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1 DOCUMENT RESUME ED CG TITLE Brief Interventions and Brief Therapies for Substance Abuse. Treatment Improvement Protocol (TIP) Series 34. INSTITUTION CDM Group, Inc.; Substance Abuse and Mental Health Services Administration (DHHS/PHS), Rockville, MD. Center for Substance Abuse Treatment. REPORT NO SMA PUB DATE NOTE 258p.; For other documents in the TIP Series, see CG and CG CONTRACT AVAILABLE FROM National Clearinghouse for Alcohol and Drug Information, P.O. Box 2345, Rockville, MD Tel: (Toll Free). PUB TYPE Guides Non-Classroom (055) Information Analyses (070) -- Tests/Questionnaires (160) EDRS PRICE MF01/PC11 Plus Postage. DESCRIPTORS At Risk Persons; *Behavior Modification; Cognitive Restructuring; Counseling Effectiveness; Counselor Training; *Drug Rehabilitation; Group Therapy; *Intervention; Mental Health; *Outcomes of Treatment; *Substance Abuse IDENTIFIERS Humanistic Psychology; *Solution Focused Brief Therapy ABSTRACT This TIP, on the best practice guidelines for treatment of substance use disorders, was compiled from an increasing body of research literature that documents the effectiveness of brief interventions and therapies in both the mental health and substance abuse treatment fields. It links research to practice by providing counselors with up-to-date information on the usefulness of these treatment forms for selected subpopulations of people with substance abuse disorders or for those at risk. The manual states that brief interventions and therapies are less costly, yet effective, in substance abuse treatment. Brief interventions have been found to be effective for a range of problems; they can greatly improve substance abuse treatment by making it available to a greater number of people and by tailoring the level of treatment to the level of client need. This TIP includes sections on brief interventions and therapy in substance abuse treatment, along with sections on brief therapies in the fields of cognitive-behavioral, strategic/interactional, humanistic and existential, psychodynamic, family, and group counseling. Appendixes include "Bibliography," "Information and Training Resources," " Glossary," "Health Promotion Workbook," "Resource Panel," and "Field Reviewers." (Contains 43 figures and approximately 450 resources.) (JDM) Reproductions supplied by EDRS are the best that can be made from the original document.

2 US. DEPARTMENT OF AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Brief Interventions And rief Therapies For Substance Abuse Treatment Improvement Protocol (TIP) Series 34 Mi4MMIE1 MINiMin7.0611MINCIEMMEGO MEMOSIIMIM/SO t MIN =me SINIZEWINIMS I=E EIIIMIIIMINMS ENEMIEBRIENIEV ME B IIIIRRICEMEMINMerl Et1.7,%-egu"-011'47 iztueirg, MMMENMIMIIMMISh. EZIZMW =1111:111BIMMI NE : / Ati.M.; U.S. DEPARTMENT OF EDUCATION Mice of Educational Research and Improvement EDUCATIONAL RESOURCES INFORMATION CENTER (ERIC) This document has been reproduced as received from the person or organization originating it. Minor changes have been made to improve reproduction quality. Points of view or opinions stated in this document do not necessarily represent official OERI position or policy. BEST COPY AVAILABLE

3 Screening and Brief Interventions for Alcoholism Screen At each visit, ask about alcohol use How many drinks per week? Maximum drinks per occasion in past 0 month? CA CIJ Use CAGE questions to probe for alcohol problems (-4 Have you ever tried to Cut down on your drinking? szt Do you get Annoyed when people talk about your drinking? et: cn Do you feel Guilty about your drinking? Have you ever had an Eye-opener? (A drink first thing in the morning) Screen is positive if 4'4 Consumption is greater than 14 drinks per 4.1 cu week or greater than 4 drinks per occasion M re) (men) Consumption is greater than 7 drinks per week or greater than 3 drinks per occasion E-4 (women) CAGE score is greater than 1 Then assess for Medical problems: e.g., blackouts, depression, 4.6 hypertension, trauma, abdominal pain, liver dysfunction, sexual problems, sleep disoro ders ;4.. Laboratory: elevated gamma-glutamyl transpeptidase or other liver function tests; elevated mean corpuscular volume; positive blood alcohol concentrations Behavioral problems: work, family, school, Et E-4 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 a

