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Center for Substance Abuse Treatment. Brief Interventions and Brief Therapies for Substance Abuse. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 34.)

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Brief Interventions and Brief Therapies for Substance Abuse.

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Chapter 1—Introduction to Brief Interventions and Therapies

The use of brief intervention and brief therapy techniques has become an increasingly important part of the continuum of care in the treatment of substance abuse problems. With the health care system changing to a managed model of care and with changes in reimbursement policies for substance abuse treatment, these short, problem-specific approaches can be valuable in the treatment of substance abuse problems. They provide the opportunity for clinicians to increase positive outcomes by using these modalities independently as stand-alone interventions or treatments and as additions to other forms of substance abuse and mental health treatment. They can be used in a variety of settings including opportunistic settings (e.g., primary care, home health care) and specialized substance abuse treatment settings (inpatient and outpatient).

Used for a variety of substance abuse problems from at-risk use to dependence, brief interventions can help clients reduce or stop abuse, act as a first step in the treatment process to determine if clients can stop or reduce on their own, and act as a method to change specific behaviors before or during treatment. For example, there are some issues associated with treatment compliance that benefit from a brief, systematic, well-planned intervention such as attending group sessions or doing homework. In other instances, brief interventions address specific family problems with a client and/or family members or deal with specific individual problems such as personal finances and work attendance. The basic goal for a client regardless of setting is to reduce the risk of harm that may result from continued use of substances. The reduction of harm, in its broadest sense, pertains to the clients themselves, their families, and the community.

The brief therapies discussed in this TIP are brief cognitive-behavioral therapy, brief strategic and interactional therapies, brief humanistic and existential therapies, brief psychodynamic therapy, short-term family therapy, and time-limited group therapy. The choice to include these therapeutic modalities was based on a combination of relevant research and, in some instances where there is a smaller research base, the clinical knowledge and expertise of the Consensus Panel. All of these approaches are currently being used in the treatment of substance abuse disorders, and all of them can contribute something to the array of treatment techniques available to the eclectic practitioner.

Brief interventions and brief therapies may be thought of as elements on a continuum of care, but they can be distinguished from each other according to differences in outcome goals. Interventions are generally aimed at motivating a client to perform a particular action (e.g., to enter treatment, change a behavior, think differently about a situation), whereas therapies are used to address larger concerns (such as altering personality, maintaining abstinence, or addressing long-standing problems that exacerbate substance abuse). This TIP presents brief interventions as a way of improving client motivation for treatment. The brief therapies considered here are ways of changing client attitudes and behaviors. Other differences that help distinguish brief interventions from brief therapies include

  • Length of the sessions (from 5 minutes for an intervention to more than six 1-hour therapy sessions)
  • Extensiveness of assessment (which will be greater for therapies than for interventions)
  • Setting (nontraditional treatment settings such as a social service or primary care setting, which will use interventions exclusively, versus traditional substance abuse treatment settings where therapy or counseling will be used in addition to interventions)
  • Personnel delivering the treatment (brief interventions can be administered by a wide range of professionals, but therapy requires training in specific therapeutic modalities)
  • Materials and media used (certain materials such as written booklets or computer programs may be used in the delivery of interventions but not therapies)

Although the theoretical bases for brief therapy and brief intervention may be different, this distinction is less obvious in practice. These two approaches to substance abuse problems and behavior change reflect a continuum rather than a clear dichotomy. The distinction may be further blurred as the change process associated with the success of brief interventions is better understood or refined and as theories are developed to explain a brief intervention's mechanism of action. Already, some forms of brief intervention overlap with therapy, such as motivational enhancement therapy, which has a clearly articulated theoretical rationale (for more on this topic, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment, which was conceived as a companion volume to this TIP [Center for Substance Abuse Treatment (CSAT), 1999c]).

For the purposes of this TIP, brief therapy involves a series of steps taken to treat a substance abuse problem, whereas 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. Therapy involves movement (or an attempt at movement) toward change. Brief therapy concentrates particularly on investigating a problem in order to develop a solution in consultation with the client; brief interventions generally involve a therapist giving advice to the client.

The increasing emphasis on brief approaches is partly attributable to recent changes in the health care delivery system, in which clinicians are urged to reduce costs while maintaining treatment efficacy. Essentially, clinicians are constrained by time and diminishing resources yet are treating an increasing number of individuals with substance abuse problems.

Fortunately, there is a body of literature on brief approaches in the treatment of substance abuse disorders. Brief interventions and brief therapies have the appeal not only of being brief but also of having research backing that supports their use. Brief interventions have been widely tested with both general clinical and substance-abusing populations and have shown great promise in changing client behavior. Brief therapies, however, have been unevenly researched. As indicated in the discussion of each type, in addition to the empirical results reported in scientific journals, clinical and anecdotal evidence supports the efficacy of brief therapies in the treatment of substance abuse. The brevity and lower delivery costs of these brief approaches make them ideal mechanisms for use in settings from primary care to substance abuse treatment where cost often plays as much of a role as efficacy in determining what treatments clients receive.

