Brief

Interventions
And Brief
Therapies for
Substance
Abuse
Treatm ent Im provem ent Protocol (TIP) Series

34
Kristen Lawton Barry, Ph.D.
C o n s e n s u s P a n e l C h a ir

U .S . D E P A R T M E N T O F H E A L T H A N D H U M A N S E R V IC E S
P u b lic H e a lth S e rv ice
S u b s ta n c e A b u s e a n d M e n ta l H e a lth S e rv ic e s A d m in is tr a tio n
C e n te r fo r S u b s ta n c e A b u s e T r e a tm e n t
R o c k w a ll II, 5 6 0 0 F is h e rs L a n e
R o c k v ille , M D 2 0 8 5 7

T h is p u b lica tio n is p a rt o f th e S u b s ta n c e A b u se

fo rm e r p ro d u c tio n e d ito r; a n d P a u l S e a m a n ,

P rev e n tio n and T re a tm e n t B lo ck G ra n t te ch n ica l

fo rm e r e d ito ria l a s s is ta n t. S p e c ia l th a n k s go to

a ssista n ce p ro g ra m . A ll m a te ria l a p p e a rin g in

c o n su ltin g w rite rs S c o tt M . B u c h a n a n , M .S .E d .;

this v o lu m e e x c e p t th a t ta k e n d ire ctly fro m

D en n is M . D o n o v a n , P h .D .; Je ffr e y M . G eorg i,

co p y rig h te d s o u rc e s is in th e p u b lic d o m a in and

M .D iv .; D e lin d a E. M e rc e r, P h .D .; L a rry Sch o r,

m ay b e re p ro d u c e d or co p ie d w ith o u t

P h .D .; an d G e o rg e E. W o o d y , M .D .

p e rm issio n fro m th e S u b sta n c e A b u se and

M en tal H e a lth S e rv ic e s A d m in is tra tio n 's
(S A M H S A ) C e n te r fo r S u b s ta n ce A b u se
T re a tm e n t (C S A T ) or th e a u th o rs. C ita tio n of
the so u rce is a p p re c ia te d .
T h is p u b lica tio n w a s w ritten u n d e r c o n tra ct

T h e o p in io n s e x p r e s s e d h e re in a re th e v ie w s of
th e C o n s e n s u s P a n e l m e m b e r s an d d o n o t re flect
the o fficia l p o sitio n o f C S A T , S A M H S A , or the
U .S . D e p a rtm e n t o f H e a lth a n d H u m a n S e rv ices
(D H H S ). N o o ffic ia l s u p p o rt o r e n d o rs e m e n t of
C S A T , S A M H S A , or D H H S fo r th e se o p in io n s or

n u m b e r 2 7 0 -9 5 -0 0 1 3 w ith T h e C D M G ro u p , Inc.

fo r p a rtic u la r in s tru m e n ts o r s o ftw a re th a t m ay

(C D M ). S a n d ra C lu n ie s, M .S ., I.C .A .D .C ., serv ed

b e d e s c rib e d in th is d o c u m e n t is in te n d e d or

as the C S A T g o v e rn m e n t p ro je c t o ffice r. R ose

sh o u ld b e in fe rre d . T h e g u id e lin e s p ro ffe re d in

M . U rb a n , L .C .S .W ., J.D ., C .C .A .S ., se rv e d as th e

th is d o c u m e n t s h o u ld n o t b e co n s id e re d as

C D M T IP s p ro je c t d irecto r. O th e r C D M T IP s

su b s titu te s fo r in d iv id u a liz e d c lie n t ca re and

p e rso n n e l in clu d e d R a q u e l In g ra h a m , M .S .,

tre a tm e n t d e c is io n s .

p ro je ct m a n a g e r; Jo n a th a n M a x G ilb ert, M .A .,
m a n a g in g e d ito r; Ja n e t G . H u m p h re y , M .A .,
e d ito r/ w rite r; C a ra S m ith , p ro d u c tio n e d ito r;
E rica F lick , e d ito ria l a s s is ta n t; Y -L a n g N g u y e n ,

D H H S P u b lic a tio n N o . (S M A ) 9 9 -3 3 5 3
P rin ted 19 99

Contents

W h a t Is a T I P ? ..................................................................................................................................................................................................vii
E d ito ria l A d v is o ry B o a r d ........................................................................................................................................................................... ix
C o n s e n s u s P a n e l ............................................................................................................................................................................................. xi
F o r e w o rd ............................................................................................................................................................................................................xiii
E x e cu tiv e S u m m a ry a n d R e c o m m e n d a t io n s ............................................................................................................................... xv
S u m m a ry an d R e c o m m e n d a tio n s ................................................................................................................................................. xvi
C h a p te r 1 In tro d u c tio n to B r ie f I n te r v e n tio n s an d T h e r a p i e s ............................................................................................1
A n O v e rv ie w o f B rie f In te r v e n tio n s ................................................................................................................................................ 3
A n O v e rv ie w o f B rie f T h e r a p i e s ........................................................................................................................................................7
T h e D em an d fo r B rie f In te rv e n tio n s an d T h e r a p ie s ............................................................................................................... 8
B a rrie rs to In c re a s in g the U se o f B rie f T r e a tm e n ts ................................................................................................................10
E v a lu a tin g B rie f In te rv e n tio n s and T h e r a p i e s ........................................................................................................................ 11
C h a p te r 2 B r ie f I n te r v e n tio n s in S u b s ta n c e A b u s e T r e a t m e n t .......................................................................................13
S ta g e s -o f-C h a n g e M o d e l......................................................................................................................................................................14
G o als o f B rief In te r v e n tio n ..................................................................................................................................................................16
C o m p o n e n ts o f B rie f In te rv e n tio n s ................................................................................................................................................ 18
B rie f In te rv e n tio n W o r k b o o k s .......................................................................................................................................................... 24
E sse n tia l K n o w le d g e an d S k ills fo r B rie f In te rv e n tio n s ..................................................................................................... 25
B rief In te rv e n tio n s in S u b s ta n c e A b u se T re a tm e n t P r o g r a m s ....................................................................................... 27
B rief In te rv e n tio n s O u tsid e S u b s ta n c e A b u se T re a tm e n t S e ttin g s ...............................................................................28
R e se a rch F in d in g s ................................................................................................................................................................................... 30
C h a p te r 3 B r ie f T h e r a p y in S u b s ta n c e A b u s e T r e a tm e n t ................................................................................................. 37
R ese arch F in d in g s ................................................................................................................................................................................... 38
W h en T o U se B rief T h e r a p y ............................................................................................................................................................... 39
A p p ro a ch e s to B rie f T h e r a p y ............................................................................................................................................................ 41
C o m p o n en ts o f E ffe c tiv e B rie f T h e r a p y ......................................................................................................................................41
T h e ra p ist C h a r a c te r is tic s ..................................................................................................................................................................... 49

C on ten ts

C h a p te r 4 B r ie f C o g n it iv e - B e h a v io r a l T h e r a p y ......................................................................................................................51
B eh a v io ra l T h e o r y ................................................................................................................................................................................... 51
B eh a v io ra l T h e ra p y T e c h n iq u e s B a sed on C la s s ic a l C o n d itio n in g M o d e ls ............................................................53
B eh a v io ra l T h e ra p y T e c h n iq u e s B a sed on O p e ra n t L e a rn in g M o d e l s ......................................................................55
C o g n itiv e T h e o r y ......................................................................................................................................................................................61
C o g n itiv e T h e r a p y .................................................................................................................................................................................. 63
C o g n itiv e -B e h a v io r a l T h e o r y ............................................................................................................................................................68
C o g n itiv e -B e h a v io r a l T h e r a p y ......................................................................................................................................................... 77
C h a p te r 5 B r ie f S tra te g ic / In te ra c tio n a l T h e r a p i e s .................................................................................................................87
S o lu tio n -F o c u se d T h e ra p y fo r S u b s ta n c e A b u s e ................................................................................................................... 88
C o m p a tib ility o f S tra te g ic / In te ra c tio n a l T h e ra p ie s a n d 1 2 -S te p P r o g r a m s ............................................................ 89
W h e n T o U se S tra te g ic / In te ra c tio n a l T h e ra p ie s .....................................................................................................................90
C a se S tu d y ....................................................................................................................................................................................................92
S tra te g ic/ In te ra c tio n a l T h e r a p ie s ...................................................................................................................................................99
C h a p te r 6 B r ie f H u m a n is tic a n d E x is te n tia l T h e r a p i e s ................................................................................................... 105
U sin g H u m a n istic an d E x is te n tia l T h e r a p ie s .........................................................................................................................106
T h e H u m a n istic A p p ro a c h to T h e r a p y ..................................................................................................................................... 109
T h e E x iste n tia l A p p ro a c h to T h e r a p y .........................................................................................................................................117
C h a p te r 7 B r ie f P s y c h o d y n a m ic T h e r a p y ................................................................................................................................. 121
B a c k g r o u n d ...............................................................................................................................................................................................121
In tro d u ctio n to B rie f P sy c h o d y n a m ic T h e r a p y .....................................................................................................................122
P sy ch o d y n a m ic P sy c h o th e ra p y fo r S u b sta n c e A b u s e ......................................................................................................123
P sy ch o d y n a m ic C o n c e p ts U se fu l in S u b s ta n c e A b u se T r e a t m e n t .............................................................................128
T r a n s fe r e n c e ..............................................................................................................................................................................................131
M o d e ls o f B rie f P sy c h o d y n a m ic T h e r a p y ................................................................................................................................ 135
O th e r R e s e a r c h ....................................................................................................................................................................................... 140
C h a p te r 8 B r ie f F a m ily T h e r a p y ..................................................................................................................................................... 143
A p p ro p ria te n e s s o f B rie f F a m ily T h e r a p y ............................................................................................................................... 144
D efin itio n s o f " F a m i l y " ......................................................................................................................................................................145
T h e o re tica l A p p ro a c h e s ......................................................................................................................................................................147
U sin g B rief F a m ily T h e r a p ie s ......................................................................................................................................................... 152
F o llo w u p ....................................................................................................................................................................................................154
C u ltu ra l I s s u e s .........................................................................................................................................................................................154
C h a p te r 9 T im e -L im ite d G ro u p T h e r a p y ................................................................................................................................. 157
A p p ro p ria te n e ss o f G ro u p T h e r a p y ........................................................................................................................................... 157
G ro u p T h e ra p y A p p r o a c h e s ............................................................................................................................................................158
T h e o rie s o f G ro u p T h e r a p y .............................................................................................................................................................. 160
U se o f P sy ch o d ra m a T e c h n iq u e s in a G ro u p S e t t in g ........................................................................................................ 164
T h e ra p e u tic F a c to r s .............................................................................................................................................................................. 166
U sin g T im e -L im ite d G ro u p T h e r a p y .......................................................................................................................................... 168
iv

C on ten ts

A p p e n d ix A B ib li o g r a p h y ..................................................................................................................................................................173
A p p e n d ix B In fo r m a tio n a n d T r a in in g R e s o u r c e s .............................................................................................................209
G e n e ra l B rie f T h e r a p y ........................................................................................................................................................................ 209
C o g n itiv e -B e h a v io r a l T h e r a p y .......................................................................................................................................................209
S tra te g ic / In te ra c tio n a l T h e r a p ie s ................................................................................................................................................ 210
H u m a n istic and E x is te n tia l T h e r a p i e s ...................................................................................................................................... 211
P sy ch o d y n a m ic T h e r a p y ................................................................................................................................................................... 213
Fam ily T h e r a p y ...................................................................................................................................................................................... 213
G ro u p T h e r a p y ....................................................................................................................................................................................... 214
A p p e n d ix C G l o s s a r y ............................................................................................................................................................................ 215
A p p e n d ix D H e a lth P ro m o tio n W o r k b o o k ............................................................................................................................. 221
P art 1: S u m m a ry o f H e a lth H a b its ............................................................................................................................................... 221
P art 2: T y p e s o f D rin k ers in th e U .S . P o p u la tio n .................................................................................................................222
P art 3: C o n s e q u e n c e s o f H e a v y D r in k in g ................................................................................................................................223
P art 4: R e a so n s T o Q u it or C u t D o w n o n Y o u r D r in k in g ............................................................................................... 224
P art 5: D rin k in g A g r e e m e n t............................................................................................................................................................. 225
P art 6: H a n d lin g R isk y S itu a tio n s ................................................................................................................................................ 227
A p p e n d ix E R e s o u rc e P a n e l .............................................................................................................................................................. 229
A p p e n d ix F F ie ld R e v ie w e r s .............................................................................................................................................................231
F ig u re s
1-1

S u b s ta n c e A b u se S e v e rity a n d L e v e l o f C a r e ................................................................................................................... 4

1-2

G o a l o f B rie f In te rv e n tio n s A cc o rd in g to S e t t i n g .......................................................................................................... 6

2-1

T h e S ta g e s o f C h a n g e .................................................................................................................................................................. 15

2 -2

S a m p le O b je c tiv e s ..........................................................................................................................................................................16

2-3

A m e ric a n S o c ie ty o f A d d ic tio n M e d ic in e (A S A M ) P a tie n t P la c e m e n t C r ite r ia .........................................18

2-4

F R A M E S ..............................................................................................................................................................................................19

2-5

S crip ts fo r B rie f In te r v e n tio n ...................................................................................................................................................20

2-6

S cre e n in g fo r B rie f In te rv e n tio n s fo r A lc o h o lis m ........................................................................................................22

2-7

C lie n t F e e d b a c k an d P la n o f A c t io n ....................................................................................................................................23

2-8

T a lk in g A b o u t C h a n g e a t D iffe re n t S ta g e s ......................................................................................................................24

2-9

S te p s in A ctiv e L is t e n in g .......................................................................................................................................................... 26

2-10 P ro fe s s io n a ls O u tsid e o f S u b s ta n c e A b u se T re a tm e n t W h o C a n A d m in is te r
B rie f I n te r v e n tio n s ........................................................................................................................................................................ 28
3-1

C rite ria fo r L o n g e r T e rm T r e a t m e n t .................................................................................................................................. 39

3-2

S e le cte d C rite ria fo r P ro v id in g B rie f T h e r a p y ..............................................................................................................40

3-3

A p p ro a c h e s to B rie f T h e r a p y ................................................................................................................................................. 42

3-4

C h a ra c te ristic s o f A ll B rie f T h e r a p ie s ................................................................................................................................44

3-5

S a m p le B a tte ry o f B rie f A s s e s sm e n t I n s tr u m e n ts ...................................................................................................... 45

4-1

C la s s ica l C o n d itio n in g a n d O p e ra n t L e a r n in g .............................................................................................................52

C on ten ts

4 -2

B asic A ssu m p tio n s of B e h a v io ra l T h e o rie s o f S u b s ta n c e A b u se an d Its T r e a tm e n t.................................. 53

4 -3

A d v a n ta g e s o f B e h a v io ra l T h e o rie s in T re a tin g S u b s ta n ce A b u s e D is o r d e r s ...............................................54

4 -4

F u n ctio n a l A n a ly s is ......................................................................................................................................................................56

4 -5

T e a ch in g S tre ss M a n a g e m e n t ................................................................................................................................................ 60

4 -6

P ro g ra m m e d T h e ra p y an d W ritin g T h e r a p y ................................................................................................................. 61

4 -7

T h e R e la tio n sh ip A m o n g F a cto rs M a in ta in in g B e h a v io r in B e h a v io ra l and

C o g n itiv e M o d e ls ........................................................................................................................................................................... 62

4-8

F ifte en C o m m o n C o g n itiv e E r r o r s .......................................................................................................................................63

4-9

C h a ra cte ristic T h in k in g o f P eo p le W ith S u b s ta n c e A b u se D is o r d e r s ............................................................. 64

4 -1 0 C o m m o n Irra tio n a l B e lie fs A b o u t A lc o h o l an d D ru g s W ith M o re R a tio n a l A lt e r n a t iv e s .................. 65

4-11 T h o u g h ts, F e elin g s, an d B e h a v io r s ..................................................................................................................................... 66
4-1 2 In tro d u cin g C o g n itiv e T h e ra p y : A S a m p le S c r ip t....................................................................................................... 67
4 -13 C o m m o n E le m e n ts o f B rief C o g n itiv e -B e h a v io r a l T h e r a p ie s ..............................................................................69
4 -1 4 A ttrib u tio n a l S t y l e s ......................................................................................................................................................................70
4 -15 R e la p se P re v e n tio n M o d e l B a sed on S e lf-E ffic a c y T h e o r y .................................................................................... 73
4 -1 6 T a x o n o m y o f H ig h -R isk S itu a tio n s B a sed on M a r la tt's O rig in a l
C a te g o riz a tio n S y s t e m ............................................................................................................................................................... 75
4 -1 7 A C o g n itiv e -B e h a v io r a l M o d e l of the R e la p se P r o c e s s .......................................................................................... 76
4 -1 8 E sse n tia l an d U n iq u e E le m e n ts o f C o g n itiv e -B e h a v io r a l I n te r v e n tio n s ....................................................... 78
4 -1 9 In tra p e rso n a l an d In te rp e rs o n a l S k ills T ra in in g E le m e n t s .................................................................................... 80
4 -2 0 A sse rtiv e n e s s T r a in in g ............................................................................................................................................................... 80
4-21 T y p e s o f C lien ts fo r W h o m O u tp a tie n t C B T Is G e n e ra lly N o t A p p r o p r ia te ............................................... 85

VI

5-1

D e lib e ra te an d R a n d o m E x ce p tio n s to S u b s ta n c e A b u se B e h a v io r s ................................................................89

5-2

S tra te g ic / In te ra c tio n a l T h e ra p y in P ra ctice: A C a se S t u d y ................................................................................... 93

6-1

A C a se S t u d y ................................................................................................................................................................................. I l l

7-1

D efen se M e c h a n is m s ................................................................................................................................................................. 132

7-2

B rief P sy c h o d y n a m ic T h e r a p y .............................................................................................................................................136

What Is a TIP?

re a tm e n t Im p ro v e m e n t P ro to c o ls (T IP s)

by th eir p e e rs. T h is P a n e l p a rtic ip a te s in a series

are b est p ra c tic e g u id e lin e s fo r the

o f d is c u ss io n s ; th e in fo r m a tio n an d

tre a tm e n t o f su b sta n ce a b u se d iso rd e rs,

re c o m m e n d a tio n s o n w h ic h it re a c h e s c o n se n su s

p ro v id e d as a s e rv ice o f th e S u b s ta n c e A b u se

fo rm th e fo u n d a tio n o f th e T IP . T h e m e m b e rs of

and M e n ta l H e a lth S e rv ic e s A d m in is tra tio n 's

e a c h C o n s e n s u s P a n e l re p re s e n t s u b s ta n ce ab u se

C e n te r fo r S u b s ta n c e A b u se T re a tm e n t (C S A T ).

tre a tm e n t p ro g ra m s , h o s p ita ls , co m m u n ity

C S A T 's O ffice o f E v a lu a tio n , S c ie n tific A n a ly sis

h e a lth c e n te rs , c o u n s e lin g p ro g ra m s , c rim in a l

and S y n th e sis d ra w s on the e x p e rie n c e an d

ju s tic e a n d c h ild w e lfa re a g e n c ie s, an d p riv ate

k n o w le d g e o f clin ica l, re se a rc h , and

p ra c titio n e rs . A P a n e l C h a ir (o r C o -C h a irs)

a d m in istra tiv e e x p e rts to p ro d u ce the T IP s,

e n s u re s th a t th e g u id e lin e s m irro r th e re su lts of

w h ich are d istrib u te d to a g ro w in g n u m b e r of

the g ro u p 's c o lla b o ra tio n .

fa cilities and in d iv id u a ls a c ro ss th e c o u n try .

A la rg e a n d d iv e rse g ro u p o f e x p e rts clo sely

T h e a u d ie n ce fo r the T IP s is e x p a n d in g b ey o n d

re v ie w s the d ra ft d o c u m e n t. O n c e the c h a n g e s

p u b lic and p riv a te s u b s ta n c e a b u se tre a tm e n t

re c o m m e n d e d b y th e s e field re v ie w e rs h av e

fa cilities as a lco h o lism an d o th e r su b sta n c e

b e e n in c o rp o ra te d , th e T IP is p re p a re d fo r

ab u se d iso rd e rs are in c re a sin g ly re c o g n iz e d as

p u b lic a tio n , in p rin t a n d o n lin e . T h e T IP s can be

m a jo r p ro b lem s.

a c c e sse d via th e In te rn e t on th e N a tio n a l L ib rary

T h e T IP s E d ito ria l A d v iso ry B o a rd , a

o f M e d ic in e 's h o m e p a g e a t th e U R L :

d istin g u ish e d g ro u p o f s u b s ta n c e a b u se e x p e rts

h ttp :/ / te x t.n lm .n ih .g o v . T h e m o v e to e le ctro n ic

and p ro fe ssio n a ls in su ch re la te d fie ld s as

m e d ia a lso m e a n s th a t th e T IP s ca n b e u p d ated

p rim a ry care , m e n ta l h e a lth , an d so cia l serv ices,

m o re e a sily so th e y c o n tin u e to p ro v id e the field

w o rk s w ith the S ta te A lco h o l and O th e r D ru g

w ith s ta te -o f-th e -a rt in fo rm a tio n .

A b u se D irecto rs to g e n e ra te to p ics fo r the T IP s

A lth o u g h e a ch T IP striv e s to in clu d e an

based on the fie ld 's c u rre n t n e e d s fo r

e v id e n c e b a se fo r th e p ra c tic e s it re c o m m e n d s,

in fo rm a tio n an d g u id a n ce .

C S A T re c o g n iz e s th a t th e field o f s u b sta n ce

A fter sele ctin g a to p ic, C S A T in v ite s sta ff

a b u se tre a tm e n t is e v o lv in g an d th a t re sea rch

fro m p e rtin e n t F e d e ra l a g e n c ie s an d n a tio n a l

fre q u e n tly la g s b e h in d th e in n o v a tio n s

o rg a n iz a tio n s to a R e so u rc e P a n el th a t

p io n e e re d in th e field . A m a jo r g o a l o f e a ch T IP

re co m m en d s sp e c ific a re a s o f fo cu s as w ell as

is to c o n v e y " f r o n t lin e " in fo r m a tio n q u ick ly bu t

re so u rces th at sh o u ld b e c o n s id e re d in

re s p o n s ib ly . F o r th is re a s o n , re c o m m e n d a tio n s

d ev elo p in g the c o n te n t o f th e T IP . T h e n

p ro ffe re d in th e T IP a re a ttrib u te d to eith er

re co m m e n d a tio n s a re c o m m u n ic a te d to a

P a n e lists' c lin ic a l e x p e rie n c e or the lite ra tu re .

C o n sen su s P a n el c o m p o se d o f n o n -F e d e ra l

If th e re is re s e a rc h to s u p p o rt a p a rtic u la r

e x p e rts on the to p ic w h o h a v e b e e n n o m in a te d

a p p ro a c h , c ita tio n s a re p ro v id e d .

W hat Is a T IP?

T h is T IP , B r ie f In terv en tio n s a n d B r ie f T h erap ies

b eh in d it as w e ll as s o m e o f th e te c h n iq u e s

f o r S u b stan ce A b u se, is in te n d e d p rim a rily fo r

d e v e lo p e d fro m th a t th e o ry th a t c a n b e used to

co u n selo rs an d th e ra p ists w o rk in g in the

tre a t c lie n ts w ith s u b s ta n c e a b u s e d iso rd e rs.

su b sta n ce a b u se tre a tm e n t field , b u t p a rts o f it

S e p a ra te c h a p te rs a re p re s e n te d d e scrib in g

w ill be o f v a lu e to o th er a u d ie n ce s , in clu d in g

c o g n itiv e -b e h a v io r a l th e ra p y ,

h e alth ca re w o rk e rs, so cia l s e rv ic e s p ro v id e rs,

stra te g ic / in te ra c tio n a l th e ra p ie s, h u m a n istic and

clerg y , te a ch e rs, an d c rim in a l ju s tic e p e rso n n e l.

e x is te n tia l th e ra p ie s, p s y c h o d y n a m ic th e ra p ie s,

In fact, th o se p o rtio n s o f th is T IP d ea lin g w ith

fa m ily th e ra p y , a n d g ro u p th e ra p y . A p p e n d ix e s

b rie f in te rv e n tio n s w ill b e o f u se to an y

a re a lso in clu d e d th a t p ro v id e re s o u rc e s fo r

p ro fe ss io n a l serv ice p ro v id e r w h o m a y n e ed to

fu rth e r in fo r m a tio n a n d tra in in g , a g lo ssa ry of

m ak e an in te rv e n tio n to h e lp p e rs o n s w ith

te rm s u sed in th e T IP , a n d a s a m p le w o rk b o o k

su b sta n ce a b u se d iso rd e rs a lte r th e ir use

fo r u se in b rie f in te rv e n tio n s .

p attern s or see k tre a tm e n t. H o w e v e r, b rie f

T h e g o a l o f th is T IP is to m a k e re a d e rs a w are

th e rap y s h o u ld o n ly b e p ra c tice d by th o se w h o

o f th e re s e a rch , re s u lts , a n d p ro m ise o f b rie f

are p ro p e rly q u a lifie d , e d u c a te d , an d licen sed .

in te rv e n tio n s an d b r ie f th e ra p ie s in th e h o p e

T h e firs t c h a p te r o f th is T IP p re se n ts an

th a t th ey w ill b e u se d m o re w id e ly in c lin ica l

ov erv iew o f b rie f in te rv e n tio n s an d b rie f

p ra ctic e a n d tre a tm e n t p ro g ra m s a c ro ss the

th e ra p ie s, d e s c rib in g th e ir b a sic c h a ra cte ris tic s

U n ite d S ta te s.

and the re a so n s fo r in c re a se d in te re s t in th em .
C h a p te r 2 d e s crib e s the g o a ls and co m p o n e n ts

viii

O th er T IP s m ay be o rd ered by c o n ta c tin g

of b rief in te rv e n tio n s, an d C h a p te r 3 d iscu sse s

S A M H S A 's N a tio n a l C lea r in g h o u se f o r A lc o h o l an d

so m e o f the b asic e le m e n ts o f all b rie f th era p ies.

D ru g In form a tio n (N C A D I), (8 0 0 ) 7 2 9 -6 6 8 6 or

C h a p te rs 4 th ro u g h 9 e a ch h ig h lig h t a d iffe re n t

(3 0 1 ) 4 6 8 -2 6 0 0 ; T D D (for h ea rin g im p aired ),

ty p e o f b rie f th e ra p y , d e s c rib in g th e th e o ry

(8 0 0 ) 4 8 7 -4 8 8 9 .

Editorial Advisory Board

K aren A llen , P h .D ., R .N ., C .A .R .N .

T h o m a s W . H e ste r, M .D .

P ro fe sso r and C h a ir

F o rm e r S ta te D ire c to r

D e p a rtm e n t o f N u rsin g

S u b s ta n c e A b u s e S e rv ic e s

A n d rew s U n iv e rsity

D iv is io n o f M e n ta l H e a lth , M e n ta l

B errie n S p rin g s, M ich ig a n

R ich ard L. B ro w n , M .D ., M .P .H .
A sso cia te P ro fe sso r
D e p a rtm e n t o f F a m ily M e d ic in e

R e ta rd a tio n an d S u b s ta n c e A b u se
G e o rg ia D e p a rtm e n t o f H u m a n R e so u rce s
A tla n ta , G e o rg ia
Ja m e s G. (G il) H ill, P h .D .

U n iv ersity o f W isc o n s in S c h o o l o f M e d ic in e

D ire c to r

M a d iso n , W isc o n s in

O ffic e o f S u b s ta n c e A b u se

D o ry n n e C z e ch o w ic z , M .D .
A sso cia te D irecto r
M e d ic a l/ P ro fe s s io n a l A ffa irs

A m e ric a n P s y c h o lo g ic a l A s s o c ia tio n
W a s h in g to n , D .C .
D o u g la s B. K a m e ro w , M .D ., M .P .H .

T re a tm e n t R e se a rc h B ra n ch

D ire cto r

D iv isio n o f C lin ic a l and S e rv ic e s R e se a rch

O ffice o f th e F o ru m fo r Q u a lity and

N a tio n a l In stitu te on D ru g A b u se
R o ck v ille , M a ry la n d
L in d a S. F oley, M .A .
F o rm er D irecto r

E ffe c tiv e n e ss in H e a lth C a re

A g e n c y fo r H e a lth C a re P o licy and R ese a rch
R o c k v ille , M a ry la n d
S te p h e n W . L o n g

P ro ject fo r A d d ic tio n C o u n s e lo r T ra in in g

D ire c to r

N a tio n a l A s s o c ia tio n o f S ta te A lco h o l and

O ffice o f P o lic y A n a ly s is

D ru g A b u se D irecto rs
W a sh in g to n , D .C .
W ay d e A . G lo v e r, M .I.S ., N .C .A .C . II
D irecto r
C o m m o n w e a lth A d d ic tio n s C o n s u lta n ts and
T ra in e rs
R ich m o n d , V irg in ia
P ed ro J. G re e r, M .D .
A ssista n t D ea n fo r H o m e le ss E d u ca tio n
U n iv ersity o f M ia m i S ch o o l o f M e d ic in e

N a tio n a l In s titu te o n A lc o h o l A b u se and

A lc o h o lis m
R o ck v ille , M a ry la n d
R ich a rd A. R a w s o n , P h .D .
E x e c u tiv e D ire c to r
M a trix C e n te r an d M a trix In stitu te on
A d d ic tio n
D e p u ty D ire cto r, U C L A A d d ic tio n M e d icin e
S e rv ic e s
L o s A n g e le s , C a lifo rn ia

M iam i, F lo rid a

IX

E ditorial A d v isory B oard

E llen A . R en z, P h .D .
F o rm e r V ice P re sid e n t o f C lin ic a l S y ste m s

S id n e y H . S c h n o ll, M .D ., P h .D .
C h a irm a n

M E D C O B e h a v io ra l C a re C o rp o ra tio n

D iv isio n o f S u b s ta n c e A b u s e M e d icin e

K a m u e la , H a w aii

M e d ica l C o lle g e o f V irg in ia

R ich ard K. R ies, M .D .

D irecto r an d A sso c ia te P ro fe sso r
O u tp a tie n t M e n ta l H e a lth S e rv ic e s and D u al
D iso rd e r P ro g ra m s
H arb o rv ie w M e d ic a l C e n te r
S e a ttle, W a sh in g to n

R ich m o n d , V irg in ia

Consensus Panel

Chair
K risten L aw to n B a rry , P h.D .

T e rry S o o -H o o , P h .D .
C lin ic D ire c to r / A s s ista n t P ro fe s s o r

A sso ciate R e se a rch S c ie n tist

C o u n s e lin g P sy c h o lo g y D e p a rtm e n t

A lco h o l R e se a rch C e n te r

U n iv e rs ity o f S a n F ra n c is c o

U n iv ersity o f M ich ig a n

S a n F ra n cis c o , C a lifo rn ia

A n n A rb o r, M ic h ig a n

Workgroup Leaders
C h risto p h e r W . D u n n , P h .D ., M .A .C ., C .D .C .
P sy ch iatry and B e h a v io ra l S c ie n c e
U n iv ersity o f W a sh in g to n
S ea ttle, W a sh in g to n
Je rry P. F la n z er, D .S .W ., L .C .S .W ., C .A .C .
D irecto r

Panelists
Ja n ic e S. B en n e tt, M .S ., C .S .A .C .
O w n e r/ C o n s u lta n t
P a cific C o n s u ltin g a n d T ra in in g S e rv ic e s of
H a w a ii
H o n o lu lu , H a w a ii
R o b e rt L. C h a p m a n , M .S .S .W ., C .A .D .O .A .C .,
C .R .P .S .

R eco v ery and F a m ily T re a tm e n t, Inc.

C u m b e rla n d H e ig h ts

A le x a n d ria , V irg in ia

N a s h v ille , T e n n e ss e e

S te p h e n G ed o , P h .D .

Jo h n W . H e rd m a n , P h .D ., C .A .D .A .C .

C lin ica l P sy c h o lo g is t

P sy c h o lo g is t

G a ffn ey , S o u th C a ro lin a

T h e E n c o u ra g e m e n t P la ce
L in c o ln , N e b ra sk a

E u g en e H e rrin g to n , P h .D .
A sso cia te P ro fe sso r
D e p a rtm e n t o f C o u n s e lin g an d P sy c h o lo g ic a l
S e rv ices

F a n n y G . N ic h o lso n , C .C .S .W ., A .C .S .W .,
N .C .A .C .I., C .S .A .E .
A lco h o l a n d D ru g S p e c ia list

C lark A tla n ta U n iv e rsity

O c o n a lu fte e Jo b C o rp s

A tlan ta, G e o rg ia

C h e ro k e e , N o rth C a ro lin a

F red rick R o tg e rs, P sy .D .

M a ry A lic e O rito , C .S .W ., C .A .S .A .C ., N .C .A .C .I.

D irecto r

E v a lu a tio n S u p e rv is o r

P ro g ram fo r A d d ic tio n s C o n s u lta tio n and

S tu y v e sa n t S q u a re O u tp a tie n t S e rv ic e s for

T re a tm e n t
C e n te r of A lco h o l S tu d ie s
R u tg ers U n iv ersity
N ew B ru n sw ick , N ew Je rse y

C h e m ic a l D e p e n d e n c y
N e w Y o rk , N e w Y o rk

C on sen su s P an el

Je ro m e J. P latt, P h.D .
P ro fe sso r o f P sy c h ia try an d P u b lic H e a lth

A v a H . S ta n le y , M .D .
S o m e rs e t, N e w Je rs e y

D irecto r, In stitu te fo r A d d ic tiv e D iso rd e rs

H a h n e m a n n S c h o o l o f M e d icin e

R o b e rt S. S te p h e n s , P h .D .

A lle g h e n y U n iv e rs ity o f th e H e a lth S cie n ce s

A s s o c ia te P ro fe s s o r

P h ila d e lp h ia , P e n n sy lv a n ia

D e p a rtm e n t o f P sy c h o lo g y
V irg in ia P o ly te c h n ic In s titu te an d S ta te

M arily n S a w y e r S o m m e rs, P h .D ., R .N .
P ro fe sso r
C o lle g e o f N u rsin g
U n iv ersity o f C in cin n a ti
C in cin n a ti, O h io
Jo se L u is S o ria , M .A ., L .C .D .C ., I.C .A .D .C .,
C .C .G .C ., C .A .D .A .C .
C lin ica l D ep u ty D irecto r
A liv ia n e N O -A D , Inc.
El P aso , T e x a s

U n iv e rs ity
B la c k s b u rg , V irg in ia

Foreword

h e T re a tm e n t Im p ro v e m e n t P ro to co l

p a rtic ip a to ry p ro c e s s h a v e b rid g e d th e gap

(T IP ) serie s fu lfills S A M H S A / C S A T 's

b e tw e e n th e p ro m ise o f re s e a rc h an d th e n eed s

m issio n to im p ro v e tre a tm e n t o f

o f p ra c tic in g c lin ic ia n s a n d a d m in is tra to rs . W e

su b sta n ce a b u se b y p ro v id in g b e s t p ra ctice s

a re g ra te fu l to all w h o h a v e jo in e d w ith us to

g u id a n ce to clin icia n s, p ro g ra m a d m in is tra to rs ,

c o n trib u te to a d v a n c e s in th e s u b s ta n c e a b u se

and p ay o rs. T IP s a re th e re su lt o f c a re fu l

tre a tm e n t field .

co n sid e ra tio n o f all re le v a n t clin ic a l an d h e a lth

serv ices re sea rch fin d in g s, d e m o n s tra tio n
e x p e rien ce, an d im p le m e n ta tio n re q u ire m e n ts.
A p a n e l o f n o n -F e d e ra l c lin ic a l re se a rc h e rs,

N e lb a C h a v e z , P h .D .
A d m in is tra to r
S u b s ta n c e A b u s e an d M e n ta l H e a lth
S e rv ic e s A d m in is tra tio n

clin icia n s, p ro g ra m a d m in is tra to rs , an d clie n t

a d v o ca tes d e b a te s an d d isc u sse s its p a rtic u la r
areas o f e x p e rtise u n til it re a ch e s co n s e n s u s on

H . W e stle y C la rk , M .D ., J.D ., M .P .H .,
C A S, FA SA M

b est p ra ctice s. T h is p a n e l's w o rk is th en

D ire c to r

rev iew ed and critiq u e d b y field re v iew e rs.

C e n te r fo r S u b s ta n c e A b u se T re a tm e n t

T h e talen t, d ed ic a tio n , and h a rd w o rk th a t

T IP s p a n e lists an d re v ie w e rs b rin g to th is h ig h ly

S u b s ta n c e A b u se a n d M e n ta l H e a lth
S e rv ic e s A d m in is tra tio n

Executive Summary and

Recommendations

his Treatment Improvement Protocol

efforts and more intensive treatment for persons with

(TIP) responds to an increasing body of

serious substance abuse disorders. However, studies

research literature that documents the

have shown that brief interventions are effective for a

ceffectiveness 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

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

developing them. The TIP will also be useful for

substance users, and as adjuncts to more extensive

health care workers, social service providers who

treatment for substance-dependent persons.

work outside the substance abuse treatment field,

Brief therapies can be used to effect significant

people in the criminal justice system, and anyone else

changes in clients' behaviors and their understanding

who may be called on to intervene with a person who

of them . The term "brief therapy" covers several

has substance abuse problems.

treatment approaches derived from a number of

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 a
re less costly yet have 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

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 .

E xecu tive S u m m ary an d R eco m m en d a tio n s

T h is T IP p re se n ts th e h is to rica l b a c k g ro u n d ,

P sy c h ia tric A s s o c ia tio n , 1 9 9 4 ]). B e c a u se the

o u tco m es re sea rch , ra tio n a le fo r use, an d sta te -

te rm "s u b s ta n c e a b u s e " is c o m m o n ly u sed by

o f-th e -a rt p ra c tic a l m e th o d s an d ca se sce n a rio s

su b sta n c e a b u se tre a tm e n t p ro fe ss io n a ls to

fo r im p le m e n ta tio n o f b rie f in te rv e n tio n s and

d e sc rib e a n y e x c e s s iv e u se o f a d d ic tiv e

th e ra p ie s fo r a ra n g e o f p ro b le m s re la ted to

s u b s ta n c e s, it w ill b e u sed to d e n o te b o th

s u b sta n ce ab u se. T h is T IP is b a se d on the b o d y

s u b s ta n c e d e p e n d e n c e an d s u b s ta n c e ab u se.

o f re se a rch co n d u cte d o n b rie f in te rv e n tio n s and

T h e te rm in c lu d e s th e u se o f a lc o h o l as w ell as

b rie f th e ra p ie s fo r s u b s ta n c e a b u se as w ell as on

o th er s u b s ta n c e s o f a b u se . R e a d e rs sh o u ld

the b ro a d clin ica l e x p e rtise o f th e C o n se n su s

atte n d to th e c o n te x t in w h ic h th e te rm o ccu rs in

P an el. B e ca u se m a n y th e ra p ists an d o th er

o rd e r to d e te rm in e th e m e a n in g ; in m o st ca ses,

p ra ctitio n e rs a re e c le c tic a lly tra in e d , e le m e n ts

the term w ill re fe r to all v a rie tie s o f su b sta n ce

fro m each o f the ch a p te rs m a y b e o f u se to a

a b u se d is o rd e rs as d e s c rib e d b y D S M -IV .

ran g e o f p ro fe ssio n a ls.

T h is d is cu ss io n o f b rie f th e ra p ie s is in no
w ay in te n d e d to d e tra c t fro m th e v a lu e o f lo n g e r
term th e ra p ie s th a t c lin icia n s h a v e fo u n d to be

Summary and
Recommendations

e ffe ctiv e in the tre a tm e n t o f s u b s ta n ce a b u se

d iso rd ers. H o w e v e r, th e C o n s e n s u s P a n el

Brief Interventions

b elie v e s it n e c e s s a ry to d isc u ss in n o v a tiv e

B rie f in te rv e n tio n s a re th o se p ra c tic e s th a t aim

an d / o r o fte n -u se d th e o rie s th a t m e m b e rs h a v e

to in v e s tig a te a p o te n tia l p ro b le m an d m o tiv a te

e n co u n te re d and a p p lie d in th e ir c lin ica l

an in d iv id u a l to b e g in to d o s o m e th in g a b o u t h is

p ractice.

s u b s ta n c e a b u s e , e ith e r b y n a tu ra l, c lie n t-

T h e C o n se n su s P a n e l's re c o m m e n d a tio n s
su m m a riz ed b elo w a re b a se d on b o th re sea rch

d ire cte d m e a n s or b y s e e k in g a d d itio n a l

s u b s ta n c e a b u s e tre a tm e n t.
A b rie f in te rv e n tio n , h o w e v e r, is o n ly o n e of

an d clin ica l e x p e rie n c e . T h o se s u p p o rte d by

s cie n tific e v id e n c e a re fo llo w e d b y (1); clin ica lly

m a n y to o ls a v a ila b le to c lin ic ia n s. It is n o t a

b ase d re co m m e n d a tio n s a re m a rk e d (2).

s u b s titu te fo r c a re fo r c lie n ts w ith a h ig h lev el of

C ita tio n s fo r the fo rm e r a re re fe re n ce d in the

d e p e n d e n c y . It ca n , h o w e v e r, b e u sed to e n g a g e

b o d y o f th is d o c u m e n t, w h ere th e g u id e lin e s are

c lie n ts w h o n eed sp ecia liz ed trea tm en t in sp e cific

p re sen ted in fu ll d eta il. M a n y o f the

a s p e cts o f tre a tm e n t p ro g ra m s , su ch as

re co m m e n d a tio n s m a d e in the la tte r c h a p te rs of

a tte n d in g g ro u p th e ra p y or A lco h o lics

th is T IP are re le v a n t o n ly w ith in a p a rtic u la r

A n o n y m o u s (A A ) m e e tin g s .

th e o retica l fra m e w o rk (e .g ., th e P a n el m ig h t

re co m m en d h o w a p e rs o n p ra c tic in g stra te g ic

in te rv e n tio n s c a n b e an e ffe c tiv e a d d itio n to

th e rap y sh o u ld a p p ro a c h a p a rtic u la r situ a tio n );

s u b s ta n c e a b u s e tre a tm e n t p ro g ra m s . T h e se

b e ca u se su ch re c o m m e n d a tio n s are n ot

a p p ro a c h e s c a n b e p a rtic u la rly u se fu l in

a p p lica b le to all re a d e rs, th ey h a v e n o t b een

tre a tm e n t se ttin g s w h e n th e y a re u sed to

in clu d e d in th is E x e c u tiv e S u m m a ry .

a d d re s s sp e c ific ta rg e te d c lie n t b e h a v io rs and

T h ro u g h o u t th is T IP , th e term "s u b s ta n c e

issu es in th e tre a tm e n t p ro c e s s th a t ca n be

a b u s e " h a s b e e n u sed in a g e n e ra l se n se to co v er

d iffic u lt to c h a n g e u sin g s ta n d a rd tre a tm e n t

b o th su b sta n ce a b u se d is o rd e rs an d s u b sta n ce
d ep en d e n ce d iso rd e rs (as d efin e d by the
D iag n ostic an d S ta tistical M a n u al o f M en tal
D isorders, 4 th E d itio n [D S M -IV ] [A m e rica n
xvi

T h e C o n s e n s u s P a n e l b e lie v e s th a t b rie f

a p p ro a c h e s. (2)

V a ria tio n s o f b rie f in te rv e n tio n s h a v e b een

fo u n d to b e e ffe c tiv e b o th fo r m o tiv a tin g
a lc o h o l-d e p e n d e n t in d iv id u a ls to e n te r

long-term alcohol treatment and for treating

Components of brief interventions

some alcohol-dependent persons. (1)

There are six elements that are critical for effective

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)

brief interventions. (1) The acronym FRAMES was

coined to summarize these six components:

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..

Substance abuse treatment personnel should

Feedback is given to the individual

about personal risk or impairment

collaborate with other providers (e.g., primary

A brief intervention consists of five basic steps that

care providers, employee assistance program,

wellness clinic staff, etc.) in developing plans that

incorporate FRAMES and remain consistent regardless

include both brief interventions and more

of the number of sessions or the length of the

intensive care to help keep clients focused on

intervention:

treatment and recovery.(2)

1.

Introducing the issues in the context of the client's

health.

2.

Screening, evaluating, and assessing.

3.

Providing feedback.

substances. The specific goal for each individual client

4.

Talking about change and setting goals.

is determined by his consumption pattern, the

5.

Summarizing and reaching closure.

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

consequences of his use, and the setting in which the

brief intervention is delivered .

Focusing on intermediate goals allows for more

components in any given session with a client.

immediate success in the intervention and

However, before eliminating steps in the brief

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)

intervention process there should be a well-defined

reason for doing so. (2)

Essential knowledge and skills for brief

interventions

When conducting a brief intervention, the clinician

should set aside the final treatment goal (e.g.,

Providing effective brief interventions requires the

accepting responsibility for one's own recovery) to

clinician to possess certain knowledge, skills, and

focus on a single behavioral objective. Once this

abilities. The following are four essential skills (2):

objective is established, a brief intervention can be

used to help reach it. (2)

xv ii

Providers may not have to use all five of these

1. An overall attitude of understanding and

acceptance.

E xecu tive S u m m ary a n d R eco m m en d a tio n s

2.

3.
4.

C o u n se lin g sk ills su ch as a ctiv e liste n in g

and h e lp in g c lie n ts e x p lo re an d re so lv e

is a v a lu a b le a p p ro a c h , b u t it sh o u ld not be

a m b iv a le n ce

c o n s id e re d a s ta n d a rd o f ca re fo r all

A fo cu s on in te rm e d ia te g o a ls

p o p u la tio n s . (1) T h e C o n s e n s u s P a n el h o p es

A w o rk in g k n o w le d g e o f the sta g e s-o f-

th a t b rie f th e ra p y w ill b e a d e q u a te ly

ch a n g e th ro u g h w h ic h a c lie n t m o v e s w h en

in v e s tig a te d in e a c h ca s e b e fo re m a n a g e d

th in k in g ab o u t, b e g in n in g , an d try in g to

ca re c o m p a n ie s a n d th ird -p a rty p a y o rs

m a in ta in new b e h a v io r

d e c id e it is th e o n ly m o d a lity fo r w h ic h they

Brief Therapies

w ill p a y .

B rie f in te rv e n tio n s an d b rie f th e ra p ie s a re

B rief th e rap y is a sy ste m a tic , fo cu se d p ro cess

w e ll su ite d fo r c lie n ts w h o m a y n o t be

th at re lie s o n a sse ssm e n t, c lie n t e n g a g e m e n t,

w illin g or a b le to e x p e n d th e sig n ific a n t

and rap id im p le m e n ta tio n o f c h a n g e stra te g ies.

p e rs o n a l an d fin a n c ia l re s o u rc e s n e c e ssa ry to

T h e b rie f th e ra p ie s p re s e n te d in th is T IP sh o u ld

c o m p le te m o re in te n siv e , lo n g e r term

be see n as s e p a ra te m o d a litie s o f tre a tm e n t, n o t

e p iso d ic fo rm s o f lo n g -te rm th e ra p y .

tre a tm e n ts. (2)

B rie f th e ra p ie s u su a lly fe a tu re m o re (as w ell

B o th re s e a rc h an d c lin ic a l e x p e rtis e in d ica te

th a t in d iv id u a ls w h o a re fu n c tio n in g in

as lo n g er) s e ssio n s th a n b rie f in te rv e n tio n s . T h e

so cie ty b u t h a v e p a tte rn s o f e x ce s s iv e or

d u ratio n o f b rie f th e ra p ie s is re p o rte d to be

a b u s iv e s u b s ta n c e u se a re u n lik e ly to

a n y w h ere fro m 1 to 4 0 se ssio n s, w ith th e ty p ica l

re sp o n d p o sitiv e ly to s o m e fo rm s o f

th e rap y lastin g b e tw e e n 6 an d 20 sessio n s.

tra d itio n a l tre a tm e n t, b u t s o m e o f the b rie fe r

B rief th e ra p ie s a lso d iffe r fro m b rie f

a p p ro a c h e s to in te rv e n tio n an d th e ra p y can

in te rv e n tio n s in th a t th e ir g o a l is to p ro v id e

b e e x tre m e ly u se fu l c lin ic a l to o ls in th eir

clien ts w ith to o ls to c h a n g e b a sic a ttitu d e s and

tre a tm e n t. (1)

h an d le a v a rie ty o f u n d e rly in g p ro b le m s. B rief

th erap y d iffe rs fro m lo n g e r te rm th e ra p y in th a t
it fo cu se s m o re on th e p re s e n t, d o w n p la y s
p sy ch ic ca u sa lity , e m p h a s iz e s th e e ffe c tiv e use
o f th e ra p e u tic to o ls in a sh o rte r tim e, and
fo cu ses on a sp e c ific b e h a v io ra l c h a n g e ra th er
th an la rg e -sc a le or p e rv a s iv e ch a n g e .
R e se a rch c o n c e rn in g re la tiv e e ffe c tiv e n e s s of
b rie f v e rsu s lo n g e r term th e ra p ie s fo r a v a rie ty
o f p re se n tin g c o m p la in ts is m ix e d . H o w e v e r,

When to use brief therapy

D e te rm in in g w h e n to u se a p a rtic u la r ty p e o f
b rie f th e ra p y is a n im p o r ta n t c o n s id e ra tio n for
c o u n s e lo rs an d th e ra p is ts . T h e P a n el
re c o m m e n d s th a t c lie n t n e e d s a n d th e su ita b ility
of b rie f th e ra p y b e e v a lu a te d on a c a s e -b y -ca se
b a sis. (2) S o m e c rite ria fo r c o n s id e rin g the
a p p r o p ria te n e s s o f b rie f th e ra p y fo r clie n ts
in c lu d e

th ere is e v id e n c e su g g e s tin g th a t b rie f th e ra p ie s

D u a l d ia g n o s is issu e s

are o ften as e ffe ctiv e as le n g th ie r tre a tm e n ts for

T h e ra n g e an d s e v e rity o f p re s e n tin g

ce rta in p o p u la tio n s.

T h e b est o u tc o m e s fo r b rie f th e ra p y m ay
d ep en d on c lin ic ia n s k ills, co m p re h e n siv e

p ro b le m s

T h e d u ra tio n o f s u b s ta n c e d e p e n d e n c e

A v a ila b ility o f fa m ilia l an d co m m u n ity

s u p p o rts

a sse ssm e n ts, an d se le c tiv e c rite ria for

e lig ib ility . U sin g se le ctiv e crite ria in

m a n y c lie n ts w ill n o t m e e t its e lig ib ility

re q u ire m e n ts. (2)

T h e le v e l an d ty p e o f in flu e n c e fro m p eers,

fa m ily , an d c o m m u n ity

p re scrib in g b rie f th e ra p y is c ritic a l, sin ce

x v iii

B rie f th e ra p y fo r s u b s ta n c e a b u se tre a tm e n t

P re v io u s tre a tm e n t o r a tte m p ts a t re co v e ry

T h e le v e l o f c lie n t m o tiv a tio n

E x ecu tiv e S u m m a ry a n d R ecom m en d ation s

term g oals

Components of effective
brief therapy

T h e c lie n t's b e lie f in th e v a lu e o f b rie f

W h ile th e re a re a v a rie ty o f d iffe re n t sch o o ls of

th e rap y

b rie f th e ra p y a v a ila b le to th e clin ic ia n , all fo rm s

T h e n u m b e rs o f c lie n ts n e e d in g tre a tm e n t

o f b rie f th e ra p y sh a re s o m e c o m m o n

T h e cla rity o f th e c lie n t's s h o rt- an d lo n g

T h e fo llo w in g c rite ria a re d e riv e d fro m P a n el

m e m b e rs' clin ic a l e x p e rie n c e :

c h a ra c te ris tic s (2):

fo c u s e d th e y ta rg e t th e s y m p to m , n o t its

L ess se v e re s u b s ta n c e d e p e n d e n c e , as

ca u se s.

m e a su re d b y an in s tru m e n t lik e the

A d d ic tio n S e v e rity In d ex (A SI)

T h e y c le a rly d e fin e g o a ls re la ted to a sp ecific

T h e y s h o u ld b e u n d e rs ta n d a b le to b o th clie n t

c h a n g e or b e h a v io r.

an d c lin ic ia n .

In su fficie n t re so u rc e s a v a ila b le fo r m o re
p ro lo n g e d th e ra p y

L ev el o f p a st tra u m a a ffe c tin g th e c lie n t's

s u b sta n ce a b u se

L im ited a m o u n t o f tim e a v a ila b le fo r

T h e y s h o u ld p ro d u c e im m e d ia te resu lts.

T h e y ca n b e e a sily in flu e n c e d b y the

p e rs o n a lity an d c o u n s e lin g sty le o f the

tre a tm e n t

th e ra p ist.

P rese n ce o f co e x is tin g m e d ic a l or m e n ta l
h e alth d ia g n o se s

T h e y re ly o n ra p id e s ta b lis h m e n t o f a stro n g
w o rk in g re la tio n sh ip b e tw e e n c lie n t and

L a rg e n u m b e rs o f clie n ts n e e d in g tre a tm e n t

th e ra p ist.

lea d in g to w a itin g lists fo r s p e cia liz e d

tre a tm e n t

T h e y a re e ith e r p ro b le m fo c u s e d or so lu tio n

T h e th e ra p e u tic sty le is h ig h ly a ctiv e,

e m p a th ic , a n d s o m e tim e s d ire c tiv e .

T h e C o n s e n s u s P a n e l a lso n o te s th a t

th e clie n t.

P lan n ed b rie f th e ra p y ca n b e a d a p te d as p a rt
o f a co u rse o f se ria l or in te rm itte n t th e rap y .

u n d e rs ta n d th a t c h a n g e is p o ssib le.

lo n g -te rm tre a tm e n t as a n u m b e r o f sh o rte r

tre a tm e n ts, w h ic h re q u ire th e c lie n t's

T e rm in a tio n is d is c u ss e d fro m th e b eg in n in g .

p ro b le m s to b e a d d re sse d se ria lly ra th e r th an

O u tc o m e s a re m e a s u ra b le .

co n c u rre n tly . (1)

Screening and assessment

B rief th e ra p ie s w ill b e m o st e ffe c tiv e w ith

clie n ts w h o se p ro b le m s a re o f s h o rt d u ra tio n
and w h o h a v e s tro n g ties to fa m ily , w o rk ,
and co m m u n ity . H o w e v e r, a n u m b e r o f
oth er co n d itio n s , su ch as lim ite d c lie n t
re so u rces, m a y a lso d icta te th e u se o f b rie f
th e rap y . (2)

E a rly in th e p ro c e s s , th e fo c u s is to h e lp the
c lie n t e n h a n c e h is s e lf-e ffic a c y an d

W h en d o in g th is, th e th e ra p is t c o n c e iv e s o f

R e sp o n s ib ility fo r c h a n g e is p la c e d c le a rly on

It is e sse n tia l to le a rn th e c lie n t's p e rc e iv e d

o b sta cle s to e n g a g in g in tre a tm e n t as w e ll as
to id e n tify any d y s fu n c tio n a l b e lie fs that
co u ld s a b o ta g e th e e n g a g e m e n t p ro c e ss. T h e
critica l fa cto r in d e te rm in in g a n in d iv id u a l's
re sp o n se is the c lie n t's s e lf-p e r c e p tio n and

S cre e n in g an d a s s e s s m e n t a re c ritic a l in itial

ste p s in b r ie f th e ra p y . S c re e n in g is a p ro ce ss in
w h ic h c lie n ts a re id e n tifie d a c c o rd in g to
c h a ra c te ris tic s th a t in d ic a te th e y a re p o ssib ly
a b u sin g s u b s ta n c e s. S c re e n in g id e n tifie s the
n e e d fo r m o re in -d e p th a s s e s s m e n t b u t is n o t an
a d e q u a te s u b s titu te fo r c o m p le te a ssessm e n t.
A s s e s sm e n t is a m o re e x te n s iv e p ro c e ss th at
in v o lv e s a b ro a d a n a ly sis o f th e fa cto rs
c o n trib u tin g to an d m a in ta in in g a c lie n t's
s u b s ta n c e a b u se , th e s e v e rity o f th e p ro b lem ,
an d th e v a rie ty o f c o n s e q u e n c e s a sso c ia te d w ith
it. S c re e n in g an d a s s e s s m e n t p ro c e d u re s fo r

asso cia ted e m o tio n s. (1)

xix

E x ecu tiv e S u m m ary a n d R ec om m en d a tio n s

b rie f th e rap y d o n o t d iffe r s ig n ific a n tly fro m

th o se u sed fo r le n g th ie r tre a tm e n ts.

g o a ls o f b rie f th e ra p y w ith th e c lie n t e a rly in

tre a tm e n t, p re fe ra b ly in th e first se ssio n . (2)

C lin icia n s ca n u se a v a rie ty o f b rie f

a sse ssm e n t in s tru m e n ts, m a n y o f w h ich are

c lie n t (a t le a s t in o u tp a tie n t tre a tm e n t

su p p le m e n te d in the firs t se s s io n b y a clin ica l

se ttin g s). A b s tin e n c e as a g o a l is n o t

a sse ssm e n t in te rv ie w th a t co v e rs c u rre n t use

n e c e s s a rily th e s o le a d m iss io n re q u ire m e n t

p a ttern s, h isto ry o f s u b s ta n c e use,

fo r tre a tm e n t, a n d th e th e ra p is t m a y h a v e to

c o n se q u e n c e s o f s u b s ta n c e a b u se, c o e x istin g

a c c e p t a n a lte rn a tiv e g o a l, s u c h as d ecrea se d

p sy ch ia tric d iso rd e rs, m a jo r m e d ic a l

su b s ta n c e u se, in o rd e r to e n g a g e th e c lie n t

p ro b le m s an d h e a lth sta tu s, e d u c a tio n and

e ffe c tiv e ly . (2)

e m p lo y m e n t sta tu s, su p p o rt m e ch a n ism s,

and fa m ily h isto ry . (2)

T h e scre e n in g an d a sse s s m e n t p ro cess

sh o u ld d e te rm in e w h e th e r th e c lie n t's
su b sta n ce a b u se p ro b le m is su ita b le fo r a

A lth o u g h a b stin e n c e is a n o p tim a l clin ica l

g o a l, it s till m u s t b e n e g o tia te d w ith the

free. T h e s e in s tru m e n ts sh o u ld be

clie n t stre n g th s an d s itu a tio n a l a d v a n ta g e s,

T h e ra p is ts s h o u ld id e n tify a n d d iscu ss the

T h e p ro v id e r o f b rie f th e ra p y m u st
a c c o m p lis h c e rta in c ritic a l ta sk s d u rin g the
firs t s e s s io n (2), in c lu d in g

P ro d u c in g ra p id e n g a g e m e n t

Id e n tify in g , fo c u s in g , an d p rio ritiz in g

p ro b le m s

b rie f th e ra p y a p p ro a c h . (2)

A sse ssm e n t is critic a l n o t o n ly b e fo re

tre a tm e n t p la n a n d p o ss ib le so lu tio n s fo r

b eg in n in g b rie f th e ra p y b u t a lso as an

s u b s ta n c e a b u s e p ro b le m s

o n g o in g p a rt o f th e p ro c e s s . (2)

T h e ra p is ts w h o p rim a rily p ro v id e b rie f

c o n tra c t b e tw e e n c lie n t a n d th e ra p ist)

in th e a s s e s s m e n t p ro c e s s w h ic h c lie n t n e ed s

E lic itin g c lie n t c o n c e rn s a b o u t p ro b le m s

U n d e rs ta n d in g c lie n t e x p e c ta tio n s

E x p la in in g th e s tru c tu r a l fra m e w o rk of

a n d so lu tio n s

to th is, an d e q u a lly im p o rta n t, th e th e ra p ist

m u st e sta b lis h re la tio n sh ip s th a t fa c ilita te the
c lie n t's re fe rra l w h e n h e r n e e d s or g o a ls

N e g o tia tin g th e a p p r o a c h to w a rd ch a n g e
w ith th e c lie n t (w h ic h m a y in v o lv e a

th e rap y sh o u ld b e a d e p t at d e te rm in in g e a rly

or g oals are a p p ro p ria te to a d d re ss. R e la te d

W o rk in g w ith th e c lie n t to d e v e lo p a

b rie f th e ra p y , in c lu d in g th e p ro c e s s an d its

ca n n o t b e m e t th ro u g h b rie f th e ra p y . (2)

lim its (i.e., th o se ite m s n o t w ith in the

The first session

sco p e o f th a t tre a tm e n t s e g m e n t or the

In the first se ssio n , th e m a in g o a ls fo r the

a g e n c y 's w o rk )

th e ra p ist are to g a in a b ro a d u n d e rsta n d in g o f

M a k in g re fe rra ls fo r c ritic a l n e e d s th a t

the clie n t's p re s e n tin g p ro b le m s, b e g in to

h a v e b e e n id e n tifie d b u t c a n n o t b e m e t

e sta b lish ra p p o rt an d a n e ffe c tiv e w o rk in g

w ith in th e tre a tm e n t s ettin g

re la tio n sh ip , an d im p le m e n t a n in itia l

C o u n se lo rs s h o u ld g a th e r as m u ch

Maintenance strategies,
termination of therapy and
followup

in fo rm a tio n as p o ssib le a b o u t a clie n t b efo re

M a in te n a n c e s tra te g ie s m u s t b e b u ilt in to the

the first co u n s e lin g se ssio n . H o w e v e r, w h en

tre a tm e n t d e s ig n fro m th e b e g in n in g . A

g a th e rin g in fo rm a tio n a b o u t a c lie n t fro m

p ra c titio n e r o f b rie f th e ra p y m u s t c o n tin u e to

o th er so u rce s, c o u n s e lo rs m u st b e se n sitiv e to

p ro v id e s u p p o rt, fe e d b a c k , a n d a s s is ta n c e in

co n fid e n tia lity a n d clie n t co n s e n t issu es. (2)

se ttin g re a lis tic g o a ls. A ls o , th e th e ra p is t sh o u ld

in te rv e n tio n , h o w e v e r sm a ll.

xx

E x ec u tiv e S u m m a ry a n d R ecom m en d ation s

h elp the clie n t id e n tify re la p se trig g e rs and

situ a tio n s th at co u ld e n d a n g e r c o n tin u e d
so b rie ty . (2)

th e ra p ie s d e p e n d s on a d m in is tra tio n o f the

e n tire re g im e n .

S tra te g ie s to h e lp clie n ts m a in ta in the

a n d m in g lin g c e rta in te c h n iq u e s an d m u s t be

p ro g re ss m a d e d u rin g b rie f th e ra p y in c lu d e the

s e n sitiv e to th e c u ltu ra l c o n te x t w ith in w h ich

fo llo w in g (2):

E d u ca tin g th e c lie n t a b o u t th e c h ro n ic ,

th e ra p ie s a re in te g ra te d . (2)

the th e ra p ie s th e y a re u sin g an d sh o u ld n o t

C o n sid e rin g w h ic h c irc u m sta n c e s m ig h t

re ly s o le ly o n a m a n u a l s u ch as th is to learn

p la n n in g h ow to a d d re ss th em

T h e ra p is ts s h o u ld b e s u ffic ie n tly tra in e d in

re la p sin g n a tu re o f s u b s ta n c e a b u se

th o se th e ra p ie s. (2)

ca u se a clie n t to re tu rn to tre a tm e n t an d

T h e th e ra p is t m u s t u se c a u tio n in co m b in in g

T ra in in g fo r b rie f th e ra p ie s, in c o n tra s t to the

R e v ie w in g p ro b le m s th a t e m e rg e d b u t w e re

tra in in g n e c e s s a ry to c o n d u c t b rie f

n o t a d d re sse d in tre a tm e n t a n d h e lp in g the

in te rv e n tio n s , re q u ire s m o n th s to y e a rs and

clie n t d e v e lo p a p la n fo r a d d re s s in g th e m in

u su a lly re s u lts in a s p e c ia lis t d e g re e or

th e fu tu re

c e rtific a tio n . T h e C o n s e n s u s P a n el

D ev e lo p in g s tra te g ie s fo r id e n tify in g and

re c o m m e n d s th a t a n y o n e s e e k in g to p ra ctice

co p in g w ith h ig h -ris k s itu a tio n s or the

the th e ra p ie s o u tlin e d h e re s h o u ld re ce iv e

re e m e rg e n c e o f su b s ta n ce a b u se b e h a v io rs

m o re th o ro u g h tra in in g a p p ro p ria te to the

T e a ch in g the c lie n t h o w to c a p ita liz e on

ty p e o f th e ra p y b e in g d e liv e re d . (A p p e n d ix

p e rso n a l stre n g th s

B o f th e T IP p ro v id e s c o n ta c t in fo rm a tio n for

E m p h a siz in g c lie n t s e lf-su ffic ie n c y and

s o m e o rg a n iz a tio n s th a t m a y b e a b le to

te a ch in g s e lf-re in fo rc e m e n t te c h n iq u e s

p ro v id e s u c h tra in in g .) (2)

D e v e lo p in g a p la n fo r fu tu re su p p o rt,

P ro v id e rs o f b rie f th e ra p y s h o u ld b e a b le to

in clu d in g m u tu a l h e lp g ro u p s, fa m ily

fo cu s e ffe c tiv e ly o n id e n tify in g an d a d h e rin g

s u p p o rt, an d c o m m u n ity su p p o rt

to sp e c ific th e ra p e u tic g o a ls in tre a tm e n t. (2)

T e rm in a tio n o f th e ra p y sh o u ld a lw a y s be
p la n n e d in a d v a n c e . (2) W h e n th e c lie n t has
m a d e the a g re e d -u p o n b e h a v io r c h a n g e s and
h as re so lv e d so m e p ro b le m s , th e th e ra p is t
sh o u ld p re p a re to en d th e b rie f th e ra p y . If a
c lie n t p ro g re ss e s m o re q u ick ly th a n a n ticip a te d ,
it is n o t n e c e s s a ry to c o m p le te th e fu ll n u m b e r o f
sessio n s.

P ro v id e rs w h o p ra c tic e b rie f th e ra p y sh ou ld
b e a b le to d istill a p p ro a c h e s fro m lo n g e r
te rm th e ra p ie s a n d a p p ly th e m w ith in the
p a ra m e te rs o f b rie f th e ra p y . (2)

Cognitive-Behavioral Therapy
C B T re p re s e n ts th e in te g ra tio n o f p rin cip le s
d e riv e d fro m b e h a v io ra l th e o ry , c o g n itiv e so cial
le a rn in g th e o ry , a n d c o g n itiv e th e ra p y , and it

Therapist characteristics

p ro v id e s th e b a sis fo r a m o re in c lu s iv e and

T h e ra p ists w ill b e n e fit fro m a firm g ro u n d in g in

c o m p re h e n s iv e a p p r o a c h to tre a tin g s u b sta n ce

th eo ry an d a b ro a d te ch n ic a l k n o w le d g e o f the

a b u se d iso rd e rs.

m an y d iffe re n t a p p ro a ch e s to b rie f th e ra p y th a t

C B T c a n b e u se d b y p ro p e rly lic e n se d and

are av a ila b le. (2) W h e n a p p ro p ria te , e le m e n ts o f

tra in e d m e n ta l h e a lth p ra c titio n e rs e v e n if th ey

d iffe re n t b rie f th e ra p ie s m a y b e c o m b in e d to

h a v e lim ite d e x p e rie n c e w ith th is ty p e of

p ro v id e su cce s s fu l o u tc o m e s. H o w e v e r, it is

th e ra p y e ith e r as a c o s t-e ffe c tiv e p rim a ry

im p o rta n t to re m e m b e r th a t th e e ffe c tiv e n e s s o f

a p p ro a ch or in c o n ju n c tio n w ith o th er th e ra p ie s

h ig h ly d efin e d in te rv e n tio n s (e .g ., w o rk b o o k -

or a 1 2 -S te p p ro g ra m . C B T c a n b e a lso used

d riv en in te rv e n tio n s ) u se d in s o m e b e h a v io ra l

e a rly in a n d th r o u g h o u t th e tre a tm e n t p ro cess

xxi

E xecu tive S u m m ary a n d R eco m m en d atio n s

w h e n e v e r the th e ra p is t feels it is im p o rta n t to

id e n tific a tio n o f h ig h -ris k re la p se

e x a m in e a c lie n t's in a cc u ra te or u n p ro d u c tiv e

s itu a tio n s , an d c o p in g sk ills tra in in g , b u t

th in k in g th a t co u ld lea d to risk y or n e g a tiv e

a lso in c o rp o ra te a d d itio n a l fe a tu re s. T h ese

b eh av io rs. (2)

a p p ro a c h e s a tte m p t to d ea l d ire c tly w ith a

n u m b e r o f th e c o g n itio n s in v o lv e d in the

C B T is g e n era lly n o t a p p ro p ria te fo r ce rta in

re la p se p ro c e s s a n d fo c u s o n h e lp in g the

clien ts, n a m e ly , th o se

in d iv id u a l g a in a m o re p o sitiv e self-

W h o h a v e p s y ch o tic or b ip o la r d is o rd e rs and

e ffic a c y .

are n o t sta b iliz e d on m e d ica tio n

W h o h a v e n o sta b le liv in g a rra n g e m e n ts

W h o are n o t m e d ica lly sta b le (as a ssesse d by

O v e ra ll, b e h a v io ra l, c o g n itiv e , a n d c o g n itiv e b e h a v io ra l in te rv e n tio n s a re e ffe c tiv e , ca n be

used w ith a w id e ra n g e o f s u b s ta n c e a b u sers,

a p re tre a tm e n t p h y sica l e x a m in a tio n ) (2)

an d ca n b e c o n d u c te d w ith in th e tim e fra m e

Cognitive-behavioral techniques
T h e c o g n itiv e -b e h a v io ra l m o d e l a ssu m e s th a t

o f b rie f th e ra p ie s. (1)

A b ro a d ra n g e o f c o g n itio n s w ill be

su b sta n ce a b u se rs a re d e fic ie n t in c o p in g sk ills,

e v a lu a te d in C B T , in c lu d in g a ttrib u tio n s,

ch o o se n o t to u se th o se th e y h a v e, or are

a p p ra is a ls , s e lf-e ffic a c y e x p e c ta n c ie s, and

in h ib ited fro m d o in g so. It a lso a s s u m e s th a t

su b s ta n c e -re la te d e ffe c t e x p e c ta n c ie s. (2)

o v er the co u rse o f tim e, su b sta n c e a b u sers

d ev elo p a p a rtic u la r se t o f e ffe c t e x p e c ta n cie s

Strategic/Interactional Therapies

b ased on th eir o b s e rv a tio n s o f p e e rs and

S tra te g ic / in te ra c tio n a l th e ra p ie s a tte m p t to

sig n ifica n t o th ers a b u sin g su b s ta n c e s to try to

id e n tify th e c lie n t's s tre n g th s an d a ctiv e ly c re a te

cop e w ith d iffic u lt s itu a tio n s, as w ell as th ro u g h

p e rs o n a l an d e n v iro n m e n ta l s itu a tio n s in w h ich

th e ir o w n e x p e rie n c e s o f th e p o sitiv e e ffe c ts of

su c c e ss ca n b e a ch ie v e d . T h e p rim a ry s tre n g th

su b sta n ce s.

o f s tra te g ic / in te ra c tio n a l a p p r o a c h e s is th a t they

C B T is g e n e ra lly e ffe c tiv e b e c a u se it h elp s

clie n ts re co g n iz e the situ a tio n s in w h ich they
are lik ely to u se s u b s ta n c e s, fin d w a y s of
av o id in g th o se situ a tio n s, an d co p e m o re
e ffe ctiv e ly w ith the v a rie ty o f situ a tio n s,
fe e lin g s, an d b e h a v io rs re la ted to th eir
s u b sta n ce a b u se. (2) T o a c h ie v e these
th e ra p e u tic g o a ls, C B T in co rp o ra te s th ree
co re ele m e n ts:

F u n ction al a n a ly s is T h is a n a ly sis a tte m p ts

to id e n tify the a n te c e d e n ts and
co n s e q u e n c e s o f s u b s ta n ce a b u se b e h a v io r,
w h ich serv e as trig g e rin g and m a in ta in in g
facto rs.