4 4 Client Feedback and Plan of Action Give specific feedback to the patient, w then advisein a firm but empathic cn = manner 4 et If diagnosed as at risk to co 0 rsi di' Advise patient of risk Advise abstinence/moderation = cf) Set consumption goals id 0 Schedule followup to discuss progress..1-, Ch 4)... t:16 es w or E.4,..lo ctr 'i".".. I:2 SUCCEEDS C fti C/3 = a. or PROGRESS CONTINUE FOLLOWUP DOES NOT SUCCEED oh, I1 If diagnosed as substance dependent.4.4 2id Advise patient of objective evidence 02 4 Advise on plan of action en Assess acute risk of intoxication/with- O., drawal E- Medical/psychiatric comorbidities 8,...1 Agree on plan of action 2 0i.. Or 4. Zgd... Plan of action Involve family: refer for family treatment and CU". E self-help (e.g., Al-Anon, etc.) (must have or 0 patient permission and involvement) z.. Abstinence should be stressed = Urge patient to attend self-help meetings = (Alcoholics Anonymous, Narcotics o.) Anonymous, SMART Recovery, etc.) t Consider referral to addiction medicine cs.),_ F+.-4 (l) U specialist, and/or possible pharmacotherapy with disulfiram (Antabuse) or Naltrexone (Re Via) Reprinted with permission from the American Society of Addiction Medicine

5 Brief Interventions And Brief Therapies for Substance Abuse Treatment Improvement Protocol (TIP) Series 34 Kristen Lawton Barry, Ph.D. Consensus Panel Chair U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD

6 This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated. This publication was written under contract number with The CDM Group, Inc. (CDM). Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT government project officer. Rose M. Urban, L.C.S.W., J.D., C.C.A.S., served as the CDM TIPs project director. Other CDM TIPs personnel included Raquel Ingraham, M.S., project manager; Jonathan Max Gilbert, M.A., managing editor; Janet G. Humphrey, M.A., editor/writer; Cara Smith, production editor; Erica Flick, editorial assistant; Y-Lang Nguyen, former production editor; and Paul Seaman, former editorial assistant. Special thanks go to consulting writers Scott M. Buchanan, M.S.Ed.; Dennis M. Donovan, Ph.D.; Jeffrey M. Georgi, M.Div.; Delinda E. Mercer, Ph.D.; Larry Schor, Ph.D.; and George E. Woody, M.D. The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized client care and treatment decisions. DHHS Publication No. (SMA) Printed 1999 ii 6

7 Contents What Is a TIP? Editorial Advisory Board Consensus Panel Foreword Executive Summary and Recommendations Summary and Recommendations vii ix xi xiii xv xvi Chapter 1 Introduction to Brief Interventions and Therapies 1 An Overview of Brief Interventions 3 An Overview of Brief Therapies 7 The Demand for Brief Interventions and Therapies 8 Barriers to Increasing the Use of Brief Treatments 10 Evaluating Brief Interventions and Therapies 11 Chapter 2Brief Interventions in Substance Abuse Treatment 13 Stages-of-Change Model 14 Goals of Brief Intervention 16 Components of Brief Interventions 18 Brief Intervention Workbooks 24 Essential Knowledge and Skills for Brief Interventions 25 Brief Interventions in Substance Abuse Treatment Programs 27 Brief Interventions Outside Substance Abuse Treatment Settings 28 Research Findings 30 Chapter 3Brief Therapy in Substance Abuse Treatment 37 Research Findings 38 When To Use Brief Therapy 39 Approaches to Brief Therapy 41 Components of Effective Brief Therapy 41 Therapist Characteristics 49 iii

8 Contents iv Chapter 4Brief Cognitive-Behavioral Therapy 51 Behavioral Theory 51 Behavioral Therapy Techniques Based on Classical Conditioning Models 53 Behavioral Therapy Techniques Based on Operant Learning Models 55 Cognitive Theory 61 Cognitive Therapy 63 Cognitive-Behavioral Theory 68 Cognitive-Behavioral Therapy 77 Chapter 5Brief Strategic/Interactional Therapies 87 Solution-Focused Therapy for Substance Abuse 88 Compatibility of Strategic/Interactional Therapies and 12-Step Programs 89 When To Use Strategic/Interactional Therapies 90 Case Study 92 Strategic/Interactional Therapies 99 Chapter 6Brief Humanistic and Existential Therapies 105 Using Humanistic and Existential Therapies 106 The Humanistic Approach to Therapy 109 The Existential Approach to Therapy 117 Chapter 7Brief Psychodynamic Therapy 121 Background 121 Introduction to Brief Psychodynamic Therapy 122 Psychodynamic Psychotherapy for Substance Abuse 123 Psychodynamic Concepts Useful in Substance Abuse Treatment 128 Transference 131 Models of Brief Psychodynamic Therapy 135 Other Research 140 Chapter 8Brief Family Therapy 143 Appropriateness of Brief Family Therapy 144 Definitions of "Family" 145 Theoretical Approaches 147 Using Brief Family Therapies 152 Follow up 154 Cultural Issues 154 Chapter 9Time-Limited Group Therapy 157 Appropriateness of Group Therapy 157 Group Therapy Approaches 158 Theories of Group Therapy 160 Use of Psychodrama Techniques in a Group Setting 164 Therapeutic Factors 166 Using Time-Limited Group Therapy 168