Brief interventions and brief therapies are also well suited for clients who may not be willing or able to expend the significant personal and financial resources necessary to complete more intensive, longer term treatments. Although much research supports the theory that longer time in treatment is associated with better outcomes, research also suggests that for some clients, there is no loss in effectiveness when length and intensity of treatment are reduced.

An Overview of Brief Interventions

Definitions of brief interventions vary. In the recent literature, they have been referred to as "simple advice," "minimal interventions," "brief counseling," or "short-term counseling." They can be simple suggestions to reduce drinking given by a professional (e.g., social worker, nurse, alcohol and drug counselor, physician, physician assistant) or a series of interventions provided within a treatment program. 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, 1995, p. 287).

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, 1994).

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, 1986b; Miller and Munoz, 1982; Miller and Rollnick, 1991; Miller and Taylor, 1980) (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 1-1). 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., 1997). 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, 1993). 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, 1997; Institute of Medicine [IOM], 1990).

Figure 1-1: Substance Abuse Severity and Level of Care.

Figure

Figure 1-1: Substance Abuse Severity and Level of Care.

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., 1981) were used to distinguish the targets of brief intervention in a World Health Organization (WHO) study (Babor and Grant, 1991). 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. Dependent use refers to drinking that has resulted in physical, psychological, or social consequences and has been the focus of major diagnostic tools, such as the Diagnostic and Statistical Manual, 4th Edition (American Psychiatric Association [APA], 1994) or the International Classification of Diseases, 9th Revision (ICD-9) (ICD-9-CM, 1995). 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, 1991; Chick et al., 1985; Fleming et al., 1997; Wallace et al., 1988) to mental health clinics (Harris and Miller, 1990). (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.

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 1-2 .

Figure 1-2: Goal of Brief Interventions According to Setting.

Table

Figure 1-2: 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.g., in detoxification programs, during treatment intake procedures). 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.g., reduced consumption, accepting a referral, self-monitoring of substance abuse). 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.

An Overview of Brief Therapies

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, 1990). 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.g., remote communities, rural areas). Brief therapies often target a substance-abusing population with more severe problems than those for whom brief interventions are sufficient. Brief therapies can be useful for special populations if the therapist understands that some client issues may be developmental or physiological in nature (see TIP 26, Substance Abuse Among Older Adults, and TIP 32, Treatment of Adolescents With Substance Use Disorders [CSAT, 1998b, 1999b]).

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 Demand for Brief Interventions and Therapies

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: provide diluted treatment in traditional models for a few or develop a system in which different levels and types of interventions are provided to clients based on their identified needs and characteristics (Miller, 1993).

Expanding Treatment Options

The development of public substance abuse treatment programs subsidized by Federal, State, and local monies dates to the late 1960s 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, 1990).

By the 1980s, 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, 1990). The standardized approach used in most of these private, hospital-based programs incorporated many aspects of the Minnesota model pioneered in the late 1950s, with a strong focus on the 12-Step philosophy developed in Alcoholics Anonymous (AA), a fixed-length, 28-day stay, and insistence on abstinence as the major treatment goal (CSAT, 1995).

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, 1997). Indeed, client assessment and treatment matching and referral has become a specialty area in itself that avoids the hazards of random treatment entry.

In order to test the efficacy of current treatment-matching knowledge, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) initiated Project MATCH (Matching Alcoholism Treatment to Client Heterogeneity), which assessed the benefits of matching alcohol-dependent clients (using 10 client characteristics) to three types of treatments: 12-Step facilitation, cognitive-behavioral therapy, and motivational enhancement therapy (Project MATCH Research Group, 1997). 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.g., employment, family, psychiatric problems), then matched the clients to services designed to address the problems (McLellan et al., 1993). 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 1990 IOM report called for more community involvement in health care, social services, workplace, educational, and criminal justice systems (IOM, 1990). 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., 1997) are those most likely to come to the attention of physicians, social workers, family therapists, employers, teachers, lawyers, and police. 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., 1993) and those whose substance use is risky but not abusive (Higgins-Biddle et al., 1997).

Cost and Funding Factors

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 12-Step programs, have only recently been subjected to rigorous tests of effectiveness in controlled clinical trials (Barry, 1997; Holder et al., 1991; Landry, 1996).