C op in g skills tra in in g A m a jo r c o m p o n e n t
in C B T is th e d e v e lo p m e n t o f a p p ro p ria te

his s tre n g th s .
T h e s tra te g ic / in te ra c tio n a l m o d e l h a s b ee n
w id e ly u se d an d s u c c e s s fu lly te sted o n p e rso n s
w ith se rio u s a n d p e rs is te n t m e n ta l illn esse s. (1)
A lth o u g h th e re s e a rc h to d a te o n th e se th e ra p ie s
(u sin g n o n e x p e rim e n ta l d e s ig n s ) h a s n o t
fo c u s e d on s u b s ta n c e a b u s e d is o rd e rs , th e u se of
th ese th e ra p ie s in tre a tin g s u b s ta n c e a b u se
d iso rd e rs is g ro w in g .
T h e C o n s e n s u s P a n e l b e lie v e s th a t these
th e ra p e u tic a p p ro a c h e s a re p o te n tia lly u se fu l fo r
c lie n ts w ith s u b s ta n c e a b u s e d is o rd e rs an d
s h o u ld b e in tro d u c e d to o ffe r n e w k n o w le d g e
an d te c h n iq u e s fo r tre a tm e n t p ro v id e rs to
c o n sid e r. (2)

R elap se p re v en tio n T h e s e a p p ro a c h e s rely

Using strategic/interactional
therapies

h e a v ily on fu n c tio n a l a n a ly se s,

N o m a tte r w h ic h ty p e o f s tra te g ic / in te ra c tio n a l

co p in g sk ills.

sh ift th e fo cu s fro m th e c lie n t's w e a k n e s se s to

th e ra p y is u se d , th is a p p r o a c h ca n h e lp to

Define the situation that contributes to substance

they tend to facilitate therapeutic rapport, increase

abuse in terms meaningful to the client (2)

self-awareness, focus on potential inner resources

Identify steps needed to control or end substance

and establish the client as the person responsible for

abuse (2)
Heal the family system so it can better support

change (2)

Maintain behaviors that will help control

recovery. Thus, clients may be more likely to see

beyond the limitations of short-term treatment and
envision recovery as a lifelong process of working to

substance abuse (2)

reach their full potential. (2)

Respond to situations in which the client has

Using humanistic and existential

returned to substance use after a period of

abstinence (2)

therapies
Many aspects of humanistic and existential

Strategic/interactional approaches are most

useful in

approaches (including empathy, encouragement of

affect, reflective listening, and acceptance of the

Learning how the client's relationships deter or

client's subjective experience) can be useful in any

contribute to substance abuse (2)

type of brief therapy. They help establish rapport and

Shifting power relationships (2)

provide grounds for meaningful engagement with all

aspects of the treatment process. (2)

Addressing fears (2)

Humanistic and existential approaches can be

used at all stages of recovery in creating a foundation

Most forms of strategic/interactional therapies are

of respect for clients and mutual acceptance of the

brief by the definition used in this TIP. Strategic/

significance of their experiences. (2) There are,

interactional therapies normally require 6 to 10

however, some therapeutic moments that lend

sessions, with 6 being most common.

themselves more readily to one or more specific

approaches.

Humanistic and Existential Therapies

Client-centered therapy can be used immediately to

Humanistic and existential psychotherapies use a

establish rapport and to clarify issues throughout the

wide range of approaches to the planning and

session. (2)

treatment of substance abuse disorders. They are,

Existential therapy may be used most

however, united by an emphasis on understanding

effectively when a client has access to emotional

human experience and a focus on the client rather

experiences or when obstacles must be

overcome to facilitate a client's entry into or

than the symptom. Humanistic and existential

continuation of recovery (e.g., to get someone

approaches share a belief that people have the

who insists on remaining helpless to accept

capacity for selfawareness and choice. However, the

responsibility for her actions). (2)

two schools come to this belief through different

theories.

Narrative therapy can be used to help the client

conceptualize treatment as an opportunity to assume

Humanistic and existential therapeutic

authorship and begin a "new chapter" in life. (2)

approaches may be particularly appropriate for

short-term substance abuse treatment because ,

Gestalt approaches can be used throughout therapy

to facilitate a genuine encounter with the therapist
and the client's own experience. (2)

E xecu tive S u m m ary a n d R eco m m en d a tio n s

T ran sp erson a l th e ra p y ca n e n h a n c e sp iritu a l

A lth o u g h th e re is s o m e d is a g re e m e n t in the

d e v e lo p m e n t b y fo c u s in g on the in ta n g ib le

d eta ils, p s y c h o d y n a m ic b rie f th e ra p y is

a sp e cts o f h u m a n e x p e rie n c e an d a w a re n e ss

g e n e ra lly th o u g h t m o re s u ita b le fo r (2)

o f u n re a liz e d sp iritu a l c a p a city . (2)

U sin g a h u m a n istic or e x is te n tia l th e ra p y

fra m e w o rk , the th e ra p is t ca n o ffe r e p iso d ic

w ith th e ir s u b s ta n c e a b u s e d is o rd e r

T h o se w h o d o n o t n e e d or w h o h a v e

tre a tm e n t, w ith a tre a tm e n t p la n th a t fo c u se s on

c o m p le te d in p a tie n t h o s p ita liz a tio n or

the c lie n t's ta sk s and e x p e rie n c e s b e tw e e n

d e to x ific a tio n

sessio n s. (2)
For m a n y clie n ts, m o m e n ta ry circ u m sta n c e s

T h o se w h o s e re c o v e ry is sta b le

T h o se w h o d o n o t h a v e o r g a n ic b ra in

and o th er p ro b le m s s u rro u n d in g su b sta n c e

d a m a g e or o th e r lim ita tio n s to th e ir m e n ta l

ab u se m a y se e m m o re p re ssin g th a n n o tio n s of

c a p a c ity

in te g ra tio n , sp iritu a lity , an d e x is te n tia l g ro w th ,

w h ich m ay be to o re m o te fro m th eir im m e d ia te
situ a tio n to b e e ffe c tiv e . In su ch in sta n ce s,
h u m a n istic an d e x is te n tia l a p p ro a c h e s ca n h elp
clie n ts fo cu s on the fa c t th a t th e y d o in d e e d
m ak e d ecisio n s a b o u t s u b s ta n ce a b u se an d are
re sp o n sib le fo r th eir o w n re co v e ry . (2)

Psychodynamic Therapies
P sy ch o d y n a m ic th e ra p y fo c u se s on u n c o n sc io u s
p ro cesse s as th e y a re m a n ife ste d in th e c lie n t's
p re s e n t b e h a v io r. T h e g o a ls o f p sy c h o d y n a m ic
th e rap y are clie n t s e lf-a w a re n e ss and
u n d e rsta n d in g o f th e p a s t's in flu e n c e on p re se n t
b eh av io r. In its b rie f fo rm , a p s y c h o d y n a m ic
a p p ro a ch e n a b le s th e c lie n t to e x a m in e
u n reso lv ed co n flic ts an d s y m p to m s th a t arise
fro m p a s t d y s fu n c tio n a l re la tio n sh ip s an d
m a n ife st th e m s e lv e s in th e n e ed a n d / o r d esire
to a b u se su b sta n ce s.
S e v e ra l o f the b rie f fo rm s o f p sy c h o d y n a m ic
th e rap y are less a p p ro p ria te fo r u se w ith
p e rso n s w ith su b s ta n c e a b u se d iso rd e rs, p a rtly
b eca u se th eir altered p e rc e p tio n s m a k e it
d ifficu lt to a ch ie v e in s ig h t an d p ro b le m
re so lu tio n . H o w e v e r, m a n y p sy c h o d y n a m ic
th e ra p ists u se fo rm s o f b rie f p sy ch o d y n a m ic
th e ra p y w ith s u b s ta n c e -a b u s in g c lie n ts in
co n ju n ctio n w ith tra d itio n a l su b s ta n c e a b u se
tre a tm e n t p ro g ra m s or as th e s o le th e ra p y fo r
clie n ts w ith co e x is tin g d iso rd e rs. (2)

x x iv

T h o se w h o h a v e c o e x is tin g p s y c h o p a th o lo g y

Integrating psychodynamic concepts

into substance abuse treatment
M o st th e ra p is ts a g re e th a t p e o p le w ith su b sta n ce
a b u se d is o rd e rs c o m p ris e a s p e c ia l p o p u la tio n ,
on e th a t o fte n re q u ire s m o re th a n o n e a p p ro a ch
if tre a tm e n t is to b e s u c c e s s fu l. T h e ra p is ts
w h o se o r ie n ta tio n s a re n o t n e c e s s a rily
p s y c h o d y n a m ic m a y s till fin d th e se te c h n iq u e s
a n d a p p ro a c h e s u se fu l, an d th e ra p is ts w h o se
a p p ro a c h e s a re p s y c h o d y n a m ic m a y b e m o re
e ffe c tiv e if th e y c o n d u c t p s y c h o th e r a p y in a w ay
th a t co m p le m e n ts th e fu ll ra n g e o f se rv ic e s fo r
clie n ts w ith s u b s ta n c e a b u s e d iso rd e rs. (2)

Family Therapy
F o r m a n y in d iv id u a ls w ith s u b s ta n c e a b u se
d iso rd e rs, in te ra c tio n s w ith th e ir fa m ily of
o rig in , as w e ll a s th e ir c u rre n t fa m ily , se t the
p a tte rn s a n d d y n a m ic s fo r th e ir p ro b le m s w ith
su b s ta n c e s. F u r th e rm o r e , fa m ily m e m b e r
in te ra c tio n s w ith th e s u b s ta n c e a b u s e r ca n e ith er
p e rp e tu a te an d a g g ra v a te th e p ro b le m or
s u b s ta n tia lly a s s is t in re s o lv in g it. F a m ily
th e ra p y is p a rtic u la rly a p p r o p ria te w h e n the
clie n t e x h ib its s ig n s th a t h is s u b s ta n c e a b u se is
stro n g ly in flu e n c e d b y fa m ily m e m b e r s '
b e h a v io rs o r c o m m u n ic a tio n s w ith th em . (2)
F a m ily in v o lv e m e n t is o fte n critic a l to
su cc e ss in tre a tin g m a n y s u b s ta n c e a b u se

E x ec u tiv e S u m m a ry an d R ecom m en d ation s

d iso rd e rs m o st o b v io u sly in ca s e s w h ere th e

fa m ily is p a rt o f th e p ro b le m . (2)
F am ily th e ra p y ca n b e u sed to

F ocu s on the e x p e c ta tio n o f c h a n g e w ith in

the fam ily (w h ich m a y in v o lv e m u ltip le
ad ju stm e n ts)

T h e ra p is ts c a n " c r e a t e " a fa m ily b y d ra w in g

on th e c lie n t's n e tw o rk o f s ig n ific a n t co n ta cts.
(2) A m o re im p o r ta n t q u e s tio n th a n w h e th e r the
c lie n t is liv in g w ith a fa m ily is, " C a n th e clie n t's
p ro b le m b e se e n a s h a v in g a re la tio n a l
(in v o lv in g tw o o r m o re p e o p le ) c o m p o n e n t? "

T e st n ew p a tte rn s o f b e h a v io r

Using brief fam ily therapies

T e a ch h ow a fa m ily sy ste m w o rk s h o w th e

In o rd e r to p ro m o te c h a n g e su c c e s s fu lly w ith in

fam ily su p p o rts s y m p to m s and m a in ta in s

a fa m ily s y s te m , th e th e ra p is t w ill n eed the

n e ed e d ro les

fa m ily 's p e rm is s io n to e n te r th e fa m ily sp a ce

E licit the stre n g th s o f e v e ry fa m ily m e m b e r

a n d sh a re th e ir c lo s e ly h e ld c o n fid e n c e s . T h e

E x p lo re the m e a n in g o f the s u b s ta n c e a b u se

th e ra p y , h o w e v e r, w ill w o rk b e s t if it v a rie s

d iso rd e r w ith in the fa m ily

a c c o rd in g to th e c u ltu ra l b a c k g ro u n d o f the

Appropriateness of brief
family therapy
L o n g -term fa m ily th e ra p y is n o t u su a lly
n e cessa ry fo r the tre a tm e n t o f s u b s ta n c e a b u se
d iso rd ers. W h ile fa m ily th e ra p y m a y b e v e ry
h e lp fu l in the in itia l sta g e s o f tre a tm e n t, it is
often e a sie r to c o n tin u e to h e lp an in d iv id u a l
w o rk w ith in th e fa m ily sy ste m th ro u g h
su b se q u e n t in d iv id u a l th e ra p y . (2)
S h o rt-te rm fa m ily th e ra p y is an o p tio n th at

fa m ily . (1)
M o st fa m ily th e ra p y is c o n d u c te d on a s h o rt
te rm b a sis. S e ss io n s a re ty p ic a lly 9 0 m in u te s to
2 h o u rs in le n g th . T h e p re fe rre d tim e lin e fo r
fa m ily th e ra p y is n o t m o re th a n 2 s e ssio n s p er
w e e k (e x c e p t in re s id e n tia l s e ttin g s), to allow
tim e to p ra c tic e n e w b e h a v io rs an d e x p e rie n ce
ch a n g e . T h e ra p y m a y c o n s is t o f as fe w as 6 or as
m a n y as 10 s e s s io n s , d e p e n d in g on th e p u rp o se
and g o a ls o f th e in te rv e n tio n .

co u ld be u sed in th e fo llo w in g c irc u m sta n c e s (2):

Group Therapy

W h en re so lv in g a sp e cific p ro b le m in the

G ro u p p s y c h o th e r a p y is o n e o f the m o st

fam ily and w o rk in g to w a rd a so lu tio n

c o m m o n m o d a litie s fo r tre a tm e n t o f su b sta n ce

W h en the th e ra p e u tic g o a ls d o n o t re q u ire in-

a b u se d is o rd e rs . G ro u p th e ra p y is d efin e d as a

d ep th , m u ltig e n e ra tio n a l fa m ily h is to ry , b u t

m e e tin g o f tw o or m o re p e o p le fo r a c o m m o n

ra th er a fo cu s on p re s e n t in te ra c tio n s

th e ra p e u tic p u rp o s e or to a c h ie v e a c o m m o n

W h e n the fa m ily as a w h o le ca n b e n e fit fro m

g o a l. It d iffe rs fro m fa m ily th e ra p y in th a t the

te ach in g an d c o m m u n ic a tio n to b e tte r

th e ra p is t c re a te s o p e n - an d c lo s e d -e n d e d g ro u p s

u n d e rsta n d s o m e a sp e ct o f th e su b s ta n c e

o f p e o p le p re v io u s ly u n k n o w n to e a ch other.

ab u se d iso rd e r

Appropriateness of group therapy

Definitions of "family"

G ro u p p s y c h o th e r a p y ca n b e e x tre m e ly

Fam ily th e ra p y ca n in v o lv e a n e tw o rk th a t

b e n e fic ia l to in d iv id u a ls w ith s u b s ta n c e a b u se

exte n d s b ey o n d the im m e d ia te fa m ily , in v o lv e s

p ro b le m s. (2) It g iv e s th e m th e o p p o rtu n ity to

only a few m e m b e rs o f the fa m ily sy stem , or

see th e p ro g re s s io n o f a b u s e an d d e p e n d e n cy in

ev en d eals w ith s e v e ra l fa m ilie s a t o n ce. (2) T h e

th e m s e lv e s a n d o th e rs; it a lso p ro v id e s an

d efin itio n o f fa m ily " v a rie s in d iffe re n t c u ltu re s

o p p o rtu n ity to e x p e rie n c e p e rs o n a l su c ce ss and

and situ a tio n s an d s h o u ld b e d e fin e d by the

the s u cc e s s o f o th e r g ro u p m e m b e r s in an

client.

a tm o s p h e re o f s u p p o rt an d h o p e.

xxv

E x ecu tiv e S u m m ary a n d R eco m m en d a tio n s

Use of psychodrama techniques

in a group setting

fe w as 6 s e s s io n s in all, or a s m a n y as 12,

P sy ch o d ra m a h a s lo n g b e e n e ffe c tiv e ly u sed

g ro u p .

w ith su b s ta n c e -a b u s in g c lie n ts in a g ro u p

d e p e n d in g o n th e p u rp o s e an d g o a ls o f th e

S e ss io n s a re ty p ic a lly IV2 to 2 h o u rs in len g th .

settin g . P sy ch o d ra m a c a n b e u sed w ith d iffe re n t

R e sid e n tia l p ro g ra m s u s u a lly h a v e m o re

m o d e ls o f g ro u p th e ra p y . It o ffe rs p e rso n s w ith

fre q u e n t s e ssio n s.

su b sta n ce ab u se d iso rd e rs an o p p o rtu n ity to

G ro u p p ro c e s s th e ra p y is m o s t e ffe c tiv e if

b etter u n d e rsta n d p a s t an d p re s e n t

p a rtic ip a n ts h a v e h a d tim e to fin d th e ir ro le s in a

e x p e rie n ce s and h o w p a s t e x p e rie n c e s

g ro u p , to " a c t " th e se ro le s , a n d to le a rn fro m

in flu e n ce th eir p re s e n t liv es. (2)

th em . T h e g ro u p n e e d s tim e to d e fin e its

Using time-limited group therapy

T h e fo cu s o f tim e -lim ite d th e ra p e u tic g ro u p s

id e n tity , d e v e lo p c o h e s io n , a n d b e c o m e a sa fe
e n v iro n m e n t in w h ic h th e re is e n o u g h tru st fo r
p a rtic ip a n ts to re v e a l th e m s e lv e s . (2)

v aries a g re a t d ea l a cc o rd in g to th e m o d e l
ch o se n by th e th e ra p ist. Y e t so m e
g e n e ra liz a tio n s ca n b e m a d e a b o u t sev era l
d im en sio n s o f the m a n n e r in w h ic h b rie f g ro u p
th e rap y is im p le m e n te d .
C lie n t p re p a ra tio n is p a rtic u la rly im p o rta n t
in any tim e -lim ite d g ro u p e x p e rie n c e . C lien ts
sh o u ld b e th o ro u g h ly a sse sse d b e fo re th e ir e n try
in to a g ro u p fo r th e ra p y . (2) G ro u p p a rtic ip a n ts
sh o u ld b e g iv e n a th o ro u g h e x p la n a tio n of
gro u p e x p e cta tio n s.
T h e p re fe rre d tim e lin e fo r tim e -lim ite d
gro u p th e ra p y is n o t m o re th a n 2 se ssio n s p er
w eek (e x ce p t in th e re s id e n tia l s e ttin g s), w ith as

X X VI

Conclusion
T h e b rie f in te rv e n tio n s a n d th e ra p ie s d escrib e d
in th is T IP a re in te n d e d to in tro d u c e a ra n g e of
te c h n iq u e s to c lin ic ia n s. C lin ic ia n s w ill find
d iffe re n t p o rtio n s o f th is T IP m o re u se fu l th a n
o th ers d e p e n d in g o n th e ir th e o re tic a l
o rie n ta tio n , b u t a ll c lin ic ia n s w h o w o rk w ith
s u b s ta n c e -a b u s in g c lie n ts s h o u ld fin d m a te ria l
o f v a lu e h e re . B rie f in te rv e n tio n s w ill b e u sefu l
fo r a w id e v a r ie ty o f s e rv ic e p ro v id e rs ; b rie f
th e ra p ie s a re in te n d e d fo r p ro p e rly q u a lifie d ,
e d u c a te d , an d lic e n s e d p ro fe ss io n a ls .

1 Introduction to Brief
Interventions and Therapies

he use of brief intervention and brief

problems with a client and/or family members or

therapy techniques has become an

deal with specific individual problems such as

increasingly important part of the

personal finances and work attendance. The basic

continuum of care in the treatment of substance

goal for a client regardless of setting is to reduce

abuse problems. With the health care system

the risk of harm that may result from continued

changing to a managed model of care and with

use of substances. The reduction of harm, in its

changes in reimbursement policies for substance

broadest sense, pertains to the clients themselves,

abuse treatment, these short, problem-specific

their families, and the community.

approaches can be valuable in the treatment of

The brief therapies discussed in this TIP

substance abuse problems. They provide the

are brief cognitive-behavioral therapy, brief

opportunity for clinicians to increase positive

strategic and interactional therapies, brief

outcomes by using these modalities independently

psychodynamic therapy, short-term family

as stand-alone interventions or treatments and as

therapy, and time-limited group therapy. The

additions to other forms of substance abuse and

choice to include these therapeutic modalities was

mental health treatment. They can be used in a

based on a combination of relevant research and,

variety of settings including opportunistic settings

in some instances where there is a much smaller

(e.g. primary care, home health care) and specialized

research base, the clinical knowledge and

abuse treatment settings (inpatient and outpatient.)

expertise of the Consensus Panel. All of these

Used for a variety of substance abuse

approaches are currently being used in the

problems from at-risk use to dependence, brief

treatment of substance abuse disorders, and all of

interventions can help clients reduce or stop abuse,

them can contribute something to the array of

act as a first step in the treatment process to

treatment techniques available to the eclectic

determine if clients can stop or reduce on their own,

practitioner.

and act as a method to change specific behaviors

Brief interventions and brief therapies

before or during treatment. For example, there are

may be thought of as elements on a continuum of

some issues associated with treatment compliance

care, but they can be distinguished from each

that benefit from a brief, systematic, well-planned

other according to differences in outcome goals.

interventions such as attending group sessions or

Interventions are generally aimed at motivating a

doing homework. In other instances, brief

client to perform a particular action (e.g. to enter

interventions address specific family

treatment, change a behavior, think

C h ap ter 1

d iffe ren tly a b o u t a s itu a tio n ), w h e re a s th e ra p ie s

m o tiv a tio n a l e n h a n c e m e n t th e ra p y , w h ic h h a s a

are u sed to a d d re ss la rg e r c o n c e rn s (su ch as

c le a rly a rtic u la te d th e o r e tic a l ra tio n a le (fo r m o re

a lterin g p e rs o n a lity , m a in ta in in g a b stin e n c e , or

on th is to p ic , se e T IP 3 5 , E n h a n cin g M otiv a tion f o r

a d d re ssin g lo n g -s ta n d in g p ro b le m s th at

C h a n g e in S u b sta n ce A b u se T rea tm en t, w h ic h w as

e x a ce rb a te su b sta n ce a b u se). T h is T IP p re se n ts

c o n c e iv e d as a c o m p a n io n v o lu m e to th is T IP

b rie f in te rv e n tio n s as a w a y o f im p ro v in g c lie n t

[C e n te r fo r S u b s ta n c e A b u s e T re a tm e n t (C S A T ),

m o tiv a tio n fo r tre a tm e n t. T h e b rie f th e ra p ie s

199 9 c]).

co n sid ere d h e re a re w a y s o f ch a n g in g c lie n t

F o r th e p u rp o s e s o f th is T IP , b rie f th e ra p y

attitu d e s an d b eh a v io rs. O th e r d iffe re n c e s th a t

in v o lv e s a se rie s o f s te p s ta k e n to tre a t a

h elp d is tin g u is h b rie f in te rv e n tio n s fro m b rie f

s u b s ta n c e a b u s e p ro b le m , w h e re a s b rie f

th e ra p ie s in clu d e

in te rv e n tio n s a re th o se p ra c tic e s th a t a im to

L en g th o f th e s e ssio n s (fro m 5 m in u te s fo r an
in te rv e n tio n to m o re th a n six 1 -h o u r th e ra p y
sessio n s)

E x te n siv e n e ss o f a ss e s s m e n t (w h ich w ill be

g re a te r fo r th e ra p ie s th a n fo r in te rv e n tio n s)

Se ttin g (n o n tra d itio n a l tre a tm e n t settin g s

su ch as a so c ia l s e rv ic e or p rim a ry ca re
settin g , w h ich w ill u se in te rv e n tio n s
e x clu siv e ly , v e rsu s tra d itio n a l su b sta n c e
ab u se tre a tm e n t se ttin g s w h e re th e ra p y or
co u n se lin g w ill b e u se d in a d d itio n to
in te rv e n tio n s)

P e rso n n e l d e liv e rin g th e tre a tm e n t (b rief

in te rv e n tio n s ca n b e a d m in iste re d b y a w id e
ra n g e o f p ro fe ss io n a ls , b u t th e ra p y re q u ires
tra in in g in sp e c ific th e ra p e u tic m o d a litie s)

M a te ria ls an d m e d ia u sed (ce rta in m a te ria ls

su ch as w ritte n b o o k le ts or c o m p u te r
p ro g ra m s m a y b e u se d in th e d e liv e ry o f
in te rv e n tio n s b u t n o t th e ra p ie s)

in v e s tig a te a p o te n tia l p ro b le m an d m o tiv a te an

in d iv id u a l to b e g in to d o s o m e th in g a b o u t h is
s u b s ta n c e a b u se . T h e ra p y in v o lv e s m o v e m e n t
(o r an a tte m p t a t m o v e m e n t) to w a rd ch a n g e .
B rie f th e ra p y c o n c e n tr a te s p a rtic u la rly on
in v e s tig a tin g a p ro b le m in o rd e r to d e v e lo p a
so lu tio n in c o n s u lta tio n w ith th e c lie n t; b rie f
in te rv e n tio n s g e n e ra lly in v o lv e a th e ra p ist
g iv in g a d v ic e to th e clie n t.
T h e in c re a s in g e m p h a s is o n b rie f a p p ro a ch e s
is p a rtly a ttrib u ta b le to r e c e n t c h a n g e s in the
h e a lth c a re d e liv e ry s y s te m , in w h ic h c lin ic ia n s
a re u rg ed to re d u c e c o sts w h ile m a in ta in in g
tre a tm e n t e ffic a c y . E s se n tia lly , c lin ic ia n s are
c o n s tra in e d b y tim e a n d d im in is h in g re so u rce s
y et a re tre a tin g a n in c re a sin g n u m b e r o f
in d iv id u a ls w ith s u b s ta n c e a b u s e p ro b le m s.
F o rtu n a te ly , th e re is a b o d y o f lite ra tu re on
b rie f a p p ro a c h e s in th e tre a tm e n t o f su b sta n ce
a b u s e d is o rd e rs . B rie f in te rv e n tio n s a n d b rie f
th e ra p ie s h a v e th e a p p e a l n o t o n ly o f b e in g b rie f

A lth o u g h th e th e o re tic a l b a se s fo r b rie f

b u t a lso o f h a v in g re s e a rc h b a c k in g th a t

th erap y and b rie f in te rv e n tio n m a y b e d iffe ren t,

s u p p o rts th e ir u se. B rie f in te rv e n tio n s h a v e

this d is tin ctio n is less o b v io u s in p ra c tic e . T h e se

b e e n w id e ly te ste d w ith b o th g e n e ra l c lin ica l

tw o a p p ro a ch e s to su b s ta n ce a b u se p ro b le m s

an d s u b s ta n c e -a b u s in g p o p u la tio n s a n d h a v e

and b e h a v io r c h a n g e re fle c t a c o n tin u u m ra th er

sh o w n g re a t p ro m ise in ch a n g in g c lie n t

th an a cle a r d ic h o to m y . T h e d is tin c tio n m a y be

b e h a v io r. B rie f th e ra p ie s, h o w e v e r, h a v e b ee n

fu rth e r b lu rre d as th e c h a n g e p ro c e ss a sso cia ted

u n e v e n ly re s e a rc h e d . A s in d ic a te d in th e

w ith th e su cce ss o f b rie f in te rv e n tio n s is b e tte r

d is c u ss io n o f e a c h ty p e , in a d d itio n to the

u n d e rsto o d or re fin e d an d as th e o rie s are

e m p iric a l re s u lts re p o rte d in s c ie n tific jo u rn a ls ,

d ev elo p e d to e x p la in a b rie f in te rv e n tio n 's

c lin ic a l an d a n e c d o ta l e v id e n c e s u p p o rts the

m e ch a n ism o f a ctio n . A lre a d y , s o m e fo rm s of

e ffic a c y o f b rie f th e ra p ie s in th e tre a tm e n t of

b rie f in te rv e n tio n o v erla p w ith th e ra p y , su ch as

s u b s ta n c e a b u se . T h e b re v ity a n d lo w e r

In trodu ction

d eliv e ry co sts o f th e se b rie f a p p ro a c h e s m a k e

B rie f in te rv e n tio n s fo r a lc o h o l p ro b le m s , fo r

them id ea l m e ch a n is m s fo r u se in se ttin g s fro m

e x a m p le , h a v e e m p lo y e d v a rio u s a p p ro a c h e s to

p rim a ry ca re to su b s ta n c e a b u se tre a tm e n t

c h a n g e d rin k in g b e h a v io rs . T h e s e a p p ro a ch e s

w h ere co st o ften p la y s as m u ch o f a ro le as

h a v e ra n g e d fro m re la tiv e ly u n stru c tu re d

e ffica cy in d e te rm in in g w h a t tre a tm e n ts clie n ts

c o u n s e lin g a n d fe e d b a c k to m o re fo rm a l

receiv e.

s tru c tu re d th e ra p y an d h a v e re lie d h e a v ily on

B rie f in te rv e n tio n s an d b rie f th e ra p ie s are

c o n c e p ts a n d te c h n iq u e s fro m th e b e h a v io ra l

also w e ll su ite d fo r c lie n ts w h o m a y n o t be

s e lf-c o n tro l tra in in g (B S C T ) lite ra tu re (M iller

w illin g or a b le to e x p e n d th e sig n ific a n t

a n d H e ste r, 1 9 8 6 b ; M ille r a n d M u n o z , 1982;

p e rso n a l an d fin a n c ia l re s o u rc e s n e c e s s a ry to

M ille r an d R o lln ic k , 1 9 9 1 ; M ille r an d T a y lo r,

co m p le te m o re in te n siv e , lo n g e r term

1980)

treatm en ts. A lth o u g h m u c h re s e a rc h su p p o rts

B S C T ). U s u a lly , b rie f tre a tm e n t in te rv e n tio n s

(see C h a p te r 4 fo r m o re in fo rm a tio n on

the th e o ry th a t lo n g e r tim e in tre a tm e n t is

h a v e fle x ib le g o a ls, a llo w in g th e in d iv id u a l to

asso cia ted w ith b e tte r o u tc o m e s, re s e a rc h also

c h o o s e m o d e ra tio n or a b stin e n c e . T h e ty p ica l

su g g e sts th a t fo r s o m e clie n ts, th e re is n o lo ss in

c o u n s e lin g g o a l is to m o tiv a te th e c lie n t to

e ffe ctiv e n e ss w h e n le n g th a n d in te n sity of

ch a n g e h e r b e h a v io r a n d n o t to a ss ig n s e lf

tre a tm e n t are re d u ce d .

b la m e . W h ile m u c h o f th e re s e a rc h to d a te has
ce n te re d on c lie n ts w ith a lc o h o l-re la te d

An Overview of Brief
Interventions

p ro b le m s , s im ila r a p p r o a c h e s ca n b e ta k e n w ith
u sers o f o th e r s u b s ta n ce s.
B rie f in te rv e n tio n s a re a u se fu l c o m p o n e n t of

D efin itio n s o f b rie f in te rv e n tio n s v a ry . In the

a fu ll sp e c tru m o f tre a tm e n t o p tio n s ; th e y are

re ce n t lite ra tu re , th e y h a v e b e e n re fe rre d to as

p a rtic u la rly v a lu a b le w h e n m o re e x te n siv e

"s im p le a d v ice/ ' "m in im a l in te r v e n tio n s ," "b r ie f

tre a tm e n ts a re u n a v a ila b le or a c lie n t is re sista n t

c o u n s e lin g ," or "s h o r t-te r m c o u n s e lin g ." T h e y

to su ch tre a tm e n t. T o o fe w c lin ic ia n s, h o w e v e r,

can b e sim p le su g g e s tio n s to re d u c e d rin k in g

a re e d u c a te d a n d sk ille d in th e u se o f b rie f

g iv en b y a p ro fe ss io n a l (e.g ., s o c ia l w o rk e r,

in te rv e n tio n s a n d th e ra p ie s to a d d re ss th e v ery

n u rse, a lco h o l and d ru g c o u n s e lo r, p h y sic ia n ,

la rg e g ro u p o f m id ra n g e s u b s ta n c e u se rs w h o

p h y s icia n a ssista n t) or a serie s o f in te rv e n tio n s

h a v e m o d e ra te a n d ris k y co n s u m p tio n p a tte rn s

p ro v id e d w ith in a tre a tm e n t p ro g ra m . A s one

(see F ig u re 1-1). A lth o u g h th is g ro u p m a y n o t

re se a rch e r n o tes,

n e e d or a c c e p t tra d itio n a l s u b s ta n c e a b u se

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 com munication and several other ways,
including their underpinning theory and
intervention philosophy (Heather, 1995, p.
287).

tre a tm e n t, th e s e in d iv id u a ls a re n o n e th e le s s
re s p o n s ib le fo r a d is p ro p o r tio n a te sh a re of
s u b s ta n c e -re la te d m o rb id ity , in c lu d in g lo w e re d
w o rk fo rc e p e rfo rm a n c e , m o to r v e h ic le a ccid e n ts
a n d o th er in ju rie s , m a rita l d is c o rd , fa m ily
d y s fu n c tio n , a n d m e d ic a l illn e s s (W ilk et al.,
1997). T h e s e h a z a rd o u s s u b s ta n c e u se rs are
id e n tifie d in e m p lo y m e n t a s s is ta n c e p ro g ra m s

B rief in te rv e n tio n s, th e re fo re , ca n b e v ie w e d as a

(E A P s), p ro g ra m s fo r p e o p le c ite d fo r d riv in g

set o f p rin cip le s re g a rd in g in te rv e n tio n s w h ich

w h ile in to x ic a te d (D W I), a n d u rin e te stin g

are d iffe re n t fro m , b u t n o t in c o n flic t w ith , th e

p ro g ra m s, a s w e ll as in p h y s ic ia n s ' o ffice s and

p rin cip le s u n d e rly in g c o n v e n tio n a l tre a tm e n t

o th er h e a lth s c re e n in g e ffo rts (M ille r, 1993).

(H eath er, 1994).

D esp ite a p p e a ls fro m s u c h d is tin g u is h e d b o d ies

3

C h ap ter 1

F ig u r e 1-1
S u b s ta n c e A b u s e S e v e rity a n d L e v e l o f C a r e

Substance Abuse Severity

The triangle represents the population of the United States with the range of problems experienced by the
population shown along the upper side.

A spectrum of responses to these substance abuse problems is

shown along the lower side (based on Skinner, 1988).

In general, specialized treatm ent is indicated for

persons with substantial or severe problems, brief intervention is indicated for persons with mild or
moderate problems, and primary prevention is indicated for persons who have not had problems but who
are at risk of developing them. The dotted lines extending the arrows suggest that both prim ary prevention
and brief intervention may have effects beyond their principal target populations.

The prevalence of

substance abuse problems in the population is represented by the area of the triangle occupied; most people
have no substance abuse problems, many people have a few substance abuse problem s, and some people
have many substance abuse problems.
Source: Adapted with permission from the Institute of M edicine, 1990.

as the N a tio n a l A c a d e m y o f S c ie n c e s in the

U n ited S ta te s an d the N a tio n a l A c a d e m y of

u su a lly in v o lv e a m o re in -d e p th a s s e s s m e n t of

P h y sicia n s and S u rg e o n s in th e U n ite d

s u b s ta n c e a b u se p a tte rn s a n d re la te d p ro b lem s

K in g d o m , w id e s p re a d a d o p tio n o f b rie f

199 0). T h e c h a ra c te riz a tio n s o f h a z a rd o u s,

in te rv e n tio n s b y m e d ic a l p ra c titio n e rs or

h a rm fu l, or d e p e n d e n t u se as th e y re la te to

tre a tm e n t p ro v id e rs h a s n o t y e t o ccu rre d

a lco h o l co n s u m p tio n p a tte rn s (E d w a rd s et al.,

(D ru m m o n d , 1 9 9 7 ; In stitu te o f M e d ic in e [IO M ],

198 1) w e re u se d to d is tin g u is h th e ta rg e ts of

1990).

B rie f in te rv e n tio n s in tra d itio n a l settin g s

In trodu ction

b rie f in te rv e n tio n in a W o rld H e a lth

m a y b e d e liv e re d b y tre a tm e n t s ta ff or oth er

O rg a n iz a tio n (W H O ) stu d y (B a b o r an d G ra n t,

p ro fe ss io n a ls , an d d o n o t re q u ire e x te n siv e

1991). H a z a rd o u s d rin k in g re fe rs to a lev el of

tra in in g . B e c a u s e o f th e s h o rt d u ra tio n o f b rie f

a lco h o l c o n s u m p tio n or p a tte rn o f d rin k in g th at,

in te rv e n tio n s tra te g ie s , th e y c a n b e co n sid ere d

sh o u ld it p e rsist, is lik e ly to re su lt in h a rm to th e

fo r u se w ith in ju re d p a tie n ts in th e e m e rg en cy

d rin k er. H a rm fu l d rin k in g is d efin e d as a lco h o l

d e p a rtm e n t w h o h a v e s u b s ta n c e a b u se

use th a t h as a lre a d y re su lte d in a d v e rs e m e n ta l

p ro b le m s. U s e fu l d is tin c tio n s b e tw e e n th e g o als

or p h y sica l e ffe cts. D e p e n d e n t u se re fe rs to

o f b rie f in te rv e n tio n s as a p p lie d in d iffe re n t

d rin k in g th a t h a s re su lte d in p h y sica l,

se ttin g s a re liste d in F ig u re 1-2.

p sy ch o lo g ica l, o r so c ia l c o n s e q u e n c e s an d h a s

B rie f in te rv e n tio n s in tra d itio n a l settin g s

b e e n the fo cu s o f m a jo r d ia g n o s tic to o ls, su ch as

u su a lly in v o lv e a m o re in -d e p th a sse s s m e n t of

the D iag n ostic an d S tatistica l M a n u a l, 4 th E d itio n

s u b s ta n c e u se p a tte rn s a n d re la te d p ro b le m s

(A m e rica n P sy c h ia tric A s s o c ia tio n [A P A ], 1994)

th a n in te rv e n tio n s a d m in is te re d in

or the In tern ation al C lassification o f D iseases, 9th

n o n tra d itio n a l se ttin g s an d ten d to e x a m in e

R e v isio n (IC D -9 ) (IC D -9 -C M , 1995).

o th e r a s p e c ts o f p a r tic ip a n ts ' a ttitu d e s, su ch as

C a te g o riz in g d rin k in g p a tte rn s in th is fa sh io n

re a d in e s s fo r or re s is ta n c e to ch a n g e . T h e y can

p ro v id e s b o th c lin ic ia n s an d re se a rc h e rs w ith

b e u se fu l fo r a d d r e s s in g sp e c ific b e h a v io r

flex ib le g u id e lin e s to id e n tify in d iv id u a ls a t risk

c h a n g e iss u e s in tre a tm e n t s e ttin g s. B eca u se

fo r a lco h o l p ro b le m s w h o m a y n o t m e e t c rite ria

th e y a re tim e ly , fo c u s e d , a n d c lie n t c e n te red ,

fo r a lco h o l d ep e n d e n c e . S im ila r le v e ls o f u se for

b rie f in te rv e n tio n s ca n q u ic k ly e n h a n c e the

o th er su b s ta n ce s a re m u ch m o re d iffic u lt to

o v e ra ll w o rk in g re la tio n sh ip w ith clie n ts.

d efin e, sin ce m o st o f th e m are illic it an d th o se

H o w e v e r, b rie f in te rv e n tio n s sh o u ld n o t b e a

that are n o t h a v e o fte n n o t b e e n w id e ly stu d ied

ca re s u b s titu te fo r c lie n ts w h o h a v e a h ig h lev el

in re la tio n to su b s ta n ce a b u se.

o f a b u se.

S tu d ie s o f b rie f in te rv e n tio n s h a v e b e e n
co n d u cte d in a w id e ra n g e o f h e a lth ca re

S o m e o f th e a s s e s s m e n ts c o n d u c te d fo r
re s e a rch s tu d ie s o f b rie f in te rv e n tio n s a re v ery

s ettin g s, fro m h o s p ita ls an d p rim a ry h e a lth ca re

e x te n s iv e a n d m a y h a v e b e e n c o n d u cte d d u rin g

lo ca tio n s (B a b o r an d G ra n t, 1 9 9 1 ; C h ic k e t al.,

p rio r tre a tm e n t (e .g ., in d e to x ific a tio n p ro g ra m s,

1985; F lem in g et al., 1 9 9 7 ; W a lla c e et al., 1988) to

d u rin g tre a tm e n t in ta k e p ro c e d u re s ). M o st b rie f

m e n ta l h e a lth clin ics (H a rris an d M ille r, 1990).

in te rv e n tio n s o ffe r th e c lie n t d e ta ile d fe e d b a ck

(R efer to "R e s e a r c h F in d in g s " in C h a p te r 2 fo r

a b o u t a s s e s s m e n t fin d in g s , w ith an o p p o rtu n ity

m o re d is cu ss io n o f re s e a rch on b rie f

fo r m o re in p u t. T h e a s s e s s m e n t ty p ic a lly

in te rv e n tio n s.) In d iv id u a ls re c ru ite d fro m su ch

in v o lv e s o b ta in in g in fo r m a tio n re g a rd in g

settin g s are lik e ly to h a v e h a d s o m e c o n ta c t w ith

fre q u e n c y a n d q u a n tity o f s u b s ta n c e a b u se,

a h e alth ca re p ro fe ss io n a l d u rin g the stu d y

c o n s e q u e n c e s o f s u b s ta n c e a b u s e , an d rela ted

p a rticip a tio n an d th e re fo re h ad a lc o h o l-re la te d

h e a lth b e h a v io rs a n d c o n d itio n s .

p ro fe ssio n a l a s s is ta n c e a v a ila b le . N o n e th e le ss,

T h e in te rv e n tio n its e lf is s tru c tu re d and

m an y o f th e se p a tie n ts w o u ld n o t b e id e n tified

fo c u se d o n s u b s ta n c e a b u se . Its p rim a ry g o als

as h a v in g an a lc o h o l p ro b le m b y th e ir h e a lth

a re to ra ise a w a re n e s s o f p ro b le m s an d th en to

care p ro v id e rs an d w o u ld n o t o rd in a rily re ce iv e

re c o m m e n d a sp e c ific c h a n g e o r a ctiv ity (e.g.,

an y a lco h o l-sp e c ific in te rv e n tio n .

In g e n era l, b rie f in te rv e n tio n s a re co n d u c te d

re d u c e d c o n s u m p tio n , a c c e p tin g a re fe rra l, se lf

m o n ito rin g o f s u b s ta n c e a b u se ). T h e p a rticip a n t

in a v arie ty o f o p p o rtu n istic an d su b s ta n c e

in a b rie f in te rv e n tio n is u s u a lly o ffe re d a m en u

a b u se tre a tm e n t se ttin g s, ta rg e t d iffe re n t g o a ls;

o f o p tio n s or s tra te g ie s fo r a c c o m p lis h in g the

5

C h ap ter 1

F ig u re 1 -2
G o a l o f B rief In te rv e n tio n s A c c o r d in g to S e ttin g
Setting

Purpose

O p p o rtu n istic settin g

F a c ilita te re fe rra ls fo r a d d itio n a l s p e c ia liz e d tre a tm e n t

(e.g ., a n u rse id e n tify in g s u b s ta n c e -a b u s in g clie n ts
th ro u g h s c re e n in g a n d a d v is in g th e m to se e k fu rth e r
a ss e s s m e n t or tre a tm e n t)

A ffe c t s u b s ta n c e a b u s e d ire c tly b y re c o m m e n d in g a

re d u c tio n in h a z a rd o u s or a t-ris k c o n s u m p tio n p a tte rn s
(e.g ., a p rim a ry c a re p h y s ic ia n a d v is in g h a z a rd o u s or atrisk d rin k e rs to c u t d o w n , N a tio n a l A lc o h o l S c re e n in g
D ay ) or e s ta b lis h in g a p la n fo r a b stin e n c e

N e u tra l e n v iro n m e n ts (e.g ., in d iv id u a ls

A sse ss s u b s ta n c e a b u se b e h a v io r a n d g iv e su p p o rtiv e
a d v ic e a b o u t h a rm re d u c tio n (e .g ., a p u b lic h e a lth

re sp o n d in g to m e d ia a d v e rtis e m e n ts )

in itia tiv e to scre e n p e o p le in s h o p p in g m a lls an d p ro v id e

fe e d b a c k an d a d v ic e )
H e alth ca re settin g

F a c ilita te re fe rra ls fo r a d d itio n a l s p e c ia liz e d tre a tm e n t

S u b sta n ce a b u se tre a tm e n t p ro g ra m s

A ct as a te m p o ra ry s u b s titu te fo r m o re e x te n d e d
tre a tm e n t fo r p e rs o n s s e e k in g a s s is ta n c e b u t w a itin g fo r
s e rv ice s to b e c o m e a v a ila b le (e .g ., a n o u tp a tie n t
tre a tm e n t c e n te r th a t o ffe rs p o te n tia l c lie n ts a ss e s s m e n t
an d fe e d b a c k w h ile th e y a re o n a w a itin g list)

A ct as a m o tiv a tio n a l p re lu d e to e n g a g e m e n t and

p a rtic ip a tio n in m o re in te n s iv e tre a tm e n t (e .g ., an
in te rv e n tio n to h e lp a c lie n t c o m m it to in p a tie n t
tre a tm e n t w h e n th e a s s e s s m e n t d e e m s it a p p ro p ria te b u t
th e c lie n t b e lie v e s o u tp a tie n t tre a tm e n t is a d e q u a te )

F a cilita te b e h a v io r c h a n g e re la te d to s u b s ta n c e a b u se or
a sso c ia te d p ro b le m s

Sou rce: A d a p te d fro m B ie n e t al., 1993.

ta rg e t g o a l an d e n c o u ra g e d to ta k e
re sp o n sib ility fo r se le c tin g a n d w o rk in g on

fa c e -to -fa c e se s s io n s , w ith or w ith o u t th e

b e h a v io ra l ch a n g e in a w a y th a t is m o st

a d d itio n o f w r itte n m a te ria ls s u c h as se lf-h e lp

co m fo rta b le fo r h im . A n y fo llo w u p v isits w ill

m a n u a ls , w o rk b o o k s , or s e lf-m o n ito r in g d iarie s.

p ro v id e an o p p o rtu n ity to m o n ito r p ro g re ss an d

A few h a v e c o n s is te d p rim a rily o f m a ile d

to e n co u ra g e th e c lie n t's m o tiv a tio n and a b ility

m a te ria ls , a u to m a te d c o m p u te r sc re e n in g and

to m a k e p o sitiv e ch a n g e s. T h e p e rso n

a d v ice, or te le p h o n e c o n ta c ts.

d eliv e rin g th e b rie f in te rv e n tio n is u su a lly

B rie f in te rv e n tio n s a re ty p ic a lly c o n d u c te d in

S o m e in te rv e n tio n s a re a im e d a t sp e cific

train ed to b e e m p a th ic , w a rm , an d e n c o u ra g in g

h e a lth p ro b le m s th a t a re a ffe c te d b y su b sta n ce

ra th e r th a n co n fro n ta tio n a l.

a b u se , ra th e r th a n s u b s ta n c e a b u s e itself.

In trodu ction

For e x a m p le , an in te rv e n tio n m a y b e c o n d u c te d

th e ra p y m a y a lso b e u se d if re s o u rc e s fo r m o re

to h e lp a clie n t re d u ce h er ch a n c e s o f c o n tra c tin g

e x te n s iv e th e ra p y a re n o t a v a ila b le or if

h u m a n im m u n o d e fic ie n c y s y n d ro m e (H IV ) by

s ta n d a rd tre a tm e n t is in a c c e s s ib le o r u n a v a ila b le

u sin g cle a n n e e d le s; as a re su lt, if th e c lie n t o n ly

(e.g ., re m o te c o m m u n itie s , ru ra l a re a s). B rief

has d irty n e e d le s, sh e m ig h t a v o id u sin g th e m in

th e ra p ie s o fte n ta rg e t a s u b s ta n c e -a b u s in g

o rd er to re d u ce h e r risk o f H IV an d th u s re d u c e

p o p u la tio n w ith m o re se v e re p ro b le m s th an

h er use o f h e ro in . B y ra isin g an in d iv id u a l's

th o se fo r w h o m b r ie f in te rv e n tio n s are

a w a ren e ss o f h e r su b s ta n c e a b u se , a b rie f

su fficie n t. B rie f th e ra p ie s ca n b e u se fu l fo r

in te rv e n tio n ca n a ct as a p o w e rfu l c a ta ly s t fo r

sp e c ia l p o p u la tio n s if th e th e ra p is t u n d e rsta n d s

ch a n g in g a su b sta n c e a b u se p a ttern .

th a t s o m e c lie n t iss u e s m a y b e d e v e lo p m e n ta l or

T h e d istress c lie n ts fe e l a b o u t th e ir su b sta n c e

p h y s io lo g ic a l in n a tu re (se e T IP 26, S u b stan ce

ab u se b e h a v io r ca n a ct as a n in flu e n c e to

A b u se A m o n g O ld er A d u lts , a n d T IP 3 2 , T reatm en t

e n co u ra g e ch a n g e as th e y re c o g n iz e th e n e g a tiv e

o f A d o les cen ts W ith S u b sta n ce U se D isord ers

c o n se q u e n ce s o f th a t b e h a v io r to th e m s e lv e s or

[C S A T , 1 9 9 8 b , 1 9 9 9 b ]).

o th ers. P o sitiv e an d n e g a tiv e e x te rn a l fo rces are

A lth o u g h b rie f th e ra p ie s a re ty p ic a lly sh o rter

also in flu e n ces. L ife e v e n ts, s u ch as a m a jo r

th a n tra d itio n a l v e rs io n s o f th e ra p y , th ese

illn ess or the d ea th o f s ig n ific a n t o th e rs, c a re e r

th e ra p ie s g e n e ra lly re q u ire a t le a s t six sessio n s

ch an g e , m a rria g e , an d d iv o rce , c a n c o n trib u te to

a n d a re m o re in te n siv e a n d lo n g e r th a n b rie f

the d esire to ch a n g e . B rie f in te rv e n tio n s ca n

in te rv e n tio n s . B rie f th e ra p y , h o w e v e r, is n o t

a d d ress th e se e v e n ts an d fe e lin g s th a t

sim p ly a s h o rte r v e rs io n o f s o m e fo rm of

a cco m p a n y th e m w ith th e u n d e rly in g g o a l of

p s y c h o th e ra p y . R a th e r, it is th e fo cu se d

ch a n g in g c lie n ts ' s u b s ta n c e a b u se b e h a v io rs.

a p p lic a tio n o f th e ra p e u tic te c h n iq u e s sp e cifica lly

ta rg e te d to a s y m p to m or b e h a v io r and o rien ted

An Overview of Brief
Therapies

to w a rd a lim ite d le n g th o f tre a tm e n t.

In a d d itio n to th e g o a ls o f b rie f in te rv e n tio n s,
th e g o a ls o f b rie f th e ra p y in s u b s ta n c e a b u se

In co n tra st to m o st s im p le a d v ic e or b rie f

tre a tm e n t is re m e d ia tio n o f s o m e sp e cifie d

in te rv e n tio n s, b rie f th e ra p ie s a re u su a lly

p s y c h o lo g ic a l, s o c ia l, o r fa m ily d y s fu n c tio n as it

d eliv e red to p e rs o n s w h o a re s e e k in g or

p e rta in s to s u b s ta n c e a b u s e ; it fo c u s e s p rim a rily

a lrea d y in tre a tm e n t fo r a s u b s ta n c e a b u se

on p re s e n t c o n c e rn s an d s tre s so rs ra th e r th a n on

d iso rd er. T h a t is, the in d iv id u a l u su a lly h a s

h is to ric a l a n te c e d e n ts . B rie f th e ra p y is

so m e re co g n itio n or a w a re n e s s o f the p ro b le m ,

c o n d u cte d b y th e ra p is ts w h o h a v e b ee n

e v e n if h e h as y e t to a c c e p t it. T h e th e ra p y itself

sp e c ific a lly tra in e d in o n e or m o re p sy c h o lo g ica l

is o ften c lie n t d riv e n ; the c lie n t id e n tifie s the

or p s y c h o s o c ia l m o d e ls o f tre a tm e n t. T h e ra p is t

p ro b le m s, an d the c lin ic ia n u se s th e c lie n t's

tra in in g re q u ire s m o n th s or y e a rs a n d u su ally

s tre n g th s to b u ild s o lu tio n s . T h e c h o ic e o f a

re su lts in a s p e c ia lis t d e g re e o r c e rtific a tio n . In

b rie f th e ra p y fo r a p a rtic u la r in d iv id u a l sh o u ld

p ra c tice , m a n y th e ra p is ts w h o h a v e b e e n train ed

b e b ase d on a c o m p re h e n siv e a s s e s s m e n t ra th e r

in sp e c ific th e o re tic a l m o d e ls o f c h a n g e b o rro w

th an a cu rso ry s c re e n in g to id e n tify p o te n tia lly

te c h n iq u e s fro m o th e r m o d e ls w h e n w o rk in g

h a z a rd o u s d rin k in g or s u b s ta n c e -a b u s in g

w ith th e ir c lie n ts. A lth o u g h th e m o d e ls re m ain

p attern s (IO M , 1990). In so m e ca ses, b rie f

d istin c t, th e ra p ists o fte n b e c o m e ecle ctic

p ra ctitio n e rs .

C h ap ter 1

The Demand for Brief

Interventions and
Therapies

sim ila r e ffo rts w e re m a d e to c u rta il h e ro in u se in

m a jo r c itie s b y e s ta b lis h in g m e th a d o n e
m a in te n a n c e c lin ic s an d re s id e n tia l th e ra p e u tic
c o m m u n itie s (IO M , 1990).
By th e 1 9 8 0 s, d ire c t F e d e ra l fin a n c ia l s u p p o rt

T h e im p e tu s fo r sh o rte r fo rm s o f in te rv e n tio n s
and tre a tm e n ts fo r a ra n g e o f s u b s ta n c e a b u se
p ro b lem s co m es fro m s e v e ra l so u rce s:

S ta te s c o n tin u e d to g ra n t s u b s id ie s , th e m o st
ra p id g ro w th in th e field sw itc h e d to the

H isto rica l d e v e lo p m e n ts in th e field that

in s u ra n c e -s u p p o rte d p riv a te s e c to r an d the

e n co u ra g e a c o m p re h e n siv e , c o m m u n ity -

d e v e lo p m e n t o f tre a tm e n t p ro g ra m s ta rg e te d

b a se d c o n tin u u m o f c a re w ith tre a tm e n t

p rim a rily to h e a v y c o n s u m e rs o f a lco h o l,

and p re v e n tio n c o m p o n e n ts to serv e clie n ts

c o c a in e , a n d m a riju a n a (G e rs te in an d H a rw o o d ,

w h o h a v e a w id e ra n g e o f s u b s ta n c e a b u se-

19 9 0 ). T h e s ta n d a rd iz e d a p p r o a c h u sed in m o st

re la ted p ro b lem s

o f th e se p riv a te , h o s p ita l-b a s e d p ro g ra m s

A g ro w in g b o d y o f e v id e n c e th a t co n siste n tly

in c o rp o ra te d m a n y a s p e c ts o f the M in n e so ta

d e m o n stra te s th e e ffic a c y o f b rie f

m o d e l p io n e e r e d in th e la te 1 9 5 0 s, w ith a stro n g

in te rv e n tio n s

fo cu s o n th e 1 2 -S te p p h ilo s o p h y d e v e lo p e d in

A n in cre a sin g d e m a n d fo r the m o st co st-

A lc o h o lic s A n o n y m o u s (A A ), a fix e d -le n g th , 28-

e ffe ctiv e ty p e s o f tre a tm e n t, e sp e c ia lly in this

d a y sta y , a n d in s is te n c e o n a b stin e n c e as the

era o f h e a lth c a re in fla tio n an d co st

m a jo r tre a tm e n t g o a l (C S A T , 1995).

c o n ta in m e n t p o licie s in th e p riv a te and

fo r tre a tm e n t h a d s lo w e d , a n d a lth o u g h so m e

In itia lly , tre a tm e n t p ro g ra m s in b o th the

p u b lic secto rs

p u b lic a n d p riv a te s e c to rs te n d e d to serv e the

C lien t in te re st in sh o rte r term tre a tm e n ts

m o st se rio u s ly im p a ire d p o p u la tio n s ; h o w e v e r,

T h e in cre a sin g d e m a n d fo r tre a tm e n t of

so m e so rt a risin g fro m th e id e n tific a tio n of
m o re a t-risk co n s u m e rs o f su b s ta n c e s th ro u g h
E A P s, s u b s ta n c e -te s tin g p ro g ra m s , h e a lth
scre e n in g e ffo rts, an d d ru n k d riv in g a rre sts
co u p led w ith d ec re a se d p u b lic fu n d in g an d co st
c o n ta in m e n t p o lic ie s o f m a n a g e d ca re le a v e on ly
tw o op tio n s: p ro v id e d ilu ted tre a tm e n t in
tra d itio n a l m o d e ls fo r a few or d e v e lo p a sy stem
in w h ich d iffe re n t lev els and ty p e s of
in te rv e n tio n s a re p ro v id e d to c lie n ts b a se d on
th eir id e n tifie d n e ed s an d c h a ra c te ris tic s (M iller,
1993).

p ro v id e rs g ra d u a lly re c o g n iz e d th e n e ed fo r
tre a tm e n t o p tio n s fo r a w id e r ra n g e o f clie n ts
w h o h a d d iffe re n t ty p e s o f s u b s ta n c e a b u se
d iso rd e rs. P ro v id e rs re a liz e d th a t n o t all clie n ts
b e n e fit fro m a sin g le s ta n d a rd iz e d tre a tm e n t
a p p ro a c h . R a th e r, tre a tm e n t s h o u ld b e ta ilo re d
to in d iv id u a l n e e d s d e te rm in e d b y in -d ep th
a s s e s s m e n ts o f th e c lie n t's p ro b le m s and
a n te c e d e n ts to h e r s u b s ta n c e a b u s e d iso rd e r.
P ro v id e rs w e re a lso a w a re th a t in te rv e n tio n s
w ith less d y s fu n c tio n a l c lie n ts o fte n h ad g re a te r
s u c c e ss ra te s. In th e in te re s t o f re d u c in g d ru n k
d riv in g , fo r e x a m p le , e d u c a tio n a l e ffo rts w ere
ta rg e te d a t o ffe n d e rs c h a rg e d w ith D W I as an

Expanding Treatm ent Options

T h e d e v e lo p m e n t o f p u b lic su b s ta n c e a b u se
tre a tm e n t p ro g ra m s su b sid iz e d by F e d e ra l,
S ta te , and lo cal m o n ie s d a te s to the la te 1960s
w h en p u b lic d ru n k e n n e s s w a s d e c rim in a liz e d
an d d e to x ifica tio n c e n te rs w e re s u b stitu te d fo r
d ru n k ta n k s in ja ils. A t a b o u t th e sa m e tim e,
8

a lte rn a tiv e to re v o k in g th e ir d riv in g lic e n se s. In

s u ch p ro g ra m s , m o re a tte n tio n w a s g iv e n to
o u tc o m e s a n d fa c to rs in th e tre a tm e n t s ettin g
th a n to th e c lie n t's h is to ry ; th e se s ee m e d to
a ffe c t su cc e s s ra te s w h e th e r o r n o t tre a tm e n t
w a s c o m p le te d .

In trodu ction

A s a sse ssm e n ts b e c a m e m o re

in d ic a te a s tro n g n e e d to c o n s id e r c lie n t

c o m p re h e n siv e , tre a tm e n t a lso b e g a n to a d d re ss

c h a ra c te ris tic s to m a tc h c lie n ts to tre a tm e n t, the

the e ffe cts o f su b sta n c e a b u se p a tte rn s on

fin d in g s d o s u g g e s t th a t th e se v e rity of

m u ltip le sy ste m s, in clu d in g p h y s ic a l an d m e n ta l

c o e x istin g p s y c h ia tric d is o rd e rs sh o u ld be

h e alth , so cia l an d p e rs o n a l fu n c tio n in g , le g a l

c o n s id e re d .

e n ta n g le m e n ts, a n d e c o n o m ic s ta b ility . In re c e n t

A n o th e r stu d y , c o n d u c te d b y M c L e lla n and

y ears, th is b io p sy c h o s o c ia l a p p ro a c h to the

c o lle a g u e s , id e n tifie d s p e c ific p ro b le m s o f

tre a tm e n t o f s u b s ta n c e a b u se d is o rd e rs has

c lie n ts in tre a tm e n t (e .g ., e m p lo y m e n t, fa m ily ,

stim u la te d m o re c ro ss -d is c ip lin a ry c o o p e ra tio n .

p s y c h ia tric p ro b le m s ), th e n m a tc h e d th e clie n ts

It h as also p ro m p te d m o re a tte m p ts to m a tc h

to se rv ic e s d e s ig n e d to a d d re s s th e p ro b lem s

clien t n e ed s to th e m o st a p p ro p ria te and

(M c L e lla n et al., 19 9 3 ). T h e s e c lie n ts sta y e d in

ex p e d itio u s in te n sity o f ca re an d tre a tm e n t

tre a tm e n t lo n g e r, w e re m o re lik e ly to co m p le te

m o d a lity . C o n s id e ra tio n is n o w g iv e n to

tre a tm e n t, an d h ad b e tte r p o sttre a tm e n t

d iffe re n ce s n o t o n ly in th e s e v e rity an d ty p e s o f

o u tc o m e s th a n u n m a tc h e d c lie n ts in th e sa m e

p ro b le m s id e n tifie d b u t a lso to th e c u ltu ra l or

tre a tm e n t p ro g ra m s .

e n v iro n m e n ta l c o n te x t in w h ic h th e p ro b le m s

In th is c o n te x t, in c re a sin g e m p h a s is h a s also

are e n co u n te re d , th e ty p e s o f su b s ta n c e s a b u sed ,

b e e n g iv e n to in te g ra tin g s p e c ia liz e d a p p ro a ch e s

and d iffe re n ce s in g e n d e r, ag e, e d u c a tio n , and

to su b s ta n c e a b u se tre a tm e n t w ith th e g e n eral

so cial sta b ility . D e te rm in in g a c lie n t's

m e d ic a l sy ste m an d th e se rv ic e s o f o th er

a p p ro p ria te n e ss fo r tre a tm e n t is o n e o f the 4 6

c o m m u n ity a g e n c ie s. A 1 9 9 0 IO M re p o rt called

g lo b al crite ria fo r c o m p e te n c y o f ce rtifie d

fo r m o re c o m m u n ity in v o lv e m e n t in h e a lth care,

a lco h o l an d d ru g a b u se c o u n s e lo rs (H e rd m a n ,

so c ia l se rv ic e s , w o rk p la c e , e d u c a tio n a l, and

1997). In d e e d , c lie n t a s s e s s m e n t an d tre a tm e n t

crim in a l ju s tic e s y s te m s (IO M , 19 9 0 ). B eca u se

m a tch in g an d re fe rra l h a s b e c o m e a s p e c ia lty

th e v a st m a jo rity o f p e rs o n s w h o u se su b sta n ce s

area in its e lf th a t a v o id s th e h a z a rd s o f ra n d o m

in m o d e ra tio n e x p e rie n c e fe w or m in o r

tre a tm e n t en try .

p ro b le m s , th ey a re n o t lik e ly to s e e k h e lp in the

In o rd e r to te st the e ffica c y o f c u rre n t

sp e c ia liz e d tre a tm e n t s y s te m . In ste a d , the

tre a tm e n t-m a tc h in g k n o w le d g e , th e N a tio n a l

e stim a te d 20 p e rc e n t o f th e a d u lt p o p u la tio n

In stitu te o n A lc o h o l A b u se an d A lc o h o lis m

w h o d rin k o r u se h e a v ily or in in a p p ro p ria te

(N IA A A ) in itia te d P ro je c t M A T C H (M a tch in g

w a y s (H ig g in s-B id d le et al., 1 9 9 7 ) a re th o se m o st

A lco h o lis m T re a tm e n t to C lie n t H e te ro g e n e ity ),

lik e ly to c o m e to th e a tte n tio n o f p h y sic ia n s,

w h ich a sse sse d th e b e n e fits o f m a tc h in g a lc o h o l-

so cia l w o rk e rs, fa m ily th e ra p is ts , e m p lo y e rs,

d e p e n d e n t c lie n ts (u sin g 10 c lie n t

te a ch e rs, la w y e rs , an d p o lic e . B e c a u se the

ch a ra cte ristics) to th re e ty p e s o f tre a tm e n ts: 12-

p re v a le n c e o f h a rm fu l a n d risk y su b s ta n c e use

Step fa cilita tio n , c o g n itiv e -b e h a v io r a l th e ra p y ,

fa r e x c e e d s th e c a p a c ity o f a v a ila b le s erv ices to

and m o tiv a tio n a l e n h a n c e m e n t th e ra p y (P ro je ct

tre a t it, b rie fe r a n d less in te n siv e in te rv e n tio n s

M A T C H R e se a rc h G ro u p , 1 9 9 7 ). C lien ts fro m

se e m w a rra n te d fo r a b ro a d ra n g e of

tw o p a ra lle l b u t in d e p e n d e n t c lin ic a l tria ls (o n e

in d iv id u a ls , in c lu d in g th o se w h o are u n w illin g

in w h ich c lie n ts w e re re ce iv in g o u tp a tie n t

to a c c e p t re fe rra l fo r m o re fo rm a l an d e x te n siv e

tre a tm e n t, the o th er in w h ic h c lie n ts w ere

sp e c ia liz e d c a re (B ien e t al., 1993) an d th o se

re ce iv in g a fte rc a re th e ra p y fo llo w in g in p a tie n t

w h o se s u b s ta n c e u se is risk y b u t n o t a b u siv e

tre atm e n t) w e re a ssig n e d to re c e iv e o n e o f the

(H ig g in s-B id d le et al., 19 9 7 ).

th ree tre a tm e n ts. A lth o u g h the re su lts d o n ot

C h ap ter 1

Cost and Funding Factors

S tu d ie s of th e c o s t-e ffe c tiv e n e s s o f d iffe re n t
tre a tm e n t a p p ro a c h e s h a v e b e e n p a rtic u la rly

Barriers to Increasing the

Use of Brief Treatments

a p p e a lin g to p o lic y m a k e rs s e e k in g to re d u ce

M a n y clin ic ia n s an d o th e r ca re p ro v id e rs in

costs and b e tte r a llo ca te s c a rc e re so u rc e s. In the

c o m m u n ity a g e n c ie s re ta in th e lo n g -s ta n d in g

m a n a g e d ca re e n v iro n m e n t, h o w e v e r, co st

n o tio n th a t c lie n ts a re g e n e ra lly re s is ta n t to

co n ta in m e n t h a s b e c o m e a b y w o rd , an d no

ch a n g e , u n m o tiv a te d , an d in d e n ia l o f p ro b le m s

sta n d a rd ty p e o f ca re or tre a tm e n t p ro to c o l fo r

a s s o c ia te d w ith th e ir s u b s ta n c e a b u se d iso rd e rs.

all clie n ts is a cc e p ta b le . In o rd e r to re ce iv e

A s a re su lt, c lin ic ia n s a re h e s ita n t to w o rk w ith

re im b u rse m e n t, su b sta n ce a b u se tre a tm e n t

th is p o p u la tio n . S o m e o f th e se a ttitu d e s also

fa cilities m u st fin d th e le a st in te n siv e y et safe

p e rs is t in th e s p e c ia lis t tre a tm e n t co m m u n ity

m o d a lity o f ca re th a t ca n b e o b je c tiv e ly p ro v e n

(M ille r, 19 9 3 ). A lth o u g h th is p e rs p e c tiv e is

to b e a p p ro p ria te an d e ffe c tiv e fo r a clie n t's

s h iftin g as c lin ic ia n s b e tte r u n d e rs ta n d the m an y

n e ed s. N o w th a t m o re tre a tm e n t is d e liv e re d in

a s p e cts o f c lie n t m o tiv a tio n , th e re is still a

a m b u la to ry ca re fa c ilitie s, th e u su a l tim e in

tra d itio n o f w a itin g fo r a s u b s ta n c e u ser to "h it

tre a tm e n t is b e in g s h o rte n e d , an d th e c re d ib ility

b o tto m " a n d a sk fo r h e lp b e fo re a tte m p tin g to

of re co m m e n d e d tre a tm e n t a p p ro a c h e s m u st be

tre a t h im .

in cre a sin g ly d o c u m e n te d th ro u g h c a re fu lly

O th e r id e o lo g ic a l o b s ta c le s p re s e n t b a rrie rs

co n d u cte d re se a rc h stu d ies. In th is c o n tex t,

in e a rlie r sta g e s o f s u b s ta n c e a b u se . T h e fo cu s of

som e o f the m o st w id ely u sed s u b s ta n c e a b u se

b rie f in te rv e n tio n s on h a rm or risk re d u c tio n

tre a tm e n t a p p ro a ch e s, su ch as th e M in n e so ta

an d m o d e ra tin g c o n s u m p tio n p a tte rn s as a first

m o d el, h a lfw a y h o u se s, an d 1 2 -S te p p ro g ra m s,

an d s o m e tim e s o n ly g o a l is n o t a lw a y s

h a v e o n ly re ce n tly b e e n s u b je c te d to rig o ro u s

a c c e p ta b le to c o u n s e lo rs w h o w e re tra in e d to

tests o f e ffe c tiv e n e s s in c o n tro lle d c lin ic a l tria ls

in s is t o n to ta l an d e n d u rin g a b stin e n c e .

