessing
"In reviewing the information you've given me, using a scale of 'not ready,' 'unsure,' and 'ready,' how prepared do you feel you are to stop drinking?"
Client says "unsure."
"One of the factors that might tie together your accident and your problems with your wife is your drinking."
"I think it would be worth talking more to some of the people at the 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?"
"Given what you see as the additional stress in your family and your desire to make the treatment work for you this time, on a scale of 1 to 10, how ready do you feel to find a way to put time into your homework?"
Client says, "6."
"I am pleased that you are willing to consider trying this, even though it won't be easy. Let's come up with some strategies that we can write down to help you accomplish this goal."
Providing Feedback
"I'd like to get some confidential information about your drinking to give me a better idea of your drinking style. Can you tell me how many days a week you drink? How many drinks a day?"
"Have you had any problems with your health, family or personal life, or work in the last 3 months? Were you drinking in the 6 hours before your accident took place?"
"I'd like to talk about what was going on when you decided not to do the homework assignment. Can you tell me a little about what you were thinking or feeling at the time? Why do you think it was difficult to get your homework done?"
"Have there been other parts of treatment that have been hard to follow?"
Talking About Change and Setting Goals
"It looks as if you have been having about 30-35 drinks a week and have been doing some binge drinking on weekends. You've said that your accident took place after you'd had some alcohol, and you said you've been under a lot of stress with your family and at work. You also indicated that you don't really think alcohol is making things worse, but you're willing to think about that. Is that an accurate assessment of how you see it?"
"You've said that you completely forgot to do the homework because of arguments with your wife and daughter and that this surprised you because you had really intended to get it done. Is that about right?"
Summarizing and Reaching Closure
"Even though you're not ready to stop drinking at this time, I'm glad you agreed to write down the pros and cons of not drinking. How about if we meet tomorrow for a followup?"
"You just did a good piece of work. I think you made some progress. I'm glad you're trying something new. How about if we meet again in a week to see how things went for you?"
Figure 2-6 Screening for Brief Interventions for Alcoholism
Screen
At each visit, ask about alcohol use
How many drinks per week?
Maximum drinks per occasion in past month?
Use CAGE questions to probe for alcohol problems
Have you ever tried to Cut down on your drinking?
Do you get Annoyed when people talk about your drinking?
Do you feel Guilty about your drinking?
Have you ever had an Eye-opener? (i.e. a drink first thing in the morning)
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
Then assess for
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
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
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.)
Form a reflective statement. To reflect your understanding, repeat in your own words what the client said.
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.
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
The following criteria are derived from clinical experience:
Less severe substance abuse, as measured by an instrument like the Addiction Severity Index (ASI)
Level of past trauma affecting the client's substance abuse
Insufficient resources available for more prolonged therapy
Limited amount of time available for treatment (e.g., 7-day average length of stay in county-jail-level correctional facilities; 30- to 45-day limitation in Job Corps program)
Presence of coexisting medical or mental health diagnoses
Large numbers of clients needing treatment leading to waiting lists for specialized treatment
This therapy posits that substance abuse disorders reflect habitual, automatic, 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 therapy
Using this approach, which is based on learning theories, the therapist teaches the 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-behavioral therapy
This approach combines elements of cognitive and behavioral therapies, but in most substance abuse treatment settings it is considered a separate therapy. This approach focuses on learning and practicing a variety of coping skills. The emphasis is placed on developing coping strategies, especially early in the therapy. Cognitive-behavioral 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/interactional therapies
These approaches seek to understand a client's viewpoint on a problem, what meaning is attributed to events, and what ineffective interpersonal interactions 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-focused therapy
Using this approach, the therapist helps a client with a substance abuse disorder 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.)
Humanistic and existential therapies
These therapies assume that the underlying cause of substance abuse disorders is a lack of meaning in one's life, a fear of death, disconnectedness from people, spiritual emptiness, or other overwhelming anxieties. Through unconditional acceptance, clients are encouraged to improve their self-respect, self-motivation, and growth. The approach can be a catalyst for seeking alternatives to substances in order to fill the emptiness experienced and expressed as substance abuse. (See Chapter 6.)