9 Contents Appendix ABibliography 173 Appendix BInformation and Training Resources 209 General Brief Therapy 209 CognitiveBehavioral Therapy 209 Strategic/Interactional Therapies 210 Humanistic and Existential Therapies 211 Psychodynamic Therapy 213 Family Therapy 213 Group Therapy 214 Appendix CGlossary 215 Appendix DHealth Promotion Workbook 221 Part 1: Summary of Health Habits 221 Part 2: Types of Drinkers in the U.S. Population 222 Part 3: Consequences of Heavy Drinking 223 Part 4: Reasons To Quit or Cut Down on Your Drinking 224 Part 5: Drinking Agreement 225 Part 6: Handling Risky Situations -227 Appendix EResource Panel 229 Appendix FField Reviewers 231 Figures 1-1 Substance Abuse Severity and Level of Care Goal of Brief Interventions According to Setting The Stages of Change Sample Objectives American Society of Addiction Medicine (ASAM) Patient Placement Criteria FRAMES Scripts for Brief Intervention Screening for Brief Interventions for Alcoholism Client Feedback and Plan of Action Talking About Change at Different Stages Steps in Active Listening Professionals Outside of Substance Abuse Treatment Who Can Administer Brief Interventions Criteria for Longer Term Treatment Selected Criteria for Providing Brief Therapy Approaches to Brief Therapy Characteristics of All Brief Therapies Sample Battery of Brief Assessment Instruments Classical Conditioning and Operant Learning 52

10 Contents 4-2 Basic Assumptions of Behavioral Theories of Substance Abuse and Its Treatment Advantages of Behavioral Theories in Treating Substance Abuse Disorders Functional Analysis Teaching Stress Management Programmed Therapy and Writing Therapy The Relationship Among Factors Maintaining Behavior in Behavioral and Cognitive Models Fifteen Common Cognitive Errors Characteristic Thinking of People With Substance Abuse Disorders Common Irrational Beliefs About Alcohol and Drugs With More Rational Alternatives Thoughts, Feelings, and Behaviors Introducing Cognitive Therapy: A Sample Script Common Elements of Brief CognitiveBehavioral Therapies Attributional Styles Relapse Prevention Model Based on Self-Efficacy Theory Taxonomy of High-Risk Situations Based on Marlatt's Original Categorization System A CognitiveBehavioral Model of the Relapse Process Essential and Unique Elements of CognitiveBehavioral Interventions Intrapersonal and Interpersonal Skills Training Elements Assertiveness Training Types of Clients for Whom Outpatient CBT Is Generally Not Appropriate Deliberate and Random Exceptions to Substance Abuse Behaviors Strategic/Interactional Therapy in Practice: A Case Study A Case Study Defense Mechanisms Brief Psychodynamic Therapy 136 vi 1.0

11 What Is a TIP? Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse disorders, provided as a service of the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIP ', which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private substance abuse treatment facilities as alcoholism and other substance abuse disorders are increasingly recognized as major problems. The TIPs Editorial Advisory Board, a distinguished group of substance abuse experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Other Drug Abuse Directors to generate topics for the TIPs based on the field's current needs for information and guidance. After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content of the TIP. Then recommendations are communicated to a Consensus Panel composed of non-federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which it reaches consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration. A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state-of-the-art information. Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving and that research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided. 11 vii