(B arry , 1997; H o ld e r e t al., 1 9 9 1 ; L a n d ry , 1996).

A s s u m p tio n s u n d e rly in g b r ie f in te rv e n tio n s

In a d d itio n to th e e m p h a s is o n co st

a im ed a t h a rm re d u c tio n m a y s e e m to c h a lle n g e

co n ta in m e n t and c a re fu l c lie n t-tr e a tm e n t

id e a s th a t s u b s ta n c e a b u s e d is o rd e rs a re a

m a tch in g , o th er re se a rc h e rs to u t th e p o te n tia lly

c h ro n ic an d p ro g re s s iv e d is e a s e re q u irin g

e n o rm o u s p u b lic h e a lth im p a c t th a t co u ld be

s p e c ia liz e d tre a tm e n t. H o w e v e r, if s u b sta n ce

d eriv ed fro m co n d u c tin g m a ss scre e n in g s in

a b u se is p la c e d on a c o n tin u u m fro m a b stin e n ce

e x istin g h e a lth c a re an d o th er co m m u n ity -b a s e d

to s e v e re a b u se , a n y m o v e to w a rd m o d e ra tio n

sy stem s to id e n tify p ro b le m d rin k e rs an d th en

a n d lo w e re d ris k is a ste p in th e rig h t d irectio n

d eliv e rin g b rie f in te rv e n tio n s a im ed a t re d u cin g

a n d n o t in c o n g ru o u s w ith a g o a l o f a b stin e n ce

ex ce ssiv e d rin k in g p a tte rn s (K a h a n et al., 1995).

as the u ltim a te fo rm o f risk re d u c tio n (M a rla tt et

If a p p ro p ria te ly se le c te d p e rso n s w ith less

al., 19 9 3 ). M o re o v e r, re s e a rc h in d ic a te s th a t

sev ere su b sta n c e a b u se re sp o n d s u c c e ssfu lly to

s u b s ta n c e -a b u s in g in d iv id u a ls w h o are

b rie f in te rv e n tio n s w ith a c o n s e q u e n t lo n g -te rm

e m p lo y e d an d g e n e ra lly fu n c tio n in g w ell in

re d u ctio n in su b s ta n c e a b u s e -re la te d m o rb id ity

so c ie ty a re u n lik e ly to re s p o n d p o sitiv e ly to

and a sso cia ted h e a lth c a re co sts, tim e and

so m e fo rm s o f tra d itio n a l tre a tm e n t w h ic h m ay ,

e n e rg y co u ld b e sa v e d fo r tre a tin g th o se w ith

fo r e x a m p le , te ll th e m th a t th e y h a v e a p rim a ry

m o re sev ere s u b s ta n ce a b u se d is o rd e rs in

d ise a se o f s u b s ta n c e d e p e n d e n c y an d m u st

sp e cia liz e d tre a tm e n t fa cilities.

a b sta in fro m all p s y c h o a c tiv e s u b s ta n c e s fo r life

(M ille r, 1993).

10

In trodu ction

In a d d itio n to re s is tin g a h a rm re d u c tio n

e n v iro n m e n t. B e c a u s e o f c h a n g e s in th e n a tu re

a p p ro a ch , tre a tm e n t sta ffs in p ro g ra m s that

an d p ro v isio n o f h e a lth c a re d e liv e ry in the

in co rp o ra te p h a rm a c o th e ra p ie s m a y b e s k e p tic a l

U n ite d S ta te s , h e a lth c a re o rg a n iz a tio n s h a v e

o f b eh a v io ra l a p p ro a c h e s to clie n t c h a n g e if they

b e e n w o rk in g to d e v e lo p s y s te m a tic q u a lity

b elie v e a d d ictio n p rim a rily ste m s fro m

im p ro v e m e n t p ro g ra m s to m o n ito r p ro v isio n of

d iso rd e re d b ra in c h e m istry th a t sh o u ld be

ca re , c lie n t s a tisfa c tio n , an d co sts. B rief

tre ate d m e d ica lly . T h e re a re m a n y m o d e ls o f

in te rv e n tio n s c a n b e a n im p o r ta n t p a rt o f a

p h a rm a co th e ra p y th a t s u g g e s t th a t c o u n s e lin g

tre a tm e n t p r o g r a m 's q u a lity im p ro v e m e n t

(o ften in a b rie f fo rm ) co u p le d w ith m e d ica tio n

in itia tiv e . T h e s e a p p r o a c h e s ca n b e u se d to

p ro v id e s the m o st w e ll-ro u n d e d an d

im p ro v e tre a tm e n t o u tc o m e s in sp e c ific areas.

co m p re h e n siv e tre a tm e n t re g im e (M c L e lla n et

N o t o n ly ca n b rie f in te rv e n tio n s im p ro v e clie n t

al., 1993; V o lp ice lli et al., 1992).

c o m p lia n c e w ith s p e c ific a s p e c ts o f tre a tm e n t

M o re o v e r, re sea rch re v e a ls th a t a lo n g e r tim e

an d th e ra p is t m o ra le b y fo c u s in g o n a tta in a b le

in tre a tm e n t m a y c o n trib u te to a g re a te r

g o a ls, b u t th e y ca n a lso d e m o n s tra te sp e cific

lik e lih o o d o f su c c e s s (L a m b et al., 19 9 8 ). B rief

c lin ic a l o u tc o m e s o f im p o r ta n c e to b o th

in te rv e n tio n s c h a lle n g e th is a s s u m p tio n by

c lin ic ia n s an d m a n a g e d c a re sy stem s.

a ck n o w le d g in g th a t sp o n ta n e o u s re m iss io n and
self-d ire cte d ch a n g e in s u b s ta n c e a b u se

Im portance of Evaluation

b eh a v io rs d o o ccu r. A n e w p e rs p e c tiv e m ig h t

T h e C o n s e n s u s P a n e l re c o m m e n d s th a t

re co n cile th e se o b s e rv a tio n s by re c o g n iz in g th a t

p ro g ra m s u se q u a lity a s s u ra n c e im p ro v e m e n t

lim ited tre a tm e n t ca n be b e n e fic ia l e sp e c ia lly

p ro je c ts to d e te rm in e w h e th e r th e u se o f a b rie f

co n sid e rin g th a t at le a s t h a lf o f all c lie n ts d ro p

in te rv e n tio n o r th e ra p y in sp e c ific tre a tm e n t

ou t o f s p e cia liz e d tre a tm e n t b e fo re c o m p le tio n .

s itu a tio n s is im p ro v in g tre a tm e n t. E x a m p le s of

P ro b a b ly th e la rg e st im p e d im e n t to b ro a d e r
a p p lica tio n o f b rie fe r fo rm s o f tre a tm e n t is th e
a lrea d y o v e rw h e lm in g re s p o n s ib ilitie s o f
fro n tlin e tre a tm e n t s ta ff m e m b e rs w h o are
o v erw o rk ed and u n fa m ilia r w ith the la test
tre a tm e n t re sea rch fin d in g s (S c h u s te r and

o u tco m e m e a s u re s in c lu d e

A fte rc a re fo llo w u p ra te s

A fte rc a re c o m p lia n c e ra te s

A lu m n i p a rtic ip a tio n ra te s

D is c h a rg e a g a in st m e d ic a l a d v ic e rates

C o u n s e lo rs ' ra tin g s o f c lie n t in v o lv e m e n t in

S ilv erm a n , 199 3 ). N o t on ly are th e se c lin icia n s

re lu cta n t to m a k e clin ic a l c h a n g e s , b u t th eir

s u b s ta n c e a b u se fo llo w in g tre a tm e n t

p ro g ra m s m a y a lso la ck th e fin a n c ia l and

T h e n u m b e r o f c o m p la in ts re la te d to the b rie f
in te rv e n tio n o r th e ra p y

p e rso n n e l re so u rce s to a d o p t in n o v a tiv e

a p p ro a ch e s. T re a tm e n t p ro g ra m s lim it

M echanism s To Use in Evaluation

th e m se lv es by s u c h in a b ility an d u n w illin g n e ss

T h e e ffe c ts o f a d d in g b r ie f a p p ro a c h e s to

to learn n ew te ch n iq u es.

sta n d a rd ca re sh o u ld b e e v a lu a te d as p a rt of

Evaluating Brief
Interventions and
Therapies
Q u a lity im p ro v e m e n t h a s b e c o m e an im p o rta n t
c o n sid era tio n in th e c o n te m p o ra ry h e a lth ca re

co n tin u o u s q u a lity im p ro v e m e n t p ro g ra m
te stin g . S o m e o f th e s e o u tc o m e s ca n b e
m e a s u re d by

C lie n t s a tis fa c tio n s u rv e y s

F o llo w u p p h o n e ca lls

C o u n s e lo r-ra tin g q u e s tio n s a d d e d to clin ical

ch a rt

21

C hapter 1

P ro g ra m s sh o u ld m o n ito r clie n t s a tisfa c tio n

serio u s h e a lth , s o c ia l, an d e m o tio n a l p ro b le m s is

sh o u ld b e in v o lv e d in q u a lity im p ro v e m e n t

h ig h , b o th fro m a p u b lic h e a lth an d a c lin ica l

activ itie s. Id e n tify in g tre n d s o v e r tim e can

p e rs p e c tiv e . A s th e h e a lth ca re sy stem

in d ica te w h a t im p ro v e m e n ts n eed to b e m ad e.

u n d e rg o e s c h a n g e s , p ro g ra m s s h o u ld ta k e th e

Im p le m e n ta tio n o f su b sta n ce a b u se p re v e n tio n

o p p o rtu n ity to d e v e lo p a n d a d v o c a te a

and b rie f in te rv e n tio n stra te g ie s in c lin ica l

c o m p re h e n siv e s y s te m o f s u b s ta n c e a b u se

p ra ctice re q u ires th e d e v e lo p m e n t of

in te rv e n tio n s , c o m b in in g th e s k ills o f c lin icia n s

sy ste m a tiz e d p ro to co ls th a t ca n p ro v id e e a sie r

w ith th e k n o w le d g e g a in e d fro m th e re se a rc h

serv ice d eliv e ry . T h e n e ed to im p le m e n t

c o m m u n ity .

e ffe ctiv e an d u n ifie d stra te g ie s fo r a v a rie ty of

12

su b s ta n c e a b u s e rs w h o a re a t risk fo r m o re

ov er tim e, and w h e n e v e r p o ss ib le c o u n se lo rs

2 Brief Interventions in Substance

Abuse Treatment

rief in te rv e n tio n s fo r s u b s ta n c e a b u se

d isc u sse d in th is T IP a re tim e lim ite d ,

p ro b le m s h a v e b ee n u sed fo r m a n y y ea rs

s tru c tu re d , a n d d ire c te d to w a rd a sp e cific g oal.

by a lco h o l and d ru g c o u n s e lo rs, so cia l

T h e y fo llo w a sp e c ific p la n (an d in so m e ca se s a

w o rk ers, p s y c h o lo g is ts , p h y s ic ia n s , and n u rses,

w o rk b o o k ) a n d h a v e tim e lin e s fo r th e a d o p tio n

e d u ca tio n a l g ro u p s, and v o ca tio n a l

fa c to rs th a t re s u lt in d iffe re n tia l re sp o n se s to

re h a b ilita tio n p ro g ra m s. P rim a ry ca re p ro v id e rs

b rie f in te rv e n tio n b y v a ry in g clie n t

find m an y b rie f in te rv e n tio n te c h n iq u e s e ffe c tiv e

c h a ra c te ris tic s or b y c o n d u c tin g su b g ro u p

in a d d re ssin g the su b s ta n c e a b u se issu es of

a n a ly se s. M o st s tu d ie s o f b rie f in te rv e n tio n s to

clie n ts w h o are u n a b le or u n w illin g to acce ss

d a te a re lim ite d b y th e ir la c k o f su ffic ie n t su b je ct

sp e cia lty care . E x a m p le s o f b rie f in te rv e n tio n s

a s s e s s m e n ts . F in d in g s fro m th e a v a ila b le

in clu d e ask in g clie n ts to try n o n u se to see if they

re s e a rc h s u g g e s t th a t c lie n t c h a ra c te ris tic s are

can stop on th eir o w n , e n c o u ra g in g

n o t g o o d p re d ic to rs o f a p e r s o n 's re s p o n s e to a

in te rv e n tio n s d irecte d to w a rd a tte n d in g a self-

b rie f in te rv e n tio n a n d th a t b rie f in te rv e n tio n s

h elp g ro u p (e.g ., A lc o h o lic s A n o n y m o u s [A A ] or

m a y b e a p p lic a b le to in d iv id u a ls fro m a w id e

N a rco tics A n o n y m o u s [N A ]), an d e n g a g in g in

ra n g e o f c u ltu re s a n d b a c k g ro u n d s (B a b o r, 1994;

b rief, stru ctu re d , tim e -lim ite d e ffo rts to h elp

B a b o r and G ra n t, 19 9 1 ).

and by so cial s e rv ic e a g e n cie s, h o s p ita l

e m e rg e n c y d e p a rtm e n ts , co u rt-o rd e re d

p re g n a n t clie n ts sto p u sin g .

B rief in te rv e n tio n s are re s e a rc h -p ro v e n

o f sp e c ific b e h a v io rs .
S e v e ra l s tu d ie s h a v e a tte m p te d to id e n tify

T h is c h a p te r p ro v id e s th e o r e tic a l an d
p ra c tic a l in fo rm a tio n on b rie f in te rv e n tio n s ,

p ro ce d u re s fo r w o rk in g w ith in d iv id u a ls w ith

b o th in o p p o rtu n istic s e ttin g s a n d in the

at-risk u se and less se v e re a b u se b e h a v io rs and

su b s ta n c e a b u s e tre a tm e n t se ttin g . T h e sta g e s-

can be s u cce ssfu l w h en tra n sp o rte d in to

o f-c h a n g e m o d e l is p re s e n te d first b e c a u se o f its

sp e cia list tre a tm e n t se ttin g s an d p e rfo rm e d by

u se fu ln e ss in u n d e rs ta n d in g th e p ro c e ss of

alco h o l and d ru g c o u n se lo rs. A s p re s e n te d in

b e h a v io ra l c h a n g e . N e x t, th e g o a ls o f b rie f

the lite ra tu re , b rie f in te rv e n tio n s to ch a n g e

in te rv e n tio n a re d e s c rib e d an d a p p lie d to

s u b sta n ce ab u se b e h a v io rs ca n in v o lv e a v a rie ty

v a rio u s le v e ls o f s u b s ta n c e u se. F R A M E S

of a p p ro a ch e s, ra n g in g fro m u n stru ctu re d

e le m e n ts c ritic a l to b rie f in te rv e n tio n are

co u n selin g and fe e d b a ck to fo rm a l stru c tu re d

d e ta ile d , an d fiv e e s s e n tia l ste p s a re listed w ith

th erap y (C h ick et al., 1 9 8 5 ; F le m in g et al., 1997;

s c rip ts to u se in v a rio u s se ttin g s. T h e b rie f

K riste n so n et al., 1 9 8 3 ; P e rsso n an d M a g n u sso n ,

in te rv e n tio n w o rk b o o k , a p ra c tic a l tool fo r use

1989). B rief in te rv e n tio n s, as d efin e d and

d u rin g a b rie f in te rv e n tio n , is e x p la in e d .

C h ap ter 2

E ssen tial c lin icia n k n o w le d g e an d sk ills fo r

n o n c o m p lia n c e co u ld re su lt. T o c o n sid e r

co n d u ctin g a su c c e s s fu l b rie f in te rv e n tio n are

ch a n g e , c lie n ts a t th e p re c o n te m p la tio n sta g e

then d escrib e d . D is cu s sio n s o f th e u se o f b rie f

m u st h a v e th e ir a w a r e n e s s ra ise d . T o re so lv e

in te rv e n tio n in su b s ta n c e a b u se p ro g ra m s and

th e ir a m b iv a le n c e , c lie n ts in th e c o n te m p la tio n

n o n sp e cia liz e d se ttin g s fo llo w . T h e fin a l sectio n

sta g e m u s t b e h e lp e d to c h o o s e p o sitiv e ch a n g e

p re sen ts re se a rc h fin d in g s o n b rie f in te rv e n tio n s

o v er th e ir c u rre n t c irc u m sta n c e s . C lie n ts in the

fo r b o th a t-risk u sers and d e p e n d e n t u sers.

p re p a ra tio n s ta g e n e ed h e lp in id e n tify in g
p o te n tia l c h a n g e s tra te g ie s an d c h o o s in g the

Stages-of-Change Model

m o st a p p ro p ria te o n e s. C lie n ts in th e actio n

s ta g e n e ed h e lp to c a rry o u t a n d c o m p ly w ith

T h e w o rk o f P ro ch a sk a an d D iC le m e n te and
th eir "s ta g e s -o f-c h a n g e " m o d e l h e lp c lin ic ia n s

T h e c lin ic ia n c a n u se b rie f in te rv e n tio n s to

tailo r b rie f in te rv e n tio n s to c lie n ts ' n e ed s

m o tiv a te p a rtic u la r b e h a v io ra l c h a n g e s a t ea ch

(P ro ch a sk a an d D iC le m e n te , 1 9 8 4 ,1 9 8 6 ).

sta g e o f th is p ro c e s s . F o r e x a m p le , in the

P ro ch a sk a and D iC le m e n te e x a m in e d sev era l

c o n te m p la tio n sta g e , a b rie f in te rv e n tio n co u ld

th e o rie s co n c e rn in g h o w ch a n g e o c c u rs and

h elp th e c lie n t w e ig h th e c o s ts an d b e n e fits of

a p p lied th eir fin d in g s to s u b s ta n c e a b u se

ch a n g e . In th e p re p a ra tio n sta g e , a sim ila r b rie f

b e h a v io r m o d ifica tio n . T h e y d ev ise d a m o d e l

in te rv e n tio n c o u ld a d d re s s th e c o sts an d b en e fits

co n sistin g o f fiv e sta g e s o f c h a n g e th a t see m e d

to b e s t re p re se n t the p ro c e s s p e o p le g o th ro u g h
w h en th in k in g a b o u t, b e g in n in g , an d try in g to
m a in ta in n ew b e h a v io r (see F ig u re 2 -1 ). T h e

of v a rio u s c h a n g e s tra te g ie s (e .g ., s e lf-ch a n g e,

b rie f tre a tm e n t, in te n siv e tre a tm e n t, self-h elp
g ro u p a tte n d a n c e ). In th e a c tio n sta g e , b rie f
in te rv e n tio n s ca n h e lp m a in ta in m o tiv a tio n to

s ta g e s-o f-ch a n g e m o d e l is e x p la in e d m o re fu lly

c o n tin u e o n th e c o u rs e o f c h a n g e b y re in fo rc in g

in T IP 35, E n h an cin g M otiv ation f o r C h a n g e in

p e rs o n a l d e c is io n s m a d e a t e a rlie r sta g e s.

S u bstan ce A b u se T reatm en t (C S A T , 1 999c).

T h e se sta g e s h a v e p ro v e n u se fu l, for
ex a m p le , in p re d ic tin g th o se m o st lik e ly to q u it

U n d e rs ta n d in g th e se sta g e s h e lp s th e
c lin ic ia n to b e p a tie n t, to a c c e p t the c lie n t's
c u rre n t p o sitio n , to a v o id "g e ttin g to o far

sm o k in g and in ta rg e tin g sp e c ific k in d s o f

a h e a d " o f th e c lie n t a n d th e re b y p ro v o k in g

in te rv e n tio n s to s m o k e rs in d iffe re n t sta g es

re s is ta n c e , a n d , m o st im p o r ta n t, to a p p ly the

(D iC lem en te et a l., 1 9 9 1 ; P ro c h a sk a , 1999;

c o rre c t c o u n s e lin g s tra te g y fo r e a ch sta g e of

P ro ch a sk a an d D iC le m e n te , 1 9 8 6 ; V e lic e r et al.,

re a d in e ss. E ffe c tiv e b rie f in te rv e n tio n ists

1992). S ta g e s o f ch a n g e are b e in g e x a m in e d in

q u ick ly a s s e s s th e c lie n t's sta g e o f re a d in e ss,

b rie f in te rv e n tio n s w ith h a z a rd o u s an d h a rm fu l

p la n a c o r re s p o n d in g s tra te g y to a s s is t h e r in

su b sta n ce u se rs as w e ll, as a m e a n s o f ta ilo rin g

p ro g re ss in g to th e n e x t sta g e , an d im p le m e n t

in te rv e n tio n s to th e in d iv id u a l's c u rre n t sta g e of

th a t s tra te g y w ith o u t s u c c u m b in g to d istra ctio n .

ch a n g e (H o d g so n an d R o lln ic k , 1 9 9 2 ; M u d d et
al., 1995).
C lien ts n e ed m o tiv a tio n a l su p p o rt
a p p ro p ria te to th e ir sta g e o f ch a n g e . If the
clin icia n d o es n o t u se s tra te g ie s a p p ro p ria te to
the stag e the clie n t is in, tre a tm e n t re sista n c e or

14

the c h a n g e s tra te g ie s.

In d e e d , c lin ic ia n d is tr a c tio n ca n b e a g re a te r
o b s ta c le to c h a n g e in b rie f in te rv e n tio n th a n
tim e lim ita tio n s . R e g a rd le ss o f th e sta g e o f
re a d in e s s , b rie f in te rv e n tio n s ca n h e lp in itia te
ch a n g e , c o n tin u e it, a c c e le ra te it, an d p re v e n t the
c lie n t fro m re g re ss in g to p re v io u s b e h a v io rs.

B r ie f In terv en tion s

F ig u r e 2-1
T h e S ta g e s o f C h a n g e
T r e a tm e n t N e e d s

E x a m p le

S ta g e
Precontem plation. The

A functional yet alcohol-d ep en d ent

T his clien t n eed s in form ation linking his

user is not consid ering

ind ivid ual w ho drinks h im self into

problem s and p o ten tial problem s w ith his

change, is aw are of few

a stup or every night but w ho goes

su b stance abuse. A b rief in tervention m ight

negative consequences,

to w ork every day, perform s his

be to ed u cate h im ab ou t the negative

and is unlikely to take

job, has no substance abuse-related

con seq u en ces of su b stance abuse. For

action soon.

legal problem s, has no health

exam p le, if he is d ep ressed , he m ight be told

problem s, and is still m arried.

how his alcohol abuse m ay cau se or

exacerb ate the d ep ression.

Contem plation. The user

An individ ual w ho has received a

This clien t should exp lore feelings of

is aw are of som e pros

citation for d riving while

am b iv alen ce and the conflicts b etw een her

and cons of substance

intoxicated and vow s that n ext tim e

su b stance abuse and personal values. The

abuse but feels

she will not drive w hen drinking.

brief in terven tion m ight seek to increase the

am bivalent about

She is aw are of the consequences

clie n t's aw aren ess of the conseq u en ces of

change. This user has

but m akes no com m itm ent to stop

continu ed abuse and the b enefits of

not yet decided to

drinking, ju st to not drive after

d ecreasin g or stop p in g use.

com m it to change.

d rinking.

Preparation. This stage

An ind ivid ual w ho d ecid es to stop

T his clien t n eed s w ork on strengthen in g

begins once the user has

abusing su bstances and plans to

com m itm ent. A b rief in terv en tion m ight

decided to change and

attend cou n selin g, AA , N A, or a

give the clien t a list o f op tions for treatm ent

begins to plan steps

form al treatm ent program .

(e.g., in p atien t treatm ent, ou tp atient

treatm ent, 12-Step m eetings) from w hich to

tow ard recovery.

choose, then help the client plan how to go

ab ou t seeking the treatm en t that is best for
him .
A ction. The user tries

A n individ ual w ho goes to

T his clien t requ ires help execu tin g an action

new behaviors, but

cou n seling and attend s m eetings

plan and m ay have to w ork on skills to

these are not yet stable.

but often thinks of using again or

m ain tain sobriety. The clin ician should

This stage involves the

m ay even relapse at times.

ack n ow led g e the clien t's feelings and

first active steps tow ard

exp erien ces as a n orm al part of recovery.

change.

Brief in terven tion s cou ld be applied

throu ghou t this stage to p revent relapse.

M aintenance. The user

A n individ ual w ho attends

This clien t n eed s help w ith relapse

establishes new

cou nseling regularly, is actively

p revention. A b rief in terv en tion could

b ehaviors on a long

involved in A A or N A, has a

reassu re, ev alu ate p resen t actions, and

term basis.

sponsor, m ay be taking d isu lfiram

red efine lon g -term sobriety m aintenance

(A ntabuse), has m ade new sober

plans.

friends, and has found new

su b stance-free recreational
activities.
Source: A dapted from P rochaska and D iC lem ente, 1984.
15

C h ap ter 2

Goals of Brief
Intervention

c irc u m sta n c e s in w h ic h c lie n ts w ith su b sta n ce

a b u se d is o rd e rs fa c e a m b iv a le n c e d u rin g the
c o u rse o f tre a tm e n t.
T h e k e y to a s u c c e s s fu l b rie f in te rv e n tio n is

T h e b asic g o al fo r a clie n t in a n y s u b sta n ce

to e x tr a c t a s in g le , m e a s u ra b le b e h a v io ra l

a b u se tre a tm e n t s e ttin g is to re d u c e th e risk of

h a rm fro m c o n tin u e d u se o f su b sta n c e s. T h e

ch a n g e fro m th e b ro a d p ro c e s s o f re co v e ry th at

g re a te st d e g re e o f h a rm re d u c tio n w o u ld

w ill a llo w th e c lie n t to e x p e rie n c e a sm a ll,

o b v io u sly re su lt fro m a b stin e n c e , h o w e v e r, the

in c re m e n ta l su c c e s s . C lie n ts w h o s u c ce e d at
m a k in g sm a ll c h a n g e s g e n e r a lly re tu rn fo r m o re

sp e cific g o a l fo r e a c h in d iv id u a l c lie n t is

su cce sses.

d e term in e d b y h is c o n s u m p tio n p a tte rn , the

T h e c lin ic ia n s h o u ld te m p o ra rily set a sid e the

c o n se q u e n ce s o f h is use, an d th e settin g in

fin a l g o a l (e .g ., a c c e p tin g r e s p o n s ib ility fo r o n e 's

w h ich the b rie f in te rv e n tio n is d eliv e red .

F o cu sin g on in te rm e d ia te g o a ls a llo w s fo r m o re

o w n re c o v e ry ) to fo c u s o n a s in g le b e h a v io ra l

im m e d ia te su c c e s s e s in th e in te rv e n tio n and

o b je ctiv e . O n c e th is o b je c tiv e is e sta b lis h e d , a

tre a tm e n t p ro c e s s , w h a te v e r th e lo n g -te rm g oals

b rie f in te rv e n tio n c a n b e u se d to re a c h it.

are. In sp e cia liz e d tre a tm e n t, in te rm e d ia te g oals

O b je c tiv e s v a ry a c c o r d in g to th e c lie n t's sta g e of

re co v e ry a n d re a d in e s s to c h a n g e , b u t b rie f

m ig h t in clu d e q u ittin g o n e su b sta n ce ,

d ecrea sin g fre q u e n c y o f u se, a tte n d in g the n ext

in te rv e n tio n s ca n b e u se fu l a t a n y sta g e o f

m e e tin g , or d o in g th e n e x t h o m e w o rk

re c o v e ry . F ig u re 2 -2 p re s e n ts s e v e ra l o b je ctiv e s

a ssig n m en t. Im m e d ia te su cc e s s e s a re im p o rta n t

th a t m ig h t b e a d d r e s s e d w ith a b rie f
in te rv e n tio n .

to k eep th e clie n t m o tiv a te d .

T h e fo llo w in g a re s u g g e s te d g o a ls fo r b rie f

Se ttin g g o a ls fo r c lie n ts is p a rtic u la rly u se fu l

in te rv e n tio n s a c c o rd in g to th e c lie n t's le v e l of

in ce n te rs th a t sp e c ia liz e in s u b s ta n c e a b u se
tre a tm e n t. P e rfo rm in g b rie f in te rv e n tio n s in this

c o n s u m p tio n .

settin g re q u ire s the a b ility to sim p lify and

Abstainer

re d u ce a clie n t's tre a tm e n t p la n to sm a lle r,

E v e n th o u g h a b sta in e rs d o n o t re q u ire

m e a su ra b le o u tc o m e s, o ften e x p re s s e d as
" o b je c tiv e s " in th e Jo in t C o m m is sio n o n the
A ccre d ita tio n o f H e a lth c a re O rg a n iz a tio n s '
(JC A H O ) la n g u a g e o f tre a tm e n t p la n n in g . T h e
clin icia n m u st b e a w a re o f the m a n y e v e ry d a y

in te rv e n tio n , th e y c a n b e e d u c a te d a b o u t
s u b s ta n c e u se w ith th e a im o f p re v e n tin g a
s u b s ta n c e a b u s e d is o rd e r. S u c h p re v e n tio n
e d u c a tio n p ro g ra m s a re p a rtic u la rly im p o rta n t
fo r y o u th .

F ig u r e 2 -2
S a m p le O b je c tiv e s

16

L e a rn in g to s c h e d u le an d p rio ritiz e tim e

E x p a n d in g a so b er s u p p o rt sy stem

S o cia liz in g w ith re co v e rin g p e o p le or lea rn in g to h a v e fu n w ith o u t s u b s ta n c e a b u se

B e g in n in g sk ills e x p lo ra tio n or tra in in g if u n e m p lo y e d

A tte n d in g an A A or N A m e e tin g

G iv in g up re s e n tm e n ts or c h o o sin g to fo rg iv e o th e rs an d self

S ta y in g in th e "h e r e and n o w "

B r ie f In terv en tion s

Light or M oderate User

T h e g o al o f a b rie f in te rv e n tio n w ith so m e o n e
w h o is a lig h t or m o d e ra te u ser is to e d u c a te h er
a b o u t g u id e lin e s fo r lo w -risk u se an d p o te n tia l
p ro b le m s o f in c re a se d use. E v e n lig h t or
m o d e ra te u se o f so m e su b s ta n c e s ca n re su lt in
h e a lth p ro b le m s or, in th e ca se o f illic it

m o re s y m p to m s w ith in a 1 2 -m o n th p e rio d ).
B rie f in te rv e n tio n s w ith th is g ro u p a d d ress the
le v e l o f u se, e n c o u ra g e m o d e ra tio n or
a b stin e n c e , a n d e d u c a te a b o u t th e c o n se q u e n ce s
of risk y b e h a v io r a n d th e risk s a s s o c ia te d w ith
in c re a se d u se. B rie f in te rv e n tio n s c a n h elp users
u n d e rsta n d th e b io lo g ic a l an d so cia l
c o n s e q u e n c e s o f th e ir s u b s ta n c e use.

su b sta n ce s, leg a l p ro b le m s. T h e s e u sers m ay

also e n g ag e in b in g e d rin k in g (i.e., fiv e or m o re

Abuser

d rin k s in a sin g le o cca sio n ). C lie n ts w h o d rin k

T h e s e a re c lie n ts w ith a s u b s ta n c e a b u se

sh ou ld b e e n co u ra g e d to sta y w ith in e m p iric a lly

d iso rd e r as d e fin e d b y th e D iag n o stic an d

e stab lish e d g u id e lin e s fo r lo w -ris k d rin k in g (no

S ta tistica l M a n u a l o f M en ta l D isord ers, 4 th E d itio n

m o re th an 14 d rin k s p e r w e e k o r 4 p e r o cca sio n

(D S M -IV ) (A m e ric a n P sy c h ia tric A s s o c ia tio n

fo r m e n and n o m o re th a n 7 d rin k s p e r w e e k or

[A P A ], 19 9 4). T h e g o a l o f in te rv e n tio n w ith this

3 p e r o cca sio n fo r w o m e n [A m e rica n S o c ie ty of

p o p u la tio n , d e p e n d in g o n th e c lin ic ia n 's

A d d ictio n M e d ic in e (A S A M ), 1994]).
B rie f in te rv e n tio n s ca n e n h a n c e u s e rs ' in s ig h t

th e o re tic a l p e rs p e c tiv e a n d th e su b s ta n c e s used ,

is to p re v e n t an y in c re a s e in th e u se of

into e x istin g or p o ss ib le c o n s e q u e n c e s or d raw

su b s ta n c e s, to fa c ilita te in tro s p e c tio n a b o u t the

a tte n tio n to the d a n g ers a sso c ia te d w ith the

c o n s e q u e n c e s o f risk y b e h a v io r, to e n co u ra g e

e sta b lish m e n t o f a n a b u siv e p a tte rn o f su b sta n ce

the c lie n t to c o n s id e r a s s e s s m e n t or tre a tm e n t,

use. For e x a m p le , a w o m a n w h o d rin k s

an d to e n c o u ra g e m o d e ra tio n or a b stin e n ce .

m o d e ra te ly and is p re g n a n t or w h o is
co n te m p la tin g a p re g n a n c y ca n b e a d v ised to
ab stain fro m a lc o h o l in o rd e r to p re v e n t fe ta l
a lco h o l sy n d ro m e . B rie f in te rv e n tio n s ca n a lso

T h e re is m ix e d e v id e n c e on w h e th e r p e rso n s
w h o m e e t c rite ria fo r s u b s ta n c e a b u se can
s u c c e s s fu lly re d u c e th e ir u se to m e e t lo w e r-risk
g u id e lin e s or if a b stin e n c e is th e o n ly re a so n a b le

e d u ca te clie n ts a b o u t th e n a tu re an d d a n g e rs of

g o a l. (S e e "R e s e a r c h F in d in g s " la te r in this

su b sta n ce ab u se an d p o ss ib le w a rn in g sig n s of

ch a p te r fo r a d is c u ss io n o f th is issu e.) B oth

d ep en d e n cy . O ld e r a d u lts w h o tak e c e rta in

re s e a rc h an d c lin ic a l e x p e rie n c e h a v e p ro d u ce d

m e d ica tio n s and u se a lco h o l, e v e n at th is lev el,

v a ry in g re s u lts re g a rd in g th is issu e. F ro m a

m ay be at risk fo r p ro b le m s d u e to the

clin ic a l s ta n d p o in t, h o w e v e r, s o m e clie n ts w h o

in te ra ctio n o f m e d ic a tio n s an d a lco h o l. See T IP

m e e t a b u se crite ria m a y n o t a c h ie v e a b stin e n ce

26, S u bstan ce A b u se A m o n g O ld er A d u lts (C S A T ,

b u t m ig h t b e n e fit fro m a p o sitiv e ,

1998b ), fo r g u id e lin e s on a lc o h o l u se in o ld er

n o n ju d g m e n ta l a p p ro a c h to c h a n g e th eir

a d u lth o o d .

b e h a v io r o v e r tim e. F o r e x a m p le , a fte r w o rk in g

At-Risk User

w ith a c lin ic ia n to m o n ito r p ro b le m s a sso cia ted

w ith th e s u b s ta n c e a b u s e , a c lie n t m ig h t a g ree

T h is g ro u p in clu d e s th o se w h o se u se is a b o v e
re co m m en d e d g u id e lin e s fo r a lco h o l u se (as
d escrib e d a b o v e ) or w h o se u se p u ts th em a t risk
fo r p ro b le m s re la ted to th e ir c o n s u m p tio n or at
risk fo r m e e tin g th e c rite ria fo r a su b sta n ce
ab u se d iso rd e r (e.g ., p e o p le w h o m a y b e a b le to
rep o rt the re q u isite n u m b e r o f s y m p to m s o f a

n o t to d riv e a fte r u sin g s u b s ta n c e s or m ig h t

c o n s id e r q u ittin g .
G o a ls o f b rie f in te rv e n tio n s w ith h a z a rd o u s
d rin k e rs w h o a re n o t a lc o h o l d e p e n d e n t h a v e
b e e n fle x ib le , a llo w in g th e in d iv id u a l to ch o o se
d rin k in g in m o d e ra tio n or a b stin e n c e . In su ch
ca ses, th e g o a l o f th e in te rv e n tio n is to m o tiv ate

su b stan ce ab u se d is o rd e r m a y n o t h a v e th ree or
17

C h ap ter 2

the p ro b lem d rin k e r to c h a n g e h is b e h a v io r, n o t

an d d e te rm in e s if th e c lie n t n e e d s an y a d d itio n a l

to a ssig n b la m e . H e lp in g clie n ts to re co g n iz e

serv ices.

the n eed fo r ch a n g e is an e ss e n tia l step in this

ASAM Criteria

p ro cess.

U n d e r A S A M c rite ria (se e F ig u re 2-3), b rie f

Substance-Dependent User

in te rv e n tio n s a re a im e d a t th e n o n d e p e n d e n t

In te rv e n tio n at th is le v e l o f u se m a y fo c u s on

u ser, a t le v e l 0 .5 or p o ss ib ly le v e l I. In d iv id u a ls

e n co u ra g in g u sers to c o n s id e r tre a tm e n t, to

a t le v e l II m a y b e a p p r o p ria te fo r a b rie f

c o n te m p la te a b stin e n c e , or to re tu rn to

in te rv e n tio n if re la p se p o te n tia l an d re c o v e ry

tre a tm e n t a fte r a re la p se . T h e g o a l o f

e n v iro n m e n t a re m a jo r p ro b le m s fo r th o se w ith

in te rv e n tio n fo r d e p e n d e n t u se rs is to

re la tiv e ly m in o r p h y s io lo g ic a l an d p s y c h o lo g ica l

re co m m en d the o p tim a l b e h a v io r c h a n g e and

s u b s ta n c e p ro b le m s a n d h ig h m o tiv a tio n to

lev el o f care . In re a lity , h o w e v e r, the clin ic ia n

c h a n g e . A S A M c rite ria h a v e b e e n e x trem ely

m ay be ab le to n e g o tia te a ch a n g e th e clie n t is

u se fu l fo r c lin ic a l m a n a g e m e n t o f p e rs o n s w ith

w illin g to a c c e p t an d w o rk o v e r tim e to w a rd

s u b s ta n c e a b u s e d is o r d e rs w h o re q u ire m o re

ab stin e n ce . F o r e x a m p le , if a c lie n t re sists

c a re th a n is n e e d e d fo r a t-ris k d rin k e rs . B rief

co m m ittin g to p ro lo n g e d a b stin e n c e , the

in te rv e n tio n s , w h e th e r d ire c te d at re d u c in g at-

p ro v id e r co u ld n e g o tia te a lim ite d p erio d

risk u se (o fte n u sed in p rim a ry c a re settin g s) or

en d in g w ith a " c h e c k u p ," a t w h ich tim e the

a ssistin g in sp e c ific a s p e c ts o f th e tre a tm e n t

clie n t m ig h t co n s id e r e x te n d in g a b stin e n c e

p ro c e ss, ca n b e h e lp fu l fo r c lie n ts at ev ery

fu rth er.

A S A M le v e l an d in m a n y tre a tm e n t settin g s.

It sh o u ld be n o ted th a t s o m e su b sta n c e -

Components of Brief
Interventions

d e p e n d e n t clie n ts m a y b e in a life -th re a te n in g

sta g e in th eir a d d ic tio n or risk serio u s
co n se q u e n ce s su ch as lo sin g th eir jo b s, g o in g to
jail, or lo sin g th e ir fa m ilie s. F o r th e se clie n ts,

T h e re is tre m e n d o u s d iv e r sity in th e p ro c e s s of

b rie f in te rv e n tio n s sh o u ld b e lin k e d to a re fe rra l

re c o v e ry fro m a s u b s ta n c e a b u s e d iso rd e r.

strate g y in w h ich th e g o a l is a th e ra p e u tic

C lie n ts m a k e c h a n g e s fo r d iffe re n t re a so n s, and

allia n ce b e tw e e n th e c lie n t an d th e re fe rra l

an in te rv e n tio n th a t w o rk s w e ll fo r o n e c lie n t

tre a tm e n t team . B rie f in te rv e n tio n in this

m a y n o t w o rk fo r a n o th e r. B rie f in te rv e n tio n s

co n tex t is m o re lik e "c a s e m a n a g e m e n t," in

a re c o m p o n e n ts o f th e jo u rn e y to w a rd re co v ery

w h ich the p rim a ry ca re p ro v id e r tra ck s the

an d c a n b e in te g ra l ste p s in th e p ro c e s s . F or

c lie n t's p ro g re ss w ith o th e r serv ice p ro v id e rs

s o m e c lie n ts , a s s is ta n c e w ith th e d e c is io n to

F ig u r e 2 -3
A m e r ic a n S o c ie ty o f A d d ic tio n M e d ic in e (A S A M ) P a tie n t P la c e m e n t C r ite r ia
A S A M h as d e v e lo p e d c lie n t p la c e m e n t c rite ria fo r the tre a tm e n t o f s u b s ta n c e -re la te d d is o rd e rs (1996).
A S A M d e lin e a te s the fo llo w in g lev els o f serv ice:

18

L ev el 0 .5 , e a rly in te rv e n tio n

L ev el I, o u tp a tie n t se rv ice s

L ev el II, in te n siv e o u tp a tie n t/ p a rtia l h o s p ita liz a tio n s erv ices

L e v e l III, re s id e n tia l in p a tie n t s erv ices

L ev el IV , m e d ic a lly -m a n a g e d in te n siv e in p a tie n t s erv ices

B r ie f In terv en tion s

m ake the ch a n g e w ill b e e n o u g h to m o tiv a te

1.

them to sta rt ch a n g in g th e b e h a v io r, w h e re a s

In tro d u cin g th e issu e in th e c o n te x t o f the

c lie n t's h e a lth

o th ers m a y n eed m o re in te n siv e clin ic a l

2.

S c re e n in g , e v a lu a tin g , an d a sse ssin g

in v o lv e m e n t th ro u g h o u t th e c h a n g e p ro cess.

3.

P ro v id in g fe e d b a c k

B rief in te rv e n tio n s c a n b e ta ilo re d to d iffe re n t

4.

T a lk in g a b o u t c h a n g e a n d s e ttin g g o a ls

p o p u la tio n s, an d m a n y o p tio n s are a v a ila b le to

5.

S u m m a riz in g a n d re a c h in g clo su re

a u g m en t in te rv e n tio n s an d tre a tm e n ts , s u c h as

P ro v id e rs m a y n o t h a v e to u se all fiv e of

A A , N A , an d m e d ic a tio n s. It sh o u ld b e n o ted ,

th e se c o m p o n e n ts in e v e ry se s s io n . It is m o re

h o w e v e r, th a t b rie f in te rv e n tio n s a re n o t a

im p o rta n t to u se th e c o m p o n e n ts th a t re flect the

su b stitu te fo r s p e cia liz e d c a re fo r clie n ts w ith a

n e e d s o f the c lie n t a n d h e r p e rs o n a l sty le.

h ig h lev el o f d e p e n d e n c y . T h e y c a n b e u sed to

B efo re e lim in a tin g ste p s in th e b rie f in te rv e n tio n

en g a g e clie n ts in sp e c ific a sp e cts o f tre a tm e n t

p ro c e s s , h o w e v e r, th e re s h o u ld b e a w e ll-

p ro g ra m s, su ch as a tte n d in g g ro u p an d A A or

d e fin e d re a s o n fo r d o in g so. M o re o v e r, a v ital

N A m e e tin g s. B rie f in te rv e n tio n s c a n a lso h e lp

p a rt o f th e in te rv e n tio n p ro c e s s is m o n ito rin g to

p o te n tia l clie n ts m o v e to w a rd s e e k in g tre a tm e n t

and can serv e as a te m p o ra ry m e a s u re fo r clie n ts
on w aitin g lists fo r tre a tm e n t p ro g ra m s. E v e n

d e te rm in e h o w th e p a tie n t is p ro g re ss in g a fter
th e in itia l in te rv e n tio n h a s b e e n co m p le te d .
M o n ito rin g a llo w s th e c lin ic ia n an d c lie n t to

clin icia n s w h o a d v o ca te a b stin e n c e as a g o a l can

use b rie f in te rv e n tio n s as to o ls to h e lp clie n ts

d e te rm in e g a in s a n d c h a lle n g e s an d to re d ire ct
th e lo n g e r te rm p la n w h e n n e c e s s a ry .

reach th at goal.

F o llo w in g a re d e sc rip tio n s o f th e fiv e b asic

T h e re are six e le m e n ts critic a l to a b rie f

step s. S a m p le sce n a rio s a re p ro v id e d w h ere b rief

in te rv e n tio n to c h a n g e s u b s ta n c e a b u se b e h a v io r
(M iller and S a n c h e z , 19 9 4 ). T h e a cro n y m

in te rv e n tio n s m ig h t b e in itia te d , w ith p ra ctica l

in fo rm a tio n a b o u t th a t p a rticu la r step . F or each

F R A M E S w as co in e d to su m m a riz e th e se a ctiv e

step , F ig u re 2-5 p re sen ts scrip ts fo r b rief

in g re d ien ts, w h ich are sh o w n in F ig u re 2-4. T h e

in te rv e n tio n s th a t clin icia n s ca n u se in su b stan ce

F R A M E S co m p o n e n ts h a v e b e e n c o m b in e d in

a b u se tre a tm e n t u n its or o th er settin g s w h ere

d iffe ren t w ay s an d te sted in d iv e rse se ttin g s and

in te rv e n tio n s m ig h t o ccu r. (F o r ex a m p le s

cu ltu ra l co n tex ts.

fo cu sed o n a t-risk d rin k ers, see T IP 24, A G u ide to

A b rie f in te rv e n tio n c o n s is ts o f fiv e b a sic

S u bstan ce A b u se S erv ices f o r P rim ary C are C linicians

step s th a t in c o rp o ra te F R A M E S a n d re m a in

[C S A T , 1997], F or d eta iled d escrip tio n s o f m ore

co n siste n t re g a rd le ss o f th e n u m b e r o f se ssio n s

te ch n iq u es, see T IP 35, E n h a n cin g M otiv ation fo r

or the len g th o f th e in te rv e n tio n :

C h an g e in S u b stan ce A b u se T reatm en t [C SA T ,
1999c]).

F ig u r e 2 -4
FRA M ES

F e ed b a ck is g iv e n to th e in d iv id u a l a b o u t p e rs o n a l risk or im p a irm e n t.

R e sp o n s ib ility fo r ch a n g e is p la c e d on th e p a rtic ip a n t.

A d v ice to ch a n g e is g iv e n b y th e p ro v id e r.

M e n u o f a lte rn a tiv e se lf-h e lp or tre a tm e n t o p tio n s is o ffe re d to th e p a rtic ip a n t.

E m p a th ic sty le is u sed in co u n se lin g .

S e lf-e ffic a c y or o p tim istic e m p o w e rm e n t is e n g e n d e re d in th e p a rtic ip a n t.

S ou rce: M ille r an d S a n c h e z , 1993.

19

C h ap ter 2

F ig u re 2 -5
S c rip ts fo r B rie f In te rv e n tio n

C om ponent

Script in the em ergency departm ent,

Script in the su b stan ce abuse

prim ary care office, or oth er setting

treatm en t unit

w here consultations w ill be

perform ed
In tro d u cin g
the Issu e

" I 'm fro m th e su b sta n c e a b u se

" W o u ld it b e O K w ith y o u if w e

d iso rd e r u n it. Y o u r d o cto r a sk ed m e

d is cu ss s o m e o f th e d iffic u ltie s y o u 'v e

to stop b y to te ll y o u a b o u t w h a t w e do

h a d in g e ttin g h o m e w o rk d o n e fo r the

on th a t un it. W o u ld y o u b e w illin g to

g ro u p m e e tin g s a n d h o w w e c a n w o rk

ta lk to m e b rie fly a b o u t it? W h a te v e r

to g e th e r to h e lp y o u ta k e a d v a n ta g e o f the

w e talk a b o u t w ill re m a in

tre a tm e n t p r o c e s s ? "

c o n fid e n tia l." O r, "T h is m u s t b e to u g h

fo r y ou . W o u ld it b e O K w ith y o u if
w e ta k e a few m in u te s to ta lk a b o u t
y o u r d rin k in g ? "
S cre en in g ,

" I n re v ie w in g the in fo rm a tio n

" G iv e n w h a t y o u se e as th e a d d itio n a l

E v a lu a tin g , an d

y o u 'v e g iv e n m e , u sin g a sc a le o f 'n o t

stre ss in y o u r fa m ily a n d y o u r d e sire to

A sse ssin g

re a d y ,' 'u n s u re ,' an d 'r e a d y ,' h o w

m a k e th e tre a tm e n t w o rk fo r y o u th is

p re p a re d d o y o u feel y ou are to stop

tim e , o n a sc a le o f 1 to 10, h o w re a d y do

d rin k in g ? "

y o u fe e l to fin d a w a y to p u t tim e into

C lie n t sa y s "u n s u r e ."

" O n e o f th e fa cto rs th a t m ig h t tie
to g e th e r y o u r a cc id e n t an d y o u r

your h o m ew o rk ?"
C lie n t sa y s, " 6 ."
" I a m p le a s e d th a t y o u a re w illin g to

p ro b le m s w ith y o u r w ife is y o u r

c o n s id e r try in g th is, e v e n th o u g h it w o n 't

d rin k in g ."

b e e a sy . L e t's c o m e u p w ith so m e

" I th in k it w o u ld b e w o rth ta lk in g
m o re to s o m e o f th e p e o p le a t th e

s tra te g ie s th a t w e c a n w rite d o w n to h e lp
y o u a c c o m p lis h th is g o a l."

su b sta n c e a b u se d iso rd e r u n it so th a t
y o u r p ro b le m s d o n 't g e t w o r s e ," or, " I
th in k a 2 -w e e k trial w h e n y o u d o n 't
d rin k a lco h o l at all w o u ld b e h e lp fu l in
d e te rm in in g w h e th e r or n o t d rin k in g
m a k e s th in g s w o rs e and if sto p p in g
u se w o rk s fo r y o u . W h a t d o y o u
th in k ? "
P ro v id in g
F e ed b a ck

20

" I 'd lik e to g e t so m e c o n fid e n tia l

" I 'd lik e to ta lk a b o u t w h a t w a s g o in g

in fo rm a tio n a b o u t y o u r d rin k in g to

on w h e n y o u d e c id e d n o t to d o the

g iv e m e a b e tte r id ea o f y o u r d rin k in g

h o m e w o rk a s s ig n m e n t. C a n y o u tell m e a

sty le. C a n y o u tell m e h o w m a n y d ay s

little a b o u t w h a t y o u w e re th in k in g or

a w e e k y o u d rin k ? H o w m a n y d rin k s

fe e lin g a t th e tim e ? W h y d o y o u th in k it

a d ay?"

w a s d iffic u lt to g e t y o u r h o m e w o rk d o n e?

B r ie f In terv en tion s

F ig u re 2 -5 (c o n tin u e d )
S c rip ts fo r B rief In te rv e n tio n
" H a v e th e re b e e n o th e r p a rts of

"H a v e y o u h a d a n y p ro b le m s w ith

P ro v id in g
F e ed b ack

y o u r h e a lth , fa m ily or p e rs o n a l life , or

(co n tin u e d )

w o rk in th e la st 3 m o n th s? W e re y o u

tre a tm e n t th a t h a v e b e e n h a rd to fo llo w ? "

d rin k in g in th e 6 h o u rs b e fo re y o u r
a cc id e n t to o k p la c e ? "
" Y o u 'v e sa id th a t y o u c o m p le te ly

" I t lo o k s as if y ou h a v e b e e n h a v in g

T alk in g
A bout

a b o u t 3 0 -3 5 d rin k s a w e e k an d h a v e b e e n

fo rg o t to d o th e h o m e w o rk b e c a u se of

C h an g e and

d o in g s o m e b in g e d rin k in g o n w e e k e n d s.

a rg u m e n ts w ith y o u r w ife a n d d a u g h ter

S e ttin g G o als

Y o u 'v e sa id th a t y o u r a c c id e n t to o k p la ce

an d th a t th is su rp ris e d y o u b e c a u se y o u

a fte r y o u 'd h a d s o m e a lco h o l, an d y ou

h a d re a lly in te n d e d to g e t it d o n e . Is th at

sa id y o u 'v e b e e n u n d e r a lo t o f s tre ss w ith

a b o u t r ig h t? "

y o u r fa m ily an d a t w o rk . Y o u a lso
in d ic a te d th a t y o u d o n 't re a lly th in k
a lco h o l is m a k in g th in g s w o rs e , b u t
y o u 're w illin g to th in k a b o u t th at. Is th a t
a n a cc u ra te a s s e s s m e n t o f h o w y o u see
it? "
S u m m a riz in g

" E v e n th o u g h y o u 're n o t re a d y to stop

" Y o u ju s t d id a g o o d p ie c e o f w o rk . I

and R e a ch in g

d rin k in g a t th is tim e, I'm g la d y ou a g re ed

th in k y o u m a d e s o m e p ro g re ss . I'm g lad

C lo su re

to w rite d o w n th e p ro s an d co n s o f n o t

y o u 're try in g s o m e th in g n e w . H o w a b o u t

d rin k in g . H o w a b o u t if w e m e e t

if w e m e e t a g a in in a w e e k to see h o w

to m o rro w fo r a fo llo w u p ? "

th in g s w e n t fo r y o u ? "

Introducing the Issue

le n g th fro m a sin g le q u e s tio n to se v e ra l h o u rs of

In th is step , the c lin ic ia n se e k s to b u ild ra p p o rt

a s s e s s m e n t o n th e ta rg e te d to p ic o f ch a n g e . It

w ith th e clie n t, d e fin e th e p u rp o s e o f th e sessio n ,

co u ld in v o lv e a s tru c tu r e d or n o n stru c tu re d

g a in p e rm issio n fro m th e c lie n t to p ro c e e d , and

in te rv ie w o r a c o m b in a tio n o f b o th , co u p led

h elp the c lie n t u n d e rsta n d th e re a s o n fo r the

w ith q u e s tio n n a ire s or sta n d a rd iz e d

in te rv e n tio n .

in s tru m e n ts, w ith th e e x te n t o f th e p ro ce ss

C o u n selin g tips: H e lp th e clie n t u n d e rsta n d

d e te rm in e d la rg e ly b y th e se ttin g , tim e, an d

the fo cu s o f th e in te rv ie w . S ta te th e ta rg e t to p ic

a v a ila b le re s o u rc e s . A s a m p le s c re e n in g

clea rly an d stre ss c o n fid e n tia lity ; b e

g u id e lin e fo r alcoh olism is p ro vid ed in Figure 2-6.

n o n ju d g m e n ta l an d a v o id la b e ls. D o n o t sk ip

A d d itio n a l in fo r m a tio n a b o u t a n d e x a m p le s o f

this o p e n in g ; w ith o u t it, the s u cc e s s o f th e n e x t

scre e n in g a n d a s s e s s m e n t in s tru m e n ts ca n b e

step s co u ld b e je o p a rd iz e d .

fo u n d in th e fo llo w in g T IP S : T IP 9, A ssessm en t
a n d T reatm en t o f P a tien ts W ith C o ex istin g M en tal

Screening, Evaluating,
And Assessing

A ssessm en t a n d T rea tm en t o f C o ca in e-A b u sin g

In g e n era l, th is is a p ro c e s s o f g a in in g

M e th a d o n e-M a in ta in e d P a tien ts; T IP 11, S im p le

in fo rm a tio n on th e ta rg e te d p ro b le m ; it v a rie s in

S creen in g In stru m en ts f o r O u trea ch f o r A lco h o l an d

Illn ess a n d A lc o h o l a n d O th er D ru g A b u se; T IP 10,

21

C hapter 2

F ig u r e 2 -6
S c re e n in g fo r B rief In te rv e n tio n s fo r A lc o h o lis m
Screen
A t each visit, a sk a b o u t a lc o h o l use

H ow m a n y d rin k s p e r w e e k ?

M a x im u m d rin k s p e r o c ca sio n in p a s t m o n th ?

Use CAG E questions to probe for alcohol problem s

H a v e you e v e r tried to C u t d o w n on y o u r d rin k in g ?

D o y o u g e t A n n o y e d w h e n p e o p le ta lk a b o u t y o u r d rin k in g ?

D o y o u fe e l G u ilty a b o u t y o u r d rin k in g ?

H av e you e v e r h a d an E y e -o p e n e r? (i.e. a d rin k firs t th in g in th e m o rn in g )

Screen is positive if

C o n s u m p tio n is g re a te r th a n 14 d rin k s p e r w e e k or g re a te r th a n 4 d rin k s p e r o c c a s io n (m en )

C o n s u m p tio n is g re a te r th a n 7 d rin k s p e r w eek or g re a te r th an 3 d rin k s p e r o c c a s io n (w o m e n )

C A G E sco re is g re a te r th a n 1

Then assess for

M ed ical p ro b lem s: b la c k o u ts , d e p re ssio n , h y p e rte n s io n , tra u m a , a b d o m in a l p a in , liv e r d y sfu n c tio n ,

sex u a l p ro b le m s, sle e p d iso rd e rs

L ab oratory : e le v a te d g a m m a -g lu ta m y l tra n sp e p tid a s e or o th e r liv e r fu n c tio n te sts; e le v a te d m e a n

c o rp u s cu la r v o lu m e ; p o sitiv e b lo o d a lc o h o l c o n c e n tra tio n s

B eh av ioral p ro b lem s: w o rk , fa m ily , sch o o l, a ccid e n ts

A lcoh ol d ep en d en ce: a sco re o f 3 or h ig h e r o n C A G E or o n e or m o re o f th e fo llo w in g : co m p u ls io n to

d rin k , im p a ire d co n tro l, w ith d ra w a l s y m p to m s , in cre a se d to le ra n c e , re lie f d rin k in g

S ou rce: A S A M , 1 9 9 4 ; re p rin te d w ith p e rm issio n .

O th er D ru g A b u se an d In fectiou s D iseases; T IP 24,

d u rin g s c re e n in g . It in v o lv e s a n in te ra c tiv e

A G u ide to S u b sta n ce A b u se S erv ices f o r P rim ary

d ia lo g fo r d is c u ss in g th e a s s e s s m e n t fin d in g s; it

C are C lin icia n s; an d T IP 3 1 , S creen in g an d

is n o t ju s t c lin ic ia n d riv e n . F e e d b a c k sh o u ld be

A ssessin g A d o lescen ts f o r S u bsta n ce U se D isord ers

g iv e n in s m a ll a m o u n ts. F irst, th e c lin ic ia n giv es

(C S A T , 1994b , 1 994c, 1994d , 1 9 9 7 ,1999a).

a sp e cific p ie c e o f fe e d b a c k , th e n a sk s fo r a

C ou n selin g tips: B e fo re y o u b e g in the b rie f

re s p o n s e fro m th e clie n t. S o m e tim e s the

in te rv e n tio n , d e c id e h o w m u c h in fo rm a tio n y ou

fe e d b a c k is a b rie f, sin g le s e n te n c e ; a t o th er

h a v e tim e to o b ta in an d w h e th e r y o u w a n t to

tim es it c o u ld la st an h o u r o r m o re . F ig u re 2-7

h a v e the clie n t a n sw e r a n y q u e stio n n a ire s.

p ro v id e s an e x a m p le o f g iv in g fe e d b a c k .

W a tch fo r d e fe n s iv e n e ss or o th er re s ista n ce , and

av o id p u sh in g to o h a rd .

C o u n selin g tips: U s e a c tiv e lis te n in g (see

"A c tiv e lis te n in g " la te r in th is c h a p te r). Be
a w a re o f c u ltu ra l, la n g u a g e , an d lite ra cy issu es.

Providing Feedback
T h is c o m p o n e n t h ig h lig h ts ce rta in a sp e c ts o f the
c lie n t's b e h a v io r u sin g in fo rm a tio n g a th e re d

22

Be n o n ju d g m e n ta l.

B r ie f In terv en tion s

F ig u r e 2 -7
C lie n t F e e d b a c k a n d P lan o f A c tio n
G ive sp ecific feed b a ck to th e p atien t, th en ad v ise in a firm b u t e m p a th ic m an n er
If diagnosed as at risk:

If diagn osed as alcohol d ep endent:

A d v ise p a tie n t o f risk

A d v is e p a tie n t o f o b je c tiv e e v id e n c e

A d v ise a b stin e n ce or m o d e ra tio n

A d v is e on p la n o f a c tio n

Set d rin k in g g o a ls

A sse ss a cu te risk o f in to x ic a tio n or w ith d ra w a l

S ch e d u le fo llo w u p to d iscu ss p ro g re ss

M e d ic a l an d p s y c h ia tric c o m o rb id itie s
A g re e o n p la n o f a c tio n

Plan of A ction
In v o lv e fa m ily : re fe r fo r fa m ily tre a tm e n t and
se lf-h e lp (e .g ., A l-A n o n , e tc .) (m u st h a v e
p a tie n t p e rm is s io n a n d in v o lv e m e n t)
S tre ss a b stin e n c e
U rg e p a tie n t to a tte n d se lf-h e lp m e e tin g s (A A ,
N A , S e lf-M a n a g e m e n t a n d R e c o v e ry T ra in in g
[S M A R T ], e tc.)
C o n s id e r re fe rra l to a d d ic tio n m e d icin e
sp e cia lis t, a n d / o r p o ss ib le p h a rm a c o th e ra p y
w ith d is u lfira m (A n ta b u s e ) or n a ltre x o n e
(R eV ia )
Sou rce: A S A M , 1 9 9 4 ;.re p rin te d w ith p e rm issio n .

Talking About Change

And Setting Goals

clie n t w h o is try in g to sto p u sin g c o ca in e b u t

w a n ts to c o n tin u e to d rin k a lco h o l.)

T a lk in g a b o u t c h a n g e in v o lv e s ta lk in g a b o u t the

In ta lk in g a b o u t c h a n g e , th e c lin ic ia n o ften

p o ssib ility o f ch a n g in g b e h a v io r. It is u sed w ith

su g g e sts a c o u rs e o f a ctio n , th e n n e g o tia te s w ith

clien ts in all s ta g e s o f ch a n g e , b u t it d iffe rs

th e c lie n t to d e te rm in e e x a c tly w h a t h e is w illin g

p ro fo u n d ly d e p e n d in g on th e sta g e th e c lie n t

to d o. S o m e tim e s , ta lk in g a b o u t ch a n g e is

has re a ch e d . F o r e x a m p le , in p re c o n te m p la tio n ,

p re m a tu re (i.e., b e fo re th e a s s e s s m e n t and

clien ts are h e lp e d to re c o g n iz e a n d ch a n g e th eir

fe e d b a c k h a v e h a p p e n e d ). In th a t ca se , it sh o u ld

v iew o f c o n s e q u e n c e s ; in c o n te m p la tio n , th e y

b e p o stp o n e d u n til la te r in th e in te rv e n tio n .

are h e lp ed to re so lv e a m b iv a le n c e a b o u t ch a n g e .

C o u n selin g tip s: O ffe r c h a n g e o p tio n s th a t

In actio n , th e fo cu s is on p la n n in g , re m o v in g

m a tc h c lie n t's re a d in e s s fo r c h a n g e . B e rea listic:

b a rrie rs, an d a v o id in g risk y s itu a tio n s ; in

R e c o m m e n d th e id e a l c h a n g e , b u t a c c e p t less if

m a in te n a n ce , th e e m p h a s is is o n e sta b lis h in g

th e c lie n t is re s is ta n t.

new lo n g -te rm b e h a v io rs. It is im p o rta n t th a t

the clin icia n a sse ss th e c lie n t's re a d in e s s to
ch an g e if it is n o t a lre a d y k n o w n . (S e e F ig u re
2-8 fo r e x a m p le s o f d isc u ssin g c h a n g e w ith a

Sum m arizing and

Reaching Closure
T h is ste p in v o lv e s a s u m m a ry o f the d iscu ssio n
an d a re v ie w o f th e a g re e d -u p o n ch a n g e s.
23

C h ap ter 2

F ig u r e 2 -8
T a lk in g A b o u t C h a n g e a t D iffe re n t S ta g e s
In this e x a m p le , a c lie n t w h o h a s c o m e to tre a tm e n t to sto p u sin g c o c a in e h a s h e r a lc o h o l u se b ro u g h t
to h e r a tte n tio n . A t e a ch sta g e o f re a d in e ss, th e c o u n s e lo r m ig h t u se a d iffe re n t s tra te g y . F o llo w in g are
so m e o f the p o ss ib le sc rip ts th a t m ig h t b e u sed :

P recon tem p la tio n : "S o m e p e o p le fin d it h e lp fu l to a sk o th e rs in a g ro u p if a n y o f th e m trie d to q u it

co ca in e b u t co n tin u e d d rin k in g . If y o u w e re to try th a t w ith y o u r g ro u p , y o u m ig h t b e su rp ris e d at
w h a t y o u h e a r. W h a t d o y o u th in k ? "

C o n tem p la tio n : "O n e th in g y o u m ig h t try is w ritin g a list o f th e p ro s a n d co n s o f s to p p in g d rin k in g ,

as y ou see th em . Ju s t w rite d o w n all the id e a s th a t c o m e to y o u , n o m a tte r h o w silly or o ffb e a t they
seem . T h is m a y h e lp y ou g e t a c le a re r p ic tu re o f y o u r situ a tio n . Is th a t s o m e th in g y o u 'd b e w illin g
to try ? "

A c tio n : " Y o u 'v e sa id y o u w a n t to try q u ittin g a lc o h o l, as w e ll as c o c a in e . C a n w e ta lk a b o u t h ow

y o u m ig h t g o a b o u t m a k in g th a t h a p p e n ? "

M a in ten an ce: "T h in g s h a v e im p ro v e d in a lo t o f w a y s fo r y o u . I'd lik e to m e e t w ith y o u e a c h m o n th

fo r a w h ile to ta lk a b o u t w h a t th in g s w o rk fo r y o u an d w h a t th in g s d o n 't w o rk as w e ll." (B e ca u se
re la p se ca n o ccu r a t an y p o in t in th e ch a n g e p ro c e ss, a d d re s s in g th is issu e in a p ro a c tiv e , p o sitiv e
m a n n e r is u se fu l.)