Psychodynamic therapy
The psychodynamic therapist works with the assumption that a person's problems with substances are rooted in unconscious and unresolved past conflicts, especially in early family relationships. The goal is to help the client gain insight into underlying causes of manifest problems, understand what function substance abuse is serving, and strengthen present defenses to work through the problem. A strong therapeutic alliance with the therapist assists the client to make positive changes. (See Chapter 7.)
Interpersonal therapy
This therapy, which combines elements of cognitive and psychodynamic therapies, was originally developed to work with clients with depression but has been used successfully with substance-abusing clients. It focuses on reducing the client's dysfunctional symptoms and improving social functioning by concentrating on a client's maladaptive patterns of behavior. It is supportive in nature, providing encouragement, reassurance, reduction of guilt, and help in modifying the client's environment. (See Chapter 7 for more information.)
Family therapy
While not a distinct "school" of therapy, family therapy is a modality that either treats the client as part of a family system or considers the entire family as "the client." It examines the family system and its hierarchy to determine dysfunctional uses of power that lead to negative or inappropriate alignments or poor communication patterns and that contribute to substance use disorder by one or more family members. The therapist helps family members discover how their own system operates, improve communication and problem-solving skills, and increase the exchange of positive reinforcement. (See Chapter 8.)
Group therapy
This modality (also not a distinct theoretical school) uses many of the techniques and theories described to accomplish specified goals. In some group therapy, the group itself and the processes that emerge are central to helping clients see themselves in the reactions of others, although the content and focus of the groups vary widely. (See Chapter 9.)
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)
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.
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.")
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.
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.
Filtering--taking negative details and magnifying them, while filtering out all positive aspects of a situation
Polarized thinking--thinking of things as black or white, good or bad, perfect or failures, with no middle ground
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
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
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?")
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
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
Fallacy of fairness--feeling resentful because you think you know what is fair, even though other people do not agree
Blaming--holding other people responsible for your pain or blaming yourself for every problem
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
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)
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
Global labeling--generalizing one or two qualities into a negative global judgment
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
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
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 do lose control once in a while. It's other people who have a problem with the way I drink.
Losing control can be the first sign of a problem, and if my drinking is a significant problem for others, sooner or later it will be for me.
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 too hard to tolerate.
I may not like it, but I have stood it in the past and can do so now.
The only time I feel comfortable is when I'm high.
It's hard to learn to be comfortable socially without drugs but people do so all the time.
It would be too hard to stop drinking. I'd lose all my friends, be bored, and never be comfortable without it.
While stopping drinking and doing drugs might cost me some things and take time and effort, if I don't, the consequences will be far worse.
People who can't or don't drink are doomed to frustration and unhappiness.
Where's the evidence of that? I'll try going to an 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 over, you're right back to where you started, and all your efforts only lead you to total failure. Once an addict, always an addict.
A slip is only a new learning experience toward recovery. It is not a failure, only a setback that can tell me what direction I need to go in now. It's my choice.
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?"
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:
A functional analysis of substance abuse
Individualized training in recognizing and coping with craving, managing thoughts about substance abuse, problemsolving, planning for emergencies, recognizing seemingly irrelevant decisions, and using refusal skills
An examination of the client's cognitive processes related to substance abuse
The identification and debriefing of past and future high-risk situations
The encouragement and review of extra-session implementation of skills
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.
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.
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.
Therapist: What led you to go gambling?
Client: I guess I'd been gambling for a few months before I got high. I was bored. Therapist: What is the experience of gambling like?
Client: I really feel alive.
Therapist: When did you first use again?
The first trigger (boredom) has been identified; this will have to be reframed as treatment progresses.
Client: I spent too much money on gambling, and my wife yelled at me the same way she used to when I got high on cocaine. I won
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