12 What Is a TIP? This TIP, Brief Interventions and Brief Therapies for Substance Abuse, is intended primarily for counselors and therapists working in the substance abuse treatment field, but parts of it will be of value to other audiences, including health care workers, social services providers, clergy, teachers, and criminal justice personnel. In fact, those portions of this TIP dealing with brief interventions will be of use to any professional service provider who may need to make an intervention to help persons with substance abuse disorders alter their use patterns or seek treatment. However, brief therapy should only be practiced by those who are properly qualified, educated, and licensed. The first chapter of this TIP presents an overview of brief interventions and brief therapies, describing their basic characteristics and the reasons for increased interest in them. Chapter 2 describes the goals and components of brief interventions, and Chapter 3 discusses some of the basic elements of all brief therapies. Chapters 4 through 9 each highlight a different type of brief therapy, describing the theory behind it as well as some of the techniques developed from that theory that can be used to treat clients with substance abuse disorders. Separate chapters are presented describing cognitivebehavioral therapy, strategic/interactional therapies, humanistic and existential therapies, psychodynamic therapies, family therapy, and group therapy. Appendixes are also included that provide resources for further information and training, a glossary of terms used in the TIP, and a sample workbook for use in brief interventions. The goal of this TIP is to make readers aware of the research, results, and promise of brief interventions and brief therapies in the hope that they will be used more widely in clinical practice and treatment programs across the United States. Other TIPs may be ordered by contacting SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI), (800) or (301) ; TDD (for hearing impaired), (800) viii 12

13 oria_ dvisory Board Karen Allen, Ph.D., R.N., C.A.R.N. Professor and Chair Department of Nursing Andrews University Berrien Springs, Michigan Richard L. Brown, M.D., M.P.H. Associate Professor Department of Family Medicine University of Wisconsin School of Medicine Madison, Wisconsin Dorynne Czechowicz, M.D. Associate Director Medical/Professional Affairs Treatment Research Branch Division of Clinical and Services Research National Institute on Drug Abuse Rockville, Maryland Linda S. Foley, M.A. Former Director Project for Addiction Counselor Training National Association of State Alcohol and Drug Abuse Directors Washington, D.C. Wayde A. Glover, M.I.S., N.C.A.C. II Director Commonwealth Addictions Consultants and Trainers Richmond, Virginia Pedro J. Greer, M.D. Assistant Dean for Homeless Education University of Miami School of Medicine Miami, Florida Thomas W. Hester, M.D. Former State Director Substance Abuse Services Division of Mental Health, Mental Retardation and Substance Abuse Georgia Department of Human Resources Atlanta, Georgia James G. (Gil) Hill, Ph.D. Director Office of Substance Abuse American Psychological Association Washington, D.C. Douglas B. Kamerow, M.D., M.P.H. Director Office of the Forum for Quality and Effectiveness in Health Care Agency for Health Care Policy and Research Rockville, Maryland Stephen W. Long Director Office of Policy Analysis National Institute on Alcohol Abuse and Alcoholism Rockville, Maryland Richard A. Rawson, Ph.D. Executive Director Matrix Center and Matrix Institute on Addiction Deputy Director, UCLA Addiction Medicine Services Los Angeles, California 13 ix

14 Editorial Advisory Board Ellen A. Renz, Ph.D. Former Vice President of Clinical Systems MEDCO Behavioral Care Corporation Kamuela, Hawaii Richard K. Ries, M.D. Director and Associate Professor Outpatient Mental Health Services and Dual Disorder Programs Harborview Medical Center Seattle, Washington Sidney H. Schnoll, M.D., Ph.D. Chairman Division of Substance Abuse Medicine Medical College of Virginia Richmond, Virginia x 14

15 Consensus Panel Chair Kristen Lawton Barry, Ph.D. Associate Research Scientist Alcohol Research Center University of Michigan Ann Arbor, Michigan Workgroup Leaders Christopher W. Dunn, Ph.D., M.A.C., C.D.C. Psychiatry and Behavioral Science University of Washington Seattle, Washington Jerry P. Flanzer, D.S.W., L.C.S.W., C.A.C. Director Recovery and Family Treatment, Inc. Alexandria, Virginia Stephen Gedo, Ph.D. Clinical Psychologist Gaffney, South Carolina Eugene Herrington, Ph.D. Associate Professor Department of Counseling and Psychological Services Clark Atlanta University Atlanta, Georgia Fredrick Rotgers, Psy.D. Director Program for Addictions Consultation and Treatment Center of Alcohol Studies Rutgers University New Brunswick, New Jersey Terry Soo-Hoo, Ph.D. Clinic Director/Assistant Professor Counseling Psychology Department University of San Francisco San Francisco, California Panelists Janice S. Bennett, M.S., C.S.A.C. Owner/Consultant Pacific Consulting and Training Services of Hawaii Honolulu, Hawaii Robert L. Chapman, M.S.S.W., C.A.D.O.A.C., C.R.P.S. Cumberland Heights Nashville, Tennessee John W. Herdman, Ph.D., C.A.D.A.C. Psychologist The Encouragement Place Lincoln, Nebraska Fanny G. Nicholson, C.C.S.W., A.C.S.W., N.C.A.C.I., C.S.A.E. Alcohol and Drug Specialist Oconaluftee Job Corps Cherokee, North Carolina Mary Alice Orito, C.S.W., C.A.S.A.C., N.C.A.C.I. Evaluation Supervisor Stuyvesant Square Outpatient Services for Chemical Dependency New York, New York 15 xi