If n o a g re e m e n t w a s re a c h e d , re v iew the
p o sitiv e a ctio n th e clie n t to o k d u rin g th e sessio n .
A t th is p o in t, it is im p o rta n t to sc h e d u le a
fo llo w u p v isit to ta lk a b o u t h o w th e c lie n t is

B rie f in te rv e n tio n p ro to c o ls o fte n in v o lv e u sin g

p ro g re ssin g . T h e fo llo w u p c o u ld b e a n o th er

a w o rk b o o k th a t is b a se d o n th e ste p s listed

fa ce -to -fa ce m e e tin g , a te le p h o n e c a ll, or e v e n a

b elo w . A w o rk b o o k p ro v id e s th e c lie n t and

v o ice m ail m e ssa g e. T h e g o a ls o f c lo sin g on

c lin ic ia n w ith o p p o rtu n itie s to d is c u ss the

goo d te rm s are to a rra n g e a n o th e r se ssio n , to

c lie n t's cu e s fo r u sin g s u b s ta n c e s, re a s o n s fo r

leav e the clie n t fe e lin g s u c c e ssfu l, an d to in still

u sin g s u b s ta n c e s, a n d re a s o n s fo r c u ttin g d o w n

co n fid e n ce th at w ill e n a b le th e c lie n t to fo llo w

or q u ittin g . It a lso u s u a lly p ro v id e s a su b sta n ce

th ro u g h on w h a t w a s a g re ed u p o n

a b u se a g re e m e n t in th e fo rm o f a p re s c rip tio n

C ou n selin g tips: T a ilo r y o u r clo su re to the

an d s u b s ta n c e a b u s e d ia ry c a rd s fo r self-

clie n t and th e p a rtic u la r c irc u m sta n c e o f this

re p o rtin g . T h e s e te c h n iq u e s , w h ic h o ften ta rg e t

b rie f in te rv e n tio n ; in te rp re t an y c lie n t re sista n c e

re d u c tio n in s u b s ta n c e a b u s e ra th e r th a n

in a p o sitiv e lig h t le a d in g to p ro g re ss. T h u s, if a

a b stin e n c e , a re s im ila r to h o m e w o rk te c h n iq u e s

c lie n t h as b e e n u n w illin g to c o m m it to ch a n g e s,

used in s u b s ta n c e a b u s e tre a tm e n t p ro g ra m s. A

th an k h er fo r h e r w illin g n e ss to c o n s id e r the

sa m p le o f a w o rk b o o k u se d to a d d re s s d rin k in g

issu es and e x p re ss th e h o p e th a t sh e w ill

p ro b le m s is p ro v id e d in A p p e n d ix D . T h e step s

co n tin u e to co n s id e r c o m m ittin g to c h a n g e s.

24

Brief Intervention
Workbooks

B r ie f In terv en tion s

in the w o rk b o o k fo llo w a s c rip t an d m a y fo cu s

on th e fo llo w in g :

Id e n tifica tio n o f fu tu re g o a ls fo r h e a lth ,

a ctiv itie s, h o b b ie s, re la tio n sh ip s , an d

Essential Knowledge and

Skills for Brief
Interventions

fin a n cia l sta b ility

C u sto m iz e d fe e d b a ck on sc re e n in g q u e stio n s
re la tin g to s u b s ta n c e a b u se p a tte rn s an d
oth er h e a lth h a b its (a lso m a y in clu d e
sm o k in g , n u tritio n , etc.)

D iscu ssio n o f w h ere th e c lie n t's su b sta n ce

ab u se p a tte rn s fit in to th e p o p u la tio n n o rm s
fo r h is ag e g ro u p

Id e n tifica tio n o f th e p ro s an d co n s of
s u b sta n ce a b u s e th is is p a rtic u la rly
im p o rta n t b e c a u se the c lin ic ia n m u st
u n d e rsta n d th e ro le o f s u b s ta n c e a b u se in the

P ro v id in g e ffe c tiv e b rie f in te rv e n tio n s re q u ires

k n o w le d g e , s k ills, a n d a b ilitie s. S tu d ie s h a v e
s h o w n th a t a p p ly in g th e c lin ic ia n 's s k ills listed
b e lo w p ro d u c e s g o o d o u tc o m e s , in clu d in g
g e ttin g c lie n ts to e n te r tre a tm e n t, w o rk h a rd e r in
tre a tm e n t, sta y lo n g e r in tre a tm e n t, and hav e
b e tte r o u tc o m e s a fte r tre a tm e n t su ch as h ig h e r
p a rtic ip a tio n in a fte rc a r e an d b e tte r so b rie ty
ra te s (B ro w n an d M ille r, 1 9 9 3 ; M ille r et al.,
1993).

a c c e p ta n c e

co n te x t o f the c lie n t's life (g iv e n the

o p p o rtu n ity to d is c u ss the p o sitiv e a sp e cts of

C o u n s e lin g s k ills s u c h as a c tiv e liste n in g and

h e r s u b s ta n c e a b u se, th e c lie n t m a y talk

h e lp in g c lie n ts e x p lo r e an d re so lv e

a b o u t h e r co n c e rn s h o n e stly in stea d of

a m b iv a le n c e

fe e lin g sh e s h o u ld say w h a t sh e th in k s the

w o rk in g re la tio n sh ip )
C o n se q u e n c e s o f c o n tin u e d s u b s ta n c e u se to
e n co u ra g e th e c lie n t to d e c re a se or stop
a b u sin g su b s ta n ce s an d a v o id lo n g e r term

A fo cu s o n in te rm e d ia te g o a ls (see d iscu ssio n

e a rlie r in th is c h a p te r)

clin icia n w a n ts to h e a r; th is b u ild s a b e tte r

O v e ra ll a ttitu d e o f u n d e rs ta n d in g and

W o rk in g k n o w le d g e o f th e s ta g e s-o f-c h a n g e
m o d e l (se e d is c u s s io n e a rlie r in th is ch a p ter)

Attitude of Understanding
And Acceptance

e ffe cts o f co n tin u e d s u b s ta n c e a b u se

R e a so n s to cu t d o w n or q u it u sin g

C lin ic ia n s m u s t a s s u re th e ir c lie n ts th a t th ey w ill

(m a in ta in in g fa m ily , w o rk , in d e p e n d e n c e ,

liste n c a re fu lly an d m a k e e v e ry e ffo rt to

and p h y sica l h e a lth all m a y be im p o rta n t

u n d e rsta n d th e c lie n t's p o in t o f v ie w d u rin g a

m o tiv a to rs)

b rie f in te rv e n tio n . B rie f in te rv e n tio n s a re by

S e n sib le u se lim its an d s tra te g ie s fo r c u ttin g

d e fin itio n tim e lim ite d , w h ic h in c re a se s th e

d o w n or q u ittin g u se fu l s tra te g ie s in clu d e

d iffic u lty o f a d o p tin g s u c h a n a ttitu d e .

d e v e lo p in g s o c ia l o p p o rtu n itie s th a t d o n o t

H o w e v e r, w h e n c lie n ts e x p e rie n c e this

in v o lv e a b u sin g su b s ta n c e s an d b e c o m in g

n o n ju d g m e n ta l, re s p e c tfu l in te re s t and

re a cq u a in ted w ith h o b b ie s an d in te rests

u n d e rs ta n d in g fro m th e c lin ic ia n , th ey fe e l safe

A su b sta n ce a b u se a g re e m e n t a g re e d -u p o n

to o p e n ly d is c u ss th e ir a m b iv a le n c e a b o u t

use lim its (or a b stin e n ce ) sig n e d by the c lie n t

c h a n g e ra th e r th a n re s is t p re s s u re fro m the

and th e c lin ic ia n ca n o ften b e an e ffe c tiv e

c lin ic ia n to c h a n g e b e fo re th e y a re re a d y to do

w ay to a lte r u se p a tte rn s

so. T h e so o n e r th e y a d d re s s th e ir a m b iv a le n ce ,

C o p in g w ith risk y situ a tio n s (e .g ., s o c ia liz in g

the so o n e r th e y p ro g re s s to w a rd la stin g ch a n g e

w ith su b sta n ce u sers, iso la tio n , b o re d o m ,

(see a lso T IP 3 5 , E n h a n cin g M o tiv a tion f o r C h an ge

and n e g a tiv e fa m ily in te ra c tio n s )

in S u b sta n ce A b u se T reatm en t [C S A T , 1999c]).

S u m m a ry o f th e sessio n
25

C h ap ter 2

W h e n c lie n ts fe e l they are b ein g p u sh ed

a sk o p e n -e n d e d q u e s tio n s to w h ich th e clie n t

to w ard ch a n g e e v e n if th e clin ic ia n is n o t

m u st re s p o n d w ith a sta te m e n t, ra th e r th a n a

p u sh in g th ey a re lik e ly to resist. C lie n ts m u st

s im p le y es or n o . In s te a d o f su m m a riz in g a

su m m o n all o f th e ir a tte n tio n an d s tre n g th to

situ a tio n an d th e n a s k in g , " I s th is c o r r e c t? " ask

reso lv e th eir a m b iv a le n c e , an d re sistin g the

th e c lie n t, "W h a t d o y o u th in k ? H o w d o y ou

clin icia n m a y ca u se th e m to lo se tra ck an d a rg u e

fe e l a b o u t th e s itu a tio n ? " O p e n -e n d e d

ag a in st ch a n g e . If th e clie n t an d clin ic ia n b eg in

q u e s tio n s a re in v ita tio n s to sh a re a n d p ro v id e a

a rg u in g or d eb a tin g , th e c lin ic ia n sh o u ld

m e a n s to p ro b e fo r im p o r ta n t in fo rm a tio n th at

im m e d ia te ly sh ift to a n ew s tra te g y , o th e rw ise

e m e rg e s in th e in te rv ie w .

the b rie f in te rv e n tio n w ill fail. In o th e r w o rd s,

Exploring and resolving ambivalence

re sista n ce is a sig n a l fo r th e c lin ic ia n to ch a n g e

A n o th e r im p o r ta n t sk ill is th e a b ility to help

stra te g ies an d d e fu se the re sista n ce .

clie n ts e x p lo re a n d re s o lv e a m b iv a le n c e .

Counseling Skills

A m b iv a le n c e is th e h a llm a rk o f a p e rs o n in the
c o n te m p la tio n sta g e o f re a d in e s s . It is o n e o f the

Active listening

m o st p re v a le n t c lin ic a l c h a lle n g e s e n c o u n te re d

O n e o f the m o st im p o rta n t sk ills fo r b rie f

in b rie f in te rv e n tio n s . W h e th e r it ta k e s 1 m in u te

in te rv e n tio n ists is " a c tiv e lis te n in g " (see F ig u re

or 4 0 m in u te s, th e g o a l is to h e lp c lie n ts b e c o m e

2-9). A ctiv e liste n in g is th e a b ility to a c cu ra te ly

m o re a w a re o f th e ir p o sitio n a n d th e d isc o m fo rt

re sta te the co n te n t, fe e lin g , an d m e a n in g o f the

th a t a c c o m p a n ie s th e ir a m b iv a le n c e . In cre a sin g

clie n t's sta te m e n ts. T h is is a lso ca lle d "r e fle c tiv e

a w a re n e s s o f th is d is c o m fo r t w ith in an

lis te n in g ," "r e fle c tin g ," or s o m e tim e s

u n d e rs ta n d in g a n d s u p p o rtin g re la tio n sh ip can

"p a ra p h ra s in g ." A ctiv e liste n in g is o n e o f the

in sp ire th e c lie n t to p ro g re ss to a s ta g e of

m o st d irect w a y s to ra p id ly fo rm a th e ra p e u tic

p re p a ra tio n o r a c tio n . F o r e x a m p le , a c lie n t

a llian ce. W h e n d o n e w e ll, it is a p o w e rfu l

m ig h t b e w illin g to g o to c o u n s e lin g b u t n o t an

te ch n iq u e fo r u n d e rs ta n d in g a n d fa c ilita tin g

A A m e e tin g ; in th a t c a s e , th e c lin ic ia n sh o u ld

ch a n g e in clie n ts. A c tiv e lis te n in g g o e s b ey o n d

w o rk w ith th e c lie n t's m o tiv a tio n a n d fo cu s on

n o n v e rb a l liste n in g sk ills or re sp o n se s su ch as,

the p o sitiv e ste p th e c lie n t is w illin g to m ak e.

"H m m m ," " U h -h u h ," " I s e e ," " I h e a r y o u ," or " I

O n e w a y to h e lp a c lie n t re c o g n iz e h is

u n d e rstan d w h e re y o u 're c o m in g fr o m ." N o n e

a m b iv a le n c e is to a sk h im to id e n tify the b e n e fits

o f th ese sh o rt sta te m e n ts d e m o n s tra te s th a t the

an d c o sts o f th e ta rg e te d b e h a v io r (e .g ., u sin g

clin icia n u n d e rsta n d s. C o u n s e lo rs sh o u ld a lso

a lco h o l) a n d th e b e n e fits an d c o sts o f c h a n g in g

F ig u re 2 -9
S te p s in A c tiv e L is te n in g
1.

Listen to w h a t th e c lie n t say s.

2.

Form a reflectiv e statem en t. T o re fle c t y o u r u n d e rsta n d in g , re p e a t in y o u r o w n w o rd s w h a t the clie n t

said .

3.

T est the accu ra cy o f y o u r reflectiv e statem en t. W a tch , liste n , a n d / o r a sk th e c lie n t to v e rify th e a cc u ra cy

o f the co n te n t, fe e lin g , a n d / o r m e a n in g o f th e sta te m e n t.

S k illed a ctiv e liste n e rs p e rfo rm th e se th ree ste p s a u to m a tic a lly , n a tu ra lly , s m o o th ly , a n d q u ick ly . A ctiv e
liste n in g sa v e s tim e b y re d u c in g or p re v e n tin g re s ista n c e , fo c u s in g th e c lie n t, fo c u s in g th e clin ic ia n ,
e n co u ra g in g s e lf-d is c lo su re , an d h e lp in g th e c lie n t re m e m b e r w h a t w a s sa id d u rin g th e in te rv e n tio n .

26

B r ie f In terv en tion s

the b eh a v io r. T h e c lin ic ia n liste n s and

in te rv e n tio n s ca n b e u se d w ith c lie n ts b efo re ,

su m m a riz es th e se b e n e fits an d co sts, th e n ask s

d u rin g , a n d a fte r s u b s ta n c e a b u s e tre a tm e n t.

T o in te g ra te th e u se o f b rie f in te rv e n tio n s

the clie n t if an y o f th e m is m o re im p o rta n t th an

the o th ers. T h is h e lp s id e n tify v a lu e s th a t are

in to s p e c ia liz e d tre a tm e n t, c o u n s e lo rs and

im p o rta n t to the c lie n t an d ca n th e re fo re

p ro v id e rs s h o u ld b e tra in e d to p ro v id e this

in cre a se or d e c re a se the c h a n ce o f ch a n g in g .

se rv ice . T h e C o n s e n s u s P a n e l re c o m m e n d s th at

C lin icia n s m ig h t a lso a sk if an y o f th e p ro s an d

a g e n cie s c o n s id e r a llo c a tin g c o u n s e lo r tra in in g

con s is m o re or less a c c u ra te th a n o th ers. T h is

tim e an d re s o u r c e s to th e s e m o d a litie s . T h e

p ro v id e s an o p p o rtu n ity fo r irra tio n a l th o u g h ts

P a n el a n tic ip a te s th a t b rie f in te rv e n tio n s w ill

to b e re fu te d , w h ich ca n h e lp re m o v e b a rrie rs to

h e lp a g e n c ie s m e e t th e in c re a s in g d e m a n d s of

ch a n g e (see e x a m p le in th e te x t b o x b elo w ).

th e m a n a g e d c a re in d u s try a n d fill th e g a p s th at

A n o th e r a p p ro a ch to ra isin g a w a re n e ss o f

h a v e b e e n le ft in c lie n t ca re . It is a lso e x trem ely

a m b iv a le n ce is to e x p lo re th e c lie n t's e x p e rie n c e

im p o r ta n t fo r s u b s ta n c e a b u s e tre a tm e n t

o f fe e lin g ca u g h t b e tw e e n o p p o s in g d e sire s. F or

p e rs o n n e l to c o lla b o r a te w ith p rim a ry care

m o re sp e cific te c h n iq u e s fo r re so lv in g

p ro v id e rs , e m p lo y e e a s s is ta n c e p ro g ra m (E A P )

a m b iv a le n ce , se e T IP 35, E n h a n cin g M otiv a tio n f o r

p e rs o n n e l, w e lln e s s c lin ic s ta ff, a n d oth er

C h an g e in S u bsta n ce A b u se T rea tm en t (C S A T ,

c o m m u n ity -b a s e d s e rv ic e p ro v id e rs in

1999c).

d e v e lo p in g p la n s th a t in c lu d e b o th b rie f
in te rv e n tio n s a n d m o re in te n siv e ca re to h elp

Brief Interventions in
Substance Abuse
Treatment Programs
S u b sta n ce a b u se tre a tm e n t p ro g ra m s fre q u e n tly

k e e p th e c lie n t fo c u s e d o n tre a tm e n t an d
re c o v e ry . T h e fo llo w in g is a list o f th e p o te n tia l
b e n e fits o f u sin g b r ie f in te rv e n tio n s in s u b sta n ce
a b u se tre a tm e n t s ettin g s:

tre a tm e n t

use b rie f in te rv e n tio n s, a lth o u g h th e y m ig h t n o t

be calle d b y th a t n a m e . B rie f in te rv e n tio n s ca n

R e d u c e n o -s h o w ra te s fo r th e sta rt of

R e d u c e d ro p o u t ra te s a fte r th e first se ssio n of

tre a tm e n t

b e e ffe ctiv e ly in te g ra te d in to m o re
co m p re h e n siv e tre a tm e n t p la n s fo r c lie n ts w ith

In c re a se tre a tm e n t e n g a g e m e n t a fte r in tak e

assessm en t

s u b sta n ce a b u se d iso rd e rs. T h e s e a p p ro a c h e s

can b e p a rticu la rly u se fu l in tre a tm e n t settin g s

In c re a s e c o m p lia n c e fo r d o in g h o m e w o rk

w h en th e y are u sed to a d d re ss sp e c ific ta rg e te d

In c re a se g ro u p p a rtic ip a tio n

clie n t b e h a v io rs an d issu es in th e tre a tm e n t

A d d re s s n o n c o m p lia n c e w ith tre a tm e n t ru les

p ro cess th a t ca n b e d iffic u lt to c h a n g e u sin g

(e .g ., s m o k in g in u n d e s ig n a te d p la ces,

sta n d a rd tre a tm e n t a p p ro a ch e s. B rie f

u n a u th o riz e d v isits, or p h o n e ca lls)

R e m o v in g a B a rrie r to C h a n g e
Y o u r clie n t, M a ry , is h o s p ita liz e d b e c a u se o f an a lc o h o l-re la te d in ju ry . Y o u c o n d u c t a b rie f in te rv e n tio n
in the h o sp ita l. D u rin g th e se s s io n , sh e sa y s th a t o n e o f th e g o o d th in g s a b o u t h e r d rin k in g is th a t she
"a lw a y s h ad fu n w h e n sh e w a s d rin k in g ." In th a t ca se , y o u ca n a sk h e r w h a t h e r p e rs p e c tiv e is on the
situ a tio n and w h e th e r sh e see s a co n n e c tio n b e tw e e n h e r d rin k in g a n d h e r c u rre n t b e h a v io r. T h is cou ld
lead to h e r c h a lle n g in g o n e o f h e r re a so n s fo r d rin k in g . B y s y s te m a tic a lly e x p lo r in g th e re a so n s fo r and
a g a in st d rin k in g , y o u c a n h elp h e r tip th e sc a le in fa v o r o f ch a n g e .
27

Reduce aggression and violence (e.g., verbal

hostility toward staff and other clients)

Reduce isolation from other clients

Reduce no-show rates for continuing care

Increase mutual-help group attendance

problems including substance abuse disorders

and merely to refer them for specialty care (Miller
et al., 1994). Many clients do not use alcohol, for
example, at a level that requires specialized
treatment. Others who use at moderate or severe
levels may be unwilling or unable to participate in

Obtain a sponsor, if involved with a 12-

specialized, mainstream substance abuse

Step program

treatment programs. Moreover, some individuals

Increase compliance with psychotropic

medication therapies

may attach a stigma to attending treatment versus

Increase compliance with outpatient mental

health referrals

women often do not seek or engage in treatment

general health care services. Older adults and

because of stigma

Serve as interim intervention for clients on

treatment program waiting lists

An individual's level of substance use is detected

through screening instruments, medical tests (e.g.,

Brief Interventions Outside

Substance Abuse Treatment
Programs

urine testing), observation, or simply asking about

consumption patterns. Those considered to have risky
or excessive patterns of substance abuse or related
problems can receive a brief intervention that rarely

Brief interventions are commonly administered in

requires more than several sessions, each lasting only

nonsubstance abuse treatment settings, often

5 minutes to 1 hour (average = 15 minutes).

referred to as opportunistic settings, where clients

The goal of a brief intervention is to raise the

are not seeking help for a substance abuse disorder

recipient's awareness of the association between the

but have come to receive medical treatment, to meet

expressed problem and substance abuse and to

with an EAP counselor, or to respond to a court

recommend change, either by natural, clientdirected

summons (see Figure 2-10 for a list of health care and

means or by seeking additional substance abuse

other professionals who often conduct brief

treatment. Because the recipient usually does not

substance use interventions). These settings and

expect to have a substance abuse problem identified,

many others provide a multitude of opportunities to

he may or may not be motivated to apply any

help people change their substance abuse patterns. It

recommendations. The brief intervention is highly

is unrealistic and unnecessary for providers in

structured and focuses on delivering a message about

opportunistic settings to avoid working with people

the individual's substance abuse

with a range of substance abuse

F ig u re 2-10
Professionals Outside of Substance Abuse Treatment Who Can Administer Brief Interventions
Primary care physicians

Lawyers

Substance abuse treatment providers

Mental health workers

Emergency department staff members

Teachers

Nurses

EAP counselors

Social workers

Crisis hotline workers, student counselors

Health educators

Clergy

B r ie f In terv en tion s

and ad v ice to re d u c e or stop it. If the in itia l

ch a rt. F o r e x a m p le , if a m e d ic a l c lie n t in a

in te rv e n tio n d o e s n o t re s u lt in su b sta n tia l

p rim a ry ca re c lin ic is a lso s e e n b y an a lco h o l and

im p ro v e m e n t, th e p ro fe ss io n a l m a y re fe r the

d ru g c o u n s e lo r fo r tre a tm e n t o f a s u b sta n ce

in d iv id u a l fo r a d d itio n a l sp e c ia liz e d su b sta n ce

a b u se d is o rd e r, th o se m e d ic a l re c o rd s are

ab u se tre a tm e n t.

stric tly p ro te c te d b y F e d e ra l la w an d m a y n o t be

T re a tm e n t p ro v id e rs w h o w o rk in settin g s

p u t in th e c lie n t's c h a rt. (F o r m o re in fo rm a tio n

oth er th a n s u b s ta n ce a b u se tre a tm e n t m u s t be

on th e se F e d e ra l la w s, s e e T IP 2 4 , A G u id e to

flex ib le w h en a s s e ssin g , p la n n in g , and c a rry in g

S u b sta n ce A b u se S erv ices f o r P rim a ry C are

ou t b rie f in te rv e n tio n s. F or e x a m p le , th e y w ill

C lin ician s [C S A T , 1 9 9 7 ].)

likely e n co u n te r m o re risk y d rin k e rs th an

H e a th e r m a k e s a n im p o r ta n t d is tin ctio n

a lco h o l-d e p e n d e n t in d iv id u a ls (in th e U n ite d

b e tw e e n b rie f in te rv e n tio n s th a t a re d e liv e re d in

States th e re a re fo u r tim e s as m a n y risk y

o p p o rtu n istic s e ttin g s w h e re p a tie n ts a re n o t

d rin k ers as d e p e n d e n t d rin k e rs [M a n g io n e et al.,

d ire c tly s e e k in g h e lp fo r a s u b s ta n c e a b u se

1999]). S o m e re s e a rc h in d ic a te s th a t the

d is o rd e r a n d th o se c o n d u c te d in tre a tm e n t

p o te n tia l fo r b rie f in te rv e n tio n s to re d u ce the

e n v iro n m e n ts w h e re p a tie n ts a re se e k in g the

h arm , p ro b le m s, an d c o sts a sso c ia te d w ith

h e lp o f s p e c ia lis ts (H e a th e r, 1 9 9 5 ). B rief

m o d e ra te to h e a v y a lco h o l u se b y risk y d rin k e rs

in te rv e n tio n s c o n d u c te d in o p p o rtu n istic

sig n ifica n tly su rp a ss e s the e ffe c tiv e n e s s fro m

se ttin g s ten d to b e s h o rte r, re ly less o n th eo ry

a p p lica tio n s o f b rie f in te rv e n tio n s on s u b sta n ce -

an d m o re o n an e x is tin g c lin ic ia n -c lie n t

d e p e n d e n t in d iv id u a ls (H ig g in s-B id d le et al.,

re la tio n sh ip , a n d a re less e x p e n s iv e b e ca u se they

1997). O th e r re s e a rc h o n b rie f in te rv e n tio n s , as

a re o ffe re d as p a rt o f an e x is tin g se rv ice .

p re sen ted b e lo w , h ig h lig h ts s o m e o f th e m o re

rig o ro u s stu d ie s w ith p o sitiv e o u tc o m e s. T h e
co sts o f a lco h o l a b u se to so cie ty , as in te rp re te d

Conducting Brief Interventions

With Older Adults

by h e alth ca re c o sts, lo st p ro d u c tiv ity , and

O ld e r a d u lts p re s e n t u n iq u e c h a lle n g e s in

crim in a l a ctiv ity , a re e n o rm o u s , an d b rie f

a p p ly in g b rie f in te rv e n tio n s tra te g ie s fo r

in te rv e n tio n s a re a c o s t-e ffe c tiv e te c h n iq u e to

re d u cin g a lc o h o l c o n s u m p tio n . T h e lev el of

a d d ress su ch a b u se. T y p ic a lly th e se b rie f

d rin k in g n e c e s s a ry to b e c o n s id e re d risk y

in te rv e n tio n s a ct as an e a rly in te rv e n tio n b e fo re

b e h a v io r is lo w e r th a n fo r y o u n g e r in d iv id u a ls

or clo se to the d e v e lo p m e n t o f a lc o h o l-re la te d

(C h e rm a c k e t a l., 1 9 9 6 ). In te rv e n tio n stra te g ies

p ro b lem s an d p rim a rily e n ta il in s tru c tio n a l and

sh o u ld b e n o n c o n fr o n ta tio n a l an d su p p o rtiv e

m o tiv a tio n a l co m p o n e n ts a d d re s s in g d rin k in g

d u e to in c re a se d s h a m e a n d g u ilt e x p e rie n c e d

b eh av io r. In su b s ta n c e a b u se tre a tm e n t, b rie f

by m a n y o ld e r p ro b le m d rin k e rs . A s a resu lt,

in te rv e n tio n s a re u sed to a s s is t in th e tre a tm e n t

o ld e r a d u lt p ro b le m d rin k e rs fin d it p a rtic u la rly

e n g a g e m e n t p ro c e ss and to d ea l w ith sp e cific

d iffic u lt to id e n tify th e ir o w n risk y d rin k in g . In

in d iv id u a l, fa m ily , or tre a tm e n t-re la te d issu es.

a d d itio n , c h ro n ic m e d ic a l c o n d itio n s m a y m ak e

W h e n d e liv e rin g a b rie f in te rv e n tio n in an y

it m o re d iffic u lt fo r c lin ic ia n s to re c o g n iz e the

tre a tm e n t settin g , th e p ro v id e r sh o u ld be

ro le o f a lc o h o l in d e c re a s e d fu n c tio n in g and

m in d fu l o f ro o m c o n d itio n s an d in te rru p tio n s

q u a lity o f life. T h e s e iss u e s p re s e n t b a rrie rs to

b eca u se clie n t c o n fid e n tia lity is o f u tm o st

co n d u c tin g e ffe c tiv e b rie f in te rv e n tio n s fo r this

im p o rta n ce . F e d e ra l law re q u ire s th a t c h a rt

v u ln e ra b le p o p u la tio n . F o r m o re o n th is to p ic,

n o tes or o th er re c o rd s o n s u b s ta n c e a b u se be

re fe r to T IP 2 6 , S u b stan ce A b u se A m o n g O ld er

k ep t a p a rt fro m the re st o f th e c lie n t's m a in

A d u lts (C S A T , 19 9 8 b ).

29

C h ap ter 2

Research Findings

s p e c ia lis t tre a tm e n t or re tu rn to th e c lin ic fo r

a d d itio n a l tre a tm e n t fo llo w in g an in itia l visit,

B rief in te rv e n tio n s fo r su b s ta n c e a b u se h a v e

B ie n a n d c o lle a g u e s c o n c lu d e d th a t re la tiv e ly

b ee n im p le m e n te d sin ce the 1 9 6 0 s. T h e

sim p le s tra te g ie s a n d s p e c ific a s p e cts of

lite ra tu re in th is a rea in c lu d e s th e o re tic a l

c o u n s e lo r s ' s ty le s ca n in c re a se ra te s of

a rticles, clin ica l ca se stu d ies an d

fo llo w th ro u g h o n re fe rra ls a s w e ll as im p ro v e

re co m m e n d a tio n s, q u a s i-e x p e rim e n ta l stu d ies,

in itia l e n g a g e m e n t an d p a rtic ip a tio n in

and ra n d o m iz e d c o n tro lle d e x p e rim e n ta l

tre a tm e n t (B ie n e t al., 1 9 9 3 ). O n ly one

re sea rch trials. M a n y o f the b rie f in te rv e n tio n

u n su c c e ss fu l tria l o f re fe rra l p ro c e d u re s is

clin ical trials h a v e b e e n c o n d u cte d in th e U n ite d

d e s c rib e d , an d th e fa ilu re is a ttrib u te d to the fact

S ta te s and E u ro p e sin ce th e e a rly 1 9 8 0 s, an d

th a t all s u b je c ts h a d p re v io u s ly fa ile d to re sp o n d

m o st h av e fo cu se d o n a lc o h o l u se. T h e re is

to b rie f a d v ic e a b o u t g e ttin g in to tre a tm e n t for

so m e e x p e rim e n ta l re s e a rc h o n b rie f

a lco h o lism .

in te rv e n tio n s fo r d ru g u se b u t v e ry little h a s

co n d u c te d tria ls o f b r ie f in te rv e n tio n s fo r

o n g o in g an d fu tu re w o rk .

e x c e s s iv e d rin k e rs id e n tifie d in h e a lth care

Reviews of Brief
Intervention Studies

se ttin g s (in c lu d in g th e la rg e -sc a le , 1 0 -n a tio n

W o rld H e a lth O rg a n iz a tio n [W H O ] stu d y ) (B ien
et al., 19 9 3 ). T h e y fo u n d th a t e ig h t o f th e stu d ies

A 1995 re v iew a rticle (K a h a n et al., 1995) so rted

sh o w e d s ig n ific a n t re d u c tio n s in a lc o h o l

th ro u g h 43 re le v a n t a rticle s fo u n d in M E D L IN E

c o n s u m p tio n le v e ls a n d / o r a s s o c ia te d p ro b le m s

p u b lish e d fro m 1 9 66 to 1985 an d 112 in

fo r th e s u b je c ts r e c e iv in g b rie f, d rin k in g -fo c u se d

E M B A S E p u b lish e d fro m 1 9 7 2 to 1994. A n o th e r,

in te rv e n tio n s in c o m p a riso n w ith th o se

m o re re ce n t re v iew (W ilk e t al., 19 9 7 ) cu lled

re c e iv in g n o c o u n s e lin g . T h re e o th e r stu d ies

n e a rly 6 ,0 0 0 a rtic le s fro m M E D L IN E and

fo u n d n o s ig n ific a n t d iffe re n c e s b e tw e e n

P sy ch L IT s e a rch e s fro m 1966 to 1995 to fin d 99

e x p e rim e n ta l a n d c o n tro l g ro u p s a t fo llo w u p ,

th at m e t crite ria fo r c lo se r in sp e c tio n . A to tal of

a lth o u g h d rin k in g le v e ls a n d o th e r p ro b le m

11 o f the a rticles fo u n d b y K a h a n an d c o lle a g u e s

m e a s u re s w e re re d u c e d in b o th g ro u p s. B ien

and 12 o f th o se re v ie w e d b y W ilk an d a sso cia tes

an d c o lle a g u e s c o n c lu d e d th a t it is b e tte r fo r

h ad co n tro l g ro u p s, a d e q u a te sa m p le siz e s, and

h e a lth c a re p ro v id e rs in o p p o rtu n istic settin g s

s p e cifie d crite ria fo r b rie f in te rv e n tio n s.

s u c h as p rim a ry c a re to in te rv e n e in a

T h e m o st re c e n t re v ie w s o f b rie f in te rv e n tio n

n o n ju d g m e n ta l m o tiv a tio n a l fo rm a t th a n it is to

stu d ies co n c lu d e d th a t b rie f in te rv e n tio n s h av e

p ro v id e n o in te rv e n tio n to p a tie n ts w h o d id n ot

m erit, e sp e cia lly fo r c a re fu lly se le c te d clie n ts

e x p e c t to h a v e th e ir d rin k in g p a tte rn s e v a lu a te d .

and can b e ap p lie d s u c c e ssfu lly in sev era l

30

B ie n an d c o lle a g u e s a lso e x a m in e d 11 w ell-

b e e n p u b lish e d to d ate. T h is is a n a rea o f

In a d d itio n , th e se a u th o rs a lso re v ie w e d 13

settin g s fo r d iffe re n t p u rp o s e s (B ien et al., 1993;

ra n d o m iz e d c lin ic a l tria ls c o m p a rin g b rie f

K ah an et al., 199 5 ; M a ttic k an d Ja rv is , 1994; W ilk

in te rv e n tio n s to a ra n g e o f m o re e x te n siv e

et al., 1997). T h e re v ie w b y B ie n and co lle a g u e s

th e ra p ie s in s p e c ia liz e d a lc o h o l tre a tm e n t

w a s o n e o f the first to c a te g o riz e b rie f

se ttin g s a n d fo u n d th a t s h o rte r c o u n s e lin g w as,

in te rv e n tio n s an d e v a lu a te th e ir e ffe c tiv e n e ss

w ith re m a rk a b le c o n s is te n c y , c o m p a ra b le in

a cco rd in g to th e sta te d g o a ls an d se ttin g s in

im p a c t to m o re tra d itio n a l a p p ro a c h e s in

w h ich th ey w e re c o n d u c te d . A fte r e x a m in in g 12

y ie ld in g sp e c ifie d o u tc o m e s (B ien et al., 1993).

co n tro lle d stu d ie s o f s tra te g ie s to im p ro v e

O n ly tw o s tu d ie s re p o rte d an a d v a n ta g e o f m o re

clie n ts ' a cce p ta n ce o f re fe rra ls fo r a d d itio n a l

e x te n s iv e tre a tm e n t o v er b rie f in te rv e n tio n s on

B r ie f In terv en tion s

no e v id e n ce su p p o rts th e in fe rio rity o f b rie f

Brief Interventions for At-Risk

And Problem Use

in te rv e n tio n s in co m p a riso n w ith m o re

A stu d y c o n d u c te d in 1 9 8 3 fo c u se d on m a les in

e x te n siv e tre a tm e n t o ffe red by tre a tm e n t

M a lm o , S w e d e n , in th e la te 1 9 7 0 s (K riste n so n et

sp e cia lists to p a tie n ts w h o a re s e e k in g h e lp fo r

al., 19 8 3 ). T h e s u b je c ts , a d v ise d to re d u ce th eir

th eir a lco h o l-re la te d p ro b le m s. H e a th e r a rg u es,

a lco h o l u se in a s e rie s o f h e a lth e d u c a tio n visits,

h o w e v e r, th a t th e fin d in g s d o n o t su p p o rt the

s u b s e q u e n tly d e m o n s tra te d sig n ific a n t

s ta te m e n t th a t th e e ffe c tiv e n e s s o f b rie f

r e d u c tio n s in g a m m a -g lu ta m y l tra n sfera se

in te rv e n tio n s is e q u a l to th a t o f o th e r stu d ied

lev els an d h e a lth c a re u tiliz a tio n up to 5 y ears

tre a tm e n ts fo r a lc o h o l a b u se (H e a th e r, 1995).

a fte r the b rie f in te rv e n tio n s . T h e M e d ic a l

so m e o u tco m e m e a s u re s . T h e y c o n c lu d e d th a t

F in ally , B ien and c o lle a g u e s co n c lu d e d fro m

R e se a rc h C o u n c il (M R C ) tria l, co n d u c te d in 47

an an aly sis o f th ree o th e r s tu d ie s th a t b rie f

g e n e ra l p ra c titio n e rs ' o ffic e s in G re a t B rita in

in te rv e n tio n s e n h a n c e d the m o tiv a tio n of

(W a lla c e et al., 1 9 8 8 ), fo u n d sig n ific a n t

tre a tm e n t-se e k in g p ro b le m d rin k e rs to e n te r and

re d u ctio n s in a lc o h o l u se b y th e in te rv e n tio n

re m a in in o u tp a tie n t or re s id e n tia l a lc o h o l

g ro u p c o m p a re d to th e c o n tro l g ro u p 12 m o n th s

tre a tm e n t co m p a re d w ith c lie n ts n o t re c e iv in g

fo llo w in g th e in te rv e n tio n .

su ch a tte n tio n (B ien et al., 1993).

A lth o u g h o th er re v ie w e rs o f b rie f
in te rv e n tio n s h a v e re p o rted m o re q u a lifie d

A n d e rs o n a n d S c o tt id e n tifie d m e n and
w o m e n fro m e ig h t g e n e ra l p ra c tic e s in E n g la n d
w h o co n s u m e d m o re th a n 15 sta n d a rd d rin k s

re actio n s, all se e m to a g re e th a t s tro n g re sea rch

(fo r m e n ) or 9 s ta n d a rd d rin k s (fo r w o m e n ) of

e v id e n ce su p p o rts th e u se o f b rie f in te rv e n tio n s

a lc o h o l p e r w e e k (A n d e rs o n a n d S co tt, 1992).

fo r h e a v y or e x c e ssiv e , n o n d e p e n d e n t d rin k ers,

T h e s e in d iv id u a ls w e re ra n d o m ly a ssig n e d to

p a rticu la rly th o se id e n tifie d in g e n e ra l m e d ica l

re c e iv e e ith e r n o in te rv e n tio n or fe e d b a c k a b o u t

p ra ctice se ttin g s (H e a th e r, 1 9 9 5 ; K a h a n et al.,

the fin d in g s fro m th e s c re e n in g an d 10 m in u tes

1995; M a ttick an d Ja rv is , 1 9 9 4 ; W ilk et al., 1997).

o f a d v ic e fro m th e p h y s ic ia n to re d u c e th eir

W ilk and co lle a g u e s e x a m in e d e v id e n ce fro m 12

c o n s u m p tio n le v e ls, a c c o m p a n ie d b y a

co n tro lle d clin ic a l tria ls th a t ra n d o m iz e d n e a rly

p a m p h le t o f se lf-h e lp in fo rm a tio n . A fte r 1 y ear,

4 ,0 0 0 h e a v y d rin k e rs to b rie f in te rv e n tio n or n o

the m a le s in th e a d v ic e g ro u p h a d s ig n ifica n tly

in te rv e n tio n (W ilk e t al., 19 9 7 ). T h e y co n c lu d e d

re d u ce d th e ir m e a n w e e k ly a lc o h o l

th at h e a v y d rin k e rs w h o re c e iv e d in te rv e n tio n s

c o n s u m p tio n b y 2 .8 o u n c e s m o re th a n th o se

in a p rim a ry ca re s ettin g w e re a lm o st tw ice as

w h o re c e iv e d n o in te rv e n tio n . T h e fe m a le s in

lik ely to m o d e ra te d rin k in g th a n th o se w h o d id

b o th g ro u p s, h o w e v e r, s h o w e d s ig n ific a n t

n o t re ce iv e an in te rv e n tio n . T h e N a tio n a l

re d u c tio n s in a lc o h o l c o n s u m p tio n a t th e sa m e

In stitu te on A lco h o l A b u se an d A lc o h o lis m

fo llo w u p p o in t, w ith n o b e tw e e n -g ro u p

(N IA A A ) h as also p re se n te d d a ta on the e ffic a c y

d iffe re n c e s.

and uses o f b rie f in te rv e n tio n s fo r d e p e n d e n t

d rin k ers (N IA A A , 1999).
T h is T IP re v ie w s th e m o st m e th o d o lo g ic a lly
so u n d b rie f in te rv e n tio n stu d ie s and d isc u sse s

In a w id e ly p u b lic iz e d e v a lu a tio n o f b rie f

in te rv e n tio n s c o n d u c te d in h e a lth ca re settin g s
in 10 n a tio n s s p o n s o re d b y W H O , the
in v e s tig a to rs id e n tifie d 1 ,4 9 0 n o n a lco h o lic h eav y

m e th o d o lo g ica l lim ita tio n s o f p re v io u s and

d rin k ers fro m e ig h t co re s ite s th ro u g h a 20-

cu rre n t re se a rch in th is a rea . T h e re s e a rch is

m in u te h e a lth in te rv ie w (B a b o r an d G ra n t, 1991;

p resen ted in tw o sectio n s: (1) b rie f in te rv e n tio n s

B a b o r et al., 19 9 4 ). T h e s e p a rtic ip a n ts w ere

fo r at-risk and p ro b lem u se an d (2) b rie f

ra n d o m ly a ss ig n e d to o n e o f fo u r g ro u p s: (1) no

in te rv e n tio n s fo r su b sta n ce a b u se.

fu rth e r in te rv e n tio n , (2) 5 m in u te s o f sim p le

C h ap ter 2

a d v ice a b o u t th e im p o rta n ce o f sen sib le

w ith a n o -in te rv e n tio n c o n tro l g ro u p , the

d rin k in g or a b stin e n c e , (3) s im p le a d v ice p lu s 15

p a tie n ts w h o re c e iv e d tw o 10- to 1 5 -m in u te

m in u tes o f b rie f co u n s e lin g an d a self-h elp

s e ssio n s o f s c rip te d a d v ic e (u sin g a w o rk b o o k

m a n u a l th at e n c o u ra g e d th e d e v e lo p m e n t o f a

th a t fo c u s e d o n a d v ic e , e d u c a tio n , an d

h a b it-b re a k in g -p la n , or (4) at fiv e o f th e sites,

co n tra c tin g in fo rm a tio n ) s h o w e d s ig n ific a n tly

ex te n d e d su p p o rtiv e c o u n s e lin g d e liv e re d in

g re a te r re d u c tio n s in a lc o h o l c o n s u m p tio n at a

th ree ex tra se ssio n s fo llo w in g th e in itia l a d v ice

1 2 -m o n th fo llo w u p b a se d o n d rin k in g lev els

an d 1 5 -m in u te se ssio n . A fte r 9 m o n th s, m a les

d u rin g th e p re v io u s w e e k , e p is o d e s o f b in g e

w h o re ce iv e d an y in te rv e n tio n , in c lu d in g th e 5

d rin k in g o v e r th e p a s t m o n th , a n d fre q u e n c y o f

m in u tes o f a d v ice, re p o rte d a p p ro x im a te ly 25

e x ce s s iv e d rin k in g in th e p re v io u s 7 d ay s.

p e rce n t less d a ily a lc o h o l c o n s u m p tio n a

M a le s in th e stu d y a lso h a d s ig n ific a n tly fe w e r

g re a te r ch a n g e th a n w a s o b serv e d in th e n o

d a y s o f h o s p ita liz a tio n th a n c o u n te rp a rts in the

in te rv e n tio n co n tro l g ro u p . S ig n ific a n tly , the

c o n tro l g ro u p . F e m a le s in th e e x p e rim e n ta l

m e n w h o sh o w e d th e g re a te st re sp o n se to

g ro u p s re d u c e d th e ir c o n s u m p tio n s ig n ifica n tly

sim p le a d v ice h a d m o re se v e re a lco h o l p ro b le m s

m o re th a n m a le s in th e e x p e rim e n ta l g ro u p .

and h ig h er co n s u m p tio n p a tte rn s.

T h is re s e a rc h g ro u p (F le m in g et a l., 19 9 9 ) also

A n o th e r in te re stin g fin d in g fro m th e W H O

stu d y w as th a t fe m a le p a rtic ip a n ts in all g ro u p s

p a tie n ts o v e r 65 a n d fo u n d sig n ific a n t

h ad re d u ce d th eir d rin k in g a t 9 m o n th s,

d iffe re n c e s in d rin k in g a fte r 12 m o n th s fo r the

re g a rd le ss o f w h e th e r th e y re c e iv e d any

e x p e rim e n ta l g ro u p c o m p a re d to th e co n tro l

in te rv e n tio n . O n e e x p la n a tio n m a y b e th a t the

g ro u p .

fe m a le p a rtic ip a n ts w e re o n ly re c ru ite d fro m

M ille r a n d c o lle a g u e s h a v e d e v e lo p e d a

tw o re la tiv e ly a fflu e n t c o u n trie s A u stra lia and

s p e c ia l fo rm o f a b r ie f in te rv e n tio n k n o w n as the

the U n ite d S ta te s th u s, th e re su lts c a n n o t be

D rin k e r's C h e c k -U p (M ille r a n d S o v e re ig n ,

g e n era liz ed to all w o m e n (S a n c h e z -C ra ig , 1994).

19 8 9 ), d e sig n e d to e v a lu a te w h e th e r a lco h o l is

F u rth e rm o re , th e 2 0 -m in u te co m p re h e n siv e

h a rm in g a n in d iv id u a l in a n y w a y . In th e 1989

a sse ssm e n t w a s s u ffic ie n tly in te n siv e th a t so m e

stu d y , p a rtic ip a n ts w e re re c ru ite d th ro u g h

w o m e n m ay h a v e re sp o n d e d to im p licit

m e d ia a d v e rtis e m e n ts a n d w e re a sk ed to co m e

m e ssa g es of cu ttin g d o w n on c o n s u m p tio n

in to a n e u tr a l s e ttin g fo r th e a s s e s s m e n t. A s

w ith o u t fu rth e r o v e rt a d v ice, e sp e cia lly

re p o rte d b y B ie n an d c o lle a g u e s , se v e ra l trials of

co n sid erin g th a t o n ly 10 m in u te s o f sim p le

th is a p p r o a c h h a v e d e m o n s tra te d e n c o u ra g in g

a d v ice or 15 m in u te s o f co u n s e lin g w e re

re su lts fro m p ro v id in g s y s te m a tic fe e d b a c k

a d d itio n a lly p ro v id e d (K riste n so n and

a b o u t a s s e s s m e n t re s u lts an d s o m e self-h elp

O sterlin g , 1994).

o p tio n s (B ie n e t al., 1 9 9 3 ). C o m p a re d w ith a n o

O n e su cce ssfu l stu d y d e m o n stra te d the

in te rv e n tio n g ro u p o f re s p o n d e n ts w h o h a d to

efficacy o f a b rie f a lco h o l in te rv e n tio n in a

w a it 6 w e e k s fo r a s s e s s m e n t, th e re c ip ie n ts of

co m m u n ity -b a se d p rim a ry ca re s ettin g (F lem in g

im m e d ia te fe e d b a c k a n d b rie f, e m p a th ic

et al., 1997). P ro je ct T rE A T (T ria l fo r E a rly

a s s is ta n c e s h o w e d p r o m p t an d p e rs is te n t

A lco h o l T re a tm e n t) id e n tified 7 2 3 m e n and

re d u ctio n s (o f 2 9 to 5 7 p e rc e n t) in c o n s u m p tio n

w o m e n as p ro b le m d rin k e rs fro m 17,695

p a tte rn s. M o re e m p a th ic c o u n s e lin g , an

p a tie n ts w h o w e re scre e n e d in 17 c o m m u n ity -

im p o rta n t c o m p o n e n t o f b r ie f in te rv e n tio n s (see

b ase d p rim a ry ca re p ra c tic e s. T h e o u tco m es

d is c u ss io n o n F R A M E S e a rlie r in th is ch a p te r), is

stu d ied w e re re d u c tio n s in a lc o h o l co n su m p tio n

a lso a s s o c ia te d w ith la rg e r re d u c tio n s th a n the

and h e a lth re so u rc e u tiliz a tio n . In c o m p a riso n

32

c o n d u c te d a s im ila r tria l w ith p rim a ry ca re

B r ie f In terven tion s

u se o f the m o re tra d itio n a l c o n fro n ta tio n a l sty les

d iffic u lt a n d im p o r ta n t c lin ic a l an d p u b lic h e alth

(M iller e t al., 1993).

issu e.

W h ile th e ty p e s o f b rie f in te rv e n tio n s v a ry ,

the b asic d esig n o f m o st stu d ie s is a ra n d o m iz e d
co n tro lle d trial th a t a ssig n s c lie n ts w ith

Brief Interventions for

Dependent Use

h a z a rd o u s d rin k in g p a tte rn s e ith e r to a b rie f

M o st stu d ie s o f b rie f in te rv e n tio n s fo r a lco h o l

in te rv e n tio n (ra n g in g fro m o n e to ten sessio n s)

use th a t h a d th e g o a l o f c h a n g in g d rin k in g

or to o n e or m o re c o n tro l c o n d itio n s (A n d e rso n

b e h a v io r h a v e in c lu d e d o n ly su b je c ts w h o did

and S co tt, 1 9 9 2 ; B a b o r, 1 9 9 2 ; B a b o r an d G ra n t,

n o t m e e t c rite ria fo r a lc o h o l d e p e n d e n c e and

1991; C h ick et al., 1 9 8 5 ; F le m in g e t al., 1997;

e x p lic itly e x c lu d e d d e p e n d e n t d rin k e rs w ith

H arris an d M ille r, 1 9 9 0 ; H e a th e r et al., 1987;

s ig n ific a n t w ith d ra w a l s y m p to m s . T h e ra tio n a le

K riste n so n et al., 1 9 8 3 ; P e rsso n an d M a g n u sso n ,

fo r th is p ra c tic e w a s th a t a lc o h o l-d e p e n d e n t

1989; W a lla ce e t al., 19 8 8 ). O v e ra ll, th e m a jo rity

in d iv id u a ls o r th o se a ffe c te d m o st se v e re ly by

o f b rie f a lco h o l in te rv e n tio n stu d ie s h a v e fo u n d

a lc o h o l s h o u ld b e re fe rre d to fo rm a l sp e cia liz e d

sig n ifica n tly g re a te r im p ro v e m e n ts in d rin k in g

a lc o h o lism tre a tm e n t p ro g ra m s b e c a u se th eir

o u tco m es fo r the e x p e rim e n ta l g ro u p c o m p a re d

c o n d itio n s a re n o t lik e ly to b e a ffe c te d by low

to the co n tro l g ro u p ; h o w e v e r, m o st a lso fo u n d

in te n sity in te rv e n tio n s (B a b o r et al, 1986;

s ig n ifica n t c h a n g e s in d rin k in g o v e r tim e fo r

In stitu te o f M e d ic in e [IO M ], 1 9 9 0 ). H o w e v e r,

b o th the co n tro l an d b rie f in te rv e n tio n

th e re h a v e b e e n p o sitiv e tria ls th a t a d d re ss this

co n d itio n s. M e ta -a n a ly s e s fo u n d an e ffe c t size

issu e s p e cific a lly .

of 20 to 30 p e rc e n t in stu d ies c o n d u c te d in

N IA A A re v ie w e d th e s tu d ie s fo cu se d on

h e alth care settin g s (B ien et al., 1 9 9 3 ; K a h a n ,

a lc o h o l-d e p e n d e n t d rin k e rs (N IA A A , 1999).

1985). T ria ls co n d u c te d sin ce 1 9 9 5 h a v e

S o m e o f th e se s tu d ie s fo c u s e d on the

g a rn e re d sim ila r e ffe c t siz e s w ith o n e trial

e ffe c tiv e n e s s o f m o tiv a tin g a lc o h o l-d e p e n d e n t

fin d in g a g re a te r e ffe c t siz e fo r w o m e n (35

p a tie n ts to e n te r s p e c ia liz e d a lc o h o l trea tm e n t.

p e rce n t) (F lem in g et al., 19 9 7 ). W o m e n w e re n o t

A s lo n g a g o as 1 9 6 2 , a n o n ra n d o m iz e d stu d y

alw ay s in clu d e d in e a rlie r tria ls, b u t la te r trials

w a s c o n d u c te d o f a lc o h o l-d e p e n d e n t p a tie n ts,

th at d id in clu d e w o m e n fo u n d th a t th ey w e re

id e n tifie d in th e e m e rg e n c y d e p a rtm e n t

m o re lik e ly th an m e n to d e c re a s e th e ir d rin k in g

(C h a fe tz e t al., 19 6 2 ). O f th o se re c e iv in g b rie f

b ase d on b rie f ta rg e te d a d v ice.

c o u n s e lin g , 65 p e rc e n t fo llo w e d th ro u g h in

B eca u se o f th e su c c e ss o f b rie f a lc o h o l

k e e p in g a s u b s e q u e n t a p p o in tm e n t in a

in te rv e n tio n s w ith a d u lts in o p p o rtu n istic

sp e c ia liz e d a lc o h o l tre a tm e n t se ttin g . O n ly 5

settin g s, n ew tria ls w ith sp e c ia l p o p u la tio n s

p e rc e n t in th e c o n tro l g ro u p fo llo w e d th ro u g h

(e.g., o ld e r a d u lts, in ju re d p a tie n ts in e m e rg e n c y

w ith an a p p o in tm e n t.

d ep a rtm e n ts, p re g n a n t w o m e n ) a re now b e in g

B rie f in te rv e n tio n s h a v e a lso b e e n co m p a re d

p ro p o se d an d c o n d u c te d . In a d d itio n , n ew

to m o re in te n siv e a n d e x te n s iv e tre a tm e n t

te ch n o lo g ie s are b e in g s tu d ie d , in clu d in g

a p p ro a c h e s u se d in tra d itio n a l tre a tm e n t

co m p u te riz e d re a l-tim e ta ilo re d b o o k le ts fo r at-

se ttin g s w ith p o sitiv e re s u lts (E d w a rd s et al.,

risk d rin k ers, and the u se o f In te ra ctiv e V o ice

1 9 7 7 ; P ro je c t M A T C H R e se a rc h G ro u p , 1997,

R e co g n itio n (IV R ) fo r in te rv e n tio n s an d

19 9 8 ). In a sm a ll stu d y , th e e ffe c tiv e n e s s o f a

fo llo w u p . T h e se an d o th er te c h n o lo g ie s, if

o n e -s e s sio n b rie f a d v ic e p ro to c o l p lu s m o n th ly

e ffica cio u s and e ffe c tiv e , w ill p ro v id e c lin icia n s

fo llo w u p te le p h o n e c a lls, fo c u s e d on the

w ith new to o ls to a ssist th e m in w o rk in g w ith a

p a tie n t's p e rs o n a l re s p o n s ib ility to stop

33

C h ap ter 2

d rin k in g , w a s c o m p a re d to sta n d a rd a lco h o l

tre a tm e n t fo r 100 m e n w h o w e re a lco h o l

w h ic h is o fte n c o n s id e re d a b rie f in te rv e n tio n

d e p e n d e n t (E d w a rd s an d O rfo rd , 1977). A t 1-

e v e n th o u g h it is m o re in te n s iv e th a n m o st b rie f

y ear fo llo w u p b o th g ro u p s re p o rte d a 4 0 p e rce n t

in te rv e n tio n s (N IA A A , 1 9 9 5 ), (2) 12 se ssio n s o f

d ecrea se in a lc o h o l-re la te d p ro b le m s. T h e stu d y

1 2 -S te p fa cilita tio n , a n d (3) 12 s e ssio n s o f

fo u n d , at 2 -y e a r fo llo w u p , th a t th e p a tie n ts w ith

c o g n itiv e -b e h a v io r a l c o p in g s k ills th e ra p y . A t

the less se v e re a lco h o l p ro b le m s d id b e s t in the

1- an d 3 -y e a rs p o s tin te rv e n tio n , all th re e g ro u p s

b rie f in te rv e n tio n g ro u p . T h e p a tie n ts w ith

re p o rte d im p ro v e m e n ts in c lu d in g d rin k in g less

m o re serio u s a lc o h o l-re la te d p ro b le m s d id b est

o ften an d d rin k in g fe w e r d rin k s p e r d ay.

in in te n siv e a lc o h o l tre a tm e n t (O rfo rd e t al.,

1976).
S e v e ra l sim ila r stu d ie s co n d u c te d in N ew

A s m a ll s u c c e s s fu l a p p lic a tio n o f a b rie f

m o tiv a tio n a l in te rv e n tio n w ith in a su b sta n c e
a b u se tre a tm e n t s e ttin g a d m in is te re d

Z ea la n d (C h a p m a n an d H u y g e n s, 1988),

a p p ro x im a te ly 1 h o u r o f m o tiv a tio n a l

L o n d o n (D ru m m o n d e t al., 1 9 9 0 ), th e U n ite d

in te rv ie w in g fo r p ro b le m d rin k e rs (a d a p te d

S ta te s (M iller e t al., 1 9 8 0 ,1 9 8 1 ; M ille r and

fro m M ille r a n d S o v e re ig n , 1 9 8 9 ) to serio u sly

M u n o z , 1982), an d N o rw a y (S k u tle an d B erg ,

o p ia te -d e p e n d e n t c lie n ts re c e n tly a d m itte d to a

1987) e sse n tia lly re p lica te d th e re su lts o f

m e th a d o n e m a in te n a n c e c lin ic (S a u n d e rs e t al.,

p re v io u s p o sitiv e tria ls, c o m p a rin g b rie f

1995). F ifty -s e v e n c lie n ts w e re ra n d o m iz e d to

in te rv e n tio n s fa v o ra b ly w ith a v a rie ty of

th e e x p e rim e n ta l g ro u p a n d w e re a sk ed to

e x te n d e d tre a tm e n ts fo r p ro b le m d rin k in g

id e n tify p o s itiv e a n d n e g a tiv e a s p e c ts o f th eir

(in clu d in g c o g n itiv e -b e h a v io r th e ra p ie s, m a rita l

o p ia te u se a n d to p ro je c t th e c o n s e q u e n c e s in to

th e rap y , co n fro n ta tio n a l c o u n s e lin g , and

the fu tu re. T h e s e c lie n ts w e re th e n a sk ed to

sta n d a rd in p a tie n t a n d o u tp a tie n t tre a tm e n t).

S a n ch e z -C ra ig an d c o lle a g u e s fo u n d th a t

th in k a b o u t th e ir u se a n d d is c u ss it a t th e 1w e e k fo llo w u p se s s io n . T h e 6 5 su b je c ts in the

w h en co m p a rin g th e 1 2 -m o n th tre a tm e n t

co n tro l g ro u p re c e iv e d a 1 -h o u r e d u ca tio n a l

o u tco m es o f se v e re ly d e p e n d e n t an d

in te rv e n tio n c o v e r in g six s u b s ta n c e -re la te d

n o n se v e re ly d e p e n d e n t m e n re c e iv in g b rie f

issu e s s u ch a s o v e rd o se re s p o n s e s , le g a l a sp ects,

tre a tm e n t in T o ro n to an d B ra z il, th e re w e re no

an d re fe rra l s o u rc e s. F o llo w u p s e s s io n s w e re

sig n ifica n t d iffe re n c e s in "s u c c e s s fu l" o u tco m es

h e ld w ith b o th g ro u p s a t 1 w e e k , 3 m o n th s, and

as m e a su re d b y ra te s o f a b stin e n c e or m o d e ra te

6 m o n th s. S ig n ific a n tly fe w e r c lie n ts re c e iv in g

d rin k in g (S a n c h e z -C ra ig et al., 19 9 1 ). T h e IO M

th e m o tiv a tio n a l in te rv e n tio n d ro p p e d o u t o f the

also n o ted th at ra te s o f sp o n ta n e o u s re m issio n of

stu d y a t e a c h o f th e fo llo w u p p o in ts co m p a re d

a lco h o lism s u g g e s t th a t so m e p o rtio n o f the

w ith th o se re c e iv in g th e e d u c a tio n a l c o m p o n e n t.

m o st sev ere a lc o h o lic p o p u la tio n w ill re d u ce or

B y the 6 -m o n th p o in t, th e m o tiv a tio n a l su b je cts

d isco n tin u e th e ir d rin k in g w ith o u t fo rm a l

h a d s ig n ific a n tly fe w e r o p ia te -re la te d p ro b le m s

in te rv e n tio n (IO M , 1990).

T h e la rg est m u ltisite N IA A A -sp o n s o re d

34

s e ssio n s o f m o tiv a tio n a l e n h a n c e m e n t th e ra p y ,

th a n th e o th ers. In c o m p a ris o n w ith th e

e d u c a tio n a l g ro u p , th e c lie n ts re c e iv in g the

stu d y o f tre a tm e n t m a tc h in g an d o u tco m es,

m o tiv a tio n a l in te rv e n tio n w e re a lso m o re lik e ly

P ro ject M A T C H (M a tch in g A lc o h o lism

to m a k e a p o sitiv e in itia l s h ift o n a sta g e -o f-

T re a tm e n t to C lie n t H e te ro g e n e ity ), co m p a re d

ch a n g e m e a s u re (se e th e d is c u ss io n o f sta g e s-o f-

the e ffe cts o f tre a tm e n t ty p e on o u tco m es fo r

ch a n g e e a rlie r in th is c h a p te r), e x p re s s a

m o re th a n 1,50 0 a lc o h o l-d e p e n d e n t p a tie n ts

stro n g e r c o m m itm e n t to a b stin e n c e , re m a in in

(P ro je ct M A T C H R e se a rch G ro u p , 1 9 9 7 ,1 9 9 8 ).

tre a tm e n t lo n g e r, an d re la p se le ss q u ic k ly if they

T re a tm e n t ty p e s in clu d e d (1) fo u r 1-h o u r

d id d ro p ou t. T h e s tu d y co n c lu d e d th a t b rie f

B r ie f In terv en tion s

m o tiv a tio n a l in te rv e n tio n s stre n g th e n e d

re c o m m e n d a tio n s . T h e c lin ic a l tria ls in th is T IP

re c ip ie n ts ' re so lu tio n to a b sta in fro m o p ia te use

o n the u se o f b rie f in te rv e n tio n s h a v e b ee n

and p a rticip a te fu lly in tre a tm e n t, an d w ere

sp e cific re g a rd in g th e ta rg e te d p o p u la tio n tested

th ere fo re u se fu l in im p ro v in g p e rfo rm a n c e and

an d th e lev el o f g e n e r a liz a b ility p o ssib le .

p ro g ra m co m p lia n ce a m o n g c lie n ts a tte n d in g a

m e th a d o n e clin ic (S a u n d e rs, 19 9 5 ). T h is an d

M ethodological Issues

oth er stu d ies h a v e fo u n d th a t co m p lia n ce w ith a

Issu e s a re fre q u e n tly ra is e d re g a rd in g sp e cific

tre a tm e n t p lan , ra th e r th a n s im p ly le n g th o f

m e th o d o lo g ic a l c o n c e rn s o f s tu d ie s on b rie f

tre a tm e n t, is o n e o f th e im p o rta n t fa cto rs

in te rv e n tio n s . F irst, m a n y o f th e b rie f

in flu e n cin g p o sitiv e o u tc o m e s fo r clie n ts

in te rv e n tio n s tu d ie s , p a rtic u la rly th o se fo cu sed

re ce iv in g tre a tm e n t.
In a stu d y lo o k in g a t th e co sts o f b rie f

on a lco h o l, re ly o n s e lf-re p o rt d a ta to d eterm in e

o u tco m e s. T h e v a lid ity o f m e a s u rin g a lco h o l

in te rv e n tio n s, H o ld e r an d c o lle a g u e s e v a lu a te d

an d o th er u se b y s e lf-re p o rt is ro u tin e ly

the e v id e n ce o f c lin ic a l e ffe c tiv e n e s s and the

q u e s tio n e d ; h o w e v e r, re v ie w e rs o f re le v a n t

ty p ical co sts o f v a rio u s a lc o h o lism tre a tm e n t

lite ra tu re h a v e c o n c lu d e d th a t th e s e d ata are

m o d a litie s and fo u n d b rie f m o tiv a tio n a l

g e n e ra lly v a lid an d re lia b le (M id a n ik , 1982;

co u n selin g a m o n g th e m o st e ffe c tiv e in te rm s of

S o b e ll an d S o b e ll, 1 9 9 0 ). R e p o rts fro m

a co m b in a tio n o f c lin ic a l an d c o st e ffe c tiv e n e s s

c o lla te ra ls , s u c h as fa m ily m e m b e r s, a re n o t as

(H o ld er e t al., 1991). It ra n k e d th ird a m o n g the

re lia b le e x c e p t fo r h ig h ly v is ib le e v e n ts, su ch as

six h ig h e st ra n k in g a p p ro a c h e s in te rm s o f

d rin k in g -re la te d a rre s ts (M id a n ik , 1982).

w e ig h te d e ffe ctiv e n e s s (b a sed o n a to tal o f n in e

P erso n s w ith h a z a rd o u s d rin k in g p a tte rn s w ill

stu d ies c o n d u cte d b e tw e e n 1983 an d 1990).

p ro v id e a cc u ra te in fo r m a tio n a b o u t th e ir use,

B rief m o tiv a tio n a l co u n s e lin g w a s a lso ra te d the

p a rtic u la rly u n d e r th e fo llo w in g c o n d itio n s: (1)

least co stly o f the six m o st e ffe c tiv e m o d a litie s

the se ttin g is a re s e a rc h o r c lin ic a l o n e, (2)

or m o st co s t-e ffe c tiv e o f 33 e v a lu a te d m o d a litie s.

c o n fid e n tia lity is a s s u re d , a n d (3) th e in te rv iew

T h e a u th o rs o f th is stu d y s p e c ific a lly sta te d th a t

is a d m in is te re d w h e n th e re s p o n d e n t is so b er

tre a tm e n t p la n n in g an d fu n d in g d e c isio n s

(S o b e ll an d S o b e ll, 1 9 9 0 ). T e c h n iq u e s to in cre a se

sh o u ld n o t b e b a se d on th is in itia l e ffo rt to m a k e

the a c c u ra c y o f s e lf-re p o rts h a v e b e e n e m p lo y e d

"fir s t le v e l a p p r o x im a tio n s " o f co st-

in re c e n t s tu d ie s (F le m in g e t a l., 1 9 9 7 ,1 9 9 9 ).

e ffe ctiv e n ess.

T h e s e s tu d ie s u se in te rv ie w e r s w h o fu lly

C ritics h a v e ra ised c o n c e rn s th a t b rie f

u n d e rsta n d d rin k in g -re la te d q u e s tio n s and can

in te rv e n tio n s co u ld b e c o n s tru e d as a tre a tm e n t

e x p la in c o n fu s io n a b o u t c o m m o n te rm s (e.g.,

p an ace a fo r all p a tie n ts w ith v a ry in g lev els of

" b la c k o u ts ," " h ig h " ).

a lco h o l-re la te d p ro b le m s an d d iffe re n t

C o n c e rn s a b o u t th e m e th o d o lo g ic a l

c o n su m p tio n p a tte rn s (D ru m m o n d , 1997;

lim ita tio n s o f s o m e tria ls h a v e in c lu d e d sa m p le

H e ath e r, 1995; M a ttic k and Ja rv is , 1994).

siz e s th a t w e re to o sm a ll a n d a s ta tis tic a l p o w e r

A lth o u g h m o st re se a rch e rs a c k n o w le d g e that

in s u ffic ie n t to re lia b ly d e te c t d iffe re n c e s

m an y clie n ts d o n o t n eed a p ro tra c te d and

b e tw e e n e ffe c ts in th e g ro u p s c o m p a re d (B ien et

e x p e n siv e co u rse o f in d iv id u a l or g ro u p

al., 1 9 9 3 ; M a ttic k an d Ja rv is , 19 9 4 ). T h e re m ay

tre a tm e n t, the lite ra tu re a d v o c a tin g b rie f

b e d iffe re n tia l a ttritio n in g ro u p s a t fo llo w u p ,

in te rv e n tio n s as a tre a tm e n t fo r all su b sta n c e

a n d th e se d ro p o u ts ca n b e ig n o re d or ex clu d e d

a b u se is o v e rsta te d (H e a th e r, 1 9 9 5 ; M a ttic k and

fro m a n a ly se s (B ien e t al., 1 9 9 3 ; D ru m m o n d ,

Ja rv is, 1994). C a u tio n a lw a y s n e e d s to b e

19 9 7 ; K a h a n e t al., 1 9 9 5 ), or th e re co u ld be

e m p lo y e d in e v a lu a tin g stu d y

c o n ta m in a tio n b e c a u s e th e c o m p a riso n g ro u p
35

C h ap ter 2

co u ld b e see k in g a d d itio n a l tre a tm e n t d u rin g

n o p u b lis h e d stu d ie s th a t d e fin itiv e ly ad d ress

the co u rse o f the re se a rch (B ien et al., 1993;

th is issu e.

K ah an et al., 1 9 9 5 ; M a ttic k an d Ja rv is , 1994).

