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As one researcher notes,. Brief interventions for excessive drinking should not be referred to as an homogenous entity, but as a family of interventions varying in length, structure, targets of intervention, personnel responsible for their delivery, media of communication and several other ways, including their underpinning theory and intervention philosophy Heather, , p. Brief interventions, therefore, can be viewed as a set of principles regarding interventions which are different from, but not in conflict with, the principles underlying conventional treatment Heather, Brief interventions for alcohol problems, for example, have employed various approaches to change drinking behaviors.
These approaches have ranged from relatively unstructured counseling and feedback to more formal structured therapy and have relied heavily on concepts and techniques from the behavioral self-control training BSCT literature Miller and Hester, b ; Miller and Munoz, ; Miller and Rollnick, ; Miller and Taylor, see Chapter 4 for more information on BSCT. Usually, brief treatment interventions have flexible goals, allowing the individual to choose moderation or abstinence. The typical counseling goal is to motivate the client to change her behavior and not to assign self-blame.
While much of the research to date has centered on clients with alcohol-related problems, similar approaches can be taken with users of other substances. Brief interventions are a useful component of a full spectrum of treatment options; they are particularly valuable when more extensive treatments are unavailable or a client is resistant to such treatment. Too few clinicians, however, are educated and skilled in the use of brief interventions and therapies to address the very large group of midrange substance users who have moderate and risky consumption patterns see Figure Although this group may not need or accept traditional substance abuse treatment, these individuals are nonetheless responsible for a disproportionate share of substance-related morbidity, including lowered workforce performance, motor vehicle accidents and other injuries, marital discord, family dysfunction, and medical illness Wilk et al.
These hazardous substance users are identified in employment assistance programs EAPs , programs for people cited for driving while intoxicated DWI , and urine testing programs, as well as in physicians' offices and other health screening efforts Miller, Despite appeals from such distinguished bodies as the National Academy of Sciences in the United States and the National Academy of Physicians and Surgeons in the United Kingdom, widespread adoption of brief interventions by medical practitioners or treatment providers has not yet occurred Drummond, ; Institute of Medicine [IOM], Brief interventions in traditional settings usually involve a more in-depth assessment of substance abuse patterns and related problems.
The characterizations of hazardous, harmful, or dependent use as they relate to alcohol consumption patterns Edwards et al. Hazardous drinking refers to a level of alcohol consumption or pattern of drinking that, should it persist, is likely to result in harm to the drinker. Harmful drinking is defined as alcohol use that has already resulted in adverse mental or physical effects.
Categorizing drinking patterns in this fashion provides both clinicians and researchers with flexible guidelines to identify individuals at risk for alcohol problems who may not meet criteria for alcohol dependence. Similar levels of use for other substances are much more difficult to define, since most of them are illicit and those that are not have often not been widely studied in relation to substance abuse. Studies of brief interventions have been conducted in a wide range of health care settings, from hospitals and primary health care locations Babor and Grant, ; Chick et al.
Refer to "Research Findings" in Chapter 2 for more discussion of research on brief interventions. Individuals recruited from such settings are likely to have had some contact with a health care professional during the study participation and therefore had alcohol-related professional assistance available. Nonetheless, many of these patients would not be identified as having an alcohol problem by their health care providers and would not ordinarily receive any alcohol-specific intervention.
Counselors who worked with a Web-based CBT training program achieved adherence and skill ratings in between these two groups. Most people who seek help want to learn how to cope with dysfunction in their daily life and modify their dysfunctional or ineffective coping strategies. Some researchers have accordingly proposed adaptable training approaches that can provide each counselor with the intensity of training that he or she needs Collins, Murphy, and Bierman, In practice, many therapists who have been trained in specific theoretical models of change borrow techniques from other models when working with their clients. When individuals have caregivers who are emotionally responsive, they are likely to develop a secure attachment and a positive internal working model of self and others.
In general, brief interventions are conducted in a variety of opportunistic and substance abuse treatment settings, target different goals; may be delivered by treatment staff or other professionals, and do not require extensive training. Because of the short duration of brief intervention strategies, they can be considered for use with injured patients in the emergency department who have substance abuse problems. Useful distinctions between the goals of brief interventions as applied in different settings are listed in Figure Goal of Brief Interventions According to Setting.
Brief interventions in traditional settings usually involve a more in-depth assessment of substance use patterns and related problems than interventions administered in nontraditional settings and tend to examine other aspects of participants' attitudes, such as readiness for or resistance to change. They can be useful for addressing specific behavior change issues in treatment settings. Because they are timely, focused, and client centered, brief interventions can quickly enhance the overall working relationship with clients.
However, brief interventions should not be a care substitute for clients who have a high level of abuse. Some of the assessments conducted for research studies of brief interventions are very extensive and may have been conducted during prior treatment e. Most brief interventions offer the client detailed feedback about assessment findings, with an opportunity for more input.
