Research Findings

Research concerning the relative effectiveness of brief versus longer term therapies for a variety of presenting complaints is mixed. Some studies have found that planned, short-term therapies are as effective as lengthier (or unlimited) therapy (Koss and Shiang, 1993; Smyrnios and Kirkby, 1993). Other studies, such as the Consumer Reports mental health study (Seligman, 1995) and the National Institute of Mental Health (NIMH) Treatment of Depression Research Program (Blatt et al., 1995; Elkin, 1994), have found that longer term treatments generally lead to better outcomes as perceived by clients. Much depends on the modality being evaluated and the goals of the treatment. (More specific research evaluating different types of brief therapy is given in Chapters 4 to 9.)

There is, however, promising evidence that brief therapies as a treatment for substance abuse disorders are often as effective as lengthier treatments (Bien et al., 1993; Gottheil et al., 1998; McLellan et al., 1993; Miller and Hester, 1986a; Miller and Rollnick, 1991). These studies are positive but are primarily limited to program effectiveness studies with smaller sample sizes. Future research should both replicate previous work and use more rigorous designs that include experimental designs with randomization. Many of the fundamental questions about brief therapies--the optimum conditions under which they should be used, the economic cost-benefits, and level and type of provider, the most suitable types of clients--have yet to be studied.

The majority of clients in therapy (regardless of the modality) remain in treatment for between 6 and 22 sessions; 90 percent end treatment before completing 20 visits (Friedberg, 1999). The fact that many clients stay in therapy for relatively short periods of time suggests that brief therapy techniques should be much more common than they are in current clinical practice (Pekarik and Wierzbicki, 1986; Phillips, 1987). Many therapists trained in long-term treatment modalities choose not to use planned short-term therapies (Bloom, 1997). Alcohol and drug counselors often have to work with clients in a limited period of time, however, and could apply brief therapy techniques even when they are designed for treatment of different types of disorders and problems.

Because brief therapy is more effective than being on a waiting list, it could benefit many clients. Wolberg suggested that all clients seeking treatment be given brief therapy initially, before moving on to long-term treatments (Wolberg, 1980). Such an approach would help to reserve longer treatments for clients with a greater need for them. However, there are clearly exceptions to this rule, such as clients who have a history of severe and persistent mental illness. Other criteria for assigning a client to longer term rather than brief therapy are presented in Figure 3-1 .

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Figure 3-1: Criteria for Longer Term Treatment. The following criteria can help identify clients who could benefit from longer term treatment: Failure of previous shorter treatment Multiple concurrent problems Severe substance abuse (i.e., dependence) (more...)

Planned brief therapy can be adapted as part of a course of serial or intermittent therapy (Budman and Gurman, 1988; Cummings, 1990). When doing this, the therapist conceives a long-term treatment as a number of shorter treatments, which requires that the client's problems be addressed serially rather than concurrently. Because of insurance constraints, many therapists are now billing by episode and treating one problem at a time.

Brief therapy may prove to be a useful tool for reconceiving how therapy is delivered. For the treatment provider working with clients with substance abuse disorders, this means that a particular type of therapy could be applied to a specific problem associated with a client's substance abuse. By treating these allied problems, long-term goals, such as continued abstinence, may be more likely to be reached (Iguchi et al., 1997; McLellan et al., 1993).

When To Use Brief Therapy

Insufficient data are available to determine which populations would benefit most from brief therapy. Therefore, client needs and the suitability of brief therapy must be evaluated on a case-by-case basis. Some criteria for considering the appropriateness of brief therapy are presented in Figure 3-2 . The American Society of Addiction Medicine (ASAM) client placement criteria for substance abuse treatment (ASAM, 1996) may also be useful for determining who could benefit from brief therapy (see discussion in Chapter 2).

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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 (more...)

Brief therapy may be appropriate for a moderate to heavy drinker such as a college student but inappropriate as the sole treatment for a commercial airline pilot who is alcohol dependent, no matter what the motivation is for treatment. Therapists must consider extenuating circumstances when recommending a particular course of treatment. In some programs, duration of therapy is determined mutually by the client and therapist; brief therapy may be the best option if the client objects to longer term treatment or if expense is an issue.

Research is needed to identify specific populations for which brief therapy would serve as the catalyst for resolution of substance abuse-related problems. The impact of brief therapy on chronically relapsing, substance-abusing persons has not been investigated. Because of these large gaps in research, therapists must rely on their clinical judgment to determine whether brief therapy is appropriate for a particular client and what kind of modality would be most effective.

The best outcomes for brief therapy may depend on the therapist's skills, comprehensive assessments, and selective criteria for eligibility. Using selection criteria in prescribing brief therapy is critical, since many clients will not meet eligibility. The Consensus Panel hopes that brief therapy will be adequately investigated before managed care and third-party payors decide it is the only modality for which they will pay.

Brief therapy for substance abuse treatment is a valuable but limited approach, and it should not be considered a standard of care for all populations. In fact, time in treatment has been found to be directly related to better outcomes within a range of modalities, including therapeutic communities, psychotherapy, methadone maintenance therapy, and extended detoxification (Hubbard et al., 1997). Therefore, although brief therapy is a useful tool in a portfolio of interventions, its use should be targeted to those clients who are most likely to benefit.