A lso, ra n d o m iz a tio n o f sa m p le s h a s n o t a lw a y s
b ee n c o n d u cte d (W ilk et al., 1 9 9 7 ), and som e

in te rv e n tio n s , in p a rtic u la r (F le m in g e t al., 1997).

early stu d ies d id n o t h a v e c o n tro l g ro u p s or did

H o w e v e r, fe w s tu d ie s to d a te h a v e te sted the

n o t h av e a n a d e q u a te co m p a riso n g ro u p (B ien et

im p le m e n ta tio n o f b rie f in te rv e n tio n stra te g ie s

al., 1993). S o m e o f th e n e w e r b rie f in te rv e n tio n

in c o m m u n ity -b a s e d m e d ic a l an d tre a tm e n t

stu d ies h a v e a d d resse d m a n y o f th e se co n c e rn s

s ettin g s. S e v e ra l n ew in itia tiv e s a d d re s s this

(F lem in g et al., 1 9 9 7 ,1 9 9 9 ). T h e se , h o w e v e r,

c ritica l n e x t ste p in th e p ro c e s s . H ig g in s-B id d le

re m a in issu es th a t m u st be a d d re sse d by new

an d c o lle a g u e s id e n tifie d th e re s e a rc h b a se and

stu d ies o f b rie f in te rv e n tio n te c h n iq u e s w ith

c u rre n t a p p lic a tio n s o f s c re e n in g an d b rie f

sp e cia l p o p u la tio n s and w ith n e w te ch n o lo g y .

in te rv e n tio n s (H ig g in s -B id d le e t al., 1997). T h e

Future Issues in Research and

Practice

fin d in g s o n th e e ffe c tiv e n e s s fro m clin ic a l trials

on s c re e n in g a n d b rie f in te rv e n tio n s w e re fo u n d
to b e e n c o u ra g in g , w ith risk y d rin k e rs re d u cin g

T h e b a ck g ro u n d re se a rc h in th is T IP is b a se d on

th e ir a lc o h o l c o n s u m p tio n b y 2 0 p e rce n t, on

the m o st rig o ro u s tria ls fro m th e 1 9 6 0 s th ro u g h

a v e ra g e . In d iv id u a l s tu d y re s u lts v a rie d fro m

the 1990s. A s stu d y d esig n s h a v e b e co m e m o re

15 to 4 0 p e rc e n t d e p e n d in g on th e p o p u la tio n

s o p h istica ted , m a n y o f the e a rlie r

an d m e th o d o lo g y u se d . In th e n e x t fe w y ears,

m e th o d o lo g ic a l issu e s a re b e in g a d d resse d .

fo cu se d w o rk in th e s e a re a s w ill in fo rm

Q u e stio n s re m a in re g a rd in g sp e cific lev els of

c lin ic ia n s re g a rd in g o p tim a l b rie f in te rv e n tio n

ab u se and d e p e n d e n c e a fte r w h ic h b rie f

im p le m e n ta tio n s tra te g ie s an d p ro v id e a b rid g e

in te rv e n tio n a p p ro a c h e s are less e ffe ctiv e and

fro m re s e a rc h e ffic a c y to p ra c tic a l a p p lic a tio n in

m o re in te n siv e tre a tm e n t is re q u ire d . It is

re a l w o rld c lin ic a l se ttin g s.

p o ssib le that fa cto rs su ch as so c ia l sta b ility an d

T h e re is e v id e n c e th a t a v a rie ty o f b rie f

s u p p o rt (as in d ic a te d in E d w a rd s and O rfo rd ,

in te rv e n tio n s a re e ffe c tiv e w ith a t-ris k and

1977) p lay a ro le in im p ro v e d re sp o n se s to

h a z a rd o u s s u b s ta n c e u se rs, an d e m e rg in g

b rie fe r tre a tm e n ts an d th a t th e se fa c to rs m a y be

e v id e n c e s u g g e s ts th a t b rie f in te rv e n tio n s can be

m o re im p o rta n t th a n the lev el o f s u b sta n ce

u sed to m o tiv a te p a tie n ts to se e k sp e cia liz e d

a b u se or d e p e n d e n ce .

s u b s ta n c e a b u se tre a tm e n t an d to tre a t so m e

A s se co n d a ry a n a ly se s a re c o n d u cte d fro m

a lc o h o l-d e p e n d e n t p e rs o n s . C lin ic a l e v id e n ce

m o re re ce n t c lin ic a l tria ls, s o m e o f th e s tro n g e s t

a lso s u g g e s ts th a t b rie f in te rv e n tio n s ca n b e

co v a ria tes w ill e m e rg e. F u rth e r re sea rch

u sed in s p e c ia liz e d tre a tm e n t p ro g ra m s to

fo cu se d sp e cific a lly o n th e m y ria d o f issu es th at

a d d re s s sp e c ific ta rg e te d issu es.

co u ld a ffe ct o u tc o m e s is n e e d e d to d e te rm in e

36

T h e re is s tro n g e v id e n c e s u p p o rtin g the

e ffic a c y o f a lc o h o l s c re e n in g an d b rie f

In su m , th e C o n s e n s u s P a n e l b e lie v e s it is

w h eth er b rie f in te rv e n tio n s ca n b e u se fu l fo r

critic a l fo r p o lic y m a k e rs an d p ro v id e rs of

clie n ts w ith d u a l d ia g n o se s or w h e th e r they

m a n a g e d ca re to u n d e rsta n d th a t b rie f

a lw a y s re q u ire m o re in te n siv e tre a tm e n ts

in te rv e n tio n s s h o u ld n e v e r b e th o u g h t o f as the

b e ca u se o f the c o m p le x ity o f th e ir illn esse s.

o n ly tre a tm e n t o p tio n fo r p e rs o n s w ith

A lth o u g h th ere is o n g o in g re se a rc h te stin g the

s u b s ta n c e a b u se p ro b le m s b u t as o n e o f a

e ffe ctiv e n e ss o f b rie f in te rv e n tio n s w ith p a tie n ts

c o n tin u u m o f te c h n iq u e s fo r u se w ith a

w h o h av e serio u s p s y c h ia tric illn e s s e s and

p o p u la tio n o f c lie n ts w ith s u b s ta n c e a b u se

co e x istin g s u b s ta n ce a b u se d iso rd e rs, th e re are

p ro b le m s ra n g in g fro m a t-ris k to d e p e n d e n t use.

3 Brief Therapy in Substance

Abuse Treatment

rie f th e ra p y is a s y s te m a tic , fo cu se d

to c h a n g e b a sic a ttitu d e s a n d h a n d le a v a rie ty o f

p ro ce ss th a t re lie s o n a s s e s s m e n t, c lie n t

u n d e rly in g p ro b le m s . C o m p a re d w ith b rie f

e n g a g e m e n t, an d ra p id im p le m e n ta tio n

th e ra p ie s, b rie f in te rv e n tio n s a re m o re

o f ch a n g e s tra te g ie s. B rie f th e ra p y p ro v id e rs

m o tiv a tio n a l, s e e k in g to m o tiv a te th e c lie n t to

can e ffe ct im p o rta n t c h a n g e s in c lie n t b e h a v io r

m a k e a sp e c ific ch a n g e (in th o u g h t or a ctio n ).

w ith in a re la tiv e ly s h o rt p e rio d . T h e b rie f

(See C h a p te r 1 fo r m o re o n h o w th is T IP

th e rap ie s p re se n te d in th is T IP sh o u ld b e se e n as

d is tin g u is h e s b rie f th e ra p ie s fro m b rie f

co n ta in e d m o d a litie s o f tre a tm e n t, n o t e p iso d ic

in te rv e n tio n s .)

fo rm s o f lo n g -te rm th e ra p y .
H o w e v e r, in th e lite ra tu re an d in p ra c tic e , the

B rie f th e ra p y d iffe rs fro m lo n g e r term

th e ra p y in th a t it fo c u s e s m o re o n th e p re sen t,

term " b r ie f th e ra p y " co v e rs a w id e ra n g e of

d o w n p la y s p s y c h ic c a u sa lity , e m p h a s iz e s u sin g

a p p ro a ch e s to tre a tm e n t o f v a ry in g le n g th s and

e ffe ctiv e th e ra p e u tic to o ls in a sh o rte r tim e, and

w ith a v a rie ty o f g o a ls. B rie f th e ra p ie s u su a lly

fo c u se s o n a sp e c ific b e h a v io ra l ch a n g e ra th er

co n sist o f m o re (as w ell as lo n g e r) s e ssio n s th an

th a n la rg e -sc a le o r p e rv a s iv e c h a n g e . A n u m b e r

b rie f in te rv e n tio n s. T h e d u ra tio n o f b rie f

o f sp e c ific ty p e s o f th e ra p y a re d e sig n e d to b e

th e ra p ie s is re p o rte d to b e a n y w h e re fro m 1

ca rrie d o u t in a b rie f p e rio d (e .g ., c o g n itiv e -

sessio n (B lo o m , 1 9 9 7 ) to 4 0 s e ssio n s (S ifn e o s,

b e h a v io ra l a p p ro a c h e s a re o fte n d e sig n e d to

1987), w ith the ty p ic a l th e ra p y la stin g b e tw e e n 6

re q u ire fe w e r th a n 2 0 s e s s io n s ). M a n y lo n g e r

and 20 sessio n s. T w e n ty s e s s io n s u su a lly is th e

a p p ro a ch e s h a v e b e e n or c a n b e a d a p te d ; ev en

m a x im u m b e ca u se o f lim ita tio n s p la c e d by

le n g th y p s y c h o d y n a m ic a p p ro a c h e s h a v e b ee n

m an y m a n a g e d ca re o rg a n iz a tio n s . A n y th e ra p y

a d a p te d fo r b r ie f th e ra p y w ith c le a r g u id elin es

m ay b e b rie f b y a c c id e n t or c irc u m sta n c e , b u t

fo r th e ir u se (D a v a n lo o , 1 9 8 0 ; L u b o rsk y , 1984;

the fo cu s o f th is T IP is o n p la n n ed b rie f th e ra p y .

M a n n , 1 9 7 3 ; S ifn e o s , 1 9 7 2 ; S tru p p an d B in d e r,

T h e th e ra p ie s d e sc rib e d h e re m a y in v o lv e a set

1984).

n u m b e r o f s e ssio n s or a se t ra n g e (e.g ., fro m 6 to

T h is c h a p te r p ro v id e s an o v e rv ie w o f b rie f

10 se ssio n s), b u t th ey a lw a y s w o rk w ith in a tim e

th e ra p y in s u b s ta n c e a b u se tre a tm e n t. F irst, the

lim ita tio n th at is c le a r to b o th th e ra p is t and

e v id e n c e fo r th e e ffic a c y o f th is a p p ro a c h is

clien t. In th e fo llo w in g p a g e s, all th e ra p ie s

p re s e n te d . T h e a p p r o p ria te n e s s o f b rie f th era p y

d escrib e d sh o u ld b e u n d e rsto o d as p la n n e d or

is d is c u ss e d n e x t, a n d c rite ria a re p ro v id e d for

tim e lim ited .

d e te rm in in g d u ra tio n o f th e ra p y . T h e

B rief th e ra p ie s d iffe r fro m b rie f in te rv e n tio n s

in th at th eir g o al is to p ro v id e c lie n ts w ith to ols

c o m p o n e n ts o f all b rie f th e ra p ie s a re then

d iscu sse d , in c lu d in g c o m m o n ch a ra c te ristics
37

C h ap ter 3

and step s in tre a tm e n t. F in a lly , e sse n tia l

sp e cific re s e a rc h e v a lu a tin g d iffe re n t ty p es of

th e ra p ist k n o w le d g e an d sk ills fo r co n d u ctin g

b rie f th e ra p y is g iv e n in C h a p te rs 4 to 9.)

su cce ssfu l b rie f th e ra p ie s a re d escrib e d .

T h e ch a p ters fo llo w in g th is p re s e n t a cro ss-

T h e re is, h o w e v e r, p ro m isin g e v id e n c e th at
b rie f th e ra p ie s as a tre a tm e n t fo r su b sta n c e

sectio n o f the a p p ro a c h e s th a t a re an d h a v e b ee n

a b u se d is o rd e rs a re o fte n as e ffe c tiv e as

used in b rie f th e ra p y . N o o n e a p p ro a c h is

le n g th ie r tre a tm e n ts (B ie n e t al., 1 9 9 3 ; G o tth e il et

e n d o rse d as th e b e s t or o n ly a p p ro a c h fo r use

al., 1 9 9 8 ; M c L e lla n et al., 1 9 9 3 ; M ille r and

w ith the ra n g e o f p e rso n s w ith su b s ta n ce a b u se

H e ster, 1 9 8 6 a ; M ille r an d R o lln ick , 199 1). T h e se

d iso rd e rs, n o r a re all o f th e m c o n sid e re d by th e

stu d ie s a re p o sitiv e b u t a re p rim a rily lim ite d to

C o n se n su s P a n el to b e e q u a lly v a lid . R a th er, the

p ro g ra m e ffe c tiv e n e s s s tu d ie s w ith sm a lle r

th erap ies in C h a p te rs 4 th ro u g h 9 w e re ch o se n

sa m p le siz e s. F u tu re re s e a rc h s h o u ld b o th

b eca u se they e ith e r re p re s e n t th e m o st w id ely

re p lic a te p re v io u s w o rk a n d u se m o re rig o ro u s

u sed b rie f th e ra p ie s or th e y re p re s e n t m o d e ls

d e sig n s th a t in c lu d e e x p e rim e n ta l d e sig n s w ith

th at h a v e g o o d p o te n tia l, a re re co m m e n d e d by

ra n d o m iz a tio n . M a n y o f th e fu n d a m e n ta l

n a tio n a l e x p e rts, an d w ill b e o f in te re s t and

q u e stio n s a b o u t b r ie f th e ra p ie s th e o p tim u m

a ssista n ce to p ro v id e rs w h o tre a t p e rso n s a cro ss

c o n d itio n s u n d e r w h ic h th e y s h o u ld b e u se d , the

the ra n g e o f su b sta n c e a b u se d iso rd e rs. S o m e of

e c o n o m ic c o s t-b e n e fits , an d le v e l an d ty p e of

th ese a p p ro a ch e s ca n b e u sed w ith the w h o le

p ro v id e r, th e m o st s u ita b le ty p e s o f c lie n ts

ran g e o f p e o p le w ith su b sta n ce a b u se d iso rd e rs;

h a v e y e t to b e stu d ie d .

oth ers are u sefu l on ly fo r a s m a lle r s u b s e t o f that

T h e m a jo rity o f c lie n ts in th e ra p y (re g a rd less

p o p u la tio n . E ach o f the c h a p te rs th a t fo llo w s

o f the m o d a lity ) re m a in in tre a tm e n t fo r

d iscu sse s a p a rtic u la r ty p e o f the in d iv id u a l

b e tw e e n 6 an d 2 2 s e s s io n s ; 9 0 p e rc e n t end

th erap ies. H o w e v e r, e a ch o f th e a p p ro a ch e s

tre a tm e n t b e fo re c o m p le tin g 2 0 v isits (F rie d b e rg ,

d escrib e d in C h a p te rs 4 to 9 w ill p ro v id e u sefu l

1999). T h e fa c t th a t m a n y c lie n ts sta y in th e rap y

te ch n iq u es fo r th e e c le c tic p ra ctitio n e r.

fo r re la tiv e ly s h o rt p e rio d s o f tim e s u g g e sts th at

b rie f th e ra p y te c h n iq u e s s h o u ld b e m u ch m o re

Research Findings

co m m o n th a n th e y a re in c u rre n t clin ic a l
p ra c tic e (P e k a rik a n d W ie rz b ic k i, 1 9 8 6 ; P h illip s,

R ese arch co n c e rn in g th e re la tiv e e ffe c tiv e n e s s of

b rie f v e rsu s lo n g e r te rm th e ra p ie s fo r a v a rie ty
of p re s e n tin g c o m p la in ts is m ix e d . S o m e stu d ies
h a v e fo u n d th a t p la n n e d , s h o rt-te rm th e ra p ie s

tre a tm e n t m o d a litie s c h o o s e n o t to u se p la n n e d
sh o rt-te rm th e ra p ie s (B lo o m , 1 9 9 7 ). A lc o h o l and
d ru g c o u n s e lo rs o fte n h a v e to w o rk w ith clie n ts

are as e ffe ctiv e as le n g th ie r (o r u n lim ited )

in a lim ite d p e rio d o f tim e , h o w e v e r, an d co u ld

th e ra p y (K o ss an d S h ia n g , 1 9 9 3 ; S m y rn io s and

a p p ly b rie f th e ra p y te c h n iq u e s e v e n w h e n they

K irk b y , 1993). O th e r stu d ies, su ch as the

are d e sig n e d fo r tre a tm e n t o f d iffe re n t ty p e s of

C on su m er R ep orts m e n ta l h e a lth stu d y (S e lig m a n ,

1995) and the N a tio n a l In stitu te o f M e n ta l

38

19 8 7 ). M a n y th e ra p ists tra in e d in lo n g -te rm

d iso rd e rs an d p ro b le m s .
B e c a u se b rie f th e ra p y is m o re e ffe c tiv e than

H ealth (N IM H ) T re a tm e n t o f D e p re ssio n

b e in g o n a w a itin g list, it c o u ld b e n e fit m a n y

R e se a rch P ro g ra m (B la tt e t al., 1 9 9 5 ; E lk in , 19 9 4 ),

clie n ts. W o lb e rg s u g g e s te d th a t all clie n ts

h av e fo u n d th a t lo n g e r te rm tre a tm e n ts

s e e k in g tre a tm e n t b e g iv e n b rie f th e ra p y

g e n e ra lly lea d to b e tte r o u tc o m e s as p e rce iv ed

in itia lly , b e fo re m o v in g o n to lo n g -te rm

by clie n ts. M u ch d e p e n d s o n th e m o d a lity b ein g

tre a tm e n ts (W o lb e rg , 1 9 8 0 ). S u c h an a p p ro a ch

e v a lu a te d and th e g o a ls o f the tre a tm e n t. (M o re

w o u ld h e lp to re s e rv e lo n g e r tre a tm e n ts fo r

B r ie f T h era p y in S u b sta n ce A b u se T reatm en t

clie n ts w ith a g re a te r n e ed fo r th e m . H o w e v e r,

b rie f th e ra p y . T h e re fo re , clie n t n e e d s an d the

th ere are cle a rly e x c e p tio n s to th is ru le, su ch as

su ita b ility o f b rie f th e ra p y m u s t b e e v a lu a te d on

clien ts w h o h av e a h isto ry o f se v e re an d

a c a s e -b y -c a se b a sis. S o m e c rite ria fo r

p e rsiste n t m e n ta l illn ess. O th e r crite ria fo r

c o n s id e rin g th e a p p r o p ria te n e s s o f b rie f th erap y

a ssig n in g a clie n t to lo n g e r te rm ra th e r th a n

a re p re s e n te d in F ig u re 3 -2 . T h e A m e ric a n

b rie f th e ra p y a re p re se n te d in F ig u re 3-1.

S o c ie ty o f A d d ic tio n M e d ic in e (A S A M ) clie n t

P la n n e d b rie f th e ra p y ca n b e a d a p te d as p a rt

p la c e m e n t c rite ria fo r s u b s ta n c e a b u se tre a tm e n t

o f a co u rse o f s e ria l o r in te rm itte n t th e ra p y

(A S A M , 19 9 6 ) m a y a lso b e u se fu l fo r

(B u d m an an d G u rm a n , 1 9 8 8 ; C u m m in g s , 1990).

d e te rm in in g w h o co u ld b e n e fit fro m b rie f

W h en d o in g th is, th e th e ra p is t co n c e iv e s a lo n g

th e ra p y (see d is c u s s io n in C h a p te r 2).
B rie f th e ra p y m a y b e a p p r o p ria te fo r a

term tre a tm e n t as a n u m b e r o f sh o rte r

treatm en ts, w h ich re q u ire s th a t th e c lie n t's

m o d e ra te to h e a v y d rin k e r s u c h as a co lle g e

p ro b lem s be a d d re sse d seria lly ra th e r th an

s tu d e n t b u t in a p p ro p ria te as th e so le tre a tm e n t

co n c u rre n tly . B e c a u se o f in s u ra n c e co n s tra in ts,

fo r a c o m m e rc ia l a irlin e p ilo t w h o is a lco h o l

m an y th e ra p ists a re n o w b illin g b y e p is o d e and

d e p e n d e n t, n o m a tte r w h a t th e m o tiv a tio n is fo r

treatin g o n e p ro b le m a t a tim e.

tre a tm e n t. T h e ra p is ts m u s t c o n s id e r
e x te n u a tin g c irc u m sta n c e s w h e n re c o m m e n d in g

B rief th e ra p y m a y p ro v e to b e a u se fu l to o l
fo r re co n ce iv in g h o w th e ra p y is d e liv e re d . F or

a p a rtic u la r c o u rs e o f tre a tm e n t. In so m e

the tre a tm e n t p ro v id e r w o rk in g w ith c lie n ts

p ro g ra m s, d u ra tio n o f th e ra p y is d e term in e d

w ith su b sta n ce a b u se d iso rd e rs, th is m e a n s th a t

m u tu a lly b y th e c lie n t a n d th e ra p is t; b rie f

a p a rticu la r ty p e o f th e ra p y co u ld b e a p p lie d to

th e ra p y m a y b e th e b e s t o p tio n if th e clie n t

a sp e cific p ro b le m a s s o c ia te d w ith a c lie n t's

o b je cts to lo n g e r te rm tre a tm e n t o r if e x p e n se is

su b sta n ce a b u se. B y tre a tin g th e s e allied

an issu e.
R e se a rc h is n e e d e d to id e n tify sp e cific

p ro b lem s, lo n g -te rm g o a ls, su ch as c o n tin u e d

a b stin e n ce , m a y b e m o re lik e ly to b e re a c h e d

p o p u la tio n s fo r w h ic h b r ie f th e ra p y w o u ld serv e

(Ig u ch i e t al., 1 9 9 7 ; M c L e lla n et al., 1993).

as th e c a ta ly s t fo r r e s o lu tio n o f s u b s ta n c e a b u sere la te d p ro b le m s. T h e im p a c t o f b rie f th era p y

When To Use Brief

Therapy

on c h ro n ic a lly re la p sin g , s u b s ta n c e -a b u s in g
p e rso n s h a s n o t b e e n in v e s tig a te d . B e c a u se of
th e se la rg e g a p s in re s e a rc h , th e ra p ists m u s t rely

In su fficie n t d ata a re a v a ila b le to d e te rm in e

o n th e ir c lin ic a l ju d g m e n t to d e te rm in e w h e th e r

w h ich p o p u la tio n s w o u ld b e n e fit m o st fro m

b rie f th e ra p y is a p p r o p ria te fo r a p a rticu la r

F ig u r e 3-1
C r ite r ia for L o n g e r T e r m T r e a tm e n t
T h e fo llo w in g c rite ria ca n h e lp id e n tify c lie n ts w h o co u ld b e n e fit fro m lo n g e r te rm tre a tm e n t:
F a ilu re o f p re v io u s s h o rte r tre a tm e n t

C o g n itiv e in a b ility to fo cu s

M u ltip le c o n c u rre n t p ro b le m s

L o n g -te rm h is to ry o f re la p se

S e v e re su b sta n ce a b u se (i.e., d e p e n d e n c e )

M a n y u n su c c e ss fu l tre a tm e n t e p is o d e s

A cu te p sy ch o se s

L o w le v e l o f s o c ia l s u p p o rt

A cu te in to x ic a tio n

S e rio u s c o n s e q u e n c e s re la te d to re la p se

A cu te w ith d ra w a l

39

C hapter 3

F ig u re 3 -2
S e le c te d C r ite r ia fo r P r o v id in g B rief T h e r a p y

D u al d ia g n o s is issu es s u c h as a c o e x istin g p s y c h ia tric d is o rd e r or d e v e lo p m e n ta l d isa b ility

T h e ra n g e an d s e v e rity o f p re s e n tin g p ro b le m s

T h e d u ra tio n o f a b u se

A v a ila b ility o f fa m ilia l an d c o m m u n ity su p p o rts

T h e lev el an d ty p e o f in flu e n c e fro m p e ers, fa m ily , an d c o m m u n ity

P re v io u s tre a tm e n t or a tte m p ts a t re c o v e ry

T h e lev el o f c lie n t m o tiv a tio n (b rie f th e ra p y m a y re q u ire m o re w o rk o n th e p a r t o f th e clie n t b u t a

less e x te n s iv e tim e c o m m itm e n t)

T h e cla rity o f th e c lie n t's sh o rt- an d lo n g -te rm g o a ls (b rie f th e ra p y w ill re q u ire m o re c le a rly d efin ed
g oals)

T h e c lie n t's b e lie f in th e v a lu e o f b rie f th e ra p y (" b u y in ")

L arg e n u m b e rs o f c lie n ts n e e d in g tre a tm e n t

T h e fo llo w in g crite ria a re d e riv e d fro m c lin ic a l e x p e rie n c e :

L ess se v e re su b s ta n c e a b u se, as m e a su re d b y an in s tru m e n t lik e th e A d d ic tio n S e v e rity

In d ex (A SI)

L ev el o f p a s t tra u m a a ffe c tin g the c lie n t's s u b s ta n c e a b u se

In su fficie n t re so u rc e s a v a ila b le fo r m o re p ro lo n g e d th e ra p y

L im ite d a m o u n t o f tim e a v a ila b le fo r tre a tm e n t (e.g ., 7 -d a y a v e ra g e le n g th o f s ta y in c o u n ty -ja illev el c o rre c tio n a l fa c ilitie s ; 3 0 - to 4 5 -d a y lim ita tio n in Jo b C o rp s p ro g ra m )

P rese n ce o f co e x is tin g m e d ic a l or m e n ta l h e a lth d ia g n o se s

L arg e n u m b e rs o f c lie n ts n e e d in g tre a tm e n t le a d in g to w a itin g lists fo r s p e c ia liz e d tre a tm e n t

clie n t and w h a t k in d o f m o d a lity w o u ld be m o st

th e ra p e u tic co m m u n itie s , p s y c h o th e ra p y ,

e ffectiv e.

m e th a d o n e m a in te n a n c e th e ra p y , an d e x te n d e d

T h e b est o u tco m e s fo r b rie f th e ra p y m ay

a lth o u g h b r ie f th e ra p y is a u se fu l to o l in a

assessm e n ts, an d se le c tiv e crite ria fo r e lig ib ility .

p o rtfo lio o f in te rv e n tio n s , its u se s h o u ld be

U sin g s e le ctio n c rite ria in p re s c rib in g b rie f

ta rg e te d to th o se c lie n ts w h o a re m o st lik e ly to

th e rap y is critica l, sin ce m a n y c lie n ts w ill n o t

b en e fit.

m e e t e lig ib ility . T h e C o n s e n s u s P a n el h o p es

D e te rm in in g w h e n to u se a p a rtic u la r ty p e of

th at b rie f th e ra p y w ill b e a d e q u a te ly

b rie f th e ra p y is a lso a n im p o r ta n t c o n sid e ra tio n

in v e stig a te d b e fo re m a n a g e d ca re an d th ird -

fo r c o u n s e lo rs a n d th e ra p is ts . C o u n s e lo rs

p arty p a y o rs d e c id e it is th e o n ly m o d a lity fo r

re c o g n iz e th a t n o t all c lie n ts a re a t th e sa m e

w h ich they w ill p ay .

sta g e in th e ir re a d in e s s fo r tre a tm e n t. C u rre n tly ,

B rie f th e ra p y fo r su b sta n ce a b u se tre a tm e n t

40

d e to x ific a tio n (H u b b a rd e t a l., 19 9 7 ). T h e re fo re ,

d ep en d on th e th e ra p is t's sk ills, co m p re h e n siv e

th e m o st w id e ly u se d m o d e l fo r u n d e rsta n d in g

is a v a lu a b le b u t lim ite d a p p ro a c h , an d it sh o u ld

c lie n ts ' re a d in e s s fo r c h a n g e is P ro c h a sk a an d

not b e co n sid e re d a sta n d a rd o f ca re fo r all

D iC le m e n te 's s ta g e s -o f-c h a n g e m o d e l, w h ic h is

p o p u la tio n s. In fa ct, tim e in tre a tm e n t h a s b ee n

d iscu sse d in C h a p te r 2. (F o r m o re in fo rm a tio n

fo u n d to b e d ire c tly re la te d to b e tte r o u tco m es

a b o u t th is m o d e l, se e a lso T IP 3 5 , E n h a n cin g

w ith in a ra n g e o f m o d a litie s, in clu d in g

M o tiv a tion f o r C h a n g e in S u b sta n ce A b u se

B r ie f T h era p y in S u b sta n ce A b u se T reatm en t

T reatm en t [C S A T , 1 9 9 9 c].) C o u n s e lo rs w h o use

th e m e s s a g e s sh e g iv e s h e rs e lf an d h e lp h er

this m o d e l w ill h a v e to d e te rm in e w h ic h th e ra p y

c o r re c t p ro b le m a tic th in k in g p a tte rn s and

is c o m p a tib le w ith th e c lie n t's sta g e o f re a d in e ss

d y s fu n c tio n a l b e lie fs (K e n d a ll a n d T u rk , 1984).

fo r ch a n g e an d the ta sk s n e ed e d to m o v e

O fte n , d y s fu n c tio n a l b e lie fs lea d to low lev els of

fo rw ard in the ch a n g e p ro c e ss and d e v e lo p an

p e rc e iv e d s e lf-e ffic a c y an d s u b s e q u e n t in a b ility

o v erall u n d e rsta n d in g o f the c o u rs e o f ch a n g e

to a d o p t or m a in ta in th e d e sire d b e h a v io r

(D iC lem en te and S co tt, 1997).

(B a n d u ra , 19 8 6 ). It is im p o rta n t to n o te th a t self-

C lin ica l in te rv e n tio n s sh o u ld b e ta rg e te d to

e ffic a c y sh ifts in a p re d ic ta b le w a y a cro ss the

the clie n t's sta g e o f re a d in e ss fo r c h a n g e to

sta g e s o f b e h a v io r c h a n g e , w ith clie n ts

in cre a se h is m o tiv a tio n to c h a n g e b e h a v io rs and

p ro g re ss iv e ly b e c o m in g m o re e ffic a c io u s as they

to a u g m en t a sen se o f e m p o w e rm e n t in

m o v e th ro u g h th e s ta g e s (M a rc u s et al., 1992;

reco v ery . T h e ra p ie s th a t w o rk w ith e x p e rie n tia l

P ro c h a sk a et al., 1994).

p ro cesse s (su ch as co n s c io u s n e s s ra isin g , s e lf

re ev a lu a tio n , an d a c o g n itiv e re s tru c tu rin g ) are
m o re im p o rta n t fo r u n d e rsta n d in g and
p re d ictin g tra n sitio n fro m p re p a ra tio n to a ctio n

Approaches to
Brief Therapy

and fro m a ctio n to m a in te n a n c e (P ro c h a sk a et

B rie f th e ra p y u ses a se le c te d p ro ce s s to ch a n g e a

al., 1994). S e e k in g and p ro ce ssin g in fo rm a tio n ,

sp e cific p ro b le m b a se d o n an u n d e rly in g th eo ry

o b serv in g o th ers, an d g a th e rin g u se fu l

a b o u t th e c a u se o f th e p ro b le m or th e b e s t w ay

in fo rm a tio n in lig h t o f the c lie n t's s itu a tio n are

to e n c o u ra g e p o sitiv e c h a n g e . F ig u re 3 -3 lists

the p rim a ry a c tiv itie s re p o rted m o st fre q u e n tly

s e v e ra l th e ra p e u tic a p p ro a c h e s th a t are

d u rin g th e c o n te m p la tio n s ta g e (P ro c h a sk a et al.,

a p p lic a b le to b rie f th e ra p y . T h e s e a p p ro a ch e s

1992). E sp ecia lly d u rin g th is e a rly sta g e the

c a n b e u se d w ith c lie n ts w ith d iffe re n t ty p es of

clie n t sh o u ld b e p ro v id e d w ith in fo rm a tio n

p ro b le m s an d v a ry in g d e g re e s o f su b sta n ce

re g a rd in g a d d ictio n as w ell as co n fro n te d w ith

a b u se se v e rity .

the sh o rt- an d lo n g -te rm c o n s e q u e n c e s of

co n tin u ed use. A sk in g th e clie n t to p e rfo rm a
risk a p p ra isa l o f c o n tin u e d u se as w ell as a
b e n e fit/ risk -re d u c tio n a p p ra is a l o f a ch ie v in g

Com ponents of Effective

Brief Therapy

a b stin e n ce can fa cilita te so u n d d e cisio n m a k in g

A lth o u g h d iffe re n t m o d e ls o f b rie f th e ra p y m ay

th at in v o lv e s a co m p a riso n o f all p o te n tia l g a in s

s tre ss c e rta in g o a ls a n d a c tiv itie s m o re than

and lo sses (Jan is an d M a n n , 1977).

F in ally , it w ill b e e ss e n tia l to le a rn th e c lie n t's

o th ers, all b rie f th e ra p ie s h a v e c o m m o n

c h a ra c te ris tic s (se e F ig u re 3 -4 ). In a d d itio n , b rief

p e rce iv ed o b sta cle s to e n g a g in g in tre a tm e n t as

th e ra p ie s sh o u ld in c o rp o ra te se v e ra l sta g e s,

w ell as to id e n tify an y d y s fu n c tio n a l b e lie fs th a t

in c lu d in g s c re e n in g a n d a s s e s s m e n t, an o p en in g

co u ld sa b o ta g e the e n g a g e m e n t p ro cess. T h e

se s s io n th a t in c lu d e s th e e sta b lis h m e n t of

b a sic a ssu m p tio n b eh in d th is a p p ro a c h is th a t

tre a tm e n t g o a ls, s u b s e q u e n t se ssio n s,

the w ay in d iv id u a ls e v a lu a te a s itu a tio n and

m a in te n a n c e s tra te g ie s , e n d in g tre a tm e n t, and

co p e w ith it d e te rm in e s th e ir e m o tio n a l re a ctio n

fo llo w u p . T h e s e s ta g e s a re d is c u ss e d b elo w .

to it (E llis an d G rie g er, 1977). T h e critic a l fa cto r

in d e te rm in in g an in d iv id u a l's re sp o n se is the

Screening and Assessm ent

c lie n t's s e lf-p e rc e p tio n an d a s s o cia te d e m o tio n s.

S cre e n in g an d a s s e s s m e n t a re critic a l in itia l

T h e th e ra p ist s h o u ld h elp th e c lie n t re c o g n iz e

ste p s in b rie f th e ra p y . S c re e n in g is a p ro cess in

41

C h ap ter 3

F ig u r e 3 -3
A p p r o a c h e s to B rief T h e r a p y
A pproaches

D escription

C o g n itiv e

T h is th e ra p y p o sits th a t s u b s ta n ce a b u se d is o rd e rs re fle c t h a b itu a l, a u to m a tic,

th erap y

n e g a tiv e th o u g h ts an d b e lie fs th a t m u s t b e id e n tifie d an d m o d ifie d to ch a n g e

e rro n e o u s w a y s o f th in k in g an d a sso c ia te d b e h a v io rs . T h e d e sire to use
su b s ta n c e s is ty p ica lly a c tiv a te d in s p e c ific , o fte n p re d ic ta b le h ig h -ris k situ a tio n s,
su ch as u p o n se e in g d ru g p a ra p h e rn a lia or e x p e rie n c in g b o re d o m , d e p re ssio n , or
a n x ie ty . T h is a p p ro a c h h e lp s c lie n ts e x a m in e th e ir n e g a tiv e th o u g h ts a n d re p la ce
th em w ith m o re p o sitiv e b e lie fs an d a c tio n s. M a n y re la p se p re v e n tio n stra te g ies
use co g n itiv e p ro ce s s e s to id e n tify trig g e rin g e v e n ts or e m o tio n a l sta te s th a t
re a c tiv a te su b sta n c e u se an d re p la ce th e se w ith m o re h e a lth fu l re sp o n se s. (See
C h a p te r 4 fo r m o re in fo rm a tio n .)

B eh a v io ra l

U sin g th is a p p ro a c h , w h ic h is b a se d on le a rn in g th e o rie s , th e th e ra p is t te a ch e s the

th e rap y

c lie n t sp e c ific sk ills to im p ro v e id e n tifie d d e fic ie n c ie s in s o c ia l fu n c tio n in g , selfco n tro l, or o th e r b e h a v io rs th a t c o n trib u te to s u b s ta n c e u se d is o rd e r. S o m e o f the
te c h n iq u e s th a t a re u sed in c lu d e a s s e rtiv e n e s s tra in in g , s o c ia l s k ills tra in in g ,
c o n tin g e n c y m a n a g e m e n t, b e h a v io r co n tra c tin g , c o m m u n ity re in fo rc e m e n t and
fa m ily tra in in g (C R A F T ), b e h a v io ra l s e lf-c o n tro l tra in in g , c o p in g s k ills, an d stress
m a n a g e m e n t. (S e e C h a p te r 4 fo r m o re g e n e ra l in fo r m a tio n o n b e h a v io ra l th e ra p y
an d C h a p te r 8 fo r m o re in fo rm a tio n o n C R A F T an d o th e r b e h a v io ra l fa m ily
th e ra p ie s.)

C o g n itiv e -

T h is a p p ro a c h c o m b in e s e le m e n ts o f c o g n itiv e a n d b e h a v io ra l th e ra p ie s, b u t in

b e h a v io ra l

m o st su b s ta n c e a b u se tre a tm e n t se ttin g s it is c o n s id e re d a s e p a ra te th e ra p y . T h is

th e rap y

a p p ro a c h fo cu se s on le a rn in g an d p ra c tic in g a v a r ie ty o f c o p in g sk ills. T h e
e m p h a s is is p la ce d o n d e v e lo p in g c o p in g s tra te g ie s , e s p e c ia lly e a rly in th e
th e ra p y . C o g n itiv e -b e h a v io r a l th e ra p y is th o u g h t to w o rk b y c h a n g in g w h a t the
c lie n t d o e s an d th in k s ra th e r th an ju s t fo c u s in g o n ch a n g in g h o w th e c lie n t th in k s.
(S ee C h a p te r 4.)

S trateg ic/

T h e se a p p ro a c h e s see k to u n d e rsta n d a c lie n t's v ie w p o in t o n a p ro b le m , w h a t

in te ra ctio n a l

m e a n in g is a ttrib u te d to e v e n ts, an d w h a t in e ffe c tiv e in te rp e rs o n a l in te ra c tio n s

th erap ies

an d c o p in g s tra te g ie s are b e in g a p p lie d . B y s h iftin g th e fo c u s to c o m p e te n c ie s,

n o t w e a k n e s se s an d p a th o lo g y , th e th e ra p is t h e lp s c lie n ts c h a n g e th e ir p e rc e p tio n
o f th e p ro b le m a n d a p p ly e x is tin g p e rs o n a l s tre n g th s to fin d in g a n d a p p ly in g a
m o re e ffe c tiv e s o lu tio n . (S e e C h a p te r 5.)

S o lu tio n -

U sin g th is a p p ro a c h , the th e ra p ist h e lp s a c lie n t w ith a s u b s ta n c e a b u se d iso rd e r

fo cu se d th e rap y

re c o g n iz e th e e x ce p tio n s to u se as a m e a n s to re in fo rc e an d c h a n g e b e h a v io r.
F u tu re b e h a v io r is b a se d o n fin d in g s o lu tio n s to p ro b le m b e h a v io rs . L ittle or no
tim e is sp e n t ta lk in g a b o u t th e p ro b le m ; ra th e r, th e ra p y is fo c u s e d o n so lu tio n s
th a t h a v e a lre a d y w o rk e d fo r th e c lie n t in th e p a s t. (S e e C h a p te r 5.)

42

B r ie f T h era p y in S u b sta n ce A b u se T reatm en t

F ig u r e 3 -3 (c o n tin u e d )
A p p r o a c h e s to B rief T h e r a p y
Approaches

D escription

H u m a n istic and

T h e s e th e ra p ie s a ssu m e th a t th e u n d e rly in g c a u se o f s u b s ta n c e a b u se d is o rd e rs is a

e x isten tia l

la ck o f m e a n in g in o n e 's life, a fe a r o f d ea th , d is c o n n e c te d n e s s fro m p e o p le ,

th erap ies

s p iritu a l e m p tin e ss , or o th er o v e rw h e lm in g a n x ie tie s . T h ro u g h u n c o n d itio n a l

a c ce p ta n ce , clie n ts a re e n c o u ra g e d to im p ro v e th e ir s e lf-re s p e c t, se lf-m o tiv a tio n ,
an d g ro w th . T h e a p p ro a c h ca n b e a c a ta ly s t fo r s e e k in g a lte r n a tiv e s to su b sta n c e s
in o rd e r to fill th e e m p tin e ss e x p e rie n c e d a n d e x p re s s e d as s u b s ta n c e a b u se. (See
C h a p te r 6.)

P sy ch o d y n a m ic

T h e p s y c h o d y n a m ic th e ra p is t w o rk s w ith th e a s s u m p tio n th a t a p e rs o n 's p ro b lem s

th erap y

w ith su b s ta n c e s a re ro o te d in u n c o n s c io u s an d u n re s o lv e d p a s t c o n flic ts , e sp ecia lly

in e a rly fa m ily re la tio n sh ip s . T h e g o a l is to h e lp th e c lie n t g a in in s ig h t in to
u n d e rly in g c a u se s o f m a n ife s t p ro b le m s , u n d e rs ta n d w h a t fu n c tio n su b s ta n c e a b u se
is se rv in g , an d s tre n g th e n p re s e n t d e fe n se s to w o rk th r o u g h th e p ro b le m . A stro n g
th e ra p e u tic a llia n c e w ith the th e ra p is t a s sists th e c lie n t to m a k e p o sitiv e ch a n g e s.
(S e e C h a p te r 7.)

In te rp e rso n a l

T h is th e ra p y , w h ic h c o m b in e s e le m e n ts o f c o g n itiv e an d p s y c h o d y n a m ic th e ra p ie s,

th e rap y

w a s o rig in a lly d e v e lo p e d to w o rk w ith c lie n ts w ith d e p re s s io n b u t h a s b e e n u sed

su c c e ssfu lly w ith s u b s ta n c e -a b u s in g c lie n ts. It fo c u se s o n re d u c in g th e clie n t's
d y s fu n c tio n a l s y m p to m s a n d im p ro v in g s o c ia l fu n c tio n in g b y c o n c e n tr a tin g on a
c lie n t's m a la d a p tiv e p a tte rn s o f b e h a v io r. It is s u p p o rtiv e in n a tu re , p ro v id in g
e n c o u ra g e m e n t, re a s su ra n c e , re d u c tio n o f g u ilt, an d h elp in m o d ify in g the c lie n t's
e n v iro n m e n t. (S ee C h a p te r 7 fo r m o re in fo rm a tio n .)

F am ily th e rap y

W h ile n o t a d is tin c t " s c h o o l" o f th e ra p y , fa m ily th e ra p y is a m o d a lity th a t e ith er

tre a ts th e c lie n t as p a rt o f a fa m ily s y s te m or c o n s id e rs th e e n tire fa m ily as "th e
c lie n t." It e x a m in e s th e fa m ily sy s te m an d its h ie r a rc h y to d e te rm in e d y sfu n c tio n a l
u ses o f p o w e r th a t lea d to n e g a tiv e or in a p p ro p ria te a lig n m e n ts or p o o r
c o m m u n ic a tio n p a tte rn s an d th a t c o n trib u te to s u b s ta n c e u se d is o r d e r b y o n e or
m o re fa m ily m e m b e rs. T h e th e ra p is t h e lp s fa m ily m e m b e rs d is c o v e r h o w th eir
o w n sy ste m o p e ra te s, im p ro v e c o m m u n ic a tio n a n d p ro b le m -s o lv in g s k ills, and
in c re a se th e e x c h a n g e o f p o sitiv e re in fo rc e m e n t. (S e e C h a p te r 8.)

G ro u p th e ra p y

T h is m o d a lity (a lso n o t a d is tin c t th e o re tic a l sc h o o l) u ses m a n y o f th e te ch n iq u es

an d th e o rie s d e s crib e d to a c c o m p lis h sp e c ifie d g o a ls. In s o m e g ro u p th e ra p y , the
g ro u p its e lf an d th e p ro c e s s e s th a t e m e rg e a re c e n tra l to h e lp in g c lie n ts see
th e m s e lv e s in th e re a c tio n s o f o th ers, a lth o u g h th e c o n te n t a n d fo c u s o f th e g ro u p s
v a ry w id ely . (S e e C h a p te r 9.)

43

C h ap ter 3

F ig u r e 3 -4
C h a r a c te r is tic s o f A ll B rief T h e r a p ie s

T h e y are e ith e r p ro b le m fo c u s e d or s o lu tio n fo c u s e d ; th e y ta rg e t th e s y m p to m a n d n o t w h a t is

b eh in d it.

T h e y c le a rly d e fin e g o a ls re la ted to a sp e cific c h a n g e or b e h a v io r.

T h ey sh o u ld be u n d e rsta n d a b le to b o th c lie n t an d clin icia n .

T h ey sh o u ld p ro d u c e im m e d ia te re su lts.

T h ey can b e e a sily in flu e n c e d b y the p e rs o n a lity an d c o u n s e lin g sty le o f th e th e ra p ist.

T h e y re ly o n ra p id e sta b lis h m e n t o f a s tro n g w o rk in g re la tio n sh ip b e tw e e n c lie n t a n d th e ra p ist.

T h e th e ra p e u tic sty le is h ig h ly a ctiv e , e m p a th ic , an d s o m e tim e s d ire c tiv e .

R e sp o n s ib ility fo r ch a n g e is p la c e d c le a rly o n th e clien t.

E a rly in th e p ro c e s s , th e fo c u s is to h e lp th e c lie n t h a v e e x p e rie n c e s th a t e n h a n c e s e lf-e ffic a c y an d

co n fid e n ce th a t ch a n g e is p o ssib le.

T e rm in a tio n is d iscu sse d fro m the b eg in n in g .

O u tco m e s are m e a su ra b le .

w h ich clie n ts are id e n tifie d a c co rd in g to

o f b rie f th e ra p y . F o r e x a m p le , if a c lie n t la ck s

ch a ra cte ristics th a t in d ic a te th a t th e y are

th e fin a n c ia l m e a n s to p a rtic ip a te in a lo n g e r

p o ssib ly a b u sin g su b sta n c e s. S cre e n in g d o e s n o t

tre a tm e n t p ro c e s s , a b r ie f th e ra p y a p p ro a c h is

in fo rm th e th e ra p is t o f the s e v e rity o f the

im p e ra tiv e . S o m e tre a tm e n t is a lm o s t a lw a y s

in d iv id u a l c lie n t's su b s ta n c e a b u se , o n ly its

b e tte r th a n n o tre a tm e n t. In a d d itio n , b rie f

p re sen ce an d , in so m e ca ses, b ro a d in d ic a tio n s

th e ra p y m a y b e in d ic a te d fo r c lie n ts w h o re sist

of risk. S c re e n in g id e n tifie s th e n eed fo r m o re

lo n g e r tre a tm e n t, ra th e r th a n risk th e loss o f an

in -d ep th a sse s s m e n t an d is n o t a s u b s titu te for

o th e rw ise m o tiv a te d clie n t. (T e c h n ica l

an a ssessm e n t.

A ss ista n c e P u b lic a tio n [T A P ] 2 1 , A d d iction

A sse ssm e n t is a th o ro u g h , e x te n s iv e p ro cess

C o u n selin g C o m p eten cies: T h e K n ow led g e, S kills,

th a t in v o lv e s a b ro a d a n a ly sis o f th e fa cto rs

a n d A ttitu d es o f P ro fe ssio n a l P ra ctice [C S A T ,

co n trib u tin g to an d m a in ta in in g a c lie n t's

199 8a ] c o n ta in s fu rth e r g u id a n c e o n scre en in g

s u b sta n ce a b u se , th e s e v e rity o f th e p ro b lem ,

an d a s s e s s m e n t fo r b rie f th e ra p y .)

and the v a rie ty o f c o n s e q u e n c e s a sso cia te d w ith

T h e ra p is ts s h o u ld g a th e r as m u c h

it. S cre e n in g an d a ss e s s m e n t p ro ce d u re s fo r

in fo rm a tio n a s p o ss ib le a b o u t a c lie n t b efo re the

b rie f th erap y d o n o t d iffe r sig n ific a n tly fro m

first c o u n s e lin g se s s io n . O n e w a y to d o th is is to

th o se used fo r le n g th ie r tre a tm e n ts.

o b ta in co p ie s o f a n y n o te s ta k e n b y an in ta k e

T h e a sse s s m e n t sh o u ld d e te rm in e w h e th e r

w o rk e r or th e re fe rra l so u rc e . H o w e v e r, w h en

the c lie n t's su b s ta n c e a b u se p ro b le m is su ita b le

g a th e rin g in fo r m a tio n a b o u t a c lie n t fro m o th er

fo r a b rie f th e ra p y a p p ro a c h . T h e c rite ria fo r

s o u rc e s, th e ra p is ts s h o u ld b e s e n sitiv e to

d e term in in g the a p p ro p ria te n e s s o f b rie f

c o n fid e n tia lity an d c lie n t c o n s e n t issu e s (for

th erap y , p re se n te d in F ig u re s 3-1 an d 3 -2, are

m o re in fo rm a tio n se e th e s e c tio n e n title d

first a p p lied d u rin g the a sse s s m e n t stag e.

"C o n fid e n tia lity o f In fo rm a tio n A b o u t C lie n ts"

It is re a so n a b le to a ssu m e th a t b rie f th e ra p ie s
are m o st e ffe ctiv e w ith clie n ts w h o se p ro b lem s

in C h a p te r 9 o f th e fo rth c o m in g T IP , S u b stan ce
A b u se T rea tm en t f o r P erso n s W ith H IV /A ID S

are o f sh o rt d u ra tio n an d w h o h a v e stro n g ties

[C S A T , in p re s s ]). O th e r o p tio n s in c lu d e a sk in g

to fam ily , w o rk , and c o m m u n ity . H o w e v e r,

in ta k e w o rk e rs to a d m in is te r q u e stio n n a ire s,

lim ite d clie n t re s o u rc e s m a y a lso d icta te th e use

u sin g c o m p u te riz e d a s s e s s m e n ts , or a sk in g the

B r ie f T h era p y in S u b sta n ce A b u se T reatm en t

clie n t to co m p le te an a s s e s s m e n t fo rm b e fo re the

the fo llo w in g s e c tio n . F o r s a m p le scre en in g

first sessio n . T h e a s s e s s m e n t in s tru m e n t ca n be

in s tru m e n ts a n d a d d itio n a l in fo rm a tio n on

b rie f and in fo rm a l, g e n e ra tin g critic a l

scre e n in g p ro c e d u re s se e a lso T IP 24, A G u ide to

in fo rm a tio n in a sh o rt tim e. A lth o u g h in itia l

S u b sta n ce A b u se S erv ices f o r P rim a ry C are

scre en in g and a s s e s s m e n t id e a lly sh o u ld be

C lin icia n s; T IP 2 6 , S u b sta n ce A b u se A m o n g O lder

co n d u cte d b efo re th e firs t th e ra p y se s s io n , th e

A d u lts; T IP 31, S creen in g a n d A ssessin g

p ro cess o f a s s e s s m e n t s h o u ld co n tin u e

A d o lescen ts f o r S u b sta n c e U se D iso rd ers; an d T IP

th ro u g h o u t tre a tm e n t.

35, E n h a n cin g M o tiv a tion f o r C h a n g e in S u bstan ce

A b u se T rea tm en t (C S A T , 1 9 9 7 , 1 9 9 8 b , 1 999a,

A v arie ty o f b rie f a s s e s s m e n t in s tru m e n ts,

19 9 9 c).

m an y of w h ich a re free, a re a v a ila b le to

clin ician s. A ssessin g A lco h o l P ro blem s (N a tio n a l

F or b rie f th e ra p y , th e s e ttin g in w h ich

In stitu te on A lco h o l A b u se an d A lc o h o lism ,

tre a tm e n t w ill o c c u r fre q u e n tly d icta te s the kind

1995) is a u se fu l so u rc e o f re s e a rc h -v a lid a te d

of a s s e s s m e n t th a t ca n b e c o n d u c te d . C lien ts

in stru m en ts. F ig u re 3 -5 p ro v id e s a sa m p le

see k tre a tm e n t in th e ty p e o f a g e n c y th e y feel

b a tte ry o f b rie f a sse s s m e n t in s tru m e n ts th a t

w ill b e s t m e e t th e ir n e e d s (e .g ., th o se w h o n eed

m ig h t b e u sed in a b rie f th e ra p y settin g , id e a lly

to c o n tin u e w o rk in g w h ile s e e k in g tre a tm e n t

b efo re the first co u n s e lin g sessio n . T h e se

w ill lik e ly e n te r an o u tp a tie n t p ro g ra m ).

in stru m e n ts ca n p ro v id e th e th e ra p is t w ith a

C o n s tra in ts m a y b e p la c e d b y in su ra n c e

q u ick a sse ssm e n t o f the m o st c ritic a l d o m a in s

c o m p a n ie s o r o th e r o u ts id e fo rc e s. F o r e x a m p le ,

ab o u t w h ich c lin ica l d e c isio n s s h o u ld b e m a d e .

m a n a g e d c a re e n v iro n m e n ts g e n e ra te th eir ow n

In g e n era l, m o st c lie n ts c a n c o m p le te th e se

a s s e s s m e n t c rite ria . A s s e s s m e n t o fte n m u st be

in stru m e n ts in less th a n 1 h o u r. T h e se

c o n d u c te d o u ts id e th e tre a tm e n t fa c ility and

in stru m en ts s h o u ld b e su p p le m e n te d in th e first

m a y n o t q u a lify as a re im b u rs a b le visit. In

co u n selin g se ssio n b y a c lin ic a l a s se ssm e n t

a d d itio n , p riv a te p ra c titio n e rs o fte n d o n o t hav e

in te rv iew th at co v e rs the co re a re a s o u tlin e d in

e a sy a cce ss to b a c k g ro u n d in fo rm a tio n

F ig u r e 3 -5
S a m p le B a tte r y o f B rief A s s e s s m e n t I n s tr u m e n ts
E x a m p le In s tr u m e n t(s )

A s s e s s m e n t D o m a in
Q u a n tity / fre q u e n cy o f use

T im e lin e F o llo w B a ck T e c h n iq u e

S e v e rity o f d ep e n d e n c e

S h o rt A lc o h o l D e p e n d e n c e D a ta (S A D D ), S e v e rity o f D e p e n d e n ce
S c a le s (S D S ), C A G E

C o n se q u e n ce s o f use

M ic h ig a n A lc o h o lis m S c re e n in g T e s t (M A S T ), D ru g A b u se
S cre e n in g T e s t (D A S T ), S u b s ta n c e A b u s e S u b tle S c re e n in g In v e n to ry
(S A S S I), D R IN K

R e a d in e ss to ch a n g e

C o m m itm e n t to C h a n g e A lg o r ith m , S O C R A T E S

P ro b le m area s

P ro b le m C h e c k lis t fro m C o m p re h e n s iv e D rin k e r P ro file, P ro b lem

O rie n te d S cre e n in g In s tru m e n t fo r T e e n a g e rs (P O S IT ), A d o le sce n t
A s s e s sm e n t/ R e fe rra l S y s te m (A A R S )

T re a tm e n t p la ce m e n t

A d d ic tio n S e v e rity In d ex (A SI)

G oal ch o ice an d c o m m itm e n t

In te n tio n s Q u e s tio n n a ire

Sou rces: A llen a n d C o lu m b u s , 1 9 9 5 ; M ille r, 1991.

45

C h ap ter 3

re g a rd in g a p o te n tia l clie n t. In a p rim a ry ca re

a c c o m p lis h c e rta in c ritic a l ta sk s d u rin g th e first

o ffice, scre e n in g and a ss e s s m e n t c o n s is t o n ly o f

s e ssio n , in c lu d in g

tak in g a c lie n t's h isto ry an d c o n d u c tin g a

p h y sica l e x a m in a tio n .

Core assessment areas

Id e n tify in g , fo c u s in g , a n d p rio ritiz in g

p ro b le m s

B efo re p ro ce e d in g w ith b rie f th e ra p y fo r

s u b sta n ce a b u se d iso rd e rs, a n u m b e r o f a rea s

P ro d u c in g ra p id e n g a g e m e n t

W o rk in g w ith th e c lie n t to d e v e lo p p o ssib le

so lu tio n s to s u b s ta n c e a b u se p ro b le m s an d a

sh o u ld b e a s se sse d , in c lu d in g th e fo llo w in g :

tre a tm e n t p la n th a t re q u ire s th e c lie n t's

C u rre n t u se p a tte rn s

H isto ry o f su b s ta n c e a b u se

a c tiv e p a rtic ip a tio n

C o n se q u e n c e s o f s u b s ta n ce a b u se (e sp e cia lly

the c lie n t (w h ich m a y in v o lv e a c o n tra ct

e x te rn a l p re ssu re s th a t a re b rin g in g th e clie n t

in to tre a tm e n t a t th is tim e , su ch as fa m ily or

b e tw e e n c lie n t a n d th e ra p ist)

leg al p re ssu re s)

C o e x istin g p s y c h ia tric d iso rd e rs

In fo rm a tio n a b o u t m a jo r m e d ic a l p ro b le m s

U n d e rs ta n d in g c lie n t e x p e c ta tio n s

E x p la in in g th e s tru c tu r a l fra m e w o rk o f b rie f

th e ra p y , in c lu d in g th e p ro c e s s an d its lim its

In fo rm a tio n a b o u t e d u c a tio n an d

(i.e., th o se ite m s n o t w ith in th e sco p e o f that

e m p lo y m e n t

S u p p o rt m e c h a n ism s

C lien t stre n g th s an d s itu a tio n a l a d v a n ta g e s

P rev io u s tre a tm e n t

F am ily h is to ry o f s u b s ta n c e a b u se d iso rd e rs
and p s y ch o lo g ic a l d iso rd e rs
A s m e n tio n e d e a rlie r, a s s e s s m e n t is c ritica l

n o t o n ly b e fo re b e g in n in g b rie f th e ra p y b u t also
as an o n g o in g p a rt o f th e p ro c e ss. O n ly by
co n tin u a lly a s s e s s in g th e c lie n t's p ro g re ss and
p ro b le m s can th e th e ra p is t a c c o m p lis h th e g o als
o f b rie f th e ra p y in th e lim ite d tim e fra m e . In
ad d itio n , o n g o in g a s s e s s m e n t ca n fu n ctio n as a
th e ra p e u tic to o l b e c a u se it h e lp s c lie n ts id e n tify
w h en th ey are at risk o f u sin g su b s ta n c e s as w ell
as oth er n e g a tiv e b e h a v io rs.

E lic itin g c lie n t c o n c e rn s a b o u t p ro b le m s and

so lu tio n s

and h e a lth sta tu s

N e g o tia tin g th e ro u te to w a rd c h a n g e w ith

tre a tm e n t s e g m e n t o r th e a g e n c y 's w o rk )

M a k in g re fe rra ls fo r critic a l n e e d s th a t h a v e
b e e n id e n tifie d b u t ca n n o t b e m e t w ith in the
tre a tm e n t s e ttin g

Goals o f treatment
T h e ra p is ts s h o u ld id e n tify a n d d isc u ss th e g o als
o f b rie f th e ra p y w ith th e c lie n t e a rly in
tre a tm e n t, p re fe ra b ly in th e firs t se ssio n . T h e
c lie n t h a s a c ritic a l ro le in d e te rm in in g th e g o als
o f th e ra p y , a n d th e th e ra p is t m ig h t h a v e to be
fle x ib le . T h e th e ra p is t ca n re c o m m e n d
tre a tm e n t g o a ls , b u t u ltim a te ly th e y are
e sta b lish e d th ro u g h in te ra c tio n an d n e g o tia tio n
w ith th e clie n t. If a c lie n t h a s ce rta in
e x p e c ta tio n s o f th e ra p y th a t m a k e it d iffic u lt fo r
h e r to c o m m it to th e g o a ls a n d p ro c e d u re s of

The Opening Session

In the first se ssio n , th e m a in g o a ls fo r th e
th e ra p ist are to g a in a b ro a d u n d e rs ta n d in g of
the clie n t's p re s e n tin g p ro b le m s, b e g in to
e sta b lish ra p p o rt a n d an e ffe c tiv e w o rk in g
re la tio n sh ip , an d im p le m e n t an in itia l
in te rv e n tio n , h o w e v e r sm a ll. T h e th e ra p ist m u s t

46

b rie f th e ra p y o r to a p a rtic u la r th e ra p e u tic

a p p ro a c h , o th e r a p p ro a c h e s s h o u ld b e
c o n s id e re d o r a re fe rra l m a d e .
T re a tm e n t g o a ls s h o u ld fo c u s o n th e ce n tra l
p ro b le m o f s u b s ta n c e a b u s e an d m a y in c lu d e the
fo llo w in g :

B r ie f T h era p y in S u b sta n ce A b u se T reatm en t

M ak in g a m e a s u ra b le c h a n g e in sp e cific

R e m a in p re p a re d to ra p id ly id e n tify and

M a in ta in an e m p h a s is on th e sk ills,

tro u b le s h o o t p ro b le m s

ta rg e t b e h a v io rs a sso c ia te d w ith su b sta n c e

ab u se

H e lp in g the c lie n t d e m o n s tra te a new

s tre n g th s , a n d re s o u r c e s c u rre n tly a v a ila b le

u n d e rsta n d in g an d k n o w le d g e o f p ro b le m s

to th e clie n t

and issu es re la ted to s u b s ta n c e a b u se

Im p ro v in g th e c lie n t's p e rs o n a l re la tio n sh ip s

R e so lv in g o th e r id e n tifie d p ro b le m s (e.g .,

im m e d ia te ly to a d d re s s th e c lie n t's p ro b lem

th e ra p y or o th e r se rv ic e s a n d h o w th ese

T h e g oals of b rie f th e ra p y m a y b e m o re clie n t

s e rv ic e s m ig h t b e s t b e p ro v id e d

d riv en th an th o se d e v e lo p e d in lo n g -te rm

p ro b le m s , in c a rc e ra tio n , th e e m e rg e n c e of

o f g o als b e sid e s th o se re la ted to s u b s ta n c e a b u se

se v e re p s y c h o p a th o lo g y , tre a tm e n t

d iso rd e rs can b e a d d re sse d e ffe c tiv e ly in a b rie f

n o n c o m p lia n c e )

th e rap y m o d a lity , b u t g iv e n tim e c o n stra in ts,

ad d resse d . T h e k ey is to id e n tify th e g o a ls m o st
im p o rta n t to th e c lie n t and to w o rk w ith h im to
a ch iev e th o se g o a ls, k e ep in g in m in d the
u ltim ate g o al o f s o b rie ty or d e cre a se d use.
A lth o u g h a b stin e n c e is an o p tim a l clin ica l
goal, it still m u st b e n e g o tia te d w ith th e c lie n t (at
least in o u tp a tie n t tre a tm e n t se ttin g s).
A b stin en ce as a g o a l is n o t n e c e s s a rily th e sole

M aintenance Strategies
M a in te n a n c e s tra te g ie s m u s t b e b u ilt in to the
tre a tm e n t d e s ig n fro m th e b e g in n in g . A
p ra c titio n e r o f b rie f th e ra p y m u s t c o n tin u e to
p ro v id e s u p p o rt, fe e d b a c k , a n d a ssista n c e in
se ttin g re a listic g o a ls. A lso , th e th e ra p is t sh ou ld
h elp th e c lie n t id e n tify re la p se trig g e rs and
s itu a tio n s th a t c o u ld e n d a n g e r co n tin u e d
so b rie ty .

ad m issio n re q u ire m e n t fo r tre a tm e n t, an d the

th e ra p ist m ay h a v e to a c c e p t an a lte rn a tiv e g oal,
su ch as d ecrea se d u se, in o rd e r to e n g a g e the

R e v ie w w ith th e c lie n t a n y re a so n s for

d ro p p in g o u t o f tre a tm e n t (e .g ., m e d ica l

n o t h av e as lon g to s h a p e th ese g o a ls. A v a rie ty

th erap ists w ill h a v e to lim it th e n u m b e r o f issu es

C o n s id e r, as p a rt o f a n o n g o in g a sse ssm e n t
o f p ro g re ss , w h e th e r th e c lie n t n e e d s fu rth e r

w o rk p ro b le m s, su p p o rt g ro u p a tte n d a n c e )

th erap ies b eca u se , by d esig n , the th e ra p is t d o es

M a in ta in a fo cu s o n w h a t ca n b e d on e

S tra te g ie s to h e lp m a in ta in th e p ro g re ss
m a d e d u rin g b rie f th e ra p y in c lu d e th e
fo llo w in g :

clie n t e ffe ctiv e ly .

E d u ca tin g th e clie n t a b o u t th e ch ro n ic,

Subsequent Sessions

re la p sin g n a tu re o f s u b s ta n c e a b u se

In su b s e q u e n t s e ssio n s o f b rie f th e ra p y ,

d iso rd e rs

th erap ists sh o u ld

p ro v id e re a s o n s fo r th e clie n t to re tu rn to

W o rk w ith th e c lie n t to h elp m a in ta in

tre a tm e n t an d p la n s to a d d re s s th em

m o tiv a tio n an d a d d re ss id e n tifie d p ro b le m s,

m o n ito rin g w h e th e r an y a c c o m p lis h m e n ts

c lie n t d e v e lo p a p la n fo r a d d re ssin g th em in

the c lie n t's e x p e c ta tio n s

th e fu tu re (o r id e n tify in g sp e c ific p ro b lem s

R e in fo rce th ro u g h a n o n g o in g re v ie w o f the

th a t m ig h t h a v e e m e rg e d b u t w e re n o t d ealt

tre a tm e n t p la n an d th e c lie n t's

w ith in tre a tm e n t)

e x p e c ta tio n s th e n eed to d o th e w o rk o f
b rie f th e ra p y (e.g ., m a in ta in p ro b le m fo cu s,
stay on track )

R e v ie w in g p ro b le m s th a t e m e rg e d b u t w ere
n o t a d d re s s e d in tre a tm e n t an d h e lp in g the

are co n s is te n t w ith th e tre a tm e n t p la n an d

D e v e lo p in g a lis t o f c irc u m sta n c e s th a t m ig h t

D e v e lo p in g s tra te g ie s fo r id e n tify in g and

co p in g w ith h ig h -ris k s itu a tio n s or the
re e m e rg e n c e o f s u b s ta n c e a b u se b eh a v io rs

47

C h ap ter 3

T e a ch in g th e c lie n t h o w to c a p ita liz e on

p e rso n a l stre n g th s

p ro b le m s

fo llo w th r o u g h o n w h a t h a s b e e n le a rn e d or

th at h a v e b e e n se t in th e ra p y ) an d te a ch in g

a c h ie v e d

R e v ie w w h a t p o s itiv e o u tc o m e s th e c lie n t can

R e v ie w p o ss ib le p itfa lls th e c lie n t m a y

D ev e lo p in g a p la n fo r fu tu re su p p o rt,
in clu d in g m u tu a l h e lp g ro u p s, fa m ily

expect

su p p o rt, an d co m m u n ity s u p p o rt (e.g.,

e n c o u n te r (e .g ., s o c ia l s itu a tio n s , old frie n d s,

re lig io u s or so cia l serv ice o rg a n iz a tio n s),

re la tio n sh ip iss u e s ) a n d ta lk a b o u t the

w h ich can b e d on e m u ch e a rlie r th a n in lo n g

lik e lih o o d o f a g o o d o u tc o m e a n d in d ica to rs

of a p o o r o u tc o m e

term th erap y
In a d d itio n to ro u tin e p ro g re ss a sse ssm e n ts

R e v ie w th e e a rly in d ic a to rs o f re la p se (e.g.,
d e p re s s io n , s tre ss, a n g e r)

th at are co n d u cte d th ro u g h o u t th e th e ra p y ,
m id w a y th ro u g h th e a g re e d -u p o n n u m b e r of

In b rie f th e ra p y , iss u e s re g a rd in g re fe rra l and

sessio n s th e th e ra p is t sh o u ld fo rm a lly re v iew

fo llo w u p a re o fte n d iffe re n t fro m th o se o f lo n g er

the c lie n t's p ro g re ss. P a rtic u la rly b e c a u se o f the

te rm th e ra p y b e c a u s e c lie n ts w ill n o t n e ce ssa rily

tim e lim ita tio n s o f b rie f th e ra p y , c o n tin u in g

re m a in in c o n ta c t w ith th e th e ra p is t. If the g o als

a ssessm e n ts are e sse n tia l to e n su re th at

o f th e ra p y h a v e n o t b e e n m e t, m o re in te n siv e

p ro b lem s are a d d resse d an d th a t the c lie n t can

th e ra p y m a y b e su g g e s te d .
D u rin g c o n tin u a l a s s e s s m e n t o f th e p ro g re ss

re co g n iz e w h en sh e is m o st a t risk o f slip p in g
into s u b sta n ce a b u se or o th e r n e g a tiv e

o f th e th e ra p y , th e th e ra p is t m a y d e c id e th a t

b eh a v io rs. A ss e s sm e n ts w ill a lso ta k e in to

re fe rra l is a p p r o p ria te b e fo re tre a tm e n t e n d s. It

a cco u n t th e lev el o f th e c lie n t's p ro g re ss. W h e n

is im p o r ta n t to re m e m b e r th a t re fe rra ls c a n be

the clie n t h a s m a d e a g re e d -u p o n b e h a v io r

m a d e a t a n y tim e d u rin g tre a tm e n t, n o t ju s t at

ch an g e s and h a s re so lv e d s o m e p ro b le m s , the

th e e n d o f th e tre a tm e n t p ro c e s s . R e a so n s fo r

th e ra p ist sh o u ld p re p a re to e n d th e b rie f

in itia tin g re fe rra ls d u rin g or a t th e en d o f

th erap y . If a c lie n t p ro g re sse s m o re q u ick ly than

tre a tm e n t in c lu d e th e fo llo w in g :

a n ticip a ted , it is n o t n e c e ssa ry to co m p le te the

fu ll n u m b e r o f sessio n s.

T e rm in a tio n o f th e ra p y sh o u ld a lw a y s b e
p lan n ed in a d v a n c e . In m a n y ty p e s o f b rie f
th erap y , the en d o f th e ra p y w ill be an e x p licit
fo cu s o f d iscu ssio n in w h ich the th e ra p is t sh o u ld

T h e c lie n t n e e d s a n c illa ry se rv ic e s fo r oth er

p ro b le m s th a t h a v e b e e n re c o g n iz e d d u rin g
th e ra p y (e .g ., m e d ic a l or p s y c h ia tric

Ending Treatment

p ro b le m s ).

T h e c lie n t re q u ire s m o re in te n siv e th e ra p y .