The assessment typically involves obtaining information regarding frequency and quantity of substance abuse, consequences of substance abuse, and related health behaviors and conditions. The intervention itself is structured and focused on substance abuse. Its primary goals are to raise awareness of problems and then to recommend a specific change or activity e. The participant in a brief intervention is usually offered a menu of options or strategies for accomplishing the target goal and encouraged to take responsibility for selecting and working on behavioral change in a way that is most comfortable for him.
Any followup visits will provide an opportunity to monitor progress and to encourage the client's motivation and ability to make positive changes. The person delivering the brief intervention is usually trained to be empathic, warm, and encouraging rather than confrontational. Brief interventions are typically conducted in face-to-face sessions, with or without the addition of written materials such as self-help manuals, workbooks, or self-monitoring diaries. A few have consisted primarily of mailed materials, automated computer screening and advice, or telephone contacts.
Some interventions are aimed at specific health problems that are affected by substance abuse, rather than substance abuse itself. For example, an intervention may be conducted to help a client reduce her chances of contracting human immunodeficiency syndrome HIV by using clean needles; as a result, if the client only has dirty needles, she might avoid using them in order to reduce her risk of HIV and thus reduce her use of heroin.
By raising an individual's awareness of her substance abuse, a brief intervention can act as a powerful catalyst for changing a substance abuse pattern. The distress clients feel about their substance abuse behavior can act as an influence to encourage change as they recognize the negative consequences of that behavior to themselves or others. Positive and negative external forces are also influences. Life events, such as a major illness or the death of significant others, career change, marriage, and divorce, can contribute to the desire to change.
Brief interventions can address these events and feelings that accompany them with the underlying goal of changing clients' substance abuse behaviors. In contrast to most simple advice or brief interventions, brief therapies are usually delivered to persons who are seeking--or already in--treatment for a substance abuse disorder. That is, the individual usually has some recognition or awareness of the problem, even if he has yet to accept it. The therapy itself is often client driven; the client identifies the problems, and the clinician uses the client's strengths to build solutions.
The choice of a brief therapy for a particular individual should be based on a comprehensive assessment rather than a cursory screening to identify potentially hazardous drinking or substance-abusing patterns IOM, In some cases, brief therapy may also be used if resources for more extensive therapy are not available or if standard treatment is inaccessible or unavailable e. Brief therapies often target a substance-abusing population with more severe problems than those for whom brief interventions are sufficient. Although brief therapies are typically shorter than traditional versions of therapy, these therapies generally require at least six sessions and are more intensive and longer than brief interventions.
Brief therapy, however, is not simply a shorter version of some form of psychotherapy. Rather, it is the focused application of therapeutic techniques specifically targeted to a symptom or behavior and oriented toward a limited length of treatment. In addition to the goals of brief interventions, the goals of brief therapy in substance abuse treatment is remediation of some specified psychological, social, or family dysfunction as it pertains to substance abuse; it focuses primarily on present concerns and stressors rather than on historical antecedents.
Brief therapy is conducted by therapists who have been specifically trained in one or more psychological or psychosocial models of treatment. Therapist training requires months or years and usually results in a specialist degree or certification. In practice, many therapists who have been trained in specific theoretical models of change borrow techniques from other models when working with their clients.
Although the models remain distinct, therapists often become eclectic practitioners. The impetus for shorter forms of interventions and treatments for a range of substance abuse problems comes from several sources: Historical developments in the field that encourage a comprehensive, community-based continuum of care--with treatment and prevention components to serve clients who have a wide range of substance abuse-related problems A growing body of evidence that consistently demonstrates the efficacy of brief interventions An increasing demand for the most cost-effective types of treatment, especially in this era of health care inflation and cost containment policies in the private and public sectors Client interest in shorter term treatments.
The increasing demand for treatment of some sort--arising from the identification of more at-risk consumers of substances through EAPs, substance-testing programs, health screening efforts, and drunk driving arrests--coupled with decreased public funding and cost containment policies of managed care leave only two options: The development of public substance abuse treatment programs subsidized by Federal, State, and local monies dates to the late s when public drunkenness was decriminalized and detoxification centers were substituted for drunk tanks in jails.
At about the same time, similar efforts were made to curtail heroin use in major cities by establishing methadone maintenance clinics and residential therapeutic communities IOM, By the s, direct Federal financial support for treatment had slowed, and although some States continued to grant subsidies, the most rapid growth in the field switched to the insurance-supported private sector and the development of treatment programs targeted primarily to heavy consumers of alcohol, cocaine, and marijuana Gerstein and Harwood, The standardized approach used in most of these private, hospital-based programs incorporated many aspects of the Minnesota model pioneered in the late s, with a strong focus on the Step philosophy developed in Alcoholics Anonymous AA , a fixed-length, day stay, and insistence on abstinence as the major treatment goal CSAT, Initially, treatment programs in both the public and private sectors tended to serve the most seriously impaired populations; however, providers gradually recognized the need for treatment options for a wider range of clients who had different types of substance abuse disorders.