Determining when to use a particular type of brief therapy is also an important consideration for counselors and therapists. Counselors recognize that not all clients are at the same stage in their readiness for treatment. Currently, the most widely used model for understanding clients' readiness for change is Prochaska and DiClemente's stages-of-change model, which is discussed in Chapter 2. (For more information about this model, see also TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT, 1999c].) Counselors who use this model will have to determine which therapy is compatible with the client's stage of readiness for change and the tasks needed to move forward in the change process and develop an overall understanding of the course of change (DiClemente and Scott, 1997).

Clinical interventions should be targeted to the client's stage of readiness for change to increase his motivation to change behaviors and to augment a sense of empowerment in recovery. Therapies that work with experiential processes (such as consciousness raising, self-reevaluation, and a cognitive restructuring) are more important for understanding and predicting transition from preparation to action and from action to maintenance (Prochaska et al., 1994). Seeking and processing information, observing others, and gathering useful information in light of the client's situation are the primary activities reported most frequently during the contemplation stage (Prochaska et al., 1992). Especially during this early stage the client should be provided with information regarding addiction as well as confronted with the short- and long-term consequences of continued use. Asking the client to perform a risk appraisal of continued use as well as a benefit/risk-reduction appraisal of achieving abstinence can facilitate sound decisionmaking that involves a comparison of all potential gains and losses (Janis and Mann, 1977).

Finally, it will be essential to learn the client's perceived obstacles to engaging in treatment as well as to identify any dysfunctional beliefs that could sabotage the engagement process. The basic assumption behind this approach is that the way individuals evaluate a situation and cope with it determines their emotional reaction to it (Ellis and Grieger, 1977). The critical factor in determining an individual's response is the client's self-perception and associated emotions. The therapist should help the client recognize the messages she gives herself and help her correct problematic thinking patterns and dysfunctional beliefs (Kendall and Turk, 1984). Often, dysfunctional beliefs lead to low levels of perceived self-efficacy and subsequent inability to adopt or maintain the desired behavior (Bandura, 1986). It is important to note that self-efficacy shifts in a predictable way across the stages of behavior change, with clients progressively becoming more efficacious as they move through the stages (Marcus et al., 1992; Prochaska et al., 1994).

Approaches to Brief Therapy

Brief therapy uses a selected process to change a specific problem based on an underlying theory about the cause of the problem or the best way to encourage positive change. Figure 3-3 lists several therapeutic approaches that are applicable to brief therapy. These approaches can be used with clients with different types of problems and varying degrees of substance abuse severity.

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Figure 3-3: Approaches to Brief Therapy.

Components of Effective Brief Therapy

Although different models of brief therapy may stress certain goals and activities more than others, all brief therapies have common characteristics (see Figure 3-4 ). In addition, brief therapies should incorporate several stages, including screening and assessment, an opening session that includes the establishment of treatment goals, subsequent sessions, maintenance strategies, ending treatment, and followup. These stages are discussed below.

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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 (more...)

Screening and Assessment

Screening and assessment are critical initial steps in brief therapy. Screening is a process in which clients are identified according to characteristics that indicate that they are possibly abusing substances. Screening does not inform the therapist of the severity of the individual client's substance abuse, only its presence and, in some cases, broad indications of risk. Screening identifies the need for more in-depth assessment and is not a substitute for an assessment.

Assessment is a thorough, extensive process that involves a broad analysis of the factors contributing to and maintaining a client's substance abuse, the severity of the problem, and the variety of consequences associated with it. Screening and assessment procedures for brief therapy do not differ significantly from those used for lengthier treatments.

The assessment should determine whether the client's substance abuse problem is suitable for a brief therapy approach. The criteria for determining the appropriateness of brief therapy, presented in Figures 3-1 and 3-2, are first applied during the assessment stage.

It is reasonable to assume that brief therapies are most effective with clients whose problems are of short duration and who have strong ties to family, work, and community. However, limited client resources may also dictate the use of brief therapy. For example, if a client lacks the financial means to participate in a longer treatment process, a brief therapy approach is imperative. Some treatment is almost always better than no treatment. In addition, brief therapy may be indicated for clients who resist longer treatment, rather than risk the loss of an otherwise motivated client. (Technical Assistance Publication [TAP] 21, Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice [CSAT, 1998a] contains further guidance on screening and assessment for brief therapy.)

Therapists should gather as much information as possible about a client before the first counseling session. One way to do this is to obtain copies of any notes taken by an intake worker or the referral source. However, when gathering information about a client from other sources, therapists should be sensitive to confidentiality and client consent issues (for more information see the section entitled "Confidentiality of Information About Clients" in Chapter 9 of the forthcoming TIP, Substance Abuse Treatment for Persons With HIV/AIDS [CSAT, in press]). Other options include asking intake workers to administer questionnaires, using computerized assessments, or asking the client to complete an assessment form before the first session. The assessment instrument can be brief and informal, generating critical information in a short time. Although initial screening and assessment ideally should be conducted before the first therapy session, the process of assessment should continue throughout treatment.