T h e c lie n t m a y b e n e fit fro m in v o lv e m e n t

w ith a s u p p o rt g ro u p , s u c h as A lc o h o lic s
A n o n y m o u s , S e lf-M a n a g e m e n t an d R e co v e ry

L eav e the c lie n t o n g o o d te rm s, w ith an

T ra in in g (S M A R T ), o r M o d e ra tio n

en h a n ce d sen se o f h o p e fo r co n tin u e d ch a n g e

M a n a g e m e n t (w h ic h m a y a lso b e a p a rt of

an d m a in te n a n ce o f c h a n g e s a lrea d y

th e b rie f th e ra p y p ro c e s s ).

acco m p lish e d

48

E licit c o m m itm e n t fro m th e c lie n t to try to

o w n p ro b le m s an d sta y fo cu se d o n th e g o als

se lf-re in fo rc e m e n t te c h n iq u e s

s e s s io n s d e a lin g w ith th e c lie n t's o th er

E m p h a siz in g c lie n t s e lf-su ffic ie n c y

(e n co u ra g in g the c lie n t to w o rk th ro u g h h is

L e a v e th e d o o r o p e n fo r p o ss ib le fu tu re

B r ie f T h era p y in S u b sta n ce A b u se T reatm en t

Followup

p s y c h o th e r a p y b u t p o ss e s s a g e n e ra l

It is alw ay s a d v isa b le fo r th e th e ra p is t to fo llo w

u n d e rs ta n d in g o f o th e r m o d e ls fro m w h ic h

up w ith clie n ts w h o h a v e co m p le te d b rie f

a p p ro p ria te te c h n iq u e s m a y b e d ra w n . T h ey

th erap y . F o llo w u p re a s su re s th e clie n t th a t the

sh o u ld b e a d e p t a t d e te rm in in g e a rly in the

th e ra p ist is c o n c e rn e d a b o u t h er p ro g re ss. In

a s s e s s m e n t p ro c e s s th e c lie n t n e e d s or g o a ls th at

a d d itio n , it is an e ffe c tiv e w a y to g a th e r m u ch -

a re a p p ro p ria te to a d d re ss. R e la te d to th is, and

n e ed e d d ata re g a rd in g tre a tm e n t e ffe ctiv e n e ss.

e q u a lly im p o rta n t, th e ra p is ts m u st e sta b lish

T h e th e ra p ist m ig h t o b ta in su ch d ata by

re la tio n sh ip s th a t fa c ilita te re fe rra l w h e n the

c o n d u ctin g a clie n t s a tisfa c tio n su rv e y via

c lie n t's n e e d s or g o a ls c a n n o t b e m e t th ro u g h

te le p h o n e or m a il. A fte rc a re , w h e n a d d itio n a l

b rie f th e ra p y . A c o m p re h e n siv e d e s c rip tio n of

tre a tm e n t is p ro v id e d , is n o t p a rt o f th e b rie f

th e p ro fe s s io n a l an d p e rs o n a l a ttrib u te s th a t

th erap y p ro cess. H o w e v e r, fo llo w u p a ctiv itie s

p ra c titio n e rs n e e d to b e e ffe c tiv e p ro v id e rs of

such as o ffe rin g re a s su ra n c e an d tra c k in g clie n t

s u b s ta n c e a b u se tre a tm e n t is p ro v id e d in T A P

statu s are cu sto m a ry .

21, A d d iction C o u n selin g C o m p eten cies: T he

K n ow led g e, S kills, a n d A ttitu d es o f P rofessio n a l

Therapist Characteristics

P ra ctice (C S A T , 1 9 9 8 a ). T A P 21 e m p h a siz e s that

p ra c titio n e rs sh o u ld

T o su cce ssfu lly in te g ra te d iffe re n t s h o rt-te rm

th e rap ie s in to p ra c tice , th e ra p ists b e n e fit fro m a

Be e m p a th ic

B e a b le to in te g ra te th e ir tra in in g w h eth er

firm g ro u n d in g in th e o ry an d a b ro a d te ch n ica l

in s u b s ta n c e a b u se tre a tm e n t or oth er

k n o w le d g e o f the m a n y d iffe re n t a p p ro a ch e s

d is c ip lin e s s u c h as s o c ia l w o rk , m e d icin e ,

av ailab le. W h e n a p p ro p ria te , e le m e n ts o f

n u rs in g , or p s y c h o lo g y w ith e x p e rie n c e ,

d iffe ren t b rie f th e ra p ie s m a y b e co m b in e d to

b o th p ro fe s s io n a l a n d p e rs o n a l, to cre a te the

p ro v id e su cce s s fu l o u tco m e s. H o w e v e r, it is
im p o rta n t to re m e m b e r th a t th e e ffe c tiv e n e s s of

b e s t th e ra p e u tic e n v iro n m e n t fo r the clie n t

h ig h ly d efin e d in te rv e n tio n s (e .g ., w o rk b o o k d riv e n in te rv e n tio n s) u sed in s o m e b e h a v io ra l

th e rap ie s d e p e n d s on a d m in is tra tio n o f th e

e n tire re g im en . T h e th e ra p is t m u s t u se c a u tio n
in co m b in in g and m in g lin g ce rta in te c h n iq u e s
and m u st b e se n sitiv e to th e cu ltu ra l co n te x t

H a v e a m a tu re se n se o f p e rs o n a l and
p ro fe ss io n a l b o u n d a rie s
B e s e n sitiv e to th e c u ltu ra l an d sp iritu a l
n e e d s o f th e c lie n t

F o llo w a p p r o p ria te F e d e ra l, S ta te , and

a g e n cy re g u la tio n s in th e p ro v isio n of
s u b s ta n c e a b u s e tre a tm e n t s e rv ice s

w ith in w h ich th e ra p ie s a re in te g ra te d .
T h e ra p ists sh o u ld a lso b e su ffic ie n tly tra in e d in

P ro v id e rs o f b rie f th e ra p y m u s t fo cu s

the th e ra p ie s th ey a re u sin g an d sh o u ld n o t re ly

e ffe c tiv e ly o n id e n tify in g an d a d h e rin g to

so lely on a m a n u a l s u c h as th is to le a rn th o se

sp e cific th e ra p e u tic g o a ls in tre a tm e n t. T h ey

th erap ies. A p p e n d ix B p ro v id e s s o m e re so u rc e s

sh o u ld b e a b le to e x tr a c t te c h n iq u e s fro m lo n g e r

fo r fu rth e r e d u ca tio n .

te rm th e ra p ie s a n d a d a p t th e m w ith in the

A lth o u g h th e ra p ists w ith m a n y lev els of

p a ra m e te rs o f b rie f th e ra p y . T h e p ro v id e r of

train in g and e x p e rie n c e ca n c o n d u c t b rie f

b rie f th e ra p y w ill h a v e to fo cu s o n sh o rt-te rm

in te rv e n tio n s, ce rta in sk ills and tra in in g are

ch a n g e th a t ca n h a v e lo n g -te rm b e n e fits and

p a rticu la rly im p o rta n t fo r c o n d u c tin g e ffe c tiv e

a v o id issu e s th a t a re m o re g lo b a l. T h e th e ra p ist

b rie f th erap y . T h o se w h o sp e c ia liz e in

m u s t b e a b le to s h ift a p p ro a c h e s d e p e n d in g on

p ro v id in g b rie f th e ra p y a re lik e ly to b e m o re

w h a t is le a rn e d a b o u t th e c lie n t d u rin g

su cce ssfu l w h en g ro u n d e d in a sp e c ific m o d e l of

tre a tm e n t.

49

C h ap ter 3

B rief th e ra p y is a m e n a b le to th e use o f a w id e

o fte n h e lp fu l, b u t s h o u ld n o t b e c o n s id e re d a

can ch o o se. It is th e re fo re h e lp fu l fo r th e ra p ists

sta n d a rd o f c a re fo r a ll p e rs o n s o r p o p u la tio n s.

to b e a w are o f th e b ro a d ra n g e o f th e ra p e u tic

B rie f th e ra p y , as p re s e n te d in th is T IP , ca n b e a

te ch n iq u es a v a ila b le. E x p o s u re to sev era l

co n ta in e d m o d a lity o f tre a tm e n t an d n o t an

p s y ch o th e ra p e u tic a p p ro a ch e s (m a n y d escrib e d

e p is o d ic fo rm o f lo n g -te rm th e ra p y . In fa ct,

in the fo llo w in g ch a p te rs) a llo w s th e ra p ists to

su c c e s s fu l b rie f th e ra p y m a y b e th e o n ly

u n d e rstan d how o th er c lin ic ia n s m ig h t a p p ro a ch

tre a tm e n t s o m e c lie n ts w ill re q u ire .

the situ a tio n , w h a t a c lie n t m ig h t h a v e

e x p e rien ced in p re v io u s tre a tm e n ts, an d h o w to
b u ild on th ese e x p e rie n ce s.

50

B rie f th e ra p y fo r s u b s ta n c e a b u se d iso rd e rs is

ran g e of te ch n iq u e s fro m w h ic h th e th e ra p ist

4 Brief Cognitive-Behavioral
Therapy

n a p p ro a ch th a t h a s g a in e d w id e s p re a d

a b u se tre a tm e n t. B o th b e h a v io ra l a n d co g n itiv e

a p p lica tio n in th e tre a tm e n t o f

th e o rie s h a v e led to in te rv e n tio n s th a t

su b sta n c e a b u se is c o g n itiv e -

in d iv id u a lly h a v e b e e n p ro v e n e ffe c tiv e in

b e h a v io ra l th e ra p y (C B T ). Its o rig in s a re in

tre a tin g s u b s ta n c e a b u se . S e v e ra l o f th e se are

b e h a v io ra l th e o ry , fo c u s in g on b o th cla ssic a l

re v ie w e d , as th e y h a v e b e e n su cc e s s fu lly

co n d itio n in g an d o p e ra n t le a rn in g ; co g n itiv e

in c o rp o ra te d in to an in te g ra te d c o g n itiv e -

so cial le a rn in g th e o ry , fro m w h ic h a re ta k e n

b e h a v io ra l m o d e l o f a d d ic tiv e b e h a v io rs and

id eas co n c e rn in g o b s e rv a tio n a l le a rn in g , th e

th e ir tre a tm e n t.

in flu e n ce o f m o d e lin g , a n d th e ro le o f c o g n itiv e

e x p e cta n cie s in d e te rm in in g b e h a v io r; and

Behavioral Theory

co g n itiv e th e o ry an d th e ra p y , w h ic h fo c u s on
the th o u g h ts, c o g n itiv e s c h e m a , b e lie fs,
attitu d e s, and a ttrib u tio n s th a t in flu e n c e o n e 's
fe e lin g s and m e d ia te th e re la tio n sh ip b e tw e e n
a n te ce d e n ts an d b e h a v io r. A lth o u g h th e re a re a
n u m b e r o f s im ila ritie s a c ro ss th e se th ree se m in a l
p e rsp e ctiv e s (see C a rro ll, 1 9 9 8 ), e a c h h a s
co n trib u te d u n iq u e id e a s c o n s is te n t w ith its
th e o retica l u n d e rp in n in g s . H o w e v e r, in m o st
su b sta n ce a b u se tre a tm e n t se ttin g s, the
p ro m in e n t fe a tu re s o f th e se th ree th e o re tic a l
a p p ro a ch e s are m e rg e d in to a c o g n itiv e b e h a v io ra l m o d e l.
B efo re fo cu sin g m o re sp e c ifica lly on the
c o g n itiv e -b e h a v io ra l m o d e l, th is ch a p te r
e x a m in e s th e b e h a v io ra l an d c o g n itiv e th e o rie s
and th e ra p ie s th a t serv e as th e fo u n d a tio n s of
and h av e c o n trib u te d s ig n ific a n tly to the
co g n itiv e -b e h a v io ra l a p p ro a c h to su b sta n ce

In c o n tra s t to m a n y o th e r m e th o d s , b e h a v io ra l
a p p ro a c h e s to th e tre a tm e n t o f su b sta n c e ab u se
h a v e s u b s ta n tia l re s e a rc h e v id e n c e in su p p o rt of
th e ir e ffe c tiv e n e s s . T w o re c e n t co m p re h e n siv e
re v ie w s o f th e tre a tm e n t re s e a rc h lite ra tu re o ffer
s tro n g e v id e n c e fo r th e ir e ffe c tiv e n e s s (H o ld e r et
al., 1 9 9 1 ; M ille r e t al., 1 9 9 5 ). H o w e v e r, so m e
critics a rg u e th a t th is is b e c a u s e b e h a v io ra l
a p p ro a c h e s h a v e b e e n d e v e lo p e d u n d e r
c o n tro lle d c o n d itio n s a n d th a t in " r e a l" th e ra p y
th e re a re m a n y m o re v a r ia b le s a t w o rk th a n can
b e m e a s u re d in c o n tro lle d e x p e rim e n ts.
P ro v id e rs s h o u ld ta k e a d v a n ta g e o f the w id e
ra n g e o f b e h a v io ra l th e ra p y te ch n iq u e s th a t are
a v a ila b le. T h e s e te c h n iq u e s ca n b e co n d u cte d
s u c c e s s fu lly in in d iv id u a l, g ro u p , an d fa m ily
se ttin g s, a m o n g o th e rs, to h e lp c lie n ts ch a n g e
th e ir s u b s ta n c e a b u se b e h a v io rs .

51

C h ap ter 4

fro m b o th o p e ra n t a n d c la ss ic a l th e o rie s of

B eh a v io ra l a p p ro a c h e s a ssu m e th a t
su b sta n ce a b u se d iso rd e rs a re d ev elo p e d and

lea rn in g . A m a jo r te n e t o f b e h a v io ra l th e ra p y is

m a in ta in ed th ro u g h th e g e n e ra l p rin c ip le s o f

th a t b e c a u se s u b s ta n c e a b u s e is a lea rn ed

learn in g an d re in fo rc e m e n t. T h e e a rly

b e h a v io r p a tte rn , ch a n g in g th e re in fo rc e m e n t

b e h a v io ra l m o d e ls o f su b sta n c e a b u se w ere

c o n tin g e n c ie s th a t g o v e rn th is b e h a v io r can

in flu e n ced p rim a rily b y the p rin c ip le s o f b o th

m o d ify it. T h is g o a l c a n b e a ch ie v e d by fo cu sin g

P av lo v ian cla ssic a l co n d itio n in g an d S k in n e ria n

on e ith e r th e c la ss ic a lly c o n d itio n e d cra v in g

o p era n t lea rn in g (O 'B rie n an d C h ild re ss, 1992;

re sp o n se s or o n th e o p e ra n t re in fo rc e m e n t

S ta siew icz an d M a isto , 1993). (S ee F ig u re 4-1 fo r

p a tte rn s th a t a re a sse sse d as m a in ta in in g the

d efin itio n s o f cla ssic a l co n d itio n in g and o p e ra n t

s u b s ta n c e a b u se . M o re s p e c ific a lly , the

learn in g .)

cla ss ica lly c o n d itio n e d re s p o n s e ca n b e

T o d a y , b e h a v io ra l th e ra p y fo r the tre a tm e n t

a d d re s s e d e ith e r th ro u g h e x tin c tio n or

o f s u b sta n ce a b u se d is o rd e rs is b a se d p rim a rily ,

c o u n te rc o n d itio n in g p ro c e d u re s ; th e o p e ra n t

th o u g h n o t e x c lu siv e ly , on m e th o d s d eriv ed

re sp o n se s ca n b e ta rg e te d th ro u g h co n tin g e n cy

F ig u r e 4-1
C la s s ic a l C o n d itio n in g a n d O p e r a n t L e a r n in g
A cco rd in g to the th e o ry o f cla ssical con d itio n in g , an o rig in a lly n e u tra l s tim u lu s c o m e s to e licit a
re sp o n se as a re su lt o f b e in g p a ire d w ith an u n c o n d itio n e d s tim u lu s (an e v e n t th a t e lic its a re sp o n se
w ith o u t an y p rio r le a rn in g h isto ry ) or w ith a c o n d itio n e d stim u lu s . A s a p p lie d to s u b s ta n c e a b u se,
re p e a ted p a irin g s b e tw e e n th e e m o tio n a l, e n v iro n m e n ta l, an d s u b je c tiv e c u e s a s s o c ia te d w ith th e u se o f
su b sta n ce s an d th e a ctu a l p h y s io lo g ic a l an d p h e n o m e n o lo g ic a l e ffe c ts p ro d u c e d b y s p e c ific su b sta n ce s
lead to the d e v e lo p m e n t o f a cla ssica lly co n d itio n e d re sp o n se . S u b s e q u e n tly , w h e n th e s u b s ta n c e a b u ser
is in the p re se n c e o f su ch cu es, a cla ss ic a lly co n d itio n e d w ith d ra w a l sta te or c ra v in g is e lic ite d . C o c a in e and o p ia te -d e p e n d e n t in d iv id u a ls, fo r e x a m p le , e x p e rie n c e m a rk e d p h y s io lo g ic a l a ro u s a l an d re p o rt
stro n g cra v in g w h en th ey see th eir d ru g w o rk s an d o th er d ru g p a ra p h e r n a lia or w h e n th e y e x p e rie n ce
n e g a tiv e e m o tio n s su ch as d e p re s s io n e v e n a fte r p ro lo n g e d d ru g -fre e p e rio d s (C h ild re ss e t al., 1994,

1988; E h rm a n et al., 1992). A lc o h o l-d e p e n d e n t c lie n ts e x p e rie n c e s im ila r p h y s io lo g ic a l re a c tiv ity to

a lco h o l-re la te d cu es su ch as b e in g in a b a r or w a tch in g o th e rs d rin k (R o h se n o w et al., 1991). T h e s e cu es
can b eco m e " tr ig g e r s " or h ig h -ris k situ a tio n s th a t ca n lea d to s u b s ta n c e u se a n d re la p se .
O p eran t learn in g re fe rs to th o se b e h a v io rs th a t a re in c re a se d in fre q u e n c y b y re in fo rc e m e n t. B eh a v io rs
th at resu lt e ith e r in re w a rd in g or p o sitiv e o u tc o m e s or th a t a llo w th e in d iv id u a l e ith e r to a v o id or e sca p e
fro m n e g a tiv e co n s e q u e n ce s a re lik e ly to in cre a se in fre q u e n cy . S u b s ta n c e a b u s e in th e p re s e n c e of
cla ssica lly co n d itio n e d cu es is in s tru m e n ta l in re d u c in g or e lim in a tin g th e a ro u s a l a s s o c ia te d w ith a state
o f cra v in g , th u s se rv in g to re in fo rc e th e su b sta n c e a b u se b e h a v io r. T h a t is, th e b e h a v io r s e rv e s a b a sic
re w a rd in g fu n c tio n fo r the in d iv id u a l. T h is re p re se n ts th e se c o n d fo rm o f le a rn in g , o p e ra n t c o n d itio n in g .
A n a lco h o l-d e p e n d e n t p e rs o n w h o d rin k s to fe e l m o re so cia l an d less a n x io u s or a co c a in e a b u s e r w h o
gets h ig h to o v e rc o m e d e p re ssio n is u sin g su b s ta n ce s in an in s tru m e n ta l w a y . T o th e e x te n t th a t they
e x p e rie n ce th e e ffe c ts th e y se e k , the g re a te r the lik e lih o o d th e y w ill u se s u b s ta n c e s u n d e r sim ila r
circu m sta n ce s in the fu tu re. P re su m a b ly , p e o p le c o n tin u e to a b u se s u b s ta n c e s e v e n in th e fa ce o f
n e g a tiv e co n s e q u e n c e s (e .g ., leg a l, m a rita l, or h e a lth p ro b le m s ) b e c a u se th e se c o n s e q u e n c e s a re q u ite
re m o v ed in tim e fro m th e p o in t o f u se; also , th e m o re im m e d ia te p o sitiv e ly re in fo rc in g e ffe c ts o f the
su b sta n ce ty p ic a lly o v e rrid e c o n s id e ra tio n o f su ch c o n se q u e n c e s.
52

B r ie f C o g n itiv e-B eh a v io ra l T herapy

m a n a g e m e n t or c o p in g sk ills tra in in g . (M o re

th e ra p y . D e c is io n s a b o u t th e le n g th of

in fo rm a tio n a b o u t th e b a sic a s s u m p tio n s of

tre a tm e n t a re m a d e on th e b a sis o f th ese

b eh a v io ra l th e o rie s c o n c e rn in g s u b s ta n c e a b u se

a ss e s s m e n ts , ra th e r th a n a c c o r d in g to a fo rm u la

d iso rd ers is c o n ta in e d in F ig u re 4 -2 .)

or th e o re tic a l a s s u m p tio n a b o u t h o w lon g

th e ra p y s h o u ld ta k e . E a c h in d iv id u a l is

A cco rd in g to b e h a v io ra l th e o ry , c h a n g e s in
b eh a v io r co m e a b o u t th ro u g h le a rn in g n ew

a p p ro a ch e d as a u n iq u e ca se , a lb e it o n e to w h ich

b eh av io rs. B e ca u se su b s ta n c e a b u se b e h a v io r is

b ro a d p rin c ip le s ca n b e a p p lie d .

learn ed , it can b e ch a n g e d b y te a ch in g th e c lie n t

m o re a d a p tiv e , a lte rn a tiv e b e h a v io rs a im ed at
a ch iev in g the sa m e re w a rd s. F ig u re 4 -3
p ro v id e s an o v erv iew o f s o m e o f th e a d v a n ta g e s
of b eh a v io ra l th e o rie s o f s u b s ta n c e a b u se and
d e p e n d e n ce an d th e ir tre a tm e n t.

Behavioral Therapy
Techniques Based on
Classical Conditioning
M odels

By its v e ry d e sig n , m o st b e h a v io ra l th e ra p y
is b rief. T h e a im is n o t to re m a k e p e rs o n a lity ,

Extinction and Cue Exposure

Procedures

b u t ra th er to h elp the c lie n t a d d re s s sp e cific,

id e n tifia b le p ro b le m s in s u ch a w a y th a t the

A p rin c ip a l o f c la ss ic a l c o n d itio n in g is th a t if a

clie n t is ab le to a p p ly th e b a sic te c h n iq u e s and

b e h a v io r o c c u rs re p e a te d ly a c ro ss tim e b u t is n o t

skills lea rn ed in th e ra p y to th e re a l w o rld ,

re in fo rce d , th e s tre n g th o f b o th th e cu e fo r the

w ith o u t th e a s s is ta n c e o f th e th e ra p ist.
B eh a v io ra l th e ra p y fo cu se s m o re o n id e n tify in g
and ch a n g in g o b se rv a b le , m e a s u ra b le b e h a v io rs

a n d the b e h a v io r w ill e x tin g u is h . T h is p rin cip a l

h a s b e e n th e fo u n d a tio n o f b e h a v io ra l

th an o th er th e ra p e u tic a p p ro a c h e s an d h e n ce
len d s its e lf to b rie f w o rk . T re a tm e n t is lin k e d to
alterin g th e b e h a v io r, and su c c e s s is th e ch a n g e ,
e lim in a tio n , or e n h a n c e m e n t o f p a rtic u la r

b e h a v io r an d th e b e h a v io r its e lf w ill d im in ish

tre a tm e n ts k n o w n a s "c u e e x p o s u r e " (O 'B rie n et

al., 1 9 9 0 ; R o h se n o w e t al., 1 9 9 1 ; R o h se n o w and
M o n ti, 19 9 5 ). E v e n a fte r re la tiv e ly lo n g p e rio d s
o f a b stin e n c e fro m s u b s ta n c e s, b e in g p la ce d in

b eh av io rs.
R e g u la r a s s e s s m e n t an d m e a s u re m e n t of
p ro g re ss are in te g ra l to e ffe c tiv e b e h a v io ra l

situ a tio n s th a t h a v e p h y s ic a l-e n v iro n m e n ta l,

so cia l, o r e m o tio n a l c u e s a s s o c ia te d w ith p a st

F ig u r e 4 -2
B a sic A s s u m p tio n s o f B e h a v io ra l T h e o r ie s o f
S u b s ta n c e A b u s e a n d Its T r e a tm e n t

H u m a n b e h a v io r is la rg e ly le a rn e d , ra th e r th a n d e te rm in e d b y g e n e tic fa c to rs.

T h e sa m e le a rn in g p ro c e s s e s th a t c re a te p ro b le m b e h a v io rs ca n b e u se d to c h a n g e th em .

B e h a v io r is la rg e ly d e te rm in e d b y c o n te x tu a l an d e n v iro n m e n ta l fa cto rs.

C o v e rt b e h a v io r su ch as th o u g h ts an d fe e lin g s is su b je c t to c h a n g e th r o u g h th e a p p lic a tio n o f lea rn in g

A ctu a lly e n g a g in g in n e w b e h a v io r in th e c o n te x ts in w h ich th e y a re to b e p e rfo rm e d is a critica l p a rt

p rin cip a ls.

o f b e h a v io r ch a n g e .

E ach clie n t is u n iq u e an d m u s t b e a sse sse d as an in d iv id u a l in a p a rtic u la r co n te x t.

T h e c o rn e rsto n e o f a d e q u a te tre a tm e n t is a th o ro u g h b e h a v io ra l a s s e s s m e n t.

Source: R otgers, 1996.

53

C h ap ter 4

F ig u r e 4 -3
A d v a n t a g e s o f B e h a v io ra l T h e o r ie s in T r e a tin g
S u b s ta n c e A b u s e D is o rd e rs

F lex ib le in m e e tin g sp e c ific c lie n t n eed s

R e a d ily a cc e p te d b y c lie n ts d u e to h ig h lev el o f c lie n t in v o lv e m e n t in tre a tm e n t p la n n in g an d g oal

S o u n d ly g ro u n d e d in e sta b lis h e d p s y c h o lo g ic a l th e o ry

D eriv ed fro m sc ie n tific k n o w le d g e and a p p lie d to tre a tm e n t p ra c tic e

S tru ctu re d in its g u id e lin e s fo r a sse ssin g tre a tm e n t p ro g re ss

E m p o w e rin g clie n ts to m a k e th eir o w n b e h a v io r ch a n g e

E ffe ctiv e , a c c o rd in g to s tro n g e m p iric a l an d s c ie n tific e v id e n ce

sele ctio n

Sou rce: R o tg e rs, 1996.

aro u sal re a ctio n s an d re p o rts o f stro n g

Counterconditioning and
Aversion Procedures

sen sa tio n s o f cra v in g . In cu e e x p o s u re , a clie n t

A n o th e r m e th o d u se d to m o d ify b e h a v io r

is p u rp o se fu lly p re se n te d w ith su ch cu es

a c c o rd in g to c la ss ic a l c o n d itio n in g p rin c ip le s is

p h y sica lly (e.g ., b y s h o w in g his p e rs o n a l d ru g

to m a k e b e h a v io rs th a t h a d b e e n a sso c ia te d w ith

p a ra p h e rn a lia or b y a c c o m p a n y in g h im in to a

p o sitiv e o u tc o m e s less a p p e a lin g b y m o re

su b sta n ce ab u se w ill e lic it s tro n g p h y sio lo g ic a l

w e ll-fre q u e n te d b a r), or v is u a lly th ro u g h v id e o

c lo se ly a s s o c ia tin g th e m w ith n e g a tiv e

d ep ictio n o f a d ru g -u sin g s c e n a rio or th ro u g h

c o n s e q u e n c e s . B y re p e a te d ly p a irin g th o se cu es

v isu a liz a tio n o f s u ch a sce n a rio . H o w e v e r, the

th a t p re v io u s ly e lic ite d a p a rtic u la r b e h a v io r

clie n t is p re v e n te d fro m d rin k in g or ta k in g

w ith n e g a tiv e ra th e r th a n p o sitiv e o u tco m e s, the

d ru g s. T h is e x tin c tio n p ro c e ss, o v er tim e, lea d s

cu es lo se th e ir a b ility to e lic it th e o rig in a l

to a d ecrea se d re a c tiv ity to s u c h cu es.

O 'B rie n an d c o lle a g u e s fo u n d th a t c o ca in e d e p e n d e n t c lie n ts s h o w e d the p ro to ty p ic a l

d e v e lo p m e n t o f w h a t h a v e b e e n d e scrib e d as

aro u sal an d c ra v in g re s p o n s e s w h en first

a v er siv e co n d itio n in g o r c o u n terc o n d itio n in g

p re sen ted d ru g -re la te d cu es th a t re m in d e d th em

tre a tm e n t a p p r o a c h e s (H o w a rd et a l., 1991;

o f th e ir d ru g u se (O 'B rie n e t a l., 19 9 0 ). C lien ts

R im m e le e t al., 1 9 9 5 ). T h e s e p ro c e d u re s

th en b e g a n th e c u e -e x tin c tio n p ro to c o l. By the

r e p e a te d ly p a ir n e g a tiv e o u tc o m e s w ith the

six th 1 -h o u r tre a tm e n t se ssio n , th e y n o lo n g e r

s u b s ta n c e -re la te d c u e s p re v io u s ly a sso c ia te d

re p o rted e ith e r su b je ctiv e h ig h s or p h y sio lo g ic a l

w ith th e p o sitiv e c o n s e q u e n c e s o f su b s ta n c e use.

w ith d ra w a l. By th e 1 5th sessio n , all clie n ts

54

cla ss ica lly c o n d itio n e d re s p o n s e ; in s te a d , th ey

e lic it a n e g a tiv e o u tc o m e . T h is h a s led to the

F o r e x a m p le , th e S h ic k -S h a d e l H o sp ita l in

re p o rted th at th ey no lo n g e r e x p e rie n c e d

S e a ttle u se s a v e rs iv e c o n d itio n in g te c h n iq u e s

cra v in g w h en p re s e n te d w ith th e d ru g -re la te d

w ith a lc o h o l-d e p e n d e n t c lie n ts (L e m e re , 1987).

cu es. C lie n ts w h o re ce iv e d th e cu e e x p o su re as

B efo re a tre a tm e n t s e s s io n , th e c lie n t is a sk ed to

p a rt o f th eir s ta n d a rd o u tp a tie n t tre a tm e n t fo r

d rin k a w a rm s a lin e s o lu tio n a n d is g iv e n an

co ca in e u se w e re a lso less lik e ly to d ro p o u t o f

e m e tic m e d ic a tio n th a t w ill u ltim a te ly lea d the

tre a tm e n t and h ad m o re c o c a in e -fre e w e e k s th an

c lie n t to b e c o m e n a u se a te d an d to v o m it. T h e

d id clie n ts a tte n d in g th e sa m e o u tp a tie n t

c lie n t is th e n b ro u g h t in to " D u ffy 's B a r ," a ro o m

p ro g ra m b u t w h o d id n o t re ce iv e cu e e xp o su re.

filled w ith v iv id a lc o h o l- a n d d rin k in g -re la te d

B r ie f C o g n itiv e-B eh a v io ra l T herapy

p o sters, a b a r w ith b o ttle s o f a la rg e n u m b e r an d

as in d e p e n d e n t, fre e -s ta n d in g tre a tm e n ts

w id e ra n g e o f a lc o h o lic b e v e ra g e s , an d o th er

(O 'B rie n , et al., 1 9 9 0 ; S m ith a n d F ra w le y , 1993).

d rin k in g -rela te d cu es. T h e ro o m is m e a n t to

In th is c o n te x t, S m ith a n d c o lle a g u e s re p o rted

h ig h lig h t an d m a k e m o re sa lie n t th e cu es

p o sitiv e o u tc o m e s fo r d e p e n d e n t u se rs o f b o th

a sso cia ted w ith d rin k in g . T h e c lie n t is a sk ed to

a lc o h o l an d c o c a in e w h o re c e iv e d ch e m ica l

id e n tify h e r fa v o rite ty p e and b ra n d o f a lco h o l.

a v e rs io n p ro c e d u re s a s p a rt o f th e ir tre a tm e n t in

A fte r p o u rin g a d rin k , sh e is a sk e d to s w irl the

c o m p a riso n to th o se w h o d id n o t re ce iv e sim ila r

a lco h o l aro u n d in th e g la ss, to sm e ll th e a lco h o l,

tre a tm e n t (F ra w le y a n d S m ith , 1 9 9 0 ; S m ith et al.,

to p lace th e g la ss to h e r lip s an d ta ste , an d th e n

19 9 7 ). R im m e le a n d c o lle a g u e s a lso

to b e g in to tak e a sip o f th e d rin k . A t th a t p o in t,

re c o m m e n d e d c o v e r t s e n s itiz a tio n as a h ig h ly

as she is a b o u t to ta k e a d rin k , th e e ffe c ts o f th e

e ffe c tiv e an d p o rta b le tre a tm e n t c o m p o n e n t

e m etic d ru g " k ic k in '' an d the c lie n t b e c o m e s

w h ich , u n lik e c h e m ic a l o r e le c tric a v e rsio n

n a u se a te d an d v o m its. O v e r re p e a te d se ssio n s,

th e ra p ie s, ca n b e u se d a t a n y tim e an d in any

w h ich o ccu r e v e ry o th er d a y fo r a 1 0 -d a y p e rio d ,

s e ttin g as a s e lf-c o n tro l s tra te g y (R im m e le et al.,

the a lco h o l-re la te d sig h t, sm e ll, an d ta ste cu es

1995).

n o t on ly d o n o t e lic it c ra v in g a n d p o sitiv e
fe e lin g s a b o u t d rin k in g , b u t ra th e r th e y n o w
e licit co n d itio n e d n a u se a .
T h e ra p ie s b a se d on c o u n te rc o n d itio n in g
th eo ry ty p ica lly u se c h e m ic a lly in d u ce d
a v e rsio n or e le ctric sh o c k as n e g a tiv e
co n se q u e n ce s to b e p a ire d w ith th e su b sta n c e related cu es. V is u a l im a g e ry ca n a lso b e u sed in
a te ch n iq u e ca lle d cov ert se n sitiz a tio n . In th is
p ro ce d u re , the c lie n t is a sk ed to im a g in e as
v iv id ly as p o ss ib le a s e q u e n ce o f e v e n ts th a t
b eg in b y see in g h is fa v o rite b a r; this is ty p ica lly
a cco m p a n ie d b y in c re a se d c ra v in g . A s the
p e rso n p ro ce e d s fu rth e r in im a g in in g e n te rin g
the b ar, sittin g d o w n , o rd e rin g a d rin k , an d so
on, the in itia l se n se o f c ra v in g sh ifts to m ild
d isco m fo rt. A s h e v is u a liz e s b e g in n in g to ta k e a
d rin k and ta ste s th e a lco h o l, h e is th e n a sk ed to

Behavioral Therapy
Techniques Based on
Operant Learning Models
A n u m b e r o f s u b s ta n c e a b u s e tre a tm e n t
s tra te g ie s h a v e d e riv e d fro m o p e ra n t lea rn in g
p rin c ip le s . W h ile th e y a re o fte n in c o rp o ra te d
in to b ro a d -s p e c tru m c o g n itiv e -b e h a v io r a l
a p p ro a c h e s, th e y h a v e a lso b e e n u se d as
in d e p e n d e n t fo rm s o f tre a tm e n t. C o m m o n
e le m e n ts o f b e h a v io ra l tre a tm e n ts b a se d on
th e o rie s o f o p e ra n t le a rn in g in c lu d e co n tin g e n cy
m a n a g e m e n t, b e h a v io r c o n tra c tin g , c o m m u n ity
re in fo rc e m e n t, a n d b e h a v io ra l se lf-co n tro l
tra in in g . T h e fo llo w in g se c tio n s d e sc rib e so m e
o f th e e le m e n ts u se d in b rie f b e h a v io ra l
th e ra p ie s b a se d o n th e o p e ra n t le a rn in g m o d el.

im a g in e b e c o m in g v io le n tly sick an d v o m itin g

(R im m e le e t al., 1995).
W h ile a v e rsiv e co n d itio n in g p ro c e d u re s h a v e
m o st o ften b e e n u sed in th e tre a tm e n t o f a lco h o l

Contingency M anagem ent and

Behavior Contracting
In c o n tin g e n c y m a n a g e m e n t a p p ro a c h e s, an

d e p en d e n ce, th ey h a v e a lso b e e n a p p lie d to the

a c tiv e a tte m p t is m a d e to c h a n g e th o se

tre a tm e n t o f m a riju a n a an d c o c a in e u se (F ra w le y

e n v iro n m e n ta l c o n tin g e n c ie s th a t ca n in flu e n ce

and S m ith , 1990; S m ith e t a l., 19 8 8 ). It sh o u ld be

s u b s ta n c e a b u s e b e h a v io r (H ig g in s e t al., 1998).

n oted th a t th e se a v e rsiv e co n d itio n in g

T h e g o a l is to d e c r e a s e or s to p s u b s ta n c e u se and

te ch n iq u es, as w e ll as cu e e x p o s u re a p p ro a c h e s,

to in c re a se b e h a v io rs th a t a re in c o m p a tib le w ith

are b est v ie w e d as c o m p o n e n ts o f a m o re

u se. In p a rtic u la r, th o se c o n tin g e n c ie s th a t are

co m p re h e n siv e tre a tm e n t p ro g ra m ra th e r th a n

fo u n d th ro u g h a fu n c tio n a l a n a ly sis (see F ig u re

55

C h ap ter 4

4-4 ) to p ro m p t as w e ll as re in fo rc e su b sta n ce

the c rite rio n fo r m a rk e d re d u c tio n in d ru g use

a b u se are w e a k e n e d b y a s s o c ia tin g e v id e n ce o f

an d a lso w e re s ig n ific a n tly m o re lik e ly to

su b sta n ce u se (e.g ., a d ru g -p o s itiv e u rin e scre en )

a c h ie v e th e c rite rio n o f h a v in g 4 c o n s e c u tiv e

w ith so m e fo rm o f n e g a tiv e c o n s e q u e n c e or

w e e k s o f d ru g -fre e u rin e sa m p le s. N o n e o f the

p u n ish m en t. C o n tin g e n c ie s th a t p ro m p t and

clie n ts in a c o n tro l c o n d itio n (no ta k e -h o m e

re in fo rce b e h a v io rs th a t are in c o m p a tib le w ith

p riv ile g e s) m e t th e se c rite ria . W h e re a s o n ly 2

su b sta n ce a b u se an d th a t p ro m o te a b stin e n ce

p e rc e n t o f th e c o n tro l g ro u p e v id e n ce d a

are stre n g th e n e d b y a s s o c ia tin g th e m w ith

d e c re a se in th e fre q u e n c y o f d ru g -p o s itiv e

p o sitiv e re in fo rc e rs.

u rin e s, c lie n ts in th e in c e n tiv e p ro g ra m

d e c re a se d u se b e tw e e n 14 a n d 18 p e rce n t.

O n e re ce n t s tu d y e v a lu a te d th e e ffe c ts o f a

In a d d itio n to in c re a s in g d ru g a b stin e n c e ,

v o u ch e r p ro g ra m in the tre a tm e n t of
m e th a d o n e -m a in ta in e d o p ia te a d d ic ts w ith a

sim ila r v o u c h e r s y s te m s h a v e b e e n e ffe c tiv e in

h isto ry o f co ca in e u se (S ilv e rm a n et al., 1998).

m a in ta in in g a tte n d a n c e o f m e th a d o n e clie n ts at

C lien ts w h o p ro v id e d c o c a in e -fre e u rin e

a jo b -sk ills tra in in g p ro g ra m (S ilv e rm a n et al.,

sa m p les re ce iv e d v o u ch e rs th a t h ad m o n eta ry

19 9 6 ). H o w e v e r, in c o n tra s t to d ru g tre a tm e n t,

v alu e. T h e v a lu e o f th e v o u c h e rs in cre a se d as

less e v id e n c e is a v a ila b le c o n c e rn in g the

the n u m b e r o f c o n s e c u tiv e c o c a in e -fre e u rin e

e ffe c tiv e n e s s o f s u c h c o n tin g e n c y m a n a g e m e n t

sa m p les in cre a se d . C lie n ts in th e c o n tin g e n t

a p p ro a c h e s in th e tre a tm e n t o f a lc o h o l p ro b le m s

v o u ch e r c o n d itio n , co m p a re d to th o se w h o

(H ig g in s et a l., 19 9 8 ).
A tte m p ts to in c o rp o ra te re a l-w o rld

re ce iv e d v o u ch e rs on a n o n c o n tin g e n t b a sis,
rep o rted d e cre a se d c ra v in g fo r c o c a in e and

c o n tin g e n c ie s in to tre a tm e n t p ro g ra m s are

s ig n ifica n tly in c re a se d c o c a in e a b stin e n c e . A

in c re a sin g (H ig g in s, 1 9 9 9 ). C le a rly , p ro g ra m s

m o re g e n era l p o sitiv e tre a tm e n t e ffe c t w a s also

ca n b u ild c o n tin g e n c ie s s u c h as ta k e -h o m e

n o ted , w ith clie n ts in th e c o n tin g e n t v o u c h e r

m e d ic a tio n p riv ile g e s in to th e s tru c tu re o f th eir

co n d itio n also d e m o n s tra tin g an in c re a se d

p ro g ra m s . M ilb y an d c o lle a g u e s p ro v id e an

a b stin e n ce fro m o p ia te s.

e x a m p le o f a c o n tin g e n c y m a n a g e m e n t sy stem
in c o rp o ra te d in to tre a tm e n t th a t is m o re

C h u tu a p e an d c o lle a g u e s h a v e a lso sh o w n
th at p ro v id in g m e th a d o n e ta k e -h o m e p riv ile g e s

re le v a n t to re a l-life s itu a tio n s o f u se rs (M ilb y et

co n tin g e n t o n d ru g -fre e u rin e sa m p le s a m o n g

al., 1996). In th is s tu d y , h o m e le ss su b sta n ce

m e th a d o n e c lie n ts w ith p e rs is te n t m u ltip le d ru g

a b u se rs w e re e n ro lle d in an in te n siv e d ay

ab u se re su lte d in m a rk e d re d u ctio n s in d ru g use

tre a tm e n t p ro g ra m . A s u b g ro u p o f th e se clie n ts

(C h u tu a p e et al., 1999). N e a rly 25 p e rc e n t of

w a s a lso in v o lv e d in a c o n tin g e n t w o rk th e rap y

clie n ts in th e ta k e -h o m e in c e n tiv e p ro g ra m m e t

an d h o u s in g p ro g ra m . A s lo n g as th e clie n ts

F ig u r e 4 -4
F u n c tio n a l A n a ly s is
A fu n ctio n a l a n a ly sis p ro b e s th e situ a tio n s s u rro u n d in g th e c lie n t's s u b s ta n c e a b u se . S p e c ific a lly , it
e x a m in e s th e re la tio n sh ip s a m o n g stim u li th a t trig g e r u se an d th e c o n s e q u e n c e s th a t fo llo w . T h is type
of an a ly sis p ro v id e s im p o rta n t clu e s re g a rd in g th e m e a n in g o f th e b e h a v io r to th e clie n t, as w ell as
p o ssib le m o tiv a to rs an d b a rrie rs to ch a n g e . In b e h a v io ra l th e ra p y , th is is th e firs t ste p in p ro v id in g the
c lie n t w ith to o ls to m a n a g e or a v o id s itu a tio n s th a t trig g e r su b s ta n ce u se. F u n c tio n a l a n a ly sis y ield s a
ro a d m a p o f a c lie n t's in te rp e rs o n a l, in tra p e rso n a l, an d e n v iro n m e n ta l c a ta ly s ts a n d re a c tio n s to
su b sta n ce u se, th e re b y id e n tify in g lik e ly p re cu rs o rs to su b s ta n c e u se. (F o r m o re in fo r m a tio n on this
to p ic, see th e s e c tio n b e lo w u n d e r th e h e a d in g " C o g n itiv e -B e h a v io r a l T h e r a p y ." )
56

B r ie f C o g n itiv e-B eh a v io ra l T herapy

re m a in ed su b s ta n c e fre e , th ey w e re a b le to

p ro g ra m . C o n tra c ts ta rg e tin g g o a ls su p p o rtiv e

rem ain in th e w o rk p ro g ra m an d re m a in in th e

o f re c o v e ry (e .g ., im p ro v in g v o c a tio n a l b e h a v io r,

th e ra p e u tic h o u sin g ; if th e y w e re fo u n d to b e

sa v in g m o n e y , b e in g p ro m p t fo r co u n se lin g ,

d rin k in g or u sin g d ru g s, th e y b e c a m e in e lig ib le

re g u la rly ta k in g m e d ic a tio n ) a re g e n e ra lly m o re

fo r b o th the jo b tra in in g / w o rk p ro g ra m and

lik e ly to b e a c h ie v e d a n d lea d to b e tte r o u tco m es

h o u sin g . C lie n ts in v o lv e d in the a b stin e n c e -

th a n th o se m o re d ire c tly re la te d to su b sta n c e use

co n tin g e n t p ro g ra m h a d fe w e r c o c a in e -p o sitiv e

(e.g ., c le a n u rin e s a m p le s ) (A n k e r an d C ro w le y ,

u rin e s a m p le s, fe w e r d a y s o f d rin k in g , fe w e r

1 9 8 2 ; Ig u ch i e t a l., 1 9 9 7 ; M a g u ra et al., 1987,

d ay s of h o m e le ss n e s s , an d m o re d a y s of

19 8 8 ). F o r in s ta n c e , re s e a r c h fo u n d th a t

e m p lo y m e n t d u rin g th e fo llo w u p p e rio d th an

re c e iv in g v o u c h e rs c o n tin g e n t o n c o m p le tin g

th o se in th e sta n d a rd tre a tm e n t.

o b je c tiv e , in d iv id u a lly ta ilo re d g o a ls re la ted to

N a tu ra listic c o n tin g e n c ie s m a y a lso b e u se fu l

o n e 's o v e ra ll tre a tm e n t p la n w a s m o re e ffe ctiv e

in tre a tm e n t. T h e se c o n tin g e n c ie s in clu d e

in re d u c in g s u b s ta n c e a b u s e th a n e ith e r a

th reate n e d loss o f jo b , sp o u se , or d riv e r's lice n se

v o u c h e r s y s te m s p e c ific a lly ta rg e tin g d ru g -fre e

and w ere p o sitiv e ly re la ted to tre a tm e n t

u rin e s a m p le s or a s ta n d a rd tre a tm e n t w ith o u t

o u tco m e am o n g a lco h o l u se rs (K ra m p e n , 1989).

e ith e r o f th e se c o n tin g e n c y c o n tra c ts a d d e d

H o w e v e r, th e p ro g n o s is w a s less fa v o ra b le in

(Ig u ch i e t al., 1 9 9 7 ). T h e e ffe c tiv e n e s s o f su ch

th o se p a tie n ts w h o h a d a lre a d y e x p e rie n ce d a

c o n tra c ts a lso a p p e a rs to b e lin k e d to the

loss in o n e o f th o se a re a s b e c a u se the

s e v e rity o f th e c o n s e q u e n c e s th a t m ig h t re su lt

co n tin g e n cy n o lo n g e r e x iste d fo r th em .

fro m a b ro k e n c o n tra c t (M a g u ra et al., 1987).

H ig g in s an d c o lle a g u e s n o ted th a t w ritten

B e h a v io ra l c o n tra c tin g a n d c o n tin g e n c y

co n tra cts m ay b e u sed to h elp im p le m e n t a

m a n a g e m e n t a re o fte n fo u n d as e le m e n ts in a

co n tin g e n cy m a n a g e m e n t p ro g ra m (H ig g in s et

n u m b e r o f m o re c o m p re h e n s iv e a p p ro a ch e s

al., 1998). T h e c o n tra c t sh o u ld s p e c ify c lea rly ,

su ch as c o m m u n ity re in fo rc e m e n t an d

u sin g the c lie n t's o w n w o rd s, the ta rg e t

b e h a v io ra l s e lf-c o n tro l tra in in g .

b e h a v io r to b e c h a n g e d , th e c o n tin g e n c ie s
s u rro u n d in g e ith e r c h a n g in g b e h a v io r or not,
and th e tim e fra m e in w h ich th e d e sire d b e h a v io r

Com m unity Reinforcem ent

Approach

ch a n g e is to o ccu r. T h e a ct o f c o m p o s in g and

T h e c o m m u n ity re in fo rc e m e n t a p p ro a ch (C R A )

sig n in g a c o n tra ct is a sm a ll b u t p o te n tia lly

w a s d e v e lo p e d as a tre a tm e n t fo r a lc o h o l a b u se

im p o rta n t ritu a l sig n ify in g th e c lie n t's

d is o rd e rs (A z rin , 1 9 7 6 ; H u n t a n d A z rin , 1973).

co m m itm e n t to th e p ro p o se d ch a n g e . In the

A fte r a p e rio d d u rin g w h ic h it a p p e a rs to hav e

co n tract, the clie n t m a y in clu d e c o n tin g e n c ie s ,

b e e n little u se d , it h a s re c e iv e d in c re a se d in terest

e sp e cia lly re w a rd s or p o sitiv e in c e n tiv e s th a t

as a b e h a v io ra l a p p r o a c h to s u b s ta n c e ab u se

w ill re in fo rce ta rg e t b e h a v io rs (e.g ., a tte n d in g

(H ig g in s et al., 1 9 9 8 ; M e y e rs a n d S m ith , 1995;

tre a tm e n t se ssio n s, g e ttin g to 1 2 -S te p m e e tin g s,

S m ith an d M e y e rs , 1 9 9 5 ). C R A is a b ro a d -

av o id in g stim u li a sso c ia te d w ith su b s ta n ce u se).

s p e c tru m a p p r o a c h b a se d on th e p rin cip le s of

G oals sh o u ld b e c le a rly d e fin e d , b ro k e n in to

o p e ra n t le a rn in g , th e g o a l o f w h ic h is to in cre ase

sm all ste p s th a t o c cu r fre q u e n tly , an d re v ise d as

the lik e lih o o d o f c o n tin u e d a b stin e n c e fro m

tre a tm e n t p ro g re sse s; c o n tin g e n c ie s sh o u ld

a lc o h o l or d ru g s b y re o rg a n iz in g th e clie n t's

o ccu r q u ick ly a fte r su cce ss or fa ilu re .

e n v iro n m e n t. In p a rtic u la r, C R A a tte m p ts to

M o st o ften , b e h a v io ra l c o n tra c ts and

w e a k e n th e in flu e n c e o f re in fo rc e m e n t re ce iv e d

co n tin g e n cy m a n a g e m e n t p ro c e d u re s are

b y s u b s ta n c e a b u s e a n d its re la te d a ctiv itie s by

em b e d d ed in a m o re c o m p re h e n siv e tre a tm e n t

in c re a sin g th e a v a ila b ility an d fre q u e n c y of

57

C h ap ter 4

re in fo rce m e n t d eriv ed fro m a lte rn a tiv e

a m o n g th o se in te rv e n tio n s h a v in g th e g re a te st

activ itie s, p a rtic u la rly th o se v o c a tio n a l, fa m ily ,

e m p iric a l s u p p o rt (M ille r e t a l., 19 9 5 ). C R A 's

so cial, and re cre a tio n a l a ctiv itie s th a t are

a p p lic a tio n to s u b s ta n c e s o th e r th a n a lco h o l also

in co m p a tib le w ith su b sta n ce a b u se (H ig g in s et

a p p e a rs to h a v e b e e n s u c c e s s fu l (H ig g in s e t al.,

al., 1998).
A g oal o f C R A is to m a k e th e se a ltern a tiv e
in te rp e rso n a l an d so cia l so u rc e s o f

m a n u a l fo r th e tre a tm e n t o f c o c a in e d ep e n d e n ce

re in fo rce m e n t a v a ila b le w h en the p e rs o n is

b y the N a tio n a l In s titu te o n D ru g A b u se

so b er or d ru g -fre e , b u t to m a k e th e m

(B u d n e y an d H ig g in s , 1 9 9 8 ). T h is m a n u a l relies

u n a v a ila b le if the p e rso n d rin k s or u ses. T h e

h e a v ily o n th e e a rly w o rk o f H ig g in s and

p ro g ra m c o n sists o f a n u m b e r o f co m p o n e n ts,

co lle a g u e s in e v a lu a tin g th e e ffe c tiv e n e s s of

and it can b e ta ilo re d to th e sp e cific

co m b in in g C R A w ith c o n tin g e n c y m a n a g e m e n t

c ircu m sta n ce s o f a clie n t. V o c a tio n a l c o u n se lin g

a p p ro a c h e s (e .g ., u se o f v o u c h e rs fo r d ru g -fre e

and jo b clu b s ca n im p ro v e c lie n ts ' b a sic sk ills as

u rin e s a m p le s ) in th e tre a tm e n t o f co ca in e

w ell as jo b -se e k in g s k ills (e.g ., re su m e

d e p e n d e n c e (H ig g in s et al., 1 9 9 1 ,1 9 9 3 ). In

d ev elo p m en t, a p p lic a tio n c o m p le tio n , jo b

co m p a riso n to s ta n d a rd o u tp a tie n t tre a tm e n t,

in te rv iew sk ills). S o cia l an d re c re a tio n a l

c lie n ts in th e C R A -p lu s -v o u c h e r s c o n d itio n

co u n se lin g is p ro v id e d to h elp c lie n ts le a rn

re m a in e d in tre a tm e n t lo n g e r, h a d m o re

ab o u t an d sa m p le a n u m b e r o f su b s ta n c e -fre e

c o n tin u o u s w e e k s o f d ru g -fre e u rin e sa m p les,

re cre a tio n a l p u rsu its an d so c ia l a c tiv itie s. In

an d h a d g re a te r a m o u n ts o f c o c a in e a b stin e n ce

so m e cases, so cia l clu b s h a v e b e e n e sta b lish e d to

e v e n at a 1 2 -m o n th fo llo w u p . A s im ila r p a ttern

p ro v id e clie n ts w ith a s u b s ta n c e -fre e

o f fin d in g s h a s b e e n o b ta in e d w ith m e th a d o n e -

e n v iro n m e n t w h ere th ey ca n g a th e r an d h a v e

m a in ta in e d o p ia te a d d ic ts (A b b o tt e t al., 1998).

fun.
For th o se c lie n ts w h o a re m a rrie d or in a

T h e C R A m o d e l h a s b e e n m o d ifie d in to the
C o m m u n ity R e in fo rc e m e n t a n d F a m ily T ra in in g

re la tio n sh ip , m a rita l c o u n s e lin g an d

p ro ce d u re (C R A F T ) (M e y e rs e t al., 1996). T h e

c o m m u n ica tio n sk ills tra in in g a re p ro v id e d to

c lie n t's s ig n ific a n t o th e rs an d fa m ily m e m b ers,

e n h a n ce th e q u a lity o f th e re la tio n sh ip and

w h o a re a n in te g ra l p a rt o f th is a p p ro a ch ,

re d u ce the stre ss o f s u b sta n c e -re la te d

re c e iv e tra in in g in b e h a v io r m o d ific a tio n and

a rg u m e n ts. C o u p le s are tra in e d to g iv e ea ch

e n h a n c in g m o tiv a tio n . C R A F T se e k s to re d u ce

oth er p o sitiv e a tte n tio n th ro u g h co m p lim e n ts,

or sto p s u b s ta n c e a b u s e b y w o rk in g th ro u g h

ap p recia tio n , a ffe c tio n , an d o ffe rs to h elp . A

n o n u s in g fa m ily a n d frie n d s. W h ile C R A

fo cu s is p la ced on cla rify in g e x p e c ta tio n s th a t

in v o lv e s fa m ily o r s ig n ific a n t o th e rs in

ea ch p a rtn e r h as a b o u t th e b e h a v io r o f th e oth er.

tre a tm e n t, C R A F T is m o re o f a fo rm o f fa m ily

For th o se w ith a p ro b le m w ith a lco h o l,

th e ra p y (ra th e r th a n in d iv id u a l th e ra p y ) and

m e d ica tio n (e.g ., d isu lfira m [A n ta b u se ])

th e re fo re is d is c u ss e d in C h a p te r 8 o f th is T IP .

m o n ito re d b y th e s p o u se m a y b e u sed . T h e
c lie n t also re ce iv e s tra in in g in p ro b le m s o lv in g

Behavioral Self-Control Training

and in w a y s to re fu se re q u e sts to d rin k or use

In c o n tra s t to C R A , w h ic h in c o rp o ra te s a w id e

d ru gs.

a rra y o f in d iv id u a ls in th e tre a tm e n t p ro c e ss, the

C R A h as b e e n d e sc rib e d as a p ro m isin g b u t

58

19 9 8 ). T h is e x te n s io n is e x e m p lifie d b y the
re c e n t p u b lic a tio n o f a d e ta ile d C R A th era p y

b e h a v io ra l s e lf-c o n tro l tra in in g a p p ro a ch

u n d e ru tiliz e d tre a tm e n t fo r a lc o h o l a b u se

fo c u se s o n th e s u b s ta n c e a b u s e r an d h is

(M cC ra d y , 1991). A re v iew o f th e a lco h o l

a tte m p ts to re d u c e or sto p s u b s ta n c e a b u se

tre a tm e n t o u tco m e lite ra tu re id e n tifie s C R A

e ith e r o n h is o w n or w ith th e aid o f a th e ra p ist

B r ie f C o g n itiv e-B eh a v io ra l T herapy

(H ester, 1995; H e ste r an d M ille r, 19 8 9 ). T h e g o a l

R a th e r th a n in v o lv e m e n t w ith a th e ra p ist, the

o f th is a p p ro a c h is e ith e r m o d e ra tio n an d h a rm

p e rs o n m a y b e g u id e d in s te a d b y self-h elp

re d u ctio n or a b stin e n c e . A s a p p lie d to a lc o h o l

m a n u a ls (M ille r a n d M u n o z , 1 9 8 2 ; S a n ch e z -

p ro b lem s, the a p p ro a c h co n s is ts o f th e eig h t

C ra ig , 1 9 9 5 ), in te rv e n tio n v ia co rre s p o n d e n c e

s e q u en tia l ste p s listed b elo w (H e ste r, 1995):

(S ith a rth a n e t a l., 1 9 9 6 ), o r e v e n a c o m p u te r

1. T h e c lie n t e sta b lis h e s an u p p e r lim it on the

n u m b e r o f d rin k s p e r d ay an d th e p e a k
b loo d a lco h o l lev el on an y o n e d rin k in g
o cca sio n .
2. T h e c lie n t b e g in s to s e lf-m o n ito r b o th the
n u m b e r o f d rin k s ta k e n an d th e d rin k in g
settin g (e.g ., w h en , w h ere , w ith w h o m , h ow
he is fe e lin g ). T h is p ro v id e s th e b a sis o f a
fu n ctio n a l a n a ly sis.
3. T h e c lie n t b e g in s to m o d ify th e ra te at w h ich
alco h o l is c o n su m e d . T h is m ig h t b e d o n e by
sw itch in g fro m th e in d iv id u a l's sta n d a rd
alco h o lic b e v e ra g e to o n e c o n ta in in g less
alco h o l, b y sip p in g a d rin k o v er a lo n g e r
p erio d o f tim e, or b y sp a c in g th e n u m b e r of
d rin k s co n su m e d a cro ss tim e.
4.

T h e c lie n t m u st d e v e lo p and p ra c tice b ein g

ab le to re fu se d rin k s a sse rtiv e ly w h en
offered them .

5. T h e c lie n t e sta b lis h e s a re in fo rc e m e n t

sy stem to re w a rd the a c h ie v e m e n t o f th e se
d rin k in g -re la te d g o als.
6. T h ro u g h th e p ro cess o f s e lf-m o n ito rin g , the
clie n t is ab le to d e te rm in e th o se so cia l,
e m o tio n a l, and e n v iro n m e n ta l a n te c e d e n ts
th at p ro m p t o v e rd rin k in g .
7. T h e c lie n t lea rn s n e w c o p in g sk ills to use
ra th er th an re ly in g on d rin k in g as a m e a n s

p ro g ra m (H e s te r a n d D e la n e y , 1997).
M c C ra d y a lso in c lu d e d b e h a v io ra l selfc o n tro l tra in in g as a n o th e r p ro m isin g b u t
u n d e ru tiliz e d tre a tm e n t a p p ro a c h (M cC ra d y ,
19 9 1 ). H e s te r in d ic a te d th a t th e re is g oo d
e m p iric a l s u p p o rt fo r b e h a v io ra l se lf-co n tro l
tra in in g in a c h ie v in g th e g o a l o f m o d e ra te ,
n o n p ro b le m a tic d rin k in g (H e ste r, 19 9 5 ). In
ra n d o m iz e d c lin ic a l tria ls, p ro b le m d rin k ers
a ssig n e d to b e h a v io ra l s e lf-c o n tro l w ith a g o al of
e ith e r m o d e ra tio n or a b stin e n c e ty p ica lly h av e
c o m p a ra b le lo n g -te rm o u tc o m e s . A lth o u g h
b e h a v io ra l s e lf-c o n tro l a p p ro a c h e s h a v e b een
u se d p rim a rily w ith a lc o h o l p ro b le m s , th ey hav e
a lso b e e n u se d w ith o th e r su b s ta n c e s su ch as
o p ia te s (v a n B ilse n a n d W h ite h e a d , 1994).

Application of Behavioral
Techniques
B e h a v io ra l th e ra p ie s a re o fte n d e liv e re d u sin g a
sp e c ific m a n u a l, b u t th e y a re a lso a d a p ta b le to
the in d iv id u a l c lie n t. A n u m b e r o f the
b e h a v io ra l te c h n iq u e s d e s c rib e d h e re a re also
u sed b y th e ra p is ts u sin g c o g n itiv e -b e h a v io ra l
th e ra p y . T h e fo llo w in g se c tio n s d e sc rib e how
b rie f b e h a v io ra l th e ra p y m ig h t b e a p p lie d at
d iffe re n t s ta g e s o f tre a tm e n t. S o m e o f the
te c h n iq u e s d e v e lo p e d fo r b rie f b e h a v io ra l
th e ra p y a re a lso p re s e n te d .

of co p in g .
8. T h e clie n t a tte m p ts to le a rn w a y s to a v o id
re la p sin g b a ck to h e a v y d rin k in g .
A lth o u g h a th e ra p is t m a y g u id e the
in d iv id u al in a b e h a v io ra l s e lf-c o n tro l m o d el,
the s u b sta n ce a b u se r m a in ta in s p rim a ry
re sp o n sib ility fo r ch a n g in g h is b e h a v io r. D u rin g
the co u rse o f th e ra p y , th e c lie n t an d th e ra p ist
m e e t in b rie f se ssio n s to go o v er h o m e w o rk and
e n su re th at th e c lie n t is fo llo w in g th ro u g h .

Initial session
T h e in itia l s e s s io n in b rie f b e h a v io ra l th e ra p y
in v o lv e s a n e x p lo r a tio n o f th e re a so n s th e clien t
is s e e k in g tre a tm e n t a t th is p a rtic u la r tim e; the
e x te n t to w h ic h th is m o tiv a tio n fo r tre a tm e n t is
in trin sic , ra th e r th a n in flu e n c e d b y e x te rn a l
s o u rce s; th e a re a s o f c o n c e rn th a t the c lie n t and
s ig n ific a n t o th e rs m a y h a v e a b o u t h is su b stan ce
a b u se ; th e s itu a tio n s in w h ich s h e d rin k s or uses

59

C h ap ter 4

ex ce ssiv e ly ; an d th e c o n s e q u e n c e s she

d e te rm in e th o se p ro b le m s to ta rg e t, th eir

ex p e rie n ce s (b o th p o sitiv e and n e g a tiv e , as w ell

re la tiv e p rio rity , an d w a y s to re s o lv e th em .

N e a r th e e n d o f th e in itia l s e s s io n th e

as p ro x im a l an d re m o v e d fro m th e a ctu a l
su b sta n ce a b u se). T h is in v o lv e s an a b b re v ia te d

th e ra p is t re v ie w s w ith th e c lie n t th e p ro c e d u re

fu n ctio n a l a n a ly sis. (S ee th e s e c tio n w ith th a t

fo r fillin g o u t th e s e lf-m o n ito r in g re c o rd s. In

n am e la ter in th is c h a p ter.)

a d d itio n , th e th e ra p is t m ig h t p ro v id e th e c lie n t
w ith s e lf-h e lp m a n u a ls th a t o u tlin e th e sp e cific

T h e in fo rm a tio n g a in e d in th e se ssio n w ill

a ssist the co u n se lo r in d e te rm in in g the

s te p s in th e b e h a v io ra l s e lf-c o n tro l p ro ce ss. S e lf

a n te ce d e n ts th a t p ro m p t s u b s ta n ce a b u se and

m o n ito rin g o f s u b s ta n c e a b u se b e h a v io r is on e

the re in fo rce rs th a t a p p e a r to m a in ta in it. B a sed

fo rm o f w ritte n h o m e w o rk c o m m o n in

on the in fo rm a tio n o b ta in e d , th e c o u n s e lo r can

b e h a v io ra l a p p ro a c h e s; o th e r ty p e s of

b eg in to fo rm u la te a tre a tm e n t p la n w ith re sp e ct

h o m e w o rk m ig h t a lso b e u se d . H o m e w o rk

to th e sp e cific ta rg e t b e h a v io rs to a d d re ss, the

a ss ig n m e n ts c a n in c lu d e s u c h th in g s as k e ep in g

b e h a v io ra l in te rv e n tio n s th a t a d d re s s th ese

a jo u rn a l o f b e h a v io rs , a c tiv itie s , a n d fe e lin g s

ta rg e t b e h a v io rs m o st e ffe c tiv e ly , an d b eh a v io rs

w h e n u sin g s u b s ta n c e s o r a t risk o f d o in g so. In

in co m p a tib le w ith h e a v y d rin k in g th a t sh o u ld

the b rie f b e h a v io ra l m o d e l d e sig n e d b y P h illip s

be re in fo rce d and ta rg e te d fo r an in cre a se in

and W e in e r, te c h n iq u e s s u c h as p ro g ra m m e d

freq u en cy .

th e ra p y an d w ritin g th e ra p y (see F ig u re 4-6)

m a k e w h a t is ty p ic a lly th o u g h t o f as

D u rin g the in itia l sessio n , the th e ra p ist

sh o u ld n o te the m o st sa lie n t p ro b le m s id e n tifie d

"h o m e w o r k " th e ce n tra l c o n c e rn o f th e th e ra p y

b y the clie n t and in te rv e n e w ith th e m first. T h e

s e ssio n (P h illip s a n d W e in e r, 19 6 6 ).

th e ra p ist also s h o u ld a sse ss the c lie n t's

Later sessions

re a d in e ss to c h a n g e an d th e n d e v e lo p in itia l
b e h a v io ra l g o als in c o lla b o ra tio n w ith the clien t.
F or s u b sta n ce a b u se d iso rd e rs, th ese g o a ls w ill,

W h ile m a n y p ro b le m d rin k e rs , fo r e x a m p le ,

su b sta n ce u se. In a d d itio n to ta rg e tin g

c h o o se a m o d e ra tio n g o a l, a cro ss tim e th o se

su b sta n ce ab u se as th e p rim a ry fo cu s, o th er

w ith m o re se v e re p ro b le m s s h ift to a g o a l of

g o als w ill b e d e v e lo p e d to a s s is t th e c lie n t in

a b stin e n c e (H o d g in s et al., 1 9 9 7 ). L a te r sessio n s

im p ro v in g d a ily fu n ctio n in g (e.g ., b y re d u cin g

m ig h t a lso c o n s id e r th e in tro d u c tio n o f cu e

stre ss, as d e scrib e d in F ig u re 4 -5 ). T h e fo cu s of

the th e rap y m ig h t b e to n e g o tia te w ith the c lie n t
to a cco m p lish th e se o th er g o a ls b y re d u c in g use.

in a co lla b o ra tiv e p ro c e ss in w h ic h th ey

th ro u g h s e lf-m o n ito r in g , s u b s e q u e n t sessio n s

in v o lv e n e g o tia tio n a b o u t tre a tm e n t g o als.

o f co u rse , in v o lv e a re d u ctio n in or c e ssa tio n of

T h e th e ra p ist w ill c o n tin u e to e n g a g e the c lie n t

B a sed o n a re v ie w o f th e in fo rm a tio n co lle cte d

e x p o s u re tra in in g or re la p se p re v e n tio n ta rg eted

a t s u b s ta n c e a b u s e a b o v e a p a rtic u la r lev el.
T h e se b e h a v io ra l te c h n iq u e s h a v e b e e n
in c o rp o ra te d in to m o re c o m p re h e n siv e

F ig u r e 4 -5
T e a c h in g S tre s s M a n a g e m e n t
T h e clie n t lea rn s m e th o d s th a t w ill h elp h e r re d u ce stre ss, in c lu d in g re la x a tio n te c h n iq u e s , sy ste m a tic
d e se n sitiz a tio n , p la n n in g in a d v a n c e fo r a p o te n tia lly stre s sfu l e v e n t, a n d c o g n itiv e stra te g ie s . T h e se
te ch n iq u e s can h elp in re sistin g the te m p ta tio n to a b u se su b s ta n c e s in o th e rw ise s tre s sfu l situ a tio n s.
W h ile it d o es n o t se e m th a t all c lie n ts w ith s u b s ta n c e a b u se d is o rd e rs fa c e in c re a se d s tre s s (C a p p e ll,
1987), fo r th o se w h o d o, stre ss m a n a g e m e n t te ch n iq u e s (su ch as th o se d e s c rib e d b y S to c k w e ll, 19 9 5 ) can
p ro v e u sefu l.
60

Figure 4-6
Programmed Therapy and Writing Therapy
These techniques lend themselves to brief therapy because they reduce the role of the therapist and increase the amount of
work required from the client. Phillips and Weiner developed these techniques as stand-alone approaches to treatment
(Phillips and Weiner, 1966). However, they can also be used as adjuncts to other forms of treatment and may be
incorporated into the homework assignments that many therapists already are using. In programmed therapy, the client
interacts with written or computerized instructions and tests that work to teach the client new behaviors, much in the way
students might learn a subject from a textbook. Writing therapy involves having the client come in at a designated time each
week to write for 1 hour in a notebook which the therapist then reads and responds to in writing. No one but the therapist
and the client should have access to the notebook. Writing therapy is a technique that may be particularly useful for clients
who have difficulty talking about their thoughts and feelings

behavioral self-control approaches, even those with an

1998; Ellis, 1982; Ellis et al., 1988). The diagram in Figure

abstinence goal (Larimer and Marlatt, 1990; Sitharthan et

4-7 illustrates the three bidirectional components of this

al., 1997). The decision to implement such interventions

theory: (1) cognitions or thoughts, (2) affect or feelings,

will be guided by the client's continued self-monitoring,

and (3) behavior. While cognitive theory owes a debt to

which the client and counselor review at each session.

the behavioral model, the differences are apparent.