16 Consensus Panel Jerome J. Platt, Ph.D. Professor of Psychiatry and Public Health Director, Institute for Addictive Disorders Hahnemann School of Medicine Allegheny University of the Health Sciences Philadelphia, Pennsylvania Marilyn Sawyer Sommers, Ph.D., R.N. Professor College of Nursing University of Cincinnati Cincinnati, Ohio Ava H. Stanley, M.D. Somerset, New Jersey Robert S. Stephens, Ph.D. Associate Professor Department of Psychology Virginia Polytechnic Institute and State University Blacksburg, Virginia Jose Luis Soria, M.A., L.C.D.C., I.C.A.D.C., C.C.G.C., C.A.D.A.C. Clinical Deputy Director Aliviane NO-AD, Inc. El Paso, Texas xii 16

17 Foreword The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance abuse by providing best practices guidance to clinicians, program administrators, and payors. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-federal clinical researchers, clinicians, program administrators, and client advocates debates and discusses its particular areas of expertise until it reaches consensus on best practices. This panel's work is then reviewed and critiqued by field reviewers. The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field. Nelba Chavez, Ph.D. Administrator Substance Abuse and Mental Health Services Administration H. West ley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration

18 Executive Summary and Recommendations This Treatment Improvement Protocol (TIP) responds to an increasing body of research literature that documents the effectiveness of brief interventions and therapies in both the mental health and substance abuse treatment fields. The general purpose of this document is to link research to practice by providing counselors and therapists in the substance abuse treatment field with up-to-date information on the usefulness of these innovative and shorter forms of treatment for selected subpopulations of people with substance abuse disorders and those at risk of developing them. The TIP will also be useful for health care workers, social service providers who work outside the substance abuse treatment field, people in the criminal justice system, and anyone else who may be called on to intervene with a person who has substance abuse problems. Brief interventions and brief therapies have become increasingly important modalities in the treatment of individuals across the substance abuse continuum. The content of the interventions and therapies will vary depending on the substance used, the severity of problem being addressed, and the desired outcome. Because brief interventions and therapies are less costly yet halve proven effective in substance abuse treatment; clinicians, clinical researchers, and policymakers have increasingly focused on them as tools to fill the gap between primary prevention efforts and more intensive treatment for persons with serious substance abuse disorders. However, studies have shown that brief interventions are effective for a range of problems, and the Consensus Panel believes that their selective use can greatly improve substance abuse treatment by making them available to a greater number of people and by tailoring the level of treatment to the level of client need. Brief interventions can be used as a method of providing more immediate attention to clients on waiting lists for specialized programs, as an initial treatment for nondependent at-risk and hazardous substance users, and as adjuncts to more extensive treatment for substancedependent persons. Brief therapies can be used to effect significant changes in clients' behaviors and their understanding of them. The term "brief therapy" covers several treatment approaches derived from a number of theoretical schools, and this TIP considers many of them. The types of therapy presented in these chapters have been selected for a variety of reasons, but by no means do they represent a comprehensive list of therapeutic approaches currently in practice. Some of these approaches (e.g., cognitive behavioral therapy) are supported by extensive research; others (e.g., existential therapy) have not been, and perhaps cannot be, tested in as rigorous a manner. 1.8 xv