Providers realized that not all clients benefit from a single standardized treatment approach. Rather, treatment should be tailored to individual needs determined by in-depth assessments of the client's problems and antecedents to her substance abuse disorder. Providers were also aware that interventions with less dysfunctional clients often had greater success rates. In the interest of reducing drunk driving, for example, educational efforts were targeted at offenders charged with DWI as an alternative to revoking their driving licenses.
In such programs, more attention was given to outcomes and factors in the treatment setting than to the client's history; these seemed to affect success rates whether or not treatment was completed. As assessments became more comprehensive, treatment also began to address the effects of substance abuse patterns on multiple systems, including physical and mental health, social and personal functioning, legal entanglements, and economic stability. In recent years, this biopsychosocial approach to the treatment of substance abuse disorders has stimulated more cross-disciplinary cooperation.
It has also prompted more attempts to match client needs to the most appropriate and expeditious intensity of care and treatment modality. Consideration is now given to differences not only in the severity and types of problems identified but also to the cultural or environmental context in which the problems are encountered, the types of substances abused, and differences in gender, age, education, and social stability.
Determining a client's appropriateness for treatment is one of the 46 global criteria for competency of certified alcohol and drug abuse counselors Herdman, Indeed, client assessment and treatment matching and referral has become a specialty area in itself that avoids the hazards of random treatment entry.
Clients from two parallel but independent clinical trials one in which clients were receiving outpatient treatment, the other in which clients were receiving aftercare therapy following inpatient treatment were assigned to receive one of the three treatments. Although the results do not indicate a strong need to consider client characteristics to match clients to treatment, the findings do suggest that the severity of coexisting psychiatric disorders should be considered.
Another study, conducted by McLellan and colleagues, identified specific problems of clients in treatment e.
These clients stayed in treatment longer, were more likely to complete treatment, and had better posttreatment outcomes than unmatched clients in the same treatment programs. In this context, increasing emphasis has also been given to integrating specialized approaches to substance abuse treatment with the general medical system and the services of other community agencies. A IOM report called for more community involvement in health care, social services, workplace, educational, and criminal justice systems IOM, Because the vast majority of persons who use substances in moderation experience few or minor problems, they are not likely to seek help in the specialized treatment system.
Instead, the estimated 20 percent of the adult population who drink or use heavily or in inappropriate ways Higgins-Biddle et al. Because the prevalence of harmful and risky substance use far exceeds the capacity of available services to treat it, briefer and less intensive interventions seem warranted for a broad range of individuals, including those who are unwilling to accept referral for more formal and extensive specialized care Bien et al.
Studies of the cost-effectiveness of different treatment approaches have been particularly appealing to policymakers seeking to reduce costs and better allocate scarce resources. In the managed care environment, however, cost containment has become a byword, and no standard type of care or treatment protocol for all clients is acceptable.
In order to receive reimbursement, substance abuse treatment facilities must find the least intensive yet safe modality of care that can be objectively proven to be appropriate and effective for a client's needs. Now that more treatment is delivered in ambulatory care facilities, the usual time in treatment is being shortened, and the credibility of recommended treatment approaches must be increasingly documented through carefully conducted research studies.
In this context, some of the most widely used substance abuse treatment approaches, such as the Minnesota model, halfway houses, and Step programs, have only recently been subjected to rigorous tests of effectiveness in controlled clinical trials Barry, ; Holder et al. Pistole , proposed the concept of care-giving from attachment theory as a metaphor for the counseling relationship and process.
In other words, therapists can be empathetic to individuals with high attachment avoidance in order to re-parent them. The therapists thus serve as role models for them so that these individuals can eventually learn to be empathetic to others, which may improve their subjective well-being. Another study found that due to their negative view of self, assisting those with high attachment anxiety to increase their level of social self-efficacy i.
Conversely, those with high attachment avoidance tended to be reluctant for self-disclosure and hold a negative view of others. For these individuals, the study confirmed that counter-complimentary interventions which enhances their comfort level of self-disclosing to others i. Clinicians not only can help those with high attachment anxiety and avoidance to modify their ineffective coping strategy, but also can help them understand the underlying unmet needs that are satisfied by their ineffective coping strategy and learn alternative ways to satisfy their psychological or emotional needs e.
Moreover, clinicians need to know that people with different insecure attachment patterns i. The implications of attachment theory in counseling and psychotherapy. Parent—child attachment and healthy human development. Theory, research, and clinical applications. Perfectionism in children and their parents: Theory, research, and treatment pp.
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