Unlike behavioral models that focus primarily on

Brief behavioral therapy might also involve the

observable behaviors, cognitive theory views antecedent

client's spouse or significant others, who may attend

events, cognitions, and behavior as interactive and

several of the therapy sessions. In addition to serving as a

dynamic, as indicated by the double-headed arrows

corroborator of the client's self-reported substance use, a

(depicted in Figure 4-7). Each of these components is

significant other may be involved in behavioral

capable of affecting the others, but the primary emphasis

contracting and community reinforcement

is placed on cognition. The way we act and feel is most

interventions. The significant other could be taught to

often affected by our beliefs, attitudes, perceptions,

positively reinforce a client's reduced drinking or

cognitive schema, and attributions. These cognitive

abstinence and not to argue with her drinking when she

factors serve as a template through which events are

is intoxicated, but rather to approach her when she is

filtered and appraised. To the extent that our thinking

sober and provide positive feedback. The client and the

processes are faulty and biased, our emotional and

significant other may develop a contingency contract

behavioral responses to what goes on in our life will be

that will encourage reinforcement of her positive

problematic. According to this theory, changing the way

behaviors.

a client thinks can change the way he feels and behaves.

Cognitive Theory

Cognitive theory was developed by A.T. Beck as a way of

understanding and treating depression but has since been

Cognitive theory assumes that most psychological

applied to numerous other mental health issues including

problems derive from faulty thinking processes (Beck

substance abuse disorders. Beck believed that

and Wright, 1992; Beck et al., 1993; Beck and Liese,

C hap ter 4

F ig u re 4 -7
T h e R e la tio n s h ip A m o n g F a c to r s M a in ta in in g B e h a v io r in B e h a v io ra l an d
C o g n itiv e M o d e ls

A n teced en ts are a ctiv a tin g situ a tio n s or life e v e n ts (s o m e th in g h a p p e n s o r is a b o u t to h a p p e n

s itu a tio n s a b o u t w h ich th e in d iv id u a l h a s s tro n g fe e lin g s). C o g n itio n s re p re s e n t th e in d iv id u a l's
o p in io n s, th o u g h ts, o r a ttitu d e s th a t serv e to filte r a n d d is to rt th e p e rc e p tio n o f th e a n te c e d e n ts.
B eh av ior is th e in d iv id u a l's o b s e rv a b le a ctio n s an d e m o tio n a l re a c tio n s th a t re s u lt fro m h is b e lie fs and
e m o tio n s (h o w s o m e o n e th in k s or fe e ls an d th e b e h a v io r re s u ltin g fro m th o se th o u g h ts ).

62

d ep resse d clie n ts h eld n e g a tiv e v ie w s of

o f in d iv id u a ls w ith e m o tio n a l an d b e h a v io ra l

th e m se lv es, the w o rld , an d th e ir fu tu re, and that

p ro b le m s, in c lu d in g s u b s ta n c e a b u se d iso rd e rs.

th ese n e g a tiv e v ie w s w e re th e re a l ca u se s of

A n o v e rv ie w o f th e n a tu re an d c o n te n t of

th eir d ep ressio n . H e fo u n d th a t th e ir

d isto rte d th in k in g m o re s p e c ific a lly a sso cia ted

p sy ch o lo g ica l d iffic u ltie s w e re d u e to a u to m a tic

w ith s u b s ta n c e a b u se is p ro v id e d in F ig u re 4-9

th o u g h ts, d y s fu n c tio n a l a s s u m p tio n s , and

(E llis e t a l., 1 9 8 8 ). T h e s e th o u g h ts are

n e g a tiv e se lf-sta te m e n ts. A u to m a tic th o u g h ts

p re s u m a b ly a u to m a tic , o v e rle a rn e d , rig id and

o ften p re ce d e e m o tio n s b u t o ccu r q u ite ra p id ly

in fle x ib le , o v e r g e n e ra liz e d an d illo g ica l,

w ith little a w a re n e ss; co n s e q u e n tly , in d iv id u a ls

d ic h o to m o u s , a n d n o t b a se d o n fa ct. T h e y also

d o n o t v alu e th em h ig h ly . For e x a m p le ,

ten d to re fle c t re lia n ce o n s u b s ta n c e s as a m e an s

d ep resse d p e o p le a d d re ss th e m s e lv e s in h ig h ly

o f c o p in g w ith b o re d o m an d n e g a tiv e e m o tio n s,

c ritica l to n es, b la m in g th e m s e lv e s fo r e v e ry th in g

a n e g a tiv e v ie w o f th e s e lf as a p e rs o n w ith a

th at h a p p e n s. F ig u re 4 -8 is a list o f 15 co m m o n

s u b s ta n c e a b u se p ro b le m , an d a te n d e n c y to

c o g n itiv e e rro rs fo u n d in th e th in k in g p ro cesse s

fa c ilita te c o n tin u e d s u b s ta n c e use.

B r ie f C o g n itiv e-B eh a v io ra l T herapy

F ig u r e 4 -8
F ifte e n C o m m o n C o g n itiv e E r r o r s
1. F ilterin g ta k in g n e g a tiv e d e ta ils an d m a g n ify in g th e m , w h ile filte rin g o u t all p o sitiv e a s p e c ts o f a
situ a tio n
2. P olarized th in k in g th in k in g o f th in g s as b la c k o r w h ite , g o o d or b a d , p e rfe c t or fa ilu re s, w ith n o
m id d le g ro u n d
3. O v erg en era liz a tio n ju m p in g to a g e n e ra l c o n c lu sio n b a se d o n a sin g le in c id e n t or p ie ce o f e v id e n c e ;
e x p e ctin g s o m e th in g b a d to h a p p e n o v er an d o v er a g a in if o n e b a d th in g o ccu rs
4.

M in d read in g th in k in g th a t y o u k n o w , w ith o u t an y e x te rn a l p ro o f, w h a t p e o p le a re fe e lin g an d w h y

they act the w a y th e y d o ; b e lie v in g y o u rs e lf a b le to d is c e rn h o w p e o p le a re fe e lin g a b o u t y ou

5.

C a tastrop h iz in g e x p e ctin g d is a s te r; h e a rin g a b o u t a p ro b le m an d th e n a u to m a tic a lly c o n s id e rin g the

p o ssib le n e g a tiv e c o n s e q u e n c e s (e.g ., "W h a t if tra g e d y s tr ik e s ? " " W h a t if it h a p p e n s to m e ? ")

6.

P erson alization th in k in g th a t e v e ry th in g p e o p le d o or sa y is s o m e k in d o f re a c tio n to y o u ; c o m p a rin g

y o u rse lf to o th e rs, try in g to d e te rm in e w h o 's s m a rte r or b e tte r lo o k in g

7.

C on trol fa lla c ie s fe e lin g e x te rn a lly c o n tro lle d as h e lp le ss or a v ic tim o f fa te or fe e lin g in te rn a lly

co n tro lle d , re s p o n s ib le fo r th e p a in an d h a p p in e s s o f e v e ry o n e a ro u n d

8.

F allacy o ffa ir n e s s fe e lin g re s e n tfu l b e c a u se y ou th in k y o u k n o w w h a t is fa ir, e v e n th o u g h oth er

p e o p le d o n o t a g re e

9.

B lam in g h o ld in g o th er p e o p le re s p o n s ib le fo r y o u r p a in or b la m in g y o u rs e lf fo r e v e ry p ro b le m

10.

S h ou ld s h a v in g a list o f iro n c la d ru le s a b o u t h o w y o u an d o th e r p e o p le " s h o u ld " a ct; b e c o m in g

a n g ry at p e o p le w h o b re a k th e ru le s an d fe e lin g g u ilty if y o u v io la te th e ru le s

11.

E m otion al rea son in g b e lie v in g th a t w h a t y o u fe e l m u s t b e tru e, a u to m a tic a lly (e .g ., if y o u fe e l stu p id

and b o rin g , th e n y o u m u st b e s tu p id an d b o rin g )

12.

F allacy o f ch a n g e e x p e c tin g th a t o th er p e o p le w ill ch a n g e to su it y o u if y o u p re s s u re th e m e n o u g h ;

h av in g to ch a n g e p e o p le b e c a u se y o u r h o p e s fo r h a p p in e s s se e m to d e p e n d o n th e m

13.

G lobal la b elin g g e n e ra liz in g o n e or tw o q u a litie s in to a n e g a tiv e g lo b a l ju d g m e n t

14.

B ein g right p ro v in g th a t y o u r o p in io n s an d a c tio n s a re c o rre c t o n a c o n tin u a l b a sis ; th in k in g that

b ein g w ro n g is u n th in k a b le ; g o in g to a n y le n g th s to p ro v e th a t y o u a re c o rre c t

15.

H eaven 's rew ard fa lla c y e x p e c tin g all sa c rific e an d s e lf-d e n ia l to p a y off, as if th e re w e re so m e o n e
k e ep in g sco re , an d fe e lin g d is a p p o in te d an d e v e n b itte r w h e n the re w a rd d o e s n o t co m e

S ou rce: B eck , 1976.

S u ch n e g a tiv e th o u g h ts an d irra tio n a l b elie fs

p a rtic u la rly fe e lin g d o o m e d a b o u t th e p a s t

h av e b ee n fo u n d to b e a sso cia te d w ith su b sta n c e

w e re p re d ic tiv e o f b o th th e fre q u e n c y of

ab u se d iso rd e rs. P ro b le m a v o id a n c e , d w e llin g

d rin k in g an d th e a v e ra g e q u a n tity o f a lco h o l

on n e g a tiv e e v e n ts, h o ld in g a n e g a tiv e o u tlo o k

c o n s u m e d fo llo w in g s u b s ta n c e a b u se tre a tm e n t

on the w o rld an d o n o n e 's fu tu re , an d a v o id a n ce

(R o h se n o w et al., 19 8 9 ).

o f re sp o n sib ility h a v e b e e n a s s o c ia te d w ith the

d e v e lo p m e n t o f p a tte rn s o f s u b s ta n c e a b u se and

Cognitive Therapy

u rg es to d rin k a m o n g in d iv id u a ls w ith a lco h o l

p ro b lem s (B u tte rfield an d L ecla ir, 1 9 8 8 ; D en o ff,
1988; R o h se n o w et al., 1989). R o h se n o w and
asso ciates fo u n d th a t irra tio n a l b e lie fs

G iv e n th e v ie w th a t d y s fu n c tio n a l b e h a v io r,
in c lu d in g s u b s ta n c e a b u s e , is d e te rm in e d in
la rg e p a rt b y fa u lty c o g n itio n s , th e ro le o f

63

C h ap ter 4

F ig u r e 4 -9
C h a r a c te r is tic T h in k in g o f P e o p le W ith S u b s ta n c e A b u s e D is o rd e rs
Q u a lita tiv e D e s c r ip to rs

A u to m a tic, n o n c o n scio u s

R ig id , in flex ib le

O v e rle a rn e d and o fte n p ra ctice d

D ich o to m o u s, a ll-o r-n o n e

O v e rg e n e ra liz e d an d illo g ica l

N o n e m p irica l an d a b so lu te

C o m m o n C o n te n t o r T h e m e s

D en ial: a lc o h o l or d ru g s a re n ot a p ro b lem

A lco h o l or d ru g s a re th e best and o n ly w a y to s o lv e e m o tio n a l p ro b le m s

L ow fru stra tio n to le ra n c e a n d / o r s e lf-d e fin e d n eeds fo r h ig h le v e ls o f s tim u la tio n , g ra tific a tio n , and
e x cite m e n t

D isco m fo rt a n x ie ty : all n e g a tiv e e m o tio n s a re to be a v o id e d a t all co sts

C h a n g e is to o d iffic u lt, th e re fo re o n e is h o p e le ss, h e lp le ss, w o rth le ss

S e lf-b la m e , g u ilt, an d sh a m e fo r b ein g an a d d ic t

S ou rce: A d a p te d fro m E llis et al., 1988.

th e rap y is to m o d ify th e n e g a tiv e or self-

O n ce a s p e c ific fa u lty th o u g h t is id e n tified ,

d efeatin g a u to m a tic th o u g h t p ro ce s s e s or

the th e ra p is t w ill c h a lle n g e a clie n t to lo o k at

p e rce p tio n s th a t s e e m to p e rp e tu a te th e

a lte rn a tiv e w a y s o f s e e in g th e sa m e e v e n t.

s y m p to m s o f e m o tio n a l d iso rd e rs. C lie n ts can

W h e n e v e r a c lie n t h a s d iffic u lty c h a n g in g a

b e tau g h t to n o tic e th e se th o u g h ts an d to ch a n g e

p e rc e p tio n , th e th e ra p is t ca n g iv e h im

th em , b u t th is is d iffic u lt a t first. C o g n itiv e

h o m e w o rk to te s t th e tru th o f h is co g n itio n s. If,

th e rap y te ch n iq u e s c h a lle n g e th e c lie n ts '

fo r e x a m p le , a c lie n t in s is ts th a t h is b o ss h a te s

u n d e rsta n d in g o f th e m se lv e s an d th e ir situ a tio n .

h im , th e th e ra p is t c a n a sk h im to v e rify th is w ith

T h e th e ra p ist h e lp s c lie n ts b e c o m e m o re

an a s s ig n m e n t: " A s k y o u r c o w o rk e rs if y o u r

o b je ctiv e a b o u t th e ir th in k in g an d d ista n ce

b o ss tre a ts th e m th e sa m e w a y h e tre a ts y o u ."

th e m se lv es fro m it w h e n re c o g n iz in g c o g n itiv e

F ig u re 4-11 g iv e s an e x a m p le o f h o w a th o u g h t

e rro rs or fau lty lo g ic b ro u g h t a b o u t by

lea d s to a fe e lin g an d th e n to a b e h a v io r.

au to m a tic th in k in g .
T re a tm e n t, th e re fo re , is d irecte d p rim a rily at

O n ce th e m a la d a p tiv e th o u g h ts are
d isc o v e re d in a p e rs o n 's h a b itu a l, a u to m a tic

ch a n g in g d isto rte d or m a la d a p tiv e th o u g h ts and

th in k in g , it b e c o m e s p o ss ib le to m o d ify th e m by

re la ted b e h a v io ra l d y sfu n c tio n . C og n itiv e

s u b s titu tin g ra tio n a l, re a lis tic id e a s fo r the

restru ctu rin g is th e g e n e ra l term g iv e n to the

d isto rte d o n e s to cre a te a h a p p ie r an d h e a lth ie r

p ro cess o f ch a n g in g th e c lie n t's th o u g h t

life w ith o u t s u b s ta n c e a b u se.

p attern s. F ig u re 4 -1 0 sh o w s a n u m b e r of

T h e a p p r o a c h d e v e lo p e d b y B e ck and

d isto rte d a d d ic tiv e th o u g h ts and m o re ra tio n a l

c o lle a g u e s to a ch ie v e th e g o a l o f a su b s ta n ce -fre e

a lte rn a tiv e s th a t th e th e ra p ist m ig h t h elp

life is re fe rre d to as c o g n itiv e th e ra p y (B eck et

d ev elo p and p ra c tic e o v e r the c o u rse of

al., 1 9 93 ; B e c k a n d L ie se , 19 9 8 ), w h ile E llis'

c o g n itiv e re stru c tu rin g .

a p p ro a c h is k n o w n as ra tio n a l-e m o tiv e th e rap y

B r ie f C o g n itiv e-B eh a v io ra l T herapy

F ig u r e 4 -1 0
C o m m o n Irra tio n a l B eliefs A b o u t A lc o h o l a n d D ru g s
W ith M o re R a tio n a l A lte r n a tiv e s
R a tio n a l A lte r n a tiv e o r D is p u te

Ir r a tio n a l B e l i e f
D rin k in g is n e v e r a p ro b le m fo r m e , e v e n if I

L o sin g c o n tro l ca n b e th e firs t sig n o f a p ro b le m , and if

d o lose co n tro l o n ce in a w h ile . It's o th er

m y d rin k in g is a s ig n ific a n t p ro b le m fo r o th ers, so o n er

p e o p le w h o h a v e a p ro b le m w ith th e w ay I

or la te r it w ill b e fo r m e.

d rink.
I need to u se d ru g s to rela x .

I w a n t to u se d ru g s b u t d o n 't h a v e to u se th em ju st
b e c a u se I w a n t to.

I c a n 't stan d n o t h a v in g w h a t I w a n t; it is ju s t

I m a y n o t lik e it, b u t I h a v e sto o d it in th e p a s t and can

too h a rd to to le ra te .

d o so n o w .

T h e o n ly tim e I fe e l c o m fo rta b le is w h e n I'm

It's h a rd to le a rn to b e c o m fo rta b le s o cia lly w ith o u t

high.

d ru g s b u t p e o p le d o so all th e tim e.

It w o u ld b e too h a rd to sto p d rin k in g . I'd lose

W h ile s to p p in g d rin k in g a n d d o in g d ru g s m ig h t co st

all m y frie n d s, b e b o re d , a n d n e v e r be

m e s o m e th in g s a n d ta k e tim e a n d e ffo rt, if I d o n 't, the

co m fo rta b le w ith o u t it.

c o n s e q u e n c e s w ill b e fa r w o rse .

P eo p le w h o c a n 't or d o n 't d rin k a re d o o m e d to

W h e re 's th e e v id e n c e o f th a t? I'll try g o in g to an

fru stra tio n an d u n h a p p in e ss.

A lc o h o lic s A n o n y m o u s m e e tin g a n d d o so m e re sea rch

o n h o w fru s tra te d a n d m is e ra b le th e s e n o n d rin k e rs
a c tu a lly are.

O n ce y o u 'v e s to p p e d u sin g an d y o u see it's all

A slip is o n ly a n e w le a rn in g e x p e rie n c e to w a rd

ov er, y o u 're rig h t b a ck to w h e re y o u sta rte d ,

re c o v e ry . It is n o t a fa ilu r e , o n ly a se tb a c k th a t ca n tell

and all y o u r e ffo rts o n ly lea d y ou to to tal

m e w h a t d ire c tio n I n e e d to g o in n o w . It's m y ch o ice.

failu re . O n ce a n a d d ic t, a lw a y s an a d d ict.
S ou rce: A d a p te d fro m R o tg e rs, 1996.
(E llis et al., 1988). G e n e ra lly , th e th e ra p is t ta k es

b e lie fs th a t all p e o p le a re p ro n e to. B eck , on the

a m o re activ e ro le in co g n itiv e th e ra p y th an in

o th er h a n d , b e lie v e s th a t th e c o g n itiv e th era p ist,

o th er ty p e s o f th e ra p y , d e p e n d in g on th e sta g e

u sin g a s u p p o rtiv e S o c r a tic m e th o d , sh o u ld

o f tre a tm e n t, s e v e rity o f the s u b s ta n c e a b u se,

e n lis t th e c lie n t in c a re fu lly e x a m in in g the

and d eg ree o f th e c lie n t's c o g n itiv e ca p a b ility .

a c c u ra c y o f h e r b e lie fs . T h u s, B eck p la ces m o re

W h ile E llis an d B eck h a v e s im ila r v ie w s

im p o rta n c e on th e c lie n t's o w n d is co v e ry of

a b o u t the p ro m in e n t ro le th a t c o g n itio n s p la y in

fa u lty an d u n p ro d u c tiv e th in k in g , w h ile E llis

the d e v e lo p m e n t an d m a in te n a n c e o f su b sta n c e

b e lie v e s th a t th e c lie n t s h o u ld sim p ly b e told

ab u se d iso rd e rs, th e ir th e o rie s d iffe r in

th a t th e se e x is t a n d w h a t th e y are. N e v e rth e le ss,

c o n sid e rin g h o w th e th e ra p is t sh o u ld trea t

th e re is s u b s ta n tia l o v e rla p in b o th th e th eo ry

irra tio n a l or m a la d a p tiv e c o g n itio n s . R a tio n a l-

an d p ra c tic e o f th e se tw o th e ra p ie s. C le a rly ,

e m o tiv e th e rap y is o ften m o re c h a lle n g in g and

d iffe re n t c lie n ts w ill h a v e d iffe re n t re sp o n se s to

co n fro n ta tiv e, w ith th e th e ra p is t in fo rm in g the

th e se q u a lita tiv e ly d iffe re n t a p p ro a ch e s to

clien t of the irra tio n a lity o f c e rta in ty p e s of

m o d ify in g th e ir th o u g h ts a n d b elie fs.

65

C h ap ter 4

F ig u r e 4-11
T h o u g h ts , F e e lin g s , a n d B e h a v io rs
T hought
" T h e r e 's o n ly o n e w a y to feel

B e h a v io r

F e e lin g

D rin k a lc o h o l, s n o rt co ca in e

D e sire to feel g o o d

really g o o d "
T h e m a la d a p tiv e th o u g h t in th is triad sh o u ld b e re p la c e d in o rd e r to a v o id th e c o n s e q u e n t b e h a v io r.
" I ca n fe e l g o o d b y jo g g in g or

W a lk in g , ru n n in g

D e sire to fe e l g o o d

tak in g a w a lk , o r . . . "
S ou rce: A d a p te d fro m R o tg e rs, 1996.
T h e ra p e u tic w o rk in co g n itiv e th e ra p y is
d ev o te d p rim a rily , a lth o u g h n o t e x c lu s iv e ly , to

u se o f su b s ta n c e s. In a d d itio n , c o g n itiv e th erap y

a d d ressin g sp e cific p ro b le m s or issu es in the

ca n h e lp th e c lie n t d e v e lo p h e a lth ie r w a y s of

c lie n t's p re s e n t life , ra th e r th a n g lo b a l th e m e s or

v ie w in g b o th h is h is to ry o f s u b s ta n c e a b u se and

lo n g -sta n d in g issu es. A t tim e s, h o w e v e r, it is

th e m e a n in g o f a re c e n t " s l ip " o r re la p se so th a t

im p o rta n t to u n d e rsta n d th e c o n n e c tio n

it d o e s n o t in e v ita b ly le a d to m o re su b sta n ce

b e tw e e n th e o rig in s o f a se t o f c o g n itio n s and

a b u se.

the c lie n t's c u rre n t b e h a v io r. S u ch an

u n d e rsta n d in g o f h o w the in d iv id u a l g o t to the

Initial Session

p re se n t e m o tio n a l an d b e h a v io ra l sta te is o ften

C o g n itiv e th e ra p y w o rk s u n d e r th e a ssu m p tio n

e sse n tia l to u n d e rsta n d in g th e m e c h a n is m of

th a t a c lie n t c a n b e e d u c a te d to a p p ro a c h h is

ch an g e . T h e c lie n t's a tte n tio n to c u rre n t

p ro b le m s ra tio n a lly . B e c a u s e o f th is e m p h a sis

p ro b lem s is in te n d e d to p ro m o te her

o n ra tio n a l u n d e rs ta n d in g , th e co g n itiv e

d e v e lo p m e n t o f a p la n o f a c tio n th a t ca n re v e rse

th e ra p is t w ill ty p ic a lly b e g in th e ra p y by

d y sfu n ctio n a l th o u g h t p ro c e s s e s, e m o tio n s, and

e x p la in in g th e n a tu re o f h e r a p p ro a c h (see

b e h a v io r su ch a s a v o id a n c e o f p ro b le m s or

F ig u re 4 -1 2 fo r a s a m p le o p e n in g scrip t).

fe e lin g s o f h e lp le ssn e ss. C lie n ts a re e n liste d as

In th e o p e n in g s e s s io n o f c o g n itiv e th e rap y ,

co in v e stig a to rs or s c ie n tists w h o stu d y th eir

the th e ra p is t w ill a s s e s s th e c lie n t's v ie w o f h is

o w n th o u g h t p a tte rn s an d a sso cia ted

p ro b le m s an d th e ir c a u se s . T h e th e ra p is t p a y s

co n se q u e n ces.

c a re fu l a tte n tio n to th e m e a n in g th e clie n t

C o g n itiv e th e ra p y ca n b e u sefu l in the

a s sig n s to s ig n ific a n t e v e n ts a n d h o w th a t

tre a tm e n t o f s u b s ta n ce a b u se d is o rd e rs in

m e a n in g is re la te d to s u b s e q u e n t fe e lin g s and

sev era l w ay s. W h e n d isto rte d or u n p ro d u c tiv e

u n w a n te d b e h a v io r. In th e m id d le to la te

w ay s o f th in k in g a b o u t d a ily life e v e n ts lea d to

p h a se s o f th e firs t s e s s io n , th e th e ra p is t w ill

n e g a tiv e e m o tio n a l sta te s th a t th e n p ro m o te

e m p h a s iz e th e c o lla b o r a tiv e a s p e c t o f the

su b sta n ce u se, co g n itiv e th e ra p y ca n be u sed to

th e ra p y p ro c e s s an d in tro d u c e s th e co g n itiv e

alter the se q u e n ce by ta rg e tin g an d m o d ify in g

m o d e l to th e clie n t. T h e re a re th re e m a jo r step s

the c lie n t's th o u g h ts. W h e n c lie n ts lim it th eir

in th is p ro cess:

o p tio n s fo r co p in g w ith stre ss b y rig id or a ll-o r-

66

b e h a v io rs a n d a ttitu d e s th a t d o n o t in v o lv e the

1. T h e th e ra p is t e s ta b lis h e s ra p p o rt b y

n o th in g th in k in g (e.g ., "n o th in g w ill h elp m e

lis te n in g c a re fu lly to th e c lie n t, u sin g

d ea l w ith th is p ro b le m b u t a d r in k "), co g n itiv e

q u e s tio n s an d re fle c tiv e lis te n in g to try to

th e rap y can h elp th e m e x p lo re a lte rn a tiv e

u n d e rsta n d h o w th e c lie n t th in k s a b o u t his

B r ie f C o g n itiv e-B eh a v io ra l T herapy

F ig u r e 4 -1 2
I n tr o d u c in g C o g n itiv e T h e r a p y : A S a m p le S c rip t
" I w a n t to sp e n d a few m in u te s te llin g y o u a b o u t m y a p p ro a c h . B a s ic a lly , it c o m e s fro m the
o b se rv a tio n by m a n y p e o p le th a t o u r fe e lin g s an d b e h a v io rs in p a rtic u la r s itu a tio n s fo llo w d ire c tly fro m
how w e th in k a b o u t th e se s itu a tio n s . M y g o a l in w o rk in g w ith y o u is to fo c u s o n try in g to u n d e rsta n d
how you see th in g s th e im p o rta n t th in g s in y o u r life th a t are re la ted to s u b s ta n c e u se a n d to h e lp y ou
lo o k at th em o b je c tiv e ly an d h o n e stly . W e m a y fin d th a t y o u a re s e e in g th e m c o r re c tly , an d w e 'll h a v e
to a d d ress th ese re a litie s. S o m e tim e s, th o u g h , p e o p le g e t in to a u to m a tic w a y s o f th in k in g a b o u t
th e m se lv es an d th e ir situ a tio n w ith o u t e x a m in in g th e m m o re c a re fu lly . L e t's lo o k a t th e se p o ssib ilitie s
and see if th ey ca n b e ch a n g e d to h e lp y ou . H o w d o e s th a t so u n d to y o u ? "

life circu m sta n c e s an d h o w th o se th o u g h ts

5.

S o cra tic q u es tio n in g to e n c o u ra g e the clie n t

relate to p ro b le m a tic fe e lin g s and b eh a v io r.

to c o n te m p la te , e v a lu a te , a n d sy n th e siz e

T h e clie n t e d u c a te s th e th e ra p is t a b o u t

d iv e rse s o u rce s o f in fo r m a tio n ; a lso k n o w n

as "g u id e d d is c o v e r y "

h im s e lf an d h is p ro b le m s.
2. T h e th e ra p ist e d u c a te s th e c lie n t a b o u t the

6.

c o n n e c tio n to th e g o a ls o f th e th e ra p y

co g n itiv e m o d e l o f th e ra p y a n d d e te rm in e s
if h e is sa tisfie d w ith th e m o d e l.

C a p su le su m m a ries to m a in ta in fo cu s and a

7. H o m ew o rk a s s ig n m e n ts to se rv e as a b rid g e
b e tw e e n s e s s io n s a n d to e n s u re th a t the

3. T h e th e ra p is t a sk s th e c lie n t to d e s c rib e a
re ce n t e v e n t th a t h a s trig g e re d s o m e re c e n t

c lie n t c o n tin u e s to w o rk o n p ro b le m s b y

n e g a tiv e fe e lin g s, as a w a y o f illu s tra tin g the

c o lle c tin g in fo r m a tio n , te stin g b e lie fs, an d

co g n itiv e th e ra p y p ro cess.

try in g n e w b e h a v io rs

Later Sessions
C o g n itiv e th e ra p y te n d s to fo llo w a sta n d a rd

8.

F eed b a ck in the th erap y sessio n s to en su re

th a t th e c lie n t an d th e ra p is t a re
c o m m u n ic a tin g

w ith in -se ssio n s tru c tu re to m a k e th e m a x im u m

c u rre n t p ro b le m s, to se t th e to n e fo r a w o rk in g

Duration of Therapy and

Frequency of Sessions

a tm o sp h e re , an d to m a in ta in c o n tin u ity b e tw e e n

C o g n itiv e th e ra p y a d h e re s to th e b a sic g o a ls of

sessio n s. B eck s tru c tu re s s e ssio n s in to eig h t

p la n n e d b rie f th e ra p y , b u t tre a tm e n t tim e s can

e le m e n ts, listed b e lo w , w h ic h h e d e sc rib e s in

v ary . It ty p ic a lly la sts fro m 12 to 20 w e e k s, w ith

g re a te r d eta il (B e ck e t a l., 1993):

th e c lie n t an d th e ra p is t m e e tin g o n ce p e r w eek .

use o f tim e, to fo cu s o n the m o st im p o rta n t

1.

S ettin g the a g en d a to fo c u s o n p rim a ry g o a ls

fo r tre a tm e n t

2. M ood ch eck to m o n ito r th e fe e lin g s o f th e

clie n t, e sp e c ia lly c h a n g e s
3.

B ridge fr o m last sessio n to m a in ta in

co n tin u ity b e tw e e n sessio n s

4.

D iscu ssion o f today's a g en d a to p rio ritiz e

to p ics, a v o id irre le v a n t ta n g e n ts, d e te rm in e
the b e s t p o ss ib le u se o f tim e , an d so lic it the
c lie n t's to p ics fo r d is cu ss io n

(F re e m a n e t al., 1 9 9 0 ). H o w e v e r, it ca n b e
c o n d u c te d in le ss tim e fo r in s ta n c e , o n ce p e r
w e e k fo r six to e ig h t se s s io n s . T h e n u m b e r of
s e ssio n s w ill d e p e n d o n th e n a tu re o f the
p ro b lem .
B e c a u se c o g n itiv e th e ra p y is u s u a lly p la n n e d
fo r c o m p a ra tiv e ly s h o rt tre a tm e n t tim e s, th ere
h a s n o t b e e n m u c h re s e a r c h to stu d y th e re la tiv e
e ffe c tiv e n e s s o f lo n g e r te rm c o g n itiv e th erap y .
H o w e v e r, L y o n s a n d W o o d s in th e ir m e ta
a n a ly sis o f 7 0 d iffe re n t ra tio n a l-e m o tiv e th era p y
67

C hap ter 4

stu d ies fo u n d th a t in c re a se d e ffe c ts co rrela te d

fa ll b a ck in to o ld , a u to m a tic w a y s o f th in k in g

w ith lo n g e r tre a tm e n t tim es (L y o n s an d W o o d ,

th a t m a y re q u ire a re tu rn to th e ra p y . T h e

1991). M o re re se a rc h n e ed s to b e co n d u cte d

th e ra p is t c a n p ro d u c tiv e ly b u ild o n w h a t w as

lo o k in g at th e e ffe c t o f tre a tm e n t d u ra tio n on the

le a rn e d in p re v io u s s e s s io n s , h e lp th e clie n t see

e ffica cy o f th ese th e ra p ie s.

h o w sh e slip p e d in to o ld p a tte rn s, an d fu rth e r

In a b rie f v e rsio n o f this th e ra p y , th ere is less

re in fo rce th e p ro c e s s o f c a tc h in g o n e s e lf in the

tim e to u n d e rsta n d an d re s tru ctu re all o f th e

p ro c e ss o f th in k in g n e g a tiv e a u to m a tic

co g n itio n s th a t m ay b e in flu e n c in g s u b sta n ce

th o u g h ts. T h e th e ra p is t m u s t b e p re p a re d to

ab u se. T h e th e ra p ist m u st u se the e a rly sessio n s

m o v e fro m to p ic to to p ic w h ile a lw a y s a d h e rin g

to d e te rm in e the m o st p ro d u c tiv e fo cu s o f the

to th e m a jo r th e m e th a t h o w th e c lie n t th in k s

th e rap y , g iv e n th e s h o rt tim e fra m e . If th e clie n t

d e te rm in e s h o w th e c lie n t fe e ls a n d acts,

used su b sta n c e s p rim a rily to co p e w ith n e g a tiv e

in c lu d in g w h e th e r th e c lie n t a b u s e s su b sta n ce s.
C o g n itiv e th e ra p y ca n b e q u ite su c c e s s fu l as

m o od states, th e n th e ra p y m a y fo cu s on
u n d e rsta n d in g h o w th e c lie n t's in te rp re ta tio n of

an o p tio n fo r b rie f th e ra p y fo r s e v e ra l oth er

e v e n ts led to th e n e g a tiv e m o o d s. R e stru ctu rin g

re a so n s (C a rro ll, 1 9 9 6 a ):

th ese th o u g h t p ro c e s s e s m a y h e lp d ecrea se

re a so n s fo r su b s ta n c e a b u se. A lte rn a tiv e ly , if

su ite d to th e re s o u rc e c a p a b ilitie s o f m a n y

the clie n t d rin k s la rg ely to p a rty an d h a v e a

goo d tim e w ith frie n d s, a fo cu s on e x p e c te d

d e liv e ry sy ste m s.

effe cts m a y lea d to th e c lie n t's g a in in g g re a te r

aw a ren e ss o f n e g a tiv e co n s e q u e n c e s an d ,
p e rh a p s, a re d u ce d a sso c ia tio n o f the s u b sta n ce
w ith p o sitiv e e x p e rie n c e s. If the c lie n t is
re tu rn in g to th e ra p y a fte r a p e rio d o f so b rie ty

It is d e sig n e d to b e a s h o rt-te rm a p p ro a ch

It fo cu se s o n im m e d ia te p ro b le m s an d is
stru ctu re d a n d g o a l o rie n te d .

It is a fle x ib le , in d iv id u a liz e d a p p ro a ch that

ca n b e a d a p te d to a w id e ra n g e o f clien ts,
se ttin g s (b o th in p a tie n t a n d o u tp a tie n t), and
fo rm a ts, in c lu d in g g ro u p s.

th at e n d ed in re la p se , a fo cu s o n th e
circu m sta n ce s le a d in g to re la p se an d o th er
re su ltin g co n s e q u e n ce s m a y sh a p e th e th e ra p y .
A n u m b e r o f sp e cific c o g n itiv e th e ra p y
te ch n iq u es m ay b e a p p ro p ria te fo r use,
d ep en d in g on th e p h a se o f tre a tm e n t an d the
issu es raised by th e clie n t. C o g n itiv e
in te rv e n tio n s c a n b e in tro d u c e d a t an y p o in t
th ro u g h o u t th e tre a tm e n t p ro c e s s , w h e n e v e r the
th e ra p ist feels it is im p o rta n t to e x a m in e a
c lie n t's in a ccu ra te or u n p ro d u c tiv e th in k in g th a t
m a y lead to the risk o f s u b s ta n c e a b u se. T h e y
also can be u sed e p iso d ica lly w ith c lie n ts w h o
leav e and th en re tu rn to tre a tm e n t or d u rin g
a fte rca re or co n tin u in g ca re fo llo w in g a m o re
in te n siv e tre a tm e n t e p iso d e .
P erio d s w ith o u t th e ra p y s e ssio n s allow
clie n ts tim e to p ra c tic e the n e w sk ills of
id e n tify in g an d c h a lle n g in g u n p ro d u ctiv e
th in k in g o n th eir o w n . H o w e v e r, it is ea sy to

68

Cognitive-Behavioral
Theory
E a rly b e h a v io ra l th e o rie s o f s u b s ta n c e a b u se
w e re n o n m e d ia tio n a l in n a tu re (D o n o v a n and
M a rla tt, 19 9 3 ). T h e y fo c u s e d a lm o s t e x c lu siv e ly
on o v ert, o b s e rv a b le b e h a v io rs , an d it w a s
b e lie v e d th a t u n d e rs ta n d in g th e a n te c e d e n ts and
re in fo rc e m e n t c o n tin g e n c ie s w a s s u ffic ie n t to
e x p la in b e h a v io r a n d to m o d ify it. O v e r tim e,
h o w e v e r, th e se b e h a v io ra l th e o rie s b e g a n to
in c o rp o ra te c o g n itiv e fa c to rs in to th eir
c o n c e p tu a liz a tio n s o f s u b s ta n c e a b u se d iso rd e rs.
T h e s e m o re re c e n t m o d e ls a re m e d ia tio n a l in
n a tu re ; th a t is, a g re a te r ro le is a ttrib u te d to the
in te ra c tio n a m o n g a v a rie ty o f in d iv id u a l
d iffe re n c e v a r ia b le s s u c h as b e lie fs , v a lu e s,
p e rc e p tio n s , e x p e c ta tio n s , a n d a ttrib u tio n a l
p ro ce s s e s in m e d ia tin g th e d e v e lo p m e n t and

B r ie f C o g n itiv e-B eh a v io ra l T herapy

co n tin u a tio n o f su b sta n ce a b u se d iso rd e rs

1 9 7 8 ). T h e b a sic a ttrib u tio n a l d im e n s io n s are

(A b ram s and N ia u ra , 1987; M a c k a y and

in te rn a l/ e x te r n a l, s ta b le / u n s ta b le , and

D o n o v an , 1991; M a rla tt et al., 1988; M a rla tt and

g lo b a l/ s p e c ific . F o r in s ta n c e , c lin ic a lly

D o n o v a n , 1981). T h is e x p a n d e d , m e d ia tio n a l

d e p re sse d p e rs o n s ten d to b la m e th e m s e lv e s fo r

m o d el h as b e e n d e sc rib e d as c o g n itiv e so cia l

a d v e rse life e v e n ts (in te rn a l), b e lie v e th a t the

learn in g or c o g n itiv e -b e h a v io r a l th e o ry . T h is

c a u se s o f n e g a tiv e s itu a tio n s w ill last

theory p o stu la te s th a t c o g n itiv e fa cto rs m e d ia te

in d e fin ite ly (sta b le ), a n d o v e rg e n e ra liz e the

all in te ra ctio n s b e tw e e n the in d iv id u a l,

c a u se s o f d isc re te o c c u rre n c e s (g lo b a l).

situ a tio n a l d e m a n d s, and the p e rs o n 's a tte m p ts

H e a lth ie r in d iv id u a ls , o n th e o th e r h a n d , view

to cop e e ffe ctiv e ly .

n e g a tiv e e v e n ts as d u e to e x te rn a l fo rces (fate,

lu ck , e n v iro n m e n t), as h a v in g iso la te d m e a n in g

C o g n itiv e -b e h a v io ra l th e o ry re p re s e n ts the
in te g ra tio n o f p rin cip le s d eriv ed fro m b o th

(lim ite d o n ly to sp e c ific e v e n ts ), an d as b ein g

b eh a v io ra l and c o g n itiv e th e o rie s, an d it

tra n sie n t or c h a n g e a b le (la stin g o n ly a sh o rt

p ro v id es th e b asis fo r a m o re in c lu s iv e an d

tim e ). F ig u re 4 -1 4 lists a n d fu rth e r d efin e s the

co m p re h e n siv e a p p ro a c h to tre a tin g s u b sta n ce

th ree d im e n s io n s o f a ttrib u tio n th a t m a k e up an

a b u se d iso rd e rs. H o w e v e r, a b ro a d e r ra n g e of

"a ttrib u tio n a l s ty le ."

co g n itio n s is in clu d e d in c o g n itiv e -b e h a v io r a l

A ttrib u tio n a l sty le s p la y a m a jo r ro le in the

th eo ry th a n h ad b e e n in v o lv e d in e a rlie r

c o g n itiv e -b e h a v io r a l th e o ry o f s u b s ta n ce ab u se

v e rsio n s o f co g n itiv e th e o ry . T h e s e in clu d e

d is o rd e rs (D a v ie s, 1 9 9 2 ; M a r la tt an d G o rd o n ,

a ttrib u tio n s, a p p ra isa ls, se lf-e ffic a c y

19 8 5 ). T h e n a tu re o f s u b s ta n c e a b u s e rs'

e x p e cta n cie s, an d s u b s ta n c e -re la te d e ffe c t

a ttrib u tio n a l s ty le s is th o u g h t to h a v e

e x p e cta n cie s. E a ch o f th e se w ill b e re v iew e d

c o n s id e ra b le b e a rin g o n th e ir p e rc e p tio n o f th eir

b riefly b elow . C o m m o n e le m e n ts o f b rie f

su b s ta n c e a b u s e p ro b le m an d th e ir a p p ro a c h to

c o g n itiv e -b e h a v io ra l th e ra p y a re listed in

re c o v e ry . A n a lc o h o l-d e p e n d e n t clie n t, fo r

Fig u re 4-13.

in sta n c e , m a y b e lie v e th a t h e d ra n k b e ca u se he
w a s w e a k (an in te rn a l a ttrib u tio n ) or b eca u se he

Attributions

w a s su rro u n d e d b y p e o p le e n c o u ra g in g h im to

A n a ttrib u tio n is a n in d iv id u a l's e x p la n a tio n of

h a v e a b e e r (an e x te rn a l a ttrib u tio n ). H e m ay

w h y an e v e n t o ccu rre d . A b ra m so n and

b e lie v e th a t h is fa ilu re to m a in ta in a b stin e n ce

co lle a g u es p ro p o s e d th a t in d iv id u a ls d ev elo p

sh o w s th a t h e is a w e a k p e rs o n w h o ca n n ev er

a ttrib u tio n a l sty les (i.e., in d iv id u a l w a y s of

su c ce e d a t a n y th in g (a g lo b a l a ttrib u tio n ) or that

e x p la in in g e v e n ts in th eir liv es th a t ca n p la y a

a d rin k in g e p is o d e d o e s n o t re p re s e n t a g e n eral

role in the d e v e lo p m e n t o f e m o tio n a l p ro b le m s

w e a k n e ss, b u t w a s in s te a d d u e to th e sp e cific

and d y sfu n ctio n a l b e h a v io rs ) (A b ra m s o n et al.,

c irc u m sta n c e s o f th e m o m e n t (a sp e c ific

F ig u r e 4 -1 3
C o m m o n E le m e n ts o f B rief C o g n it iv e - B e h a v io r a l T h e r a p ie s

T h e th e ra p ist fo c u se s on c u rre n t p ro b lem s.

Sh e e sta b lish e s a tta in a b le an d c o n tra c te d g o als.

Sh e see k s to o b ta in q u ick re su lts fo r th e m o st p re s s in g p ro b le m s.

She re lie s on a v a rie ty o f e m p iric a lly b a se d te c h n iq u e s to in c re a se th e c lie n t's a b ility to h a n d le his ow n

p ro b lem s.

S ource: A d a p te d fro m B lo o m , 1 9 9 7 ; P ea k e e t al., 1988.

69

C h ap ter 4

F ig u r e 4 -1 4
A ttrib u tio n a l S ty le s
In te rn a l/ E x te rn a l: D o y o u a ttrib u te e v e n ts an d th e ir ca u se s to y o u rs e lf or to o th e rs?
S ta b le / U n s ta b le :

W ill th is c a u se c o n tin u e to a ffe c t y o u r fu tu re or ca n it c h a n g e o r sto p ?

G lo b a l/ S p e c ific :

D o e s th e c a u se o f o n e b ad c irc u m sta n c e a ffe c t all a re a s o f y o u r life or ju s t o n e?

attrib u tio n ). H e m ay b e lie v e th a t th e ca u se of

d e p e n d e n t o n a lc o h o l, m a riju a n a , o p ia te s, and

h is slip is so m e th in g h e c a n n o t c h a n g e (a sta b le

o th er illic it d ru g s , p ro v id e s e m p iric a l su p p o rt

attrib u tio n ) or th a t the n e x t tim e, h e w ill catch

fo r the a ttr ib u tio n a l sty le h y p o th e siz e d to

h im se lf and e x e rt b e tte r c o p in g re sp o n se s (an

m e d ia te th e A V E (B irk e et al., 1 9 9 0 ; B ra d le y et

u n stab le a ttrib u tio n ). W h e re a s the in te rn a l,

al., 1 9 9 2 ; R e ich a n d G u tie rre s , 1 9 8 7 ; S te p h e n s et

g lo b al, an d sta b le a ttrib u tio n fo r the u se of

al., 1 9 9 4 ; W a lto n et al., 19 9 4 ).

a lco h o l is lik e ly to lea d to fe e lin g s o f

h o p e le ssn e ss an d a re tu rn to d rin k in g , the
ex te rn al, sp e cific, u n sta b le a ttrib u tio n is lik e ly to

F o r th e c o g n itiv e -b e h a v io r a l th e ra p ist, an

lead to g re a te r e ffo rts to co p e w ith sim ila r

in d iv id u a l's a p p ra is a l o f s tre s sfu l situ a tio n s and

situ a tio n s in th e fu tu re.

h is a b ility to c o p e w ith th e d e m a n d s o f th e se

M a rla tt an d G o rd o n d e sc rib e d a n e g a tiv e

situ a tio n s a re im p o r ta n t in flu e n c e s o n th e

a ttrib u tio n a l p ro c e s s th a t ca n o c c u r a fte r a slip

in itia tio n a n d m a in te n a n c e o f su b s ta n c e a b u se,

(th e first u se o f a s u b s ta n c e a fte r a p e rio d of

as w e ll as re la p se a fte r c e ss a tio n o f u se

a b stin e n ce ) and th a t m a y lea d to co n tin u e d use

(H a w k in s, 1 9 9 2 ; M a r la tt an d G o rd o n , 1985;

in a fu ll-b lo w n re la p se (M a rla tt an d G o rd o n ,

S h iftm a n , 1 9 8 7 ,1 9 8 9 ; W ills a n d H irk y , 1996).

1985). T h is p ro c e ss, k n o w n as th e ab stin en ce

F o lk m a n an d L a z a ru s d e s c rib e d tw o

v iolation effect (A V E ), in v o lv e s the a ttrib u tio n of

d iffe re n t le v e ls o f c o g n itiv e a p p ra is a l (F o lk m a n

the ca u se o f an in itia l slip to in te rn a l, sta b le , and

a n d L a z a ru s , 1 9 8 8 ,1 9 9 1 ). T h e firs t le v e l is a

g lo b al facto rs. T h e s e clie n ts m a y b e lie v e th at

p rim a ry a p p ra is a l. T h is re p re s e n ts the

they are h o p eless a d d icts and fa ilu re s, th a t they

in d iv id u a l's p e rc e p tio n o f a s itu a tio n an d an

w ill n e v e r b e a b le to a c h ie v e an d m a in ta in

e stim a tio n o f th e p o te n tia l le v e l o f stre ss,

so b rie ty , an d th a t th e re is n o u se in try in g to

p e rs o n a l c h a lle n g e , o r th r e a t in v o lv e d w ith the

ch a n g e b e ca u se th e y th in k th a t th e y c a n n o t

situ a tio n . S e c o n d a ry a p p r a is a l re p re s e n ts the

su cceed .

in d iv id u a l's e v a lu a tio n o f h e r a b ility to m e e t the

A V E also h a s an e m o tio n a l c o m p o n e n t

c h a lle n g e s a n d d e m a n d s sp e c ific to the

asso cia ted w ith it. S u b s ta n c e a b u se rs w h o h a v e

situ a tio n . T h is s e c o n d a ry a p p ra is a l, w h ic h w ill

s lip p ed and h a v e in te rn a l, sta b le , and

b e in flu e n c e d b y th e e x te n t, n a tu re , an d

g e n era liz ed a ttrib u tio n s w ill fe e l d ep resse d ,

a v a ila b ility o f th e in d iv id u a l's c o p in g sk ills,

w o rth le ss, h e lp le ss, and h o p e le s s . T h is

fu rth e r m e d ia te s th e in d iv id u a l's p e rc e p tio n o f

attrib u tio n a l sty le ten d s to b e a sso c ia te d w ith a

stre ss an d th e p e r s o n 's e m o tio n a l re sp o n se .

fo rm o f "le a rn e d h e lp le s s n e s s " th a t is

70

Cognitive Appraisal

T o the e x te n t th a t th e in d iv id u a l sen se s th at

p e rp e tu a te d b y th e su b sta n ce u s e rs ' d isto rte d

sh e h a s th e n e c e s s a ry b e h a v io ra l, c o g n itiv e , or

p e rce p tio n s. T o g e th e r, th e se n se o f h e lp le ssn e ss

e m o tio n a l c o p in g s k ills to m e e t th e c h a lle n g e s of

and the n e g a tiv e e m o tio n a l sta te in c re a se the

th e s itu a tio n , it w ill b e a p p ra is e d as less

lik e lih o o d th at th e in itia l la p se w ill d ev elo p in to

th re a te n in g o r s tre s sfu l. C o n v e rs e ly , if the

a fu ll-b lo w n re la p se . R e se a rch w ith in d iv id u a ls

p e rs o n ju d g e s th a t th e n e c e s s a ry c o p in g sk ills

B r ie f C o g n itiv e-B eh a v io ra l T herapy

are lack in g , the s itu a tio n is v ie w e d as m o re

(1) b a sic a v o id a n c e o f s itu a tio n s th a t h a v e b een

th reate n in g and s tre ssfu l, an d the p e rs o n is

p re v io u s ly a s s o c ia te d w ith s u b s ta n c e a b u se and

likely to b e frig h te n e d , a n x io u s, d e p re sse d , or

(2) s e e k in g s o c ia l s u p p o rt w h e n co n fro n te d w ith

h e lp le ss. T h e re su lts o f S m ith an d c o lle a g u e s

th e te m p ta tio n to d rin k o r u se d ru g s.

s u g g e st th at su ch c o g n itiv e a p p ra is a ls m a y p la y

T h e c o g n itiv e d o m a in a lso in c lu d e s tw o

a m o re p ro m in e n t ro le th a n a ttrib u tio n s in

g e n e ra l c a te g o rie s o f co p in g : (1) n e g a tiv e

m e d ia tin g e m o tio n a l re sp o n se s to p o te n tia lly

th in k in g , or th in k in g a b o u t all th e n e g a tiv e

th reate n in g s itu a tio n s (S m ith et al., 1993).

c o n s e q u e n c e s th a t h a v e re s u lte d fro m su b sta n ce

Coping behaviors
In s u b sta n ce u s e -re la ted s itu a tio n s , co p in g
"re fe rs to w h at an in d iv id u a l d o e s or th in k s in a
relap se crisis s itu a tio n so as to h a n d le the risk
fo r re n e w e d s u b s ta n c e u s e " (M o se r an d A n n is,
1996, p. 1101). C o g n itiv e -b e h a v io r a l th e o ry
p o sits th a t su b s ta n c e u se rs a re d e fic ie n t in th eir
a b ility to co p e w ith in te rp e rs o n a l, so cia l,
e m o tio n a l, and p e rs o n a l p ro b le m s. In the
a b se n ce o f th ese s k ills, su ch p ro b le m s are
v iew ed as th re a te n in g , s tre ssfu l, an d p o te n tia lly
u n so lv a b le. B ased on th e in d iv id u a l's
o b se rv a tio n o f b o th fa m ily m e m b e r s ' an d p e e rs'
re sp o n se s to sim ila r situ a tio n s a n d fro m th e ir
ow n in itia l e x p e rim e n ta l u se o f a lco h o l or d ru g s,
the in d iv id u a l u ses su b s ta n c e s as a m e a n s of
try in g to d ea l w ith th e se p ro b le m s and the
e m o tio n a l re a ctio n s th e y c re a te . F ro m this
p e rsp e ctiv e , su b s ta n c e a b u se is v ie w e d as a
learn ed b e h a v io r h a v in g fu n c tio n a l u tility fo r
the in d iv id u a l th e in d iv id u a l u se s su b s ta n ce s
in re sp o n se to p ro b le m a tic s itu a tio n s as an
a tte m p t to co p e in th e a b se n c e o f m o re
a p p ro p ria te b e h a v io ra l, c o g n itiv e , and
e m o tio n a l co p in g sk ills.
A n u m b e r o f d im e n s io n s a re in v o lv e d in th e
co p in g p ro ce ss as it re la te s to s u b s ta n c e a b u se
(D o n o v a n , 1996; H a w k in s, 1 9 9 2 ; L a z a ru s, 1993;
S h iftm a n , 1987; W ills and H irk y , 19 9 6 ). T h e first
is the g e n e ra l d o m a in in w h ich th e co p in g
re sp o n se o ccu rs. C o p in g re s p o n s e s c a n o ccu r
w ith in th e a ffe ctiv e , b e h a v io ra l, an d c o g n itiv e
d o m ain s. L itm a n id e n tifie d a n u m b e r of
b e h a v io ra l an d c o g n itiv e s tra te g ie s th a t are
p ro te ctiv e a g a in st re la p se (L itm a n , 19 8 6 ). T h e re
are tw o b e h a v io ra l c la sse s o f c o p in g b eh a v io r:

a b u se an d a d e sire to n o lo n g e r e x p e rie n c e these,

an d (2) p o sitiv e th in k in g , or th in k in g a b o u t all
the b e n e fits th a t a re a c c ru e d b y b e in g c le a n and
s o b e r a n d n o t w a n tin g to lo se th e se. L itm a n
s u g g e sts th a t th e se c o p in g s tra te g ie s o p era te in a
s o m e w h a t s e q u e n tia l m a n n e r (L itm a n , 1986).
In itia lly , w h e n c lie n ts a re a tte m p tin g to in itia te
an d s ta b iliz e a b stin e n c e fro m s u b s ta n c e s, they
a p p e a r to re ly m o re h e a v ily o n th e b e h a v io ra l
s tra te g ie s. A s th e p e rio d o f a b stin e n c e in cre a se s,
th e re a p p e a rs to b e a tra n sitio n fro m
p re d o m in a n tly b e h a v io ra l s tra te g ie s to w a rd a
g re a te r re lia n c e o n c o g n itiv e m e th o d s o f co p in g .
C o p in g s tra te g ie s h a v e a n u m b e r o f oth er
d im e n sio n s. T h e y ca n b e e m o tio n fo cu se d ,
p ro b le m fo c u s e d , o r a v o id a n t. A d is tin c tio n is
a lso m a d e b e tw e e n th o se th a t a re g e n e ra l co p in g
s tra te g ie s a n d th o se th a t a re e x p re s s ly
a tte m p tin g to c o p e w ith u rg e s, c ra v in g , and
te m p ta tio n to u se in s e ttin g s a s s o c ia te d w ith
p a s t su b s ta n ce a b u se . A n o th e r im p o rta n t
d im e n s io n o f c o p in g s tra te g ie s is th e sta g e at
w h ic h th e y a re u se d in re s p o n s e to a p o ten tia lly
d iffic u lt s u b s ta n c e -re la te d s itu a tio n (S h iftm a n ,
1 9 8 9 ). A n tic ip a to ry c o p in g is e m p lo y e d as one
a n tic ip a te s a n d a tte m p ts to p la n h o w to d ea l
w ith u p co m in g s itu a tio n s . T h e y ta k e th e fo rm
o f "W h a t ca n I d o i f . . . . " T h e re a re a lso co p in g
s tra te g ie s th a t a re e m p lo y e d in th e m o m e n t th at
o n e is h a v in g to d e a l w ith th e d iffic u lt
s u b s ta n c e -re la te d s itu a tio n s . T h e y tak e th e fo rm
o f "W h a t c a n I d o n o w ....'' F in a lly , th e re are
re s to ra tiv e co p in g s tra te g ie s th a t ca n b e
e m p lo y e d if o n e fa ils to co p e a n d fin d s h im se lf
u sin g in th e s itu a tio n . T h e s e ta k e the fo rm of
"W h a t ca n I d o n o w th a t I 'v e . . . " It is th ese
71

C h ap ter 4

re sto ra tiv e co p in g stra te g ie s th a t p la y a ro le in

c o n s id e ra b le d e g re e o f s itu a tio n a l sp e c ific ity in

d eterm in in g w h e th e r an in itia l d rin k or u se of

th e c o p in g p ro c e s s . T h a t is, d iffe re n t ty p e s of

d ru g s w ill e sca la te in to a fu ll-b lo w n re la p se .

s u b s ta n c e -re la te d s itu a tio n s se e m to re q u ire

R e se a rch on co p in g b e h a v io r as it re la tes to
su b sta n ce ab u se d iso rd e rs h a s g e n e ra lly

g e n e ra l c o p in g s tr a te g y 's b e in g e q u a lly e ffe ctiv e

su p p o rte d th e b a sic te n e t o f c o g n itiv e -

a c ro ss s itu a tio n s . S e c o n d , s tra te g ie s u se d to

b e h a v io ra l a p p ro a ch e s, n a m e ly th a t th e se clie n ts

c o p e w ith n o n s p e c ific stre ss a p p e a r to be

are d e ficie n t in th eir c o p in g s k ills, th a t these

s o m e w h a t d iffe re n t fro m th o se u sed to co p e

d e ficie n cie s co n trib u te to th e ir c o n tin u ed

w ith te m p ta tio n . T h e s e fin d in g s s u g g e s t th at

su b sta n ce a b u se, and th a t th o se w h o se d eficits

tre a tm e n t n o t o n ly s h o u ld re c tify d e fic ie n c ie s in

are n o t re m e d ie d a re at a g re a te r risk o f re la p se

c o p in g a b ilitie s, b u t th a t it m a y b e n e c e ssa ry to

than th o se w h o in c re a se th e ir co p in g th ro u g h

fo cu s o n s k ills to d e a l w ith b o th g e n e ra l stress

tre a tm e n t (W ills an d H irk y , 19 9 6 ). A n o th e r

an d s u b s ta n c e -re la te d te m p ta tio n . F u rth e rm o re ,

stu d y fo u n d th a t th e n u m b e r o f c o p in g a tte m p ts

it m a y b e n e c e s s a ry to d e v e lo p co p in g sk ills

and the ty p e o f c o p in g w ill in flu e n ce b o th

sp e cific to s e v e r a l p o ss ib le s itu a tio n s in w h ich

re la p se and the re tu rn to a b stin e n ce (M o ser and

th e clie n t m a y u se su b s ta n c e s.

A n n is, 1996). A tte m p tin g to co p e w ith a re la p se

crisis led to h ig h er ra tes o f a b stin e n c e th an n o t

Self-Efficacy Expectancies

try in g to co p e, and th e g re a te r th e n u m b e r of

T h e a p p a r e n t la c k o f c o p in g s k ills a m o n g

co p in g stra te g ie s e m p lo y e d , the less lik e ly th e

s u b s ta n c e u se rs is an im p o r ta n t c o n trib u to r to

p e rso n w as to u se. If one c o p in g re sp o n se w a s

a n o th e r k e y c o n s tr u c t in c o g n itiv e -b e h a v io ra l

p e rfo rm e d , the p ro b a b ility o f a b stin e n c e w a s 40

a p p ro a c h e s, n a m e ly s e lf-e ffic a c y e x p e c ta n cie s

p e rce n t; the p ro b a b ility ro se to 8 0 p e rc e n t if tw o

(B a n d u ra , 1 9 7 7 ). T h e s e e x p e c ta n c ie s re fe r to an

co p in g a tte m p ts w e re m a d e . S im ila rly , th e

in d iv id u a l's b e lie fs a b o u t h is a b ility to

g re a te r the n u m b e r o f c o p in g s tra te g ie s u sed by

su c c e s s fu lly e x e c u te a n a p p r o p ria te re s p o n s e in

an in d iv id u a l fo llo w in g a re la p se , the g re a te r the

o rd e r to c o p e w ith a g iv e n s itu a tio n . S elf-

lik e lih o o d o f re tu rn in g to a b stin e n c e . E x clu siv e

e ffic a c y e x p e c ta n c ie s a re d e te rm in e d in p a rt by

use o f activ e co p in g s tra te g ie s (e.g ., e n g a g in g in

the in d iv id u a l's re p e rto ire o f c o p in g sk ills and

a ltern a tiv e a ctiv itie s th a t are in c o m p a tib le w ith

an a p p ra is a l o f th e ir re la tiv e e ffe c tiv e n e s s in

d rin k in g , p ro b le m s o lv in g , se e k in g s u p p o rt fro m

re la tio n to th e s p e c ific d e m a n d s o f th e situ a tio n .

o th ers, th in k in g o f c o n s e q u e n c e s o f u sin g , u sin g

B a n d u ra h a s h y p o th e siz e d th a t e x p e c ta tio n s of

p o sitiv e / n e g a tiv e se lf-ta lk ) w a s a sso c ia te d w ith

p e rs o n a l e ffic a c y d e te rm in e w h e th e r co p in g

m a in ta in in g a b stin e n c e in c o n tra s t to e x clu siv e

b e h a v io r w ill b e in itia te d or n o t, th e a m o u n t of

re lia n ce on a v o id a n t s tra te g ie s (e .g ., ig n o rin g the

e ffo rt th a t w ill b e e x p e n d e d in a tte m p tin g to

situ a tio n , d ea lin g w ith it in d ire c tly by e a tin g , or

co p e, an d h o w lo n g a c o p in g a tte m p t w ill

re ly in g on w illp o w e r).

c o n tin u e in th e fa c e o f o b s ta c le s an d a v e rsiv e

N e id ig h and c o lle a g u e s in v e stig a te d the

stra te g ies e m p lo y e d to co p e w ith stre ss an d the

72

d iffe re n t ty p e s o f c o p in g re s p o n s e s ra th e r th a n a

e x p e rie n c e s (B a n d u ra , 19 7 7 ). H e a lso su g g e ste d

th a t s e lf-e ffic a c y e x e rts a n in flu e n c e on the

te m p ta tio n to d rin k a m o n g in d iv id u a ls

in d iv id u a l's b e h a v io r th r o u g h c o g n itiv e ,

a tte m p tin g to c o n tro l th e ir d rin k in g (N e id ig h et

m o tiv a tio n a l, a n d e m o tio n a l s y ste m s (B a n d u ra ,

al., 1988). T h e y fo u n d th a t b o th c o g n itiv e and

19 9 4 ). If a p e rs o n h a s lo w s e lf-e ffic a c y d u e to a

b e h a v io ra l co p in g s tra te g ie s w e re e ffe c tiv e in

la ck o f n e c e s s a ry c o p in g s k ills, s h e m ig h t be

re sistin g a d rin k . T w o o th e r im p o rta n t fin d in g s

e x p e c te d to h a v e n e g a tiv e or d isto rte d th o u g h ts

w ere o b ta in ed . F irst, th e re a p p e a rs to be a

an d b e lie fs a b o u t h e rs e lf a n d h e r situ a tio n , h av e

B r ie f C o g n itiv e-B eh a v io ra l T herapy

re d u ce d m o tiv a tio n to e v e n try to co p e, an d m a y

re p re s e n t th e in d iv id u a l's e x p e c ta tio n th a t

b e d ep resse d and p e rc e iv e h e rs e lf as h e lp le ss.

ce rta in e ffe c ts w ill p re d ic ta b ly re s u lt fro m

C o g n itiv e -b e h a v io ra l a p p ro a c h e s to
su b sta n ce a b u se d is o rd e rs p o stu la te th a t low

su b s ta n ce u se. A lth o u g h th e re h a s b e e n m o re
re s e a rc h on a lc o h o l-re la te d e ffe c t e x p e c ta n c ie s

lev els o f se lf-e ffic a cy a re re la ted to s u b s ta n c e u se

(G o ld m a n , 1 9 9 4 ), th e re h a s b e e n an in cre a se d

and an in cre a se d lik e lih o o d o f re la p se a fte r

in te re s t in d ru g -re la te d e x p e c ta n c ie s (B ro w n ,

h av in g a ch ie v e d a b stin e n c e (A n n is an d D a v is,

19 9 3 ). G iv e n th a t d ru g s h a v e d iffe rin g e ffe cts, it

1988b , 1989b ; D iC le m e n te a n d F a irh u rst, 1995;

h a s b e e n n e c e s s a ry to d e v e lo p m e a s u re s sp e cific

M a rla tt and G o rd o n , 19 8 5 ). A m o d e l o f re la p se

to th e e ffe c ts a n tic ip a te d fro m th e se d iffe ren t

th at is b a se d o n the ro le o f se lf-e ffic a c y and

d ru g s, s u c h as m a riju a n a (S c h a fe r an d B row n ,

co p in g is d ep icte d in F ig u re 4 -1 5 .

1991) a n d co c a in e (Ja ffe a n d K ilb e y , 1994;

S e lf-e ffica cy h a s b e e n th o u g h t o f as b o th th e
d eg ree o f a c lie n t's te m p ta tio n to u se in

S c h a fe r an d B ro w n , 19 9 1 ).
T h e in itia l fo c u s in s tu d y in g a lc o h o l-re la te d

su b sta n ce -re la te d se ttin g s an d h is d e g re e of

e x p e c ta n c ie s w a s o n th e p o sitiv e e ffe c ts that

co n fid e n ce in h is a b ility to re fra in fro m u sin g in

in d iv id u a ls a n tic ip a te d fro m a lc o h o l (G o ld m a n

th o se settin g s (A n n is a n d D a v is, 19 8 8 b ;

an d B ro w n , 1 9 8 7 ). D rin k e rs a n ticip a te d th a t

D iC le m e n te e t al., 1 9 9 4 ; S k la r e t al., 19 9 7 ). T h e

a lc o h o l w o u ld se rv e as a g lo b a l e lix ir, h a v in g

ro le o f se lf-e ffic a c y h a s b e e n e x a m in e d fo r

p o sitiv e e ffe c ts o n m o o d , s o c ia l and

a lco h o l (E v an s an d D u n n , 1 9 9 5 ; S o lo m o n and

in te rp e rs o n a l b e h a v io r, se x u a l b e h a v io r,

A n n is, 1990), co ca in e (C o o n et al., 1 9 9 8 ; R o u n d s-

a s s e rtiv e n e s s , an d te n sio n re d u c tio n . P o sitiv e

B ry an t et al., 19 9 7 ), m a riju a n a (S te p h e n s et al.,

e ffe c t e x p e c ta n c ie s fo r m a riju a n a in clu d e

1993), o p ia te s (R e illy et al., 1 9 9 5 ), an d a cro ss all

re la x a tio n a n d te n s io n re d u c tio n , so c ia l and

o f th ese su b s ta n ce s o f a b u se (S k la r e t al., 1997).

se x u a l fa c ilita tio n , a n d p e rc e p tu a l an d co g n itiv e

T h is re se a rch g e n e ra lly s u p p o rts the h y p o th e sis

e n h a n c e m e n t (S c h a fe r a n d B ro w n , 1991).

th at th o se w ith lo w e r le v e ls o f se lf-e ffic a c y are

P o s itiv e c o c a in e -re la te d e x p e c ta n c ie s in clu d e

m o re lik e ly to a b u se su b sta n c e s.

g lo b a l p o sitiv e e ffe cts , g e n e ra liz e d a ro u sa l,

Substance-Related Effect
Expectancies

e u p h o ria , e n h a n c e d a b ilitie s, an d re la x a tio n and

te n sio n re d u c tio n (Ja ffe a n d K ilb e y , 1994;
S c h a fe r an d B ro w n , 19 9 1 ).

A s s u b sta n ce u se is re in fo rc e d b y th e p o sitiv e

M o re re c e n tly , th e re h a s b e e n a n in cre a se d

e ffe cts o f th e s u b s ta n c e b e in g ta k e n , it is a lso

in te re s t in th e e x p e c ta tio n s o f n e g a tiv e o u tco m es

lik e ly th a t th e in d iv id u a l w ill d e v e lo p a se t o f

th a t in d iv id u a ls h o ld a b o u t s u b s ta n ce s.

co g n itiv e e x p e c ta n c ie s a b o u t th e s e a n ticip a te d

N e g a tiv e e x p e c ta n c ie s a b o u t a lc o h o l in clu d e

e ffe cts on h e r fe e lin g s an d b e h a v io r. T h e y

c o g n itiv e an d b e h a v io ra l im p a irm e n t, risk and

Figure 4-15
Relapse Prevention Model Based on Self-Efficacy Theory

Source: Annis and Davis, 1991, p.205.