19 Executive Summary and Recommendations xvi This TIP presents the historical background, outcomes research, rationale for use, and stateof-the-art practical methods and case scenarios for implementation of brief interventions and therapies for a range of problems related to substance abuse. This TIP is based on the body of research conducted on brief interventions and brief therapies for substance abuse as well as on the broad clinical expertise of the Consensus Panel. Because many therapists and other practitioners are eclectically trained, elements from each of the chapters may be of use to a range of professionals. This discussion of brief therapies is in no way intended to detract from the value of longer term therapies that clinicians have found to be effective in the treatment of substance abuse disorders. However, the Consensus Panel believes it necessary to discuss innovative and/or often-used theories that members have encountered and applied in their clinical practice. The Consensus Panel's recommendations summarized below are based on both research and clinical experience. Those supported by scientific evidence are followed by (1); clinically based recommendations are marked (2). Citations for the former are referenced in the body of this document, where the guidelines are presented in full detail. Many of the recommendations made in the latter chapters of this TIP are relevant only within a particular theoretical framework (e.g., the Panel might recommend how a person practicing strategic therapy should approach a particular situation); because such recommendations are not applicable to all readers, they have not been included in this Executive Summary. Throughout this TIP, the term "substance abuse" has been used in a general sense to cover both substance abuse disorders and substance dependence disorders (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV) [American Psychiatric Association, 1994)). Because the term "substance abuse" is commonly used by substance abuse treatment professionals to describe any excessive use of addictive substances, it will be used to denote both substance dependence and substance abuse. The term includes the use of alcohol as well as other substances of abuse. Readers should attend to the context in which the term occurs in order to determine the meaning; in most cases, the term will refer to all varieties of substance abuse disorders as described by DSM-IV. Summary and Recommendations Brief Interventions Brief interventions are those practices that aim to investigate a potential problem and motivate an individual to begin to do something about his substance abuse, either by natural, clientdirected means or by seeking additional substance abuse treatment. A brief intervention, however, is only one of many tools available to clinicians. It is not a substitute for care for clients with a high level of dependency. It can, however, be used to engage clients who need specialized treatment in specific aspects of treatment programs, such as attending group therapy or Alcoholics Anonymous (AA) meetings. The Consensus Panel believes that brief interventions can be an effective addition to substance abuse treatment programs. These approaches can be particularly useful in treatment settings when they are used to address specific targeted client behaviors and issues in the treatment process that can be difficult to change using standard treatment approaches. (2) a Variations of brief interventions have been found to be effective both for motivating alcohol-dependent individuals to enter 19

20 Executive Summary and Recommendations in al re long-term alcohol treatment and for treating some alcohol-dependent persons. (1) The Consensus Panel recommends that programs use quality assurance improvement projects to determine whether the use of a brief intervention or therapy in specific treatment situations is enhancing treatment. (2) The Consensus Panel recommends that agencies allocate counselor training time and resources to these modalities. It anticipates that brief interventions will help agencies meet the increasing demands of the managed care industry and fill the gaps that have been left in client care. (2) Substance abuse treatment personnel should collaborate with other providers (e.g., primary care providers, employee assistance program, wellness clinic staff, etc.) in developing plans that include both brief interventions and more intensive care to help keep clients focused on treatment and recovery. (2) Goals of brief interventions The basic goal of any brief intervention is to reduce the risk of harm that could result from continued use of substances. The specific goal for each individual client is determined by his consumption pattern, the consequences of his use, and the setting in which the brief intervention is delivered. al Focusing on intermediate goals allows for more immediate success in the intervention and treatment process, whatever the longterm goals may be. Intermediate goals might include quitting one substance, decreasing frequency of use, or attending a meeting. Immediate successes are important to keep the client motivated. (2) la When conducting a brief intervention, the clinician should set aside the final treatment goal (e.g., accepting responsibility for one's own recovery) to focus on a single behavioral objective. Once this objective is established, a brief intervention can be used to help reach it. (2) Components of brief interventions There are six elements that are critical for effective brief interventions. (1) The acronym FRAMES was coined to summarize these six components: El 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 clinician. Menu of alternative self-help or treatment options is offered to the participant. Empathic style is used by the counselor. Self-efficacy or optimistic empowerment is engendered in the participant. A brief intervention consists of five basic steps that incorporate FRAMES and remain consistent regardless of the number of sessions or the length of the intervention: 1. Introducing the issues in the context of the client's health. 2. Screening, evaluating, and assessing. 3. Providing feedback. 4. Talking about change and setting goals. 5. Summarizing and reaching closure. Providers may not have to use all five of these components in any given session with a client. However, before eliminating steps in the brief intervention process there should be a well-defined reason for doing so. (2) Essential knowledge and skills for brief interventions Providing effective brief interventions requires the clinician to possess certain knowledge, skills, and abilities. The following are four essential skills (2): 1. An overall attitude of understanding and acceptance 2 xvii