In addition to the emphasis on cost containment and careful client-treatment matching, other researchers tout the potentially enormous public health impact that could be derived from conducting mass screenings in existing health care and other community-based systems to identify problem drinkers and then delivering brief interventions aimed at reducing excessive drinking patterns (Kahan et al., 1995). If appropriately selected persons with less severe substance abuse respond successfully to brief interventions with a consequent long-term reduction in substance abuse-related morbidity and associated health care costs, time and energy could be saved for treating those with more severe substance abuse disorders in specialized treatment facilities.

Barriers to Increasing the Use of Brief Treatments

Many clinicians and other care providers in community agencies retain the long-standing notion that clients are generally resistant to change, unmotivated, and in denial of problems associated with their substance abuse disorders. As a result, clinicians are hesitant to work with this population. Some of these attitudes also persist in the specialist treatment community (Miller, 1993). Although this perspective is shifting as clinicians better understand the many aspects of client motivation, there is still a tradition of waiting for a substance user to "hit bottom" and ask for help before attempting to treat him.

Other ideological obstacles present barriers in earlier stages of substance abuse. The focus of brief interventions on harm or risk reduction and moderating consumption patterns as a first and sometimes only goal is not always acceptable to counselors who were trained to insist on total and enduring abstinence. Assumptions underlying brief interventions aimed at harm reduction may seem to challenge ideas that substance abuse disorders are a chronic and progressive disease requiring specialized treatment. However, if substance abuse is placed on a continuum from abstinence to severe abuse, any move toward moderation and lowered risk is a step in the right direction and not incongruous with a goal of abstinence as the ultimate form of risk reduction (Marlatt et al., 1993). Moreover, research indicates that substance-abusing individuals who are employed and generally functioning well in society are unlikely to respond positively to some forms of traditional treatment which may, for example, tell them that they have a primary disease of substance dependency and must abstain from all psychoactive substances for life (Miller, 1993).

In addition to resisting a harm reduction approach, treatment staffs in programs that incorporate pharmacotherapies may be skeptical of behavioral approaches to client change if they believe addiction primarily stems from disordered brain chemistry that should be treated medically. There are many models of pharmacotherapy that suggest that counseling (often in a brief form) coupled with medication provides the most well-rounded and comprehensive treatment regime (McLellan et al., 1993; Volpicelli et al., 1992).

Moreover, research reveals that a longer time in treatment may contribute to a greater likelihood of success (Lamb et al., 1998). Brief interventions challenge this assumption by acknowledging that spontaneous remission and self-directed change in substance abuse behaviors do occur. A new perspective might reconcile these observations by recognizing that limited treatment can be beneficial--especially considering that at least half of all clients drop out of specialized treatment before completion.

Probably the largest impediment to broader application of briefer forms of treatment is the already overwhelming responsibilities of frontline treatment staff members who are overworked and unfamiliar with the latest treatment research findings (Schuster and Silverman, 1993). Not only are these clinicians reluctant to make clinical changes, but their programs may also lack the financial and personnel resources to adopt innovative approaches. Treatment programs limit themselves by such inability and unwillingness to learn new techniques.

Evaluating Brief Interventions and Therapies

Quality improvement has become an important consideration in the contemporary health care environment. Because of changes in the nature and provision of health care delivery in the United States, health care organizations have been working to develop systematic quality improvement programs to monitor provision of care, client satisfaction, and costs. Brief interventions can be an important part of a treatment program's quality improvement initiative. These approaches can be used to improve treatment outcomes in specific areas. Not only can brief interventions improve client compliance with specific aspects of treatment and therapist morale by focusing on attainable goals, but they can also demonstrate specific clinical outcomes of importance to both clinicians and managed care systems.

Importance of Evaluation

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 improving treatment. Examples of outcome measures include

  • Aftercare followup rates
  • Aftercare compliance rates
  • Alumni participation rates
  • Discharge against medical advice rates
  • Counselors' ratings of client involvement in substance abuse following treatment
  • The number of complaints related to the brief intervention or therapy

Mechanisms To Use in Evaluation

The effects of adding brief approaches to standard care should be evaluated as part of continuous quality improvement program testing. Some of these outcomes can be measured by

  • Client satisfaction surveys
  • Followup phone calls
  • Counselor-rating questions added to clinical chart

Programs should monitor client satisfaction over time, and whenever possible counselors should be involved in quality improvement activities. Identifying trends over time can indicate what improvements need to be made. Implementation of substance abuse prevention and brief intervention strategies in clinical practice requires the development of systematized protocols that can provide easier service delivery. The need to implement effective and unified strategies for a variety of substance abusers who are at risk for more serious health, social, and emotional problems is high, both from a public health and a clinical perspective. As the health care system undergoes changes, programs should take the opportunity to develop and advocate a comprehensive system of substance abuse interventions, combining the skills of clinicians with the knowledge gained from the research community

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