A variety of brief assessment instruments, many of which are free, are available to clinicians. Assessing Alcohol Problems (National Institute on Alcohol Abuse and Alcoholism, 1995) is a useful source of research-validated instruments. Figure 3-5 provides a sample battery of brief assessment instruments that might be used in a brief therapy setting, ideally before the first counseling session. These instruments can provide the therapist with a quick assessment of the most critical domains about which clinical decisions should be made. In general, most clients can complete these instruments in less than 1 hour. These instruments should be supplemented in the first counseling session by a clinical assessment interview that covers the core areas outlined in the following section. For sample screening instruments and additional information on screening procedures see also TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians; TIP 26, Substance Abuse Among Older Adults; TIP 31, Screening and Assessing Adolescents for Substance Use Disorders; and TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT, 1997, 1998b, 1999a, 1999c).

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Figure 3-5: Sample Battery of Brief Assessment Instruments.

For brief therapy, the setting in which treatment will occur frequently dictates the kind of assessment that can be conducted. Clients seek treatment in the type of agency they feel will best meet their needs (e.g., those who need to continue working while seeking treatment will likely enter an outpatient program). Constraints may be placed by insurance companies or other outside forces. For example, managed care environments generate their own assessment criteria. Assessment often must be conducted outside the treatment facility and may not qualify as a reimbursable visit. In addition, private practitioners often do not have easy access to background information regarding a potential client. In a primary care office, screening and assessment consist only of taking a client's history and conducting a physical examination.

Core assessment areas

Before proceeding with brief therapy for substance abuse disorders, a number of areas should be assessed, including the following:

• Current use patterns
• History of substance abuse
• Consequences of substance abuse (especially external pressures that are bringing the client into treatment at this time, such as family or legal pressures)
• Coexisting psychiatric disorders
• Information about major medical problems and health status
• Information about education and employment
• Support mechanisms
• Client strengths and situational advantages
• Previous treatment
• Family history of substance abuse disorders and psychological disorders

As mentioned earlier, assessment is critical not only before beginning brief therapy but also as an ongoing part of the process. Only by continually assessing the client's progress and problems can the therapist accomplish the goals of brief therapy in the limited timeframe. In addition, ongoing assessment can function as a therapeutic tool because it helps clients identify when they are at risk of using substances as well as other negative behaviors.

Therapist Characteristics

To successfully integrate different short-term therapies into practice, therapists benefit from a firm grounding in theory and a broad technical knowledge of the many different approaches available. When appropriate, elements of different brief therapies may be combined to provide successful outcomes. However, it is important to remember that the effectiveness of highly defined interventions (e.g., workbook-driven interventions) used in some behavioral therapies depends on administration of the entire regimen. The therapist must use caution in combining and mingling certain techniques and must be sensitive to the cultural context within which therapies are integrated. Therapists should also be sufficiently trained in the therapies they are using and should not rely solely on a manual such as this to learn those therapies. Appendix B provides some resources for further education.

Although therapists with many levels of training and experience can conduct brief interventions, certain skills and training are particularly important for conducting effective brief therapy. Those who specialize in providing brief therapy are likely to be more successful when grounded in a specific model of psychotherapy but possess a general understanding of other models from which appropriate techniques may be drawn. They should be adept at determining early in the assessment process the client needs or goals that are appropriate to address. Related to this, and equally important, therapists must establish relationships that facilitate referral when the client's needs or goals cannot be met through brief therapy. A comprehensive description of the professional and personal attributes that practitioners need to be effective providers of substance abuse treatment is provided in TAP 21, Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice (CSAT, 1998a). TAP 21 emphasizes that practitioners should

• Be empathic
• Be able to integrate their training--whether in substance abuse treatment or other disciplines such as social work, medicine, nursing, or psychology--with experience, both professional and personal, to create the best therapeutic environment for the client
• Have a mature sense of personal and professional boundaries
• Be sensitive to the cultural and spiritual needs of the client
• Follow appropriate Federal, State, and agency regulations in the provision of substance abuse treatment services

Providers of brief therapy must focus effectively on identifying and adhering to specific therapeutic goals in treatment. They should be able to extract techniques from longer term therapies and adapt them within the parameters of brief therapy. The provider of brief therapy will have to focus on short-term change that can have long-term benefits and avoid issues that are more global. The therapist must be able to shift approaches depending on what is learned about the client during treatment.

Brief therapy is amenable to the use of a wide range of techniques from which the therapist can choose. It is therefore helpful for therapists to be aware of the broad range of therapeutic techniques available. Exposure to several psychotherapeutic approaches (many described in the following chapters) allows therapists to understand how other clinicians might approach the situation, what a client might have experienced in previous treatments, and how to build on these experiences.

Brief therapy for substance abuse disorders is often helpful, but should not be considered a standard of care for all persons or populations. Brief therapy, as presented in this TIP, can be a contained modality of treatment and not an episodic form of long-term therapy. In fact, successful brief therapy may be the only treatment some clients will require.