73

C h ap ter 4

a g g re ssio n , an d n e g a tiv e s e lf-p e rc e p tio n

c o n d itio n e d c u e s th a t ca n e lic it a s tro n g cra v in g

(F ro m m e e t al., 1993). N e g a tiv e co n se q u e n c e s

or d e sire to u se. T o th e e x te n t th a t su b sta n ce

e x p e cte d fro m c o ca in e in clu d e g lo b a l n e g a tiv e

a b u se a llo w s th e in d iv id u a l to a v o id or esca p e

e ffe cts, a n x ie ty , d e p re ssio n , and p a ra n o ia (Ja ffe

su ch p ro b le m s itu a tio n s or th e ir re s u lta n t

and K ilb ey , 1994; S c h a fe r an d B ro w n , 19 9 1 ). It is

e m o tio n a l re a c tio n s , th e u se o f su b s ta n c e s w ill

th o u g h t th a t th e a n tic ip a te d p o sitiv e e ffe c ts of

b e re in fo rce d th ro u g h o p e ra n t le a rn in g . T h u s

su b sta n ce s se rv e as an in c e n tiv e or m o tiv a tio n to

th e lik e lih o o d is in c re a se d th a t s u b s ta n c e s w ill

use. C o n v e rse ly , n e g a tiv e e x p e c ta n c ie s are

b e a b u se d an d w ill c o m e to b e re lie d o n in the

th o u g h t to act as a d isin ce n tiv e an d c o n trib u te to

fu tu re w h e n th e in d iv id u a l e n c o u n te rs sim ila r

re d u ce d d rin k in g or d ru g u se (M c M a h o n and

s itu a tio n s.

Jo n e s, 1993; M ic h a le c et al., 1996).

R e se a rch su p p o rts th e se h y p o th e siz e d
actio n s of p o sitiv e an d n e g a tiv e e x p e c ta n cie s

a b u sed (C h a n e y et al., 1 9 8 2 ; C u m m in g s and

(Jaffe and K ilb ey , 1 9 9 4 ; Jo n e s an d M cM a h o n ,

G o rd o n , 1 9 8 0 ; M a r la tt a n d G o rd o n , 1 9 8 0 ,1 9 8 5 ).

1994b ; R o u n d s-B ry a n t et al., 19 9 7 ). P o sitiv e

W h ile th e o rig in a l ta x o n o m y o f th e se situ a tio n s

a lco h o l- and co c a in e -re la te d e x p e c ta n cie s are

fo cu se d on s e ttin g s in w h ic h re la p se o ccu rre d

a sso cia ted w ith a g re a te r lik e lih o o d o f re la p se

fo llo w in g a p e rio d o f a b stin e n c e fro m a

and p o o re r su b s ta n c e -re la te d o u tc o m e s (B ro w n

s u b s ta n c e , th e se ttin g s a p p e a r to re p re s e n t

et al., 1998; R o u n d s-B ry a n t e t al., 19 9 7 ), w h ere a s

s itu a tio n s in w h ic h s u b s ta n c e u se in g e n e ra l w ill

n e g a tiv e a lco h o l e ffe ct e x p e c ta n c ie s are re la ted

b e m o re lik e ly to o c c u r (A n n is an d D a v is, 1 9 88a;

to d ecrease d lik e lih o o d o f re la p se a n d less

M a rla tt, 1 9 9 6 ). T h e s itu a tio n s a s o rig in a lly

a lco h o l co n s u m p tio n (Jo n e s an d M cM a h o n ,

c a te g o riz e d a re fo u n d in F ig u re 4 -1 6 .

1994a; M cM a h o n a n d Jo n e s , 19 9 6 ).
R e se a rch also in d ica te s th a t a lc o h o l-re la te d

T h e s e s itu a tio n s h a v e b e e n c la ss ifie d in to

c a te g o rie s. A t th e b ro a d e s t le v e l, th e y are

e ffe ct e x p e cta n cie s w e re n e g a tiv e ly c o rrela te d

c o n s id e re d e ith e r in te rp e rs o n a l (i.e., in v o lv in g a

w ith c lie n ts ' ra tin g s o f se lf-e ffic a c y a t the

p re s e n t or re c e n t in te ra c tio n w ith s o m e o n e else)

b eg in n in g o f tre a tm e n t (B ro w n et al., 19 9 8 ); th at

or in tr a p e r s o n a l-e n v ir o n m e n ta l (i.e., fa cto rs th at

is, the lo w e r the p e rc e iv e d s e lf-e ffic a c y , the

a re e ith e r in te rn a l to th e in d iv id u a l or re a ctio n s

g re a te r the lev el o f a n ticip a te d p o sitiv e e ffe cts of

to n o n p e rso n a l e n v iro n m e n ta l e v e n ts ). T h e re

alco h o l. B o th th e se sets o f e x p e c ta n c ie s ch a n g e d

a re a n u m b e r o f m o re sp e c ific s itu a tio n s w ith in

o v er the 4 -w e e k c o u rse o f tre a tm e n t, w ith self-

e a c h o f th e se b ro a d e r c a te g o rie s. T h e se

e ffica cy in cre a sin g an d a lco h o l e ffe ct

situ a tio n s in c lu d e m a n y e m o tio n a l,

e x p e cta n cie s d e c re a sin g . L o w e r s e lf-e ffic a c y

in te rp e rs o n a l, an d e n v iro n m e n ta l se ttin g s in

ju d g m e n ts , p o sitiv e a lc o h o l e x p e c ta n c ie s, an d

w h ic h p e o p le c o m m o n ly a b u s e s u b s ta n c e s an d

re lia n ce on a v o id a n t, e m o tio n -fo c u s e d co p in g

w h e re th e y a re lik e ly to re la p se . T h e re fo re ,

stra te g ies w e re sig n ific a n tly a s s o c ia te d w ith

th e se a re c a lle d " h ig h -r is k " s itu a tio n s . T h e se

in cre ase d a lco h o l co n s u m p tio n an d a lco h o l-

s itu a tio n s a lso s e rv e as th e fo u n d a tio n fro m

related p ro b le m s a m o n g h e a v y d rin k in g co lle g e

w h ic h a n u m b e r o f m e a s u re s o f s u b s ta n c e -

stu d e n ts (E v an s an d D u n n , 19 9 5 ).

re la te d s e lf-e ffic a c y h a v e b e e n d e v e lo p e d (A n n is

High-Risk Situations
O v e r tim e, w ith re p e a te d e x p o s u re , a sp e cts o f a

74

M a r la tt an d c o lle a g u e s h a v e c h a ra c te riz e d a
n u m b e r o f s itu a tio n s in w h ic h s u b s ta n c e s are

and D a v is, 1 9 8 8 b ; D iC le m e n te e t al., 1 9 9 4 ; S k lar

et al., 19 9 7 ).
W h ile th e re a p p e a rs to b e co n s id e ra b le

s itu a tio n a l c o n te x t (e.g ., the p e o p le , p la ces,

o v e rla p in h ig h -ris k s itu a tio n s a c ro ss su b sta n ce s

fe e lin g s, a ctiv itie s) ca n c o m e to serv e as

(C u m m in g s a n d G o rd o n , 1 9 8 0 ), th e re a re a lso a

B r ie f C o g n itiv e-B eh a v io ra l T herapy

F ig u r e 4 - 1 6
T a x o n o m y o f H ig h -R is k S itu a tio n s B a se d on
M a r la tt's O rig in a l C a te g o r iz a tio n S y s te m
I n tr a p e r s o n a l- E n v ir o n m e n ta l D e te r m in a n ts

C o p in g w ith n e g a tiv e e m o tio n a l sta tes

C o p in g w ith fru s tra tio n an d a n g e r

C o p in g w ith o th e r n e g a tiv e e m o tio n a l sta te s (e.g ., fe a r, a n x ie ty , te n s io n , d e p re s s io n , lo n e lin e ss,

s a d n e ss, b o re d o m , g rief, lo ss, g u ilt)

C o p in g w ith n e g a tiv e p h y s ic a l/ p h y s io lo g ic a l sta te s

C o p in g w ith p h y s ic a l sta te s a s s o c ia te d w ith p rio r s u b s ta n c e u se (e .g ., w ith d ra w a l d istress)

C o p in g w ith o th e r n e g a tiv e p h y s ic a l sta te s (e.g ., p a in , illn e ss, in ju ry , fa tig u e )

E n h a n ce m e n t o f p o sitiv e e m o tio n a l sta te s (e .g ., u sin g s u b s ta n c e s to e n h a n c e p le a s u re , fo r ce le b ra tio n )

T e s tin g p e rs o n a l co n tro l (e.g ., u sin g to test " w illp o w e r " to see if tre a tm e n t w o rk e d , to se e if on e can
d rin k or u se in a m o d e ra te w a y )

G iv in g in to te m p ta tio n s or u rg es

In the p re s e n c e o f s u b s ta n c e -re la te d cu es

In th e a b se n ce o f su b s ta n c e -re la te d cu es
In te r p e r s o n a l D e te r m in a n ts

C o p in g w ith in te rp e rs o n a l co n flict

C o p in g w ith fru s tra tio n an d a n g e r

C o p in g w ith o th e r in te rp e rs o n a l co n flict

S o cia l p re ssu re to d rin k or use

D ire ct so c ia l p re ssu re

In d ire ct so c ia l p re s s u re

E n h a n ce m e n t o f p o sitiv e e m o tio n a l sta te s

S ou rce: M a rla tt, 1996.

n u m b e r o f s u b s ta n c e -s p e c ific p a tte rn s.

s itu a tio n s , in te rm s o f its th r e a t to m a in ta in in g

E m o tio n a l and s itu a tio n a l risk fa c to rs h a v e b ee n

a b stin e n c e re la tiv e to th e ir a v a ila b le co p in g

e x a m in e d am o n g a clin ic a l sa m p le o f

a b ilitie s, th a t d e te rm in e s th e s itu a tio n a l risk fo r

in d iv id u a ls w h o w e re p rim a ry a b u se rs of

the in d iv id u a l (M y e rs e t a l., 19 9 6 ).

a lco h o l, co ca in e , m a riju a n a , se d a tiv e s and

tra n q u iliz e rs, or h e ro in / o p ia te s . T h e y fo u n d
th at p o sitiv e so cia l e x p e rie n c e s a n d n e g a tiv e
e m o tio n a l sta te s w e re im p o rta n t risk fa c to rs fo r
p a tie n ts w h o w e re d e p e n d e n t on a lc o h o l or

The C ognitive-Behavioral
Approach to Substance Abuse
Disorders
T h e c o g n itiv e -b e h a v io r a l a p p ro a c h a tte m p ts to

co cain e . P o sitiv e e m o tio n a l an d situ a tio n a l

in te g ra te all o f th e s e th e o r e tic a l d eta ils in to a

facto rs w e re m o st im p o rta n t fo r th o se u sin g

m e a n in g fu l m o d e l o f s u b s ta n c e a b u se d iso rd e rs

m a riju a n a . In d iv id u a ls d e p e n d e n t o n se d a tiv e s

(M a c k a y e t al., 1 9 9 1 ; M a r la tt e t al., 1988). F ig u re

and tra n q u iliz e rs or h e ro in / o p ia te s re p o rte d

4 -1 7 p re s e n ts a flo w c h a rt th a t d e p icts th is m o d e l

th at n e g a tiv e p h y s ic a l sta te s a n d in te rp e rs o n a l

o f s u b s ta n c e a b u se a n d d e p e n d e n c e .

co n flict w e re th e m o st im p o rta n t risk fa cto rs.

A g ain , it is th e in d iv id u a l's a p p ra isa l o f su ch

T h e c o g n itiv e -b e h a v io r a l m o d e l a ssu m es
th a t s u b s ta n c e a b u s e rs a re d e fic ie n t in co p in g
75

C h a p ter 4

76

B r ie f C o g n itiv e-B eh a v io ra l T herapy

sk ills, ch o o se n o t to u se th o se th e y h a v e, or are

a b stin e n c e o r m o d e ra tio n a n d fo r th o se w h o

in h ib ited fro m d o in g so (M o n ti et a l., 1994,

h a v e m a in ta in e d s u c h g o a ls lo n g e r. T h e se

1995). It also a ssu m e s th a t o v e r the c o u rse of

n e g a tiv e e m o tio n s re p re s e n t y e t a n o th e r h ig h -

tim e, su b sta n ce a b u sers d e v e lo p a p a rtic u la r set

risk s itu a tio n . If th e in d iv id u a l d o e s n o t h a v e

o f e ffe ct e x p e cta n cie s b a se d o n th eir

th e n e c e s s a ry re s to ra tiv e c o p in g sk ills to d eal

o b se rv a tio n s o f p e e rs an d s ig n ific a n t o th ers

w ith th e m a n d to c o u n te ra c t th e im p a c t o f a

a b u sin g su b s ta n c e s to try to co p e w ith d iffic u lt

n e g a tiv e a ttr ib u tio n a l s ty le , it is m o re lik e ly th at

situ a tio n s an d th ro u g h th e ir o w n e x p e rie n c e s of

a n in itia l slip w ill c o n tin u e o n as a fu ll-b lo w n

the p o sitiv e e ffe c ts o f s u b s ta n c e s. T h e y h a v e

re la p se (S te p h e n s e t a l., 1 9 9 4 ).

co m e to b e lie v e th a t su b s ta n c e s h a v e p o sitiv e
b en e fits th at are m o re im m e d ia te and p ro m in e n t
th an th eir n e g a tiv e c o n s e q u e n c e s . T h e y a lso
com e to re ly on su b s ta n ce s as a m e a n s o f try in g
to co p e w ith th e se situ a tio n s.
T o the e x te n t th a t th e in d iv id u a l is la ck in g in

C ognitive-Behavioral
Therapy
C o g n itiv e -b e h a v io r a l th e ra p y (C B T ) d eriv es, in
p a rt, fro m b o th b e h a v io ra l an d co g n itiv e

the co p in g sk ills n e c e s s a ry to d ea l w ith the

th e o rie s. W h ile sh a rin g a n u m b e r o f p ro c e d u re s

d em a n d s o f h ig h -ris k su b s ta n c e a b u se or re la p se

in c o m m o n , C B T is a lso d is tin c t in m a n y w ay s

situ a tio n s, h is se n se o f se lf-e ffic a c y d e cre a se s.

fro m th e se o th e r th e ra p ie s (C a rro ll, 19 9 8 ). In

A s p e rso n a l e ffica c y d e c re a se s, the a n ticip a te d

co m p a riso n to c o g n itiv e th e ra p y , C B T p la ces

p o sitiv e e ffe cts o f su b sta n c e a b u se in c re a se and

less e m p h a s is o n id e n tify in g , u n d e rsta n d in g ,

b eco m e m o re sa lie n t (B ro w n et al., 1998). U n d e r

an d c h a n g in g u n d e rly in g b e lie fs a b o u t th e self

su ch co n d itio n s, th e in d iv id u a l is lik e ly to use

a n d th e s e lf in re la tio n sh ip to s u b s ta n c e ab u se.

(M o ser and A n n is, 19 9 6 ). W h e n co n fro n te d b y

It fo cu se s in s te a d o n le a rn in g an d p ra c tic in g a

sim ila r situ a tio n s in th e fu tu re, th e lik e lih o o d o f

v a rie ty o f c o p in g s k ills , o n ly s o m e o f w h ich are

usin g co n tin u e s to b e q u ite h ig h , u n le ss n e w

co g n itiv e . A g re a te r e m p h a s is is a lso p la ced on

co p in g sk ills h a v e b e e n lea rn e d . G iv e n th e

u sin g b e h a v io ra l c o p in g s tra te g ie s , e sp e c ia lly

in te ra ctio n o f s e lf-e ffic a c y , su b s ta n c e -re la te d

e a rly in th e ra p y . C B T trie s to c h a n g e w h a t the

effe cts e x p e cta n c ie s, an d h ig h -risk s itu a tio n s,

clie n t b o th d o e s a n d th in k s.

"th e d e cisio n to d rin k or e x e rcise re s tra in t (self-

In c o m p a ris o n to b e h a v io ra l tre a tm e n ts su ch

co n tro l) is u ltim a te ly d e te rm in e d by s e lf-e ffic a c y

as th e c o m m u n ity re in fo rc e m e n t a p p ro a c h , C B T

and o u tco m e e x p e c ta tio n s fo rm u la te d a ro u n d a

fo cu se s m o re o n c o g n itio n s , b e lie fs , and

cu rre n t s itu a tio n a l c o n te x t" (A b ra m s and

e x p e c ta n c ie s. A lso , C B T g e n e ra lly d o es n ot

N ia u ra , 1987, p. 152).

in c o rp o ra te c o n tin g e n c y m a n a g e m e n t

A ttrib u tio n a l p ro ce s s e s an d e m o tio n a l

a p p ro a c h e s s u ch as th e u se o f v o u c h e rs to

re sp o n se s also p la y a ro le in an in d iv id u a l's

re in fo rc e d e sire d b e h a v io rs . C B T is u su a lly

d ecisio n to u se (M a rla tt an d G o rd o n , 1985).

c o n fin e d to th e tre a tm e n t se s s io n (a lth o u g h

Sh ou ld the clie n t a ttrib u te h e r s u b s ta n c e a b u se

th e ra p ists o fte n g iv e h o m e w o rk to clie n ts to be

to in te rn a l, sta b le , an d g lo b a l ch a ra c te ris tic s

co m p le te d o u ts id e th e th e ra p y s e ssio n ), w h ere as

(e.g., " I'm n o th in g b u t an a d d ict; th e re 's n o th in g

the c o m m u n ity re in fo rc e m e n t a p p ro a c h stresses

th at I can d o to sto p u s in g "), th e n it is lik e ly that

the im p o rta n c e o f in c o rp o ra tin g in te rv e n tio n s

she w ill feel a n g ry , d e p re sse d , h o p e le s s , and

in to re a l w o rld se ttin g s an d ta k in g a d v a n ta g e of

h e lp le ss. T h e se re a c tio n s a re less lik e ly to o ccu r

c o m m u n ity re s o u rc e s . F ig u re 4 -1 8 lists a

and to be less p ro n o u n c e d fo r in d iv id u a ls w h o

n u m b e r o f fe a tu re s th o u g h t to b e u n iq u e to

are m o re firm ly c o m m itte d to th e g o a l of

c o g n itiv e -b e h a v io r a l in te rv e n tio n s .
77

C h ap ter 4

F ig u r e 4 -1 8
E s s e n tia l a n d U n iq u e E le m e n ts o f C o g n it iv e - B e h a v io r a l I n te r v e n tio n s
T h e k ey in g re d ie n ts th a t d is tin g u is h C B T fro m o th e r s o m e o th e r th e ra p ie s a n d th a t m u s t b e in c lu d e d in a
C B T tre a tm e n t in c lu d e the fo llo w in g :

A fu n ctio n a l a n a ly sis o f su b s ta n c e a b u se

In d iv id u a liz e d tra in in g in re c o g n iz in g an d c o p in g w ith cra v in g , m a n a g in g th o u g h ts a b o u t su b sta n ce

ab u se, p ro b le m s o lv in g , p la n n in g fo r e m e rg e n c ie s , re c o g n iz in g s e e m in g ly irre le v a n t d e cis io n s , and
u sin g re fu sa l sk ills

A n e x a m in a tio n o f the c lie n t's c o g n itiv e p ro ce s s e s re la te d to s u b s ta n c e a b u se

T h e id e n tific a tio n an d d e b rie fin g o f p a s t an d fu tu re h ig h -ris k s itu a tio n s

T h e e n c o u ra g e m e n t and re v iew o f e x tra -s e s s io n im p le m e n ta tio n o f sk ills

P ra ctice o f sk ills w ith in se ssio n s

S ou rce: C a rro ll, 1998.

C B T u ses le a rn in g p ro c e s s e s to h e lp

an d e ffe c tiv e n e s s o f th e in d iv id u a l's co p in g

in d iv id u a ls re d u c e th e ir d ru g u se. It w o rk s by

sk ills. W h ile a m a jo r e m p h a s is in c o g n itiv e -

h e lp in g c lie n ts re c o g n iz e th e s itu a tio n s in w h ich

b e h a v io ra l th e ra p y is o n id e n tify in g an d

th ey are lik e ly to u se, fin d w a y s o f a v o id in g

re m e d ia tin g d e fic its in c o p in g s k ills, it is a lso

th o se s itu a tio n s, a n d co p e m o re e ffe c tiv e ly w ith

im p o rta n t to a s s e s s th e c lie n t's stre n g th s and

s itu a tio n s, fe e lin g s, an d b e h a v io rs re la ted to

a d a p tiv e s k ills (D e N e ls k y an d B o a t, 1986).

th eir su b sta n ce a b u se (C a rro ll, 19 9 8 ). T o a ch iev e

T h e fu n c tio n a l a n a ly sis w ill a lso a ssess

these th e ra p e u tic g o a ls, c o g n itiv e -b e h a v io ra l

fe a tu re s in th e c lie n t's e m o tio n a l sta te s and

th e ra p ie s in c o rp o ra te th ree co re e le m e n ts: (1)

th o u g h ts a n d in h e r e n v iro n m e n t th a t are h ig h ly

fu n ctio n a l a n a ly sis, (2) c o p in g sk ills tra in in g ,

a s s o c ia te d w ith s u b s ta n c e a b u se . T h is a llo w s

and (3) re la p se p re v e n tio n (R o tg e rs, 1996).

th e id e n tific a tio n o f s itu a tio n s th a t a re

p a rtic u la rly h ig h ris k fo r th e in d iv id u a l. In

Functional Analysis

a d d itio n , it is im p o r ta n t to d e te rm in e w h a t the

B eh a v io ra l, co g n itiv e , an d c o g n itiv e -b e h a v io ra l

p e rs o n th o u g h t, felt, a n d d id b o th d u rin g an d

tre a tm e n ts all re ly h e a v ily on an a w a re n e s s o f

a fte r h ig h -ris k s itu a tio n s . G a in in g in fo rm a tio n

the a n te ce d e n ts an d c o n s e q u e n c e s o f s u b sta n ce

a b o u t h ig h -ris k s itu a tio n s in w h ic h th e p e rso n

ab u se. In all o f th e se th e ra p e u tic a p p ro a c h e s,

d ra n k or u se d d ru g s an d th o se in w h ic h a

the c lie n t an d th e ra p is t ty p ica lly b e g in th e ra p y

re la p se cris is w a s e n c o u n te re d b u t a v e rte d is

b y co n d u ctin g a th o ro u g h fu n c tio n a l a n a ly sis o f

h e lp fu l in a s s e s s in g c o p in g a b ilitie s, s e lf-e ffica cy

su b sta n ce ab u se b e h a v io r (C a rro ll, 1 9 9 8 ; M o n ti

p e rc e p tio n s , s u b s ta n c e -re la te d e ffe ct

et al., 1994; R o tg e rs, 19 9 6 ). T h is a n a ly sis

e x p e c ta n c ie s, an d a ttrib u tio n a l p ro c e sse s.

a tte m p ts to id e n tify th e a n te ce d e n ts and

co n se q u e n ce s o f su b sta n c e a b u se b e h a v io r,

tre a tm e n t c a n n o t p ro c e e d a n d is lik e ly to fail

w h ich serv e as trig g e rin g an d m a in ta in in g

(R o tg ers, 1 9 9 6 ). T h is d e ta ile d a n a ly sis serv e s to

facto rs. A n te ce d e n ts o f u se ca n co m e fro m

in fo rm th e tre a tm e n t p ro c e s s a n d in d iv id u a liz e

e m o tio n a l, so cia l, c o g n itiv e , situ a tio n a l/

the sp e c ific in te rv e n tio n s a n d tre a tm e n t p la n fo r

e n v iro n m e n ta l, an d p h y s io lo g ic a l d o m a in s

the clie n t. T h e th e ra p is t a n d c lie n t ca n th e n u se

(M iller an d M a stria , 19 7 7 ). T h e fu n ctio n a l

th e re s u lts o f th e fu n c tio n a l a n a ly sis to

an aly sis sh o u ld a lso fo cu s on th e n u m b e r, ra n g e,

78

W ith o u t s u c h a th o ro u g h a s s e s s m e n t, C B T

B r ie f C o g n itiv e-B eh a v io ra l T herapy

a n ticip a te h ig h -risk situ a tio n s an d d ev elo p

sp e cific m e th o d s to a v o id or co p e w ith th em .
Q u e stio n n a ire s, in te rv ie w s , an d ro le -p la y in g
m e a su re s are a v a ila b le to a s s is t th e th e ra p is t in

A n u m b e r o f p u b lis h e d tre a tm e n t m a n u a ls
are a v a ila b le to g u id e s k ills tra in in g w ith
su b s ta n ce u se rs (C a rro ll, 1 9 9 8 ; K a d d e n e t al.,
1 9 9 2 ; M o n ti et a l., 19 8 9 ). T h e s e m a n u a ls p ro v id e

the a sse s s m e n t an d fu n ctio n a l a n a ly sis. T h e

a s e s s io n -b y -s e s s io n o v e rv ie w o f the

th e ra p ist sh o u ld try to e v a lu a te th e n u m b e r and

in te rv e n tio n . T h e m a te ria l c o v e re d in these

ty p e o f h ig h -risk s itu a tio n s, th e te m p ta tio n to

in te rv e n tio n s ca n b e c a te g o riz e d in to a n u m b e r

u se in th e se situ a tio n s , co n fid e n c e th a t o n e w ill

of b ro a d cla ss e s . T h e s k ills to b e ta u g h t are

n o t u se in h ig h -ris k s itu a tio n s , s u b s ta n c e a b u se-

e ith e r sp e c ific to s u b s ta n c e a b u s e (e .g ., co p in g

related se lf-e ffica c y , fre q u e n c y an d e ffe c tiv e n e s s

w ith cra v in g , re fu sin g an o ffe r o f a lc o h o l or

of co p in g , and s u b s ta n c e -s p e c ific e ffe ct

d ru g s) or a p p ly to m o re g e n e ra l in te rp e rso n a l

e x p e cta n cie s. M o re d e ta ile d in fo rm a tio n o n the

an d e m o tio n a l a re a s (e .g ., c o m m u n ic a tio n skills,

a sse ssm e n t p ro c e s s in c o g n itiv e -b e h a v io ra l

c o p in g w ith a n g e r or d e p re s s io n ). T h e y are

a p p ro a ch e s to su b s ta n c e a b u se an d its tre a tm e n t

e ith e r c o g n itiv e or b e h a v io ra l in n a tu re . Som e

is a v a ila b le in a n u m b e r o f s o u rc e s (D o n o v a n ,

m ig h t b e v ie w e d a s e ss e n tia l an d w o u ld be

1998; D o n o v a n an d M a rla tt, 1 9 8 8 ; M o n ti e t al.,

e x p e c te d to b e u sed fo r all c lie n ts , w h ile o th ers

1994; S o b ell et al., 1 9 8 8 ; an d S o b e ll et al., 1994).

w o u ld b e v ie w e d as m o re e le c tiv e in n a tu re and

For a re v iew o f a s s e s s m e n t to o ls th a t c a n be

w o u ld b e se le c te d fo r a p a rtic u la r in d iv id u a l

u sed in d e v e lo p in g a fu n c tio n a l a n a ly sis see T IP

b a se d on th e fu n c tio n a l a n a ly sis . T h e a b ility to

35, E n h an cin g M o tiv a tio n f o r C h a n g e in S u b sta n ce

in d iv id u a lly ta ilo r th e s k ills tra in in g to the

A b u se T reatm en t (C S A T , 1 999c).

Coping Skills Training

c lie n t's n e e d s re p re s e n ts o n e o f th e stre n g th s of

CBT.
F ig u re 4 -1 9 p re s e n ts a lis t o f se s s io n to p ics

A m a jo r c o m p o n e n t in c o g n itiv e -b e h a v io r a l

(M o n ti e t al., 1 9 8 9 ) w h ic h se rv e d as th e

th e rap y is th e d e v e lo p m e n t o f a p p ro p ria te

fo u n d a tio n fo r th e C B T d e liv e re d in P ro je ct

co p in g sk ills. D eficits in c o p in g s k ills a m o n g

M A T C H (M a tc h in g A lc o h o l T re a tm e n t to C lien t

su b sta n ce a b u se rs m a y b e th e re s u lt o f a n u m b e r

H e te ro g e n e ity P ro je c t) (K a d d e n et al., 19 9 2 ), a

o f p o ssib le fa cto rs (C a rro ll, 1 9 9 8 ). T h e y m ay

la rg e m u ltis ite s tu d y o f tre a tm e n t m a tc h in g

h av e n e v e r d e v e lo p e d th e se sk ills, p o ss ib ly

fu n d e d b y th e N a tio n a l In s titu te on A lco h o l

b eca u se the e a rly o n s e t o f s u b s ta n c e a b u se

A b u se an d A lc o h o lis m (N IA A A ). W h ile the

im p a ired the d e v e lo p m e n t o f a g e -s e n s itiv e

to p ics u se d in th is p a rtic u la r e x a m p le w ere

skills. P rev io u sly d e v e lo p e d c o p in g sk ills m ay

d e v e lo p e d fo r u se w ith c lie n ts w ith a lco h o l

h a v e b ee n c o m p ro m is e d b y an in cre a se d

a b u se d is o rd e rs , th e y a re e a sily a d a p te d to the

re lian ce on su b s ta n c e s u se as a p rim a ry m e a n s

n e e d s o f c lie n ts w h o a re a b u s in g o th er

o f co p in g . S o m e c lie n ts c o n tin u e to u se sk ills

s u b s ta n ce s.

th at are a p p ro p ria te a t a n e a rlie r ag e b u t a re n o

A c c o rd in g to C a rro ll, te a c h in g c o p in g sk ills

lo n g e r a p p ro p ria te or e ffe c tiv e . O th e rs h a v e

is th e co re o f C B T (i.e., h e lp in g c lie n ts re co g n iz e

ap p ro p ria te co p in g sk ills a v a ila b le to th e m b u t

the h ig h -ris k s itu a tio n s in w h ic h th e y are m o st

are in h ib ited fro m u sin g th em . W h a te v e r the

lik e ly to a b u s e s u b s ta n c e s a n d to d e v e lo p other,

o rig in o f the d e ficits, a p rim a ry g o a l o f C B T is to

m o re e ffe c tiv e m e a n s o f c o p in g w ith th em )

h elp the in d iv id u a l d e v e lo p an d e m p lo y c o p in g

(C a rro ll, 19 9 8 ). T h e th e ra p is t te a ch e s the clie n t

skills th a t e ffe ctiv e ly d ea l w ith th e d e m a n d s of

sp e cific b e h a v io ra l s k ills fo r fo rm in g an d

h ig h -risk s itu a tio n s w ith o u t h a v in g to re s o rt to

m a in ta in in g in te rp e rs o n a l re la tio n sh ip s . For

su b sta n ce s as an a lte rn a tiv e re sp o n se .

e x a m p le , a c lie n t m a y b e ta u g h t h o w to refu se a
79

C h ap ter 4

F ig u r e 4 -1 9
I n tr a p e r s o n a l a n d I n te rp e rs o n a l Skills T r a in in g E le m e n ts
Intrapersonal Skills

In terp erson al Skills

M a n a g in g th o u g h ts a b o u t su b sta n c e a b u se

R e fu sin g o ffe rs to d rin k o r u se d ru g s

P ro b le m so lv in g

S ta rtin g c o n v e rs a tio n s

D e cisio n m a k in g

U sin g b o d y la n g u a g e

R e la x a tio n tra in in g an d stre ss m a n a g e m e n t

G iv in g a n d re c e iv in g c o m p lim e n ts

B eco m in g a w a re o f a n g e r

A s s e rtiv e n e s s tra in in g

M a n a g in g a n g er

R e fu sin g re q u e sts

B eco m in g a w a re o f n e g a tiv e th in k in g

C o m m u n ic a tin g e m o tio n s

M a n a g in g n e g a tiv e th in k in g

C o m m u n ic a tin g in in tim a te re la tio n sh ip s

In cre a sin g p le a s a n t a c tiv itie s

G iv in g c ritic is m

P la n n in g fo r e m e rg e n c ie s

R e ce iv in g c ritic is m

C o p in g w ith p e rs is te n t p ro b le m s

R e ce iv in g c ritic is m a b o u t s u b s ta n c e a b u se

E n h a n c in g s o c ia l s u p p o rt n e tw o rk s

S ou rce: K a d d e n , 1995, a d a p te d fro m M o n ti et al., 1989.

d rin k in a so cia l s itu a tio n (w h ich m ig h t in clu d e

in v o lv e d in th e s e s s io n , th e th e ra p is t m o d e ls the

som e fo rm o f a s s e rtiv e n e ss tra in in g , as

e ffe c tiv e c o p in g sk ill fo r th e p a rtic u la r to p ic.

d escrib e d in F ig u re 4 -2 0 ). L ea rn in g h o w to

T h e th e ra p is t th e n a sk s th e c lie n t to p a rtic ip a te

d ev elo p n ew so cia l c o n ta c ts w ith p e o p le w h o

in a ro le -p la y in g s c e n a rio in w h ic h h e can

are n o t su b sta n c e a b u sers is a n o th e r e x a m p le .

re h e a rs e th e n e w c o p in g b e h a v io rs . T h e

S k ills tra in in g s e ssio n s fo llo w a re la tiv ely

s ta n d a rd iz e d fo rm a t. T h e c lie n t is g iv e n an

th e ra p is t p ro v id e s fe e d b a c k an d g u id a n c e w h ile
the c lie n t co n tin u e s in th e b e h a v io ra l re h e a rsa l.

o v erv iew o f th e se ssio n , d e scrib in g th e a rea to

B e tw e e n s e s s io n s , th e ra p is ts o fte n g iv e

be a d d resse d an d th e ra tio n a le fo r the sp e cific

h o m e w o rk a s s ig n m e n ts th a t p ro v id e th e clie n t

in te rv e n tio n to b e u sed . T h is is fa c ilita te d by

w ith an o p p o rtu n ity to try b e h a v io rs lea rn ed in

sk ill g u id elin es th a t fo cu s a tte n tio n on the m o st

s e ssio n s in re a l-life se ttin g s. T h e n e x t sessio n

im p o rta n t a sp e cts o f the a p p ro a c h as it ap p lie s

u su a lly b e g in s w ith a re v ie w o f th is h o m e w o rk

to s u b sta n ce a b u se. A fte r d isc u ssin g th e issu es

an d th e c lie n t's re a c tio n s to it.

F ig u r e 4 -2 0
A s s e r tiv e n e s s T ra in in g
T h e c lie n t is e n c o u ra g e d to d isc lo se an d e x p re ss e m o tio n s an d n e e d s, to sta n d up fo r h is rig h ts, to do
w h at is b e s t fo r h im se lf, and to e x p re s s n e g a tiv e e m o tio n s c o n s tru c tiv e ly . T h is is u se fu l fo r clie n ts w ith
su b sta n ce a b u se d is o rd e rs b e c a u se b e in g u n a b le to e x p re ss th e ir e m o tio n s an d n e e d s m a y lea d to relap se
A s a clie n t b e c o m e s m o re a sse rtiv e , h e w ill be b e tte r a b le to c o n tro l h is im p u ls iv e b e h a v io r as w e ll as the
e n v iro n m e n ta l fa c to rs th a t m a y lea d to re la p se . A sse rtiv e n e s s tra in in g is u s u a lly c o m b in e d w ith oth er
p s y ch o th e ra p y b e c a u se it re q u ire s a ch a n g e in a ttitu d e as w e ll as in b e h a v io r.

80

B r ie f C o g n itiv e-B eh a v io ra l T herapy

S k ills tra in in g a p p ro a c h e s h a v e b ee n

It is o fte n n e c e s s a ry to h e lp th e c lie n t ch a n g e the

e v a lu a te d m o re th an m a n y o th e r a p p ro a c h e s to

p a s s iv ity a n d se n se o f h e lp le s s n e s s th a t o ften

su b sta n ce a b u se d iso rd e rs. M o n ti and

a c c o m p a n y lo w s e lf-e ffic a c y . B a n d u ra n o ted

co lle a g u es e v a lu a te d a c o p in g s k ills tra in in g

th a t th e re a re a n u m b e r o f w a y s to in c re a se self-

in te rv e n tio n fo r c o c a in e -d e p e n d e n t clie n ts

e ffic a c y (B a n d u ra , 1 9 7 7 ). H o w e v e r, th e m o d e l

(M o n ti et al., 1997). A c o c a in e -s p e c ific sk ills

th a t a p p e a rs to h a v e th e g re a te s t im p a c t an d

train in g in te rv e n tio n , a d m in is te re d as

la stin g in flu e n c e u ses th e id e a o f p e rfo rm a n c e

in d iv id u a l c o u n s e lin g , w a s a d d e d to a m o re

a c c o m p lis h m e n ts to e n h a n c e c lie n t self-e ffic a cy .

c o m p re h e n siv e tre a tm e n t p ro g ra m a lo n g w ith a

In th is m o d e l, th e c lie n t is c o a c h e d to d o

p laceb o co n tro l. T h e a p p ro a c h in v o lv e d the

s o m e th in g th a t sh e p re v io u s ly w a s u n a b le to do.

id e n tifica tio n o f h ig h -risk s itu a tio n s b a se d on a

A n n is an d D a v is u se g ra d u a te d h o m e w o rk

fu n ctio n a l a n a ly sis an d th e te a c h in g o f co p in g

a ss ig n m e n ts to h e lp in th is p ro c e s s (A n n is and

skills to d ea l w ith th e se situ a tio n s. In

D a v is, 1 9 8 8 b ). T h e c lie n t g ra d u a lly e x p o se s

co m p a riso n to th e co n tro l c o n d itio n , clie n ts w h o

h e rs e lf to in c re a sin g ly d iffic u lt s itu a tio n s w ith

receiv ed in d iv id u a liz e d c o p in g sk ills tra in in g

g re a te r re la p se risk b u t d o e s so w ith o u t u sin g.

h ad sig n ifica n tly fe w e r d a y s o f co c a in e u se and

T h e ra te o f th e e x p o s u re is c a lc u la te d to b e at a

sig n ifica n tly sh o rte r p e rio d s o f b in g e u se of

lev el th a t ca n b e h a n d le d b y th e c lie n t. T h e

co ca in e o v er a 3 -m o n th fo llo w u p p e rio d .

a c c o m p lis h m e n t o f th e se h o m e w o rk ta sk s serv e s

A lth o u g h the tw o g ro u p s d id n o t d iffe r in th eir

as a p o in t o f d is c u s s io n to re in fo rc e the clie n t's

rates o f re la p se , th e p a tte rn o f u se an d the h a rm

g ro w in g se n se o f s e lf-e ffic a c y .

a sso cia ted w ith it c le a rly fa v o re d th e sk ills

train in g co n d itio n .

Relapse Prevention

T h e th e ra p is t p ra c tic in g C B T w ill a lso

c h a lle n g e th e a ttrib u tio n a l p ro c e s s and
e m o tio n a l a fte rm a th o f a re la p se . If a slip
o ccu rs, th e th e ra p is t s h o u ld try to b rin g the

T h e third co re e le m e n t o f C B T is re la p se

m o re n e g a tiv e a ttr ib u tio n s fo r re la p se (in tern al,

p re v e n tio n . W h ile th e re a re a n u m b e r o f

sta b le , an d g e n e r a liz e d ) to th e c lie n t's a tte n tio n

d iffe ren t m o d e ls o f re la p se (D o n o v a n and

so th a t h e c a n id e n tify th e se te n d e n c ie s and

C h a n ey , 1985), the tw o b e s t a rtic u la te d w ith in

le a rn h o w to c h a n g e th e m . C lie n ts ca n be

the c o g n itiv e -b e h a v io ra l m o d e l are th o se

h e lp e d to see th e re la p s e as c a u se d b y a la ck of

p re sen ted b y A n n is an d D a v is an d M a rla tt and

a p p ro p ria te c o p in g s k ills fo r th e p a rtic u la r

G o rd o n (A n n is an d D a v is, 1 9 8 8 b ; M a rla tt and

s itu a tio n (i.e., e x te rn a l), a lte r a b le w ith tra in in g

G o rd o n , 1985). R e la p se p re v e n tio n a p p ro a ch e s

or p ra c tic e (i.e., u n sta b le ), an d n o t im p ly in g that

rely h e a v ily on fu n c tio n a l a n a ly se s,

e v e ry th in g th e p e rs o n d o e s is w ro n g (i.e.,

id e n tifica tio n o f h ig h -risk re la p se s itu a tio n s, and

sp e c ific ). T h is c h a n g e in p e rs p e c tiv e w ill h e lp

co p in g sk ills tra in in g , b u t a lso in c o rp o ra te

re d u c e th e c lie n t's se n se o f h e lp le s sn e s s an d loss

a d d itio n a l fe a tu re s. T h e s e a p p ro a c h e s a tte m p t

o f co n tro l. A d d re s s in g th e a ttrib u tio n a l p ro cess

to d eal d irectly w ith a n u m b e r o f the c o g n itio n s

sh o u ld b e d o n e in th e b ro a d e r c o n te x t of

in v o lv e d in th e re la p se p ro c e ss an d fo cu s on

e d u c a tin g th e c lie n t a b o u t th e re la p se p ro cess.

h elp in g the in d iv id u a l g a in a m o re p o sitiv e selfefficacy .

A lth o u g h se lf-e ffic a cy is re la ted to the

R e se a rc h h a s c o n s is te n tly s h o w n th a t p e o p le
w h o e x p e c t m o re p o s itiv e e ffe c ts fro m
su b s ta n c e s a re m o re lik e ly to a b u se th em

a v ailab ility of co p in g sk ills and w o u ld be

(B ro w n , 1 9 9 3 ; G o ld m a n a n d R a th e r, 1993). It

exp e cte d to in cre a se as th e c lie n t le a rn s new

h a s a lso b e c o m e c le a r m o re re c e n tly that

skills, th is d o es n o t a lw a y s o c c u r sp o n ta n e o u sly .

in d iv id u a ls w h o a re a w a re o f an d c o n c ern e d
81

C h ap ter 4

a b o u t the m o re n e g a tiv e c o n se q u e n c e s

a lco h o l. C h a lle n g in g s o c ia l b e lie fs a b o u t the

asso cia ted w ith su b s ta n c e a b u se a re less lik e ly to

e ffe c ts o f a s u b s ta n c e m a y a lte r its use.

u se (Jo n e s an d M c M a h o n , 19 9 6 ). T h e re a re also
s ig n ifica n t d iffe re n c e s in the w a y m e n and

in fo rm a tio n in th e ra p y is to h a v e th e c lie n t

w o m e n re a ct to e x p e c ta n cie s c o n c e rn in g

c o n s id e r b o th th e p o sitiv e a n d n e g a tiv e e ffe cts

su b sta n ce s; m a les a re m o re a ffe c te d b y p o sitiv e

o f th e s u b s ta n c e . M a n y c lie n ts h a v e a u to m a tic

e x p e cta n cie s, w h e re a s th e p o sitiv e e x p e c ta n c ie s

s c rip ts lik e " I 'll fe e l m o re re la x e d if I d rin k "

of fe m a les are m o re b a la n c e d b y n e g a tiv e

w ith o u t c o n s id e rin g o th e r s c e n a rio s , lik e: " I 'll

e x p e cta n cie s (R o m a c h an d S e lle rs, 1998).

T h e th e ra p is t ca n w o rk to ch a lle n g e a c lie n t's

d rin k to o m u c h . I 'll h a v e a fig h t w ith m y

g irlfrie n d , a n d th e n I'll s le e p in a n d n o t go to

p o sitiv e e x p e c ta n c ie s a b o u t the e ffe c ts of

c la s s ." T h e th e ra p is t h e lp s th e c lie n t

su b sta n ce s. T h e re a re tw o s tra te g ie s th a t the

a c k n o w le d g e th a t th e o th e r c o n s e q u e n c e s e x ist

th e ra p ist ca n u se c o n c e rn in g e x p e c ta n c ie s in

a n d a re n o t b e in g a tte n d e d to. It is p o ss ib le to

o rd er to d ecre a se su b sta n c e a b u se: ch a n g e th e

u se a d e c is io n a l b a la n c e p ro c e d u re in this

clie n t's b e lie f in th e p o sitiv e e ffe c ts o f the

p ro c e s s , w h e re in th e c lie n t is a sk e d to list all the

su b sta n ce or g e t h e r to p a y m o re a tte n tio n to h er

p o sitiv e an d n e g a tiv e th in g s a s s o c ia te d w ith

k n o w le d g e an d e x p e rie n c e o f its n e g a tiv e

d ru g u se. B y a c k n o w le d g in g th e s u b s ta n c e 's

effects.

p o sitiv e e ffe cts , th e th e ra p is t g a in s c re d ib ility

For a lo n g tim e , re se a rc h e rs d id n o t b elie v e

a n d re d u c e s re s is ta n c e fro m th e clie n t. T h e

th at p o sitiv e e x p e c ta n c ie s co n c e rn in g su b sta n c e

c lie n t ca n m o re e a sily a c k n o w le d g e th e n e g a tiv e

e ffe cts co u ld b e ch a n g e d , b u t a stu d y o n h e a v y -

a s p e c ts o f s u b s ta n c e a b u s e a n d m a k e th o se

d rin k in g c o lle g e stu d e n ts sh o w e d th a t

b e lie fs m o re sa lie n t. T h is te c h n iq u e is a

ex p e cta tio n s re g a rd in g a lc o h o l e ffe cts co u ld be

m a in s ta y o f m o tiv a tio n e n h a n c e m e n t th e ra p ie s

altered (D a rk e s an d G o ld m a n , 19 9 3 ). In g ro u p

th a t a re la rg e ly c o g n itiv e in n a tu re (M ille r and

sessio n s, s e v e ra l te c h n iq u e s w e re u sed to m a k e

R o lln ick , 1 9 9 1 ). (T IP 3 5 , E n h a n cin g M otiv ation f o r

the stu d e n ts a w a re th a t s o m e o f th e ir a lco h o l-

C h a n g e in S u b sta n c e A b u se T rea tm en t [C S A T ,

related e x p e c ta n c ie s w e re fa lse. F o r e x a m p le ,

1 9 9 9 c], g iv e s m o re d e ta ile d in fo r m a tio n o n th ese

the h e a v y -d rin k in g c o lle g e stu d e n ts w e re told

a p p ro a c h e s.)

th at th e b e v e ra g e s th e y w e re d rin k in g co n ta in e d

82

A n o th e r w a y to u se s u b s ta n c e e x p e cta n cy

R e la p s e p re v e n tio n a lso s tre s se s th e

a lco h o l, b u t th e y w e re a ctu a lly g iv e n

im p o rta n c e o f p re p a rin g fo r th e p o ss ib ility o f a

n o n a lco h o lic d rin k s, d isg u ise d to lo o k , sm ell,

re la p se a n d p la n n in g w a y s to a v o id it or, fa ilin g

and e v e n ta ste lik e a lco h o l. T h e y th e n en g a g ed

th is, sto p th e p ro c e s s q u ic k ly an d w ith m in im a l

in g ro u p p a rty g a m e s, in w h ich m o st d isp la y ed

h a rm w h e n it d o e s o c c u r. C lie n ts a re so m e tim e s

th e u n in h ib ite d b e h a v io r th a t is a sso c ia te d w ith

a p p re h e n s iv e a b o u t ta lk in g so d ire ctly a b o u t the

alco h o l in to x ic a tio n . L a te r, w h e n th ey w e re told

p o ss ib ility o f re la p se . T h e th e ra p is t ca n h elp

th at th eir b e v e ra g e s w e re a c tu a lly p la ce b o s, they

d isp e l th e se c o n c e rn s b y u sin g an a n a lo g y o f fire

w e re su rp rise d . G ro u p d is cu ss io n an d o th er

d rills. H a v in g a d rill an d b e in g p re p a re d fo r a

in fo rm a tio n on p la c e b o e ffe c ts a ltered th eir

fire d o e s n o t n e c e s s a rily m e a n th a t a fire w ill

p e rce p tio n s o f the p o sitiv e e ffe c ts o f a lco h o l. A

o ccu r. H o w e v e r, if o n e d o e s, it w ill b e p o ssib le

s ig n ifica n t d e cre a se in a lc o h o l c o n s u m p tio n w as

to g e t o u t o f th e s itu a tio n w ith o u t g e ttin g

n o ted in th is g ro u p a fte r th e in te rv e n tio n ,

b u rn e d . It is h e lp fu l to h a v e v e ry c o n c re te

co m p a re d to a co n tro l g ro u p th a t re ce iv e d

e m e rg e n c y p la n s , in c lu d in g th e p h o n e n u m b e rs

co n v e n tio n a l in fo rm a tio n on th e e ffe cts of

o f in d iv id u a ls s u p p o rtiv e o f th e c lie n t's re c o v e ry

B r ie f C o g n itiv e-B eh a v io ra l T herapy

p ro cess. In clu d in g fa m ily m e m b e rs in the

W hen I lo o k a t m y track record, I don 't

p lan n in g p ro ce ss is im p o rta n t b e ca u se th e y are

see m u ch o f a fu tu r e .

often b e tte r ab le th a n th e c lie n t to see th e

T h e ra p is t:

I w o u ld n 't g iv e up h o p e yet. W e'll w ork

to g eth er to h elp y o u g e t a b etter look at

w arn in g sig n s o f an im p e n d in g re la p se .

y o u r co ca in e use, so m e o f the thin gs

R e lap se p re v e n tio n a lso s tre s se s the

d e v e lo p m e n t o f a m o re b a la n c e d an d h e a lth ie r

th at trig g er it, a n d so m e o f the ben efits

life sty le. M a rla tt an d G o rd o n p o sit th a t on e

y ou th in k y ou g e t fr o m it. S om etim es

so u rce o f p o ss ib le re la p se risk h a s to d o w ith the

by lo o k in g a t y o u r use fr o m a differen t

d eg ree o f stre ss or d a ily h a ssle s th a t th e clie n t

p ersp ectiv e, y ou can h elp p u t it into

ex p e rien ces (M a rla tt an d G o rd o n , 19 8 5 ). T h ey

co n tex t a n d th in g s d on 't seem so

su g g e st th at w h en th e d e m a n d s an d o b lig a tio n s

h op eless. N o w w h y d on 't y ou tell m e

a clie n t fe e ls (" s h o u ld s " ) o u tw e ig h the p le a s u re s

a b o u t h o w y o u slip p ed a n d started

the in d iv id u a l ca n e n g a g e in (" w a n ts " ), th e n h is

u sin g a fte r y o u r last tim e in treatm en t.

life is o u t o f b a la n ce . T h is o fte n re su lts in

W hat w as g o in g on in y o u r life? W hat

fe e lin g s o f d e p riv a tio n a n d re s e n tm e n t. In

w ere y ou fe e lin g ? W hat w ere you

th in k in g a b o u t y o u r s e lf a n d y o u r life?

re sp o n se to th e se fe e lin g s, th e in d iv id u a l co u ld
b eg in m a k in g d e cisio n s th a t g ra d u a lly lea d

C lien t:

W ell, w h en I g o t ou t I still h a d som e

to w ard p o ssib le re la p se . T h e g o a l is to h elp the

d ou b ts a b o u t w h eth er I w ou ld m ake it

in d iv id u a l fin d a b e tte r b a la n c e , in c re a sin g

o r not. I m ean I f e l t b etter a b o u t m yself,

in v o lv e m e n t in p le a s a n t an d re w a rd in g

bu t th ere w as still a lot o f cra p g o in g on

activ itie s w h ile re d u c in g th e le v e l an d s o u rc e s of

in m y life. I h a d bills to pay. M y

stress.

re la tio n sh ip w as fa llin g ap art. I w as

still b ein g h a ss led by m y p rob ation

A Case Study Using CBT

officer. I w as fe e lin g k in d o f

T h e fo llo w in g ca se stu d y in v o lv e s a y o u n g m a le

ov erw h elm ed . H e re I th o u g h t I w ou ld

co cain e u ser w h o h a s s o u g h t o u tp a tie n t

w a lk o u t o f th ere a n ew m an , bu t I

treatm en t. It re fle c ts in te ra ctio n s e a rly in the

w a lk ed ou t w ith a ll the sa m e p roblem s.

co u rse o f the s e ssio n an d is m e a n t to d e p ic t

T h e ra p is t:

W as th ere a n y tim e a fter treatm en t

so m e o f the q u e stio n s th e th e ra p is t c o u ld a sk to

w hen y ou f e l t y ou co u ld h an d le all the

g ain in fo rm a tio n a b o u t th e a n te c e d e n ts,

p ro b lem s fa c in g y ou ?

co n se q u e n ce s, an d co g n itiv e m e d ia to rs in v o lv e d

C lien t:

in h is use.
T h e ra p ist:

d ep ressed . I m ean y ou g o throu gh

trea tm en t, a n d this s t u ff sh ou ld n 't be

So, can you tell m e a b ou t y o u r co cain e

h ap p en in g .

use a n d w h y y ou a re co m in g to
treatm en t now ?
C lien t:

W ell, f o r a w h ile, then I sta rted to fe e l

T h e ra p is t:

all?

W ell, I fin a lly ca m e to the en d o f m y

rope. I kep t u sin g even th ou g h I d id n t
w an t to, an d I fe lt that I w as n oth in g
but a ju n k ie w h o h a d no fu tu r e . It's
ju s t hopeless.

T h e ra p ist:

W hat m akes y ou sa y that?

C lient:

W ell, I ju s t can 't stop using. E ven

w hen I've g o n e th rou g h treatm en t in

W hat d id y ou try to d o to d ea l w ith it

C lien t:

A t fi r s t I th o u g h t I w o u ld g e t m y s e lf
o rg a n iz ed a n d g e t a p lan . B u t it didn 't
w ork. As m u ch as I tried, I cou ldn 't
fig u r e o u t a w a y to p u t a ll this s t u ff in
its p la c e a n d h a n d le it. So I ju s t threw
up m y h a n d s a n d said , "S crew it!" I
f e l t lik e th e best th in g to d o w as to p u ll

the p ast, I en d up u sin g in no tim e.

83

C h ap ter 4

the blan kets o v er m y h ead an d h op e that

e v e ry th in g th at h ad h a p p en ed to m e an d

it w ou ld a ll blow over.

w as n ot su re ivhat I w as g o in g to do.

T h erap ist:

So, d id it blow over?

M y fr ie n d p u lled o u t so m e c ok e an d

C lient:

No. T h in g s ju s t k ep t g ettin g w orse. I

a sk ed i f I'd lik e som e. I ju s t kept

cou ld n 't p a y m y bills. M y relation sh ip

th in k in g o f h o w lou sy I fe lt an d how

w as g on e, an d I g o t bo o ted ou t o f m y

g o o d I w o u ld fe e l i f I used. So I said

ap artm en t.

y ea h , w h y not.

T h e ra p ist:

A s a ll this ivas h a p p en in g , d id you

th in k abo u t u sin g cocain e?

C lient:

You bet I d id ! I k ep t th in kin g , "D am n,

it su re w ou ld fe e l g o o d to g et all this o ff
m y m in d ." A n d I kn ew th at i f I used
c o k e it w ou ld all g o a w a y at least f o r a
w hile.

T h e ra p ist:

So, as y ou th o u g h t a b ou t the cocain e,

w h at p o sitiv e th in g s d id y ou th in k you
w ou ld fe e l i f y ou used?

C lient:

I kn ew I'd fe e l a ru sh, I'd fe e l dam n

g o o d a n d I'd ju s t fo r g e t. I co u ld g et
ou t o f the d ep ression a n d fu n k I'd been
in. I w as ju s t lo o k in g to fe e l better.

T h e rap ist:

D id y ou th in k o f a n y n eg a tiv e things
abo u t usin g?

C lient:

Y eah. I a lw ay s seem to crash a fter

using. So I lo se the h ig h a n d fin d
m y s e lf so m etim es even m ore d ep ressed
than before. B ut th at did n 't seem to
b o th er me. I m w illin g to p u t up w ith it
f o r a w hile. I'll take th e h ig h a n y day.
It lets m e g e t a w a y fr o m a ll this crap
at least f o r a w hile.

T h e rap ist:

So w h at w ere the circu m sta n ces o f y o u r

sta rtin g to use ag ain ?

C lient:

W ell, like I said, I g o t booted fr o m m y

ap artm en t. A n d I cou ld n 't g o stay w ith
m y g irlfrien d sin ce sh e b ooted m e too.
So I h ad to fin d a p la c e to stay. I called
an old fr ie n d w h o said I cou ld stay at
his p la c e f o r a w hile. W e u sed to d o a lot
o f d ru g s together. I kn ew h e m ight not
be the best p erson to be sta y in g w ith,
bu t h e w as the on ly o n e I fe lt w ou ld pu t
up w ith me. So, I m ov ed in. I w as
fe e lin g p re tty low , th in k in g ab o u t

84

In th is ca se stu d y , it is c le a r th a t the c lie n t has

a low se n se o f s e lf-e ffic a c y p re d ic a te d in p a rt by
h is p a st tre a tm e n t fa ilu re s an d h is in a b ility to
co p e w ith d iffic u lt s itu a tio n s . A s a re su lt, he
fe e ls d e p re s s e d an d h e lp le ss. H e m a k e s a h a lf
h e a rte d a tte m p t a t p ro b le m s o lv in g b u t fails in
th is a tte m p t. T h e n h e s w itc h e s to p a ssiv e a v o id a n t a p p ro a c h e s in o rd e r to co p e (e.g .,
p u llin g the b la n k e t o v e r h is h ea d an d h o p in g it
w ill all b lo w a w a y ). H is d e p re s s io n co n tin u e s
u n a b a te d as th e d a ily h a s s le s m o u n t. T h e
p o sitiv e e x p e c ta n c ie s h e h a s a b o u t c o c a in e as the
" m a g ic e lix ir " a re q u ite s tro n g an d se e m to
o u tw e ig h p o te n tia l n e g a tiv e c o n s e q u e n c e s . H is
s itu a tio n a l c o n te x t c o n ta in s tw o h ig h -risk
situ a tio n s. T h e first is th e n e g a tiv e m o o d states
th a t h e e x p e rie n c e s , w h e n h e h a s a b u sed
s u b s ta n c e s in th e p a st. T h e se c o n d is the
in d ire c t so c ia l p re s s u re in v o lv e d in re tu rn in g to
a s ettin g th a t h a d b e e n a s s o c ia te d w ith
s u b s ta n c e a b u se in h is p a st. T h e re is a lso the
p ro x im a l in flu e n c e o f th e d ir e c t so cia l p re ssu re
to u se fro m h is frie n d . T h e lik e lih o o d o f re lap se
w a s h ig h , a n d , in fa ct, re la p se o ccu rre d .
T h e th e ra p is t in th is ca se m ig h t c o n sid e r
u sin g s k ills tra in in g th a t fo c u s e s on
p ro b le m s o lv in g , s tre ss m a n a g e m e n t to a lle v ia te
h is d e p re s s io n , d e v e lo p in g c o m m u n ic a tio n
sk ills, p ra c tic in g s u b s ta n c e re fu sa l sk ills, and
d e v e lo p in g a s o c ia l s u p p o rt n e tw o rk . T h e
th e ra p is t s h o u ld ta rg e t b o th th is c lie n t's low selfe ffic a c y an d his p o sitiv e c o c a in e -e ffe c t
e x p e c ta n c ie s. C le a rly the fu ll in te rv e n tio n p lan
w o u ld re q u ire fu rth e r a s s e s s m e n t an d a
fu n c tio n a l a n a ly sis ; h o w e v e r, a d ire c tio n fo r
fu rth e r tre a tm e n t ca n a lre a d y b e se e n in this
b rie f in te rch a n g e .

B r ie f C o g n itiv e-B eh a v io ra l T herapy

Duration of Therapy and

Frequency of Sessions

th o u g h th e s e c rite ria w e re d e riv e d fro m co ca in e

T w o a d v a n ta g e s o f C B T are th a t it is re la tiv ely

u sin g o th e r su b s ta n c e s.

u se rs, th ey a p p e a r to b e a p p lic a b le to clie n ts

W h ile re lia n c e o n th e re s u lts o f th e fu n ctio n a l

b rie f in d u ra tio n an d q u ite fle x ib le in

im p le m e n ta tio n . C B T ty p ic a lly h a s b e e n o ffe red

a n a ly sis m a k e s s k ills tra in in g p a rtic u la rly w ell

in 12 to 16 se ssio n s, u s u a lly o v e r 12 w e e k s

su ite d fo r in d iv id u a l th e ra p y , th ese

(C arro ll, 1998). T h e fo rm o f C B T u sed in

in te rv e n tio n s c a n e a sily b e a d a p te d fo r u se in

N IA A A 's P ro je c t M A T C H (K a d d e n e t al., 1992)

g ro u p s e ttin g s (M o n ti e t al., 1 9 8 9 ). S im ila rly ,

co n siste d o f 12 s e ssio n s, a d m in is te re d as

th e y ca n b e u se d w ith in p a tie n ts or o u tp a tie n ts

in d iv id u a l th e ra p y , m e e tin g o n ce p e r w eek . T h e

an d ca n b e a d m in is te re d as p a rt o f an in te n siv e

sessio n s in clu d e d e ig h t " c o r e " s e ssio n s th a t

p h a se o f tre a tm e n t o r as p a rt o f less in te n siv e

d ealt w ith a lco h o l-re la te d issu es (e.g ., co p in g

a fte rc a re or c o n tin u in g ca re . C B T is also

w ith cra v in g , d rin k re fu sa l, re la p se e m e rg e n c y

c o m p a tib le w ith a n u m b e r o f o th e r e le m e n ts in

p la n n in g ) and g e n e ra l p ro b le m -s o lv in g sk ills

tre a tm e n t an d re c o v e ry , ra n g in g fro m

th a t all clie n ts w e re e x p e cte d to re c e iv e , an d fo u r

in v o lv e m e n t in se lf-h e lp g ro u p s to

" e le c tiv e " to p ic a re a s c h o se n fro m a m e n u of

p h a r m a c o th e ra p y (C a rro ll, 19 9 8 ).

m o re g e n e ra l so cia l an d in te rp e rs o n a l issu es
b ase d on in d iv id u a lly a ssesse d p ro b le m areas.
A 1 2 -se ssio n C B T fo r co ca in e a d d ic ts su g g e ste d

Efficacy for Treating Substance

Abuse Disorders
In c o n tra s t to m a n y o th e r th e ra p ie s, c o g n itiv e -

th at th is len g th o f tre a tm e n t is s u ffic ie n t to

b e h a v io ra l th e ra p y fo r th e tre a tm e n t of

a ch iev e and sta b iliz e a b stin e n c e fro m co ca in e

s u b s ta n c e a b u s e d is o r d e rs h a s su b sta n tia l

(C arro ll, 1998). H o w e v e r, n o t all clie n ts w ill

re s e a rch e v id e n c e in s u p p o rt o f its e ffe ctiv e n e ss.

re sp o n d in th a t a m o u n t o f tim e. In su ch ca ses,

T h e re s e a rc h fin d in g s o n th e u se o f co p in g

an in itial trial C B T c a n serv e as p re p a ra to ry to a

sk ills tra in in g w ith a lc o h o l- a n d co ca in e -

m o re in te n siv e tre a tm e n t e x p e rie n ce .

d e p e n d e n t c lie n ts in d ic a te th a t th is s tra te g y has

When To Use C ognitiveBehavioral Therapy

s tro n g e m p iric a l s u p p o rt. A re v ie w o f o u tco m e

V a rie tie s o f c o g n itiv e -b e h a v io ra l th e ra p y are

p re v e n tio n in te rv e n tio n s in d ic a te s th a t the

ap p lica b le to a w id e ra n g e o f su b s ta n ce a b u sers.

s u p p o rt fo r re la p se p re v e n tio n is m o re e q u iv o ca l

s tu d ie s e v a lu a tin g th e e ffic a c y o f re la p se

T h e o u tp a tie n t C B T p ro g ra m d e v e lo p e d b y

(C a rro ll, 1 9 9 6 b ). R e la p s e p re v e n tio n w a s fo u n d

C a rro ll fo r co ca in e u se rs e x c lu d e d a n u m b e r of

to b e s u p e rio r to n o tre a tm e n t, b u t th e resu lts

d iffe re n t clie n ts as in a p p ro p ria te fo r th a t fo rm of

h a v e b e e n less c o n s is te n t w h e n it is c o m p a re d to

tre a tm e n t (see F ig u re 4 -2 1 ). H o w e v e r, e v e n

v a rio u s c o n tro l c o n d itio n s o r to o th e r a ctiv e

F ig u r e 4-21
T y p e s o f C lie n ts fo r W h o m O u tp a tie n t C B T Is G e n e r a lly N o t A p p r o p r ia te

T h o se w h o h a v e p s y c h o tic or b ip o la r d is o rd e rs an d a re n o t s ta b iliz e d o n m e d ic a tio n

T h o se w h o h a v e n o sta b le liv in g a rra n g e m e n ts

T h o se w h o are n o t m e d ic a lly sta b le (as a sse sse d b y a p re tre a tm e n t p h y s ic a l e x a m in a tio n )

T h o se w h o h a v e co n c u rre n t s u b s ta n ce d e p e n d e n c e d iso rd e rs, w ith th e p o s s ib le e x c e p tio n o f a lco h o l or

m a riju a n a d e p e n d e n c e

Sou rce: C a rroll, 1998.

85

C hapter 4

tre a tm e n ts. T h e re a re s o m e o u tc o m e s on w h ich

re la p se p re v e n tio n m a y h a v e c o n sid e ra b le
im p a ct (C arro ll, 1 9 9 6 b ); fo r in sta n ce, a lth o u g h

u sed w ith a w id e ra n g e o f su b s ta n c e a b u se rs,

n o t n e ce ssa rily re d u c in g th e ra te o f re la p se ,

an d ca n b e co n d u c te d w ith in th e tim e fra m e o f

clie n ts tre ate d in re la p se p re v e n tio n a p p e a r to

b rie f th e ra p ie s.

h av e less se v e re re la p se s w h e n th e y o ccu r.

86

O v e ra ll, b e h a v io ra l, c o g n itiv e , an d cognitiveb e h a v io ra l in te rv e n tio n s a re e ffe c tiv e , ca n be

5 Brief Strategic/Interactional
Therapies

trategic/interactional therapies attempt to

All of these models stem in part from the work of

identify the client's strengths and actively

Milton Erikson. He coined the term strategic therapy

create personal and environmental

situations where success can be achieved. In these

therapies, the focus is on the individual's strengths
rather than on pathology, the relationship to the
therapist is essential, and interventions are based on
client selfdetermination with the community serving as
a resource rather than an obstacle. This model has been
widely used and successfully tested on persons with

to describe an approach in which the therapist takes

responsibility for finding new and effective strategies
to help clients in distress. Jay Haley, John Weakland,
and other theorists of the Mental Research Institute
(MRI) consulted with Erikson as they expanded on
his theoretical approach.
More recently, Steve De Shazer and his colleagues,

serious and persistent mental illnesses (Rapp and

who were influenced by the MRI approach, shifted

Wintersteen, 1989; Saleebey, 1996; Solomon, 1992). It

the focus of treatment from problems to solutions,

has also been used with persons who have problems

calling their modality solution-focused therapy. Their

related to substance abuse (Juhnke and Coker, 1997;

approach, originally developed to work in brief

Miller and Berg, 1991; Ratner and Yandoli, 1996;

marriage and family therapy, has since been used in a

Watzlawick et al., 1967). Although the research to date

variety of situations for a variety of presenting

on these therapies (using nonexperimental designs) has

problems, including substance abuse disorders. (See

not focused exclusively on substance abuse disorders,

Chapter 8 for more information on the application of

the use of these therapies in treating substance abuse

all these therapies to the treatment of families.)

disorders is growing.
Many different theoretical approaches have
strategic or interactional roots. They can be
distinguished from each other primarily by the
different emphasis and value they place on
components of the change process. Therapists rarely
follow a single theoretical approach strictly; therapists
today influence and learn from each other,
incorporating what they find useful into their own
work.

Interactional therapy is based on the assumption

that problems can best be understood by examining
clients' (often dysfunctional) interactions with others
and their resulting problems. Strategic therapy is a
form of interactional therapy because it does not focus
on the root causes of the client's problems but instead
tries to increase competency and develop problemsolving skills that will help the client in her
interactions with others. For the

C h ap ter 5

p u rp o se o f th is d isc u ssio n , h o w e v e r, the

fo cu se d th e ra p is ts (Ig u ch i et al., 19 9 7 ). T h e

c o m b in e d te rm stra teg ic/in tera ctio n a l th erap y is

s o lu tio n -fo c u s e d th e ra p is t b e lie v e s th a t h e lp in g

u sed . T h is b ro a d e r term a llo w s s o lu tio n -

clie n ts w ith s u b s ta n c e a b u se d is o rd e rs to

fo cu sed th e rap y , w h ich is c e rta in ly in te ra c tio n a l,

a d d re ss an y life p ro b le m s th e y fin d s ig n ific a n t

to be in clu d e d in th is sectio n . A lth o u g h it h a s a

w ill h e lp th e m to re d u c e th e ir s u b s ta n c e use.

stro n g k in sh ip w ith stra te g ic a p p ro a ch e s, n o t all

W h a t is im p o r ta n t is fin d in g a s o lu tio n to the

p ra ctitio n e rs c o n sid e r s o lu tio n -fo c u s e d th e ra p y

p ro b le m s th e c lie n t id e n tifie s as sig n ific a n t, th en

to b e "s tr a te g ic ."

re in fo rc in g th e c lie n t's s u c c e s s in so lv in g th o se

T h e sig n ific a n c e o f th e se d iffe re n t

p ro b le m s. T h is p ro c e d u re h e lp s th e c lie n t to

a p p ro a ch e s ca n b e fo u n d in th e ir p re s e n ta tio n of

re c o g n iz e h e r o w n a b ility to s o lv e h e r p ro b lem s.

an a lte rn a tiv e a p p ro a ch to u n d e rsta n d in g h ow

T h e stu d y b y Ig u c h i a n d c o lle a g u e s co m p a re d

su b sta n ce a b u se d iso rd e rs e v o lv e an d h ow n ew

the ro le o f u rin e te stin g , tra d itio n a l su b sta n ce

in n o v a tiv e so lu tio n s co u ld b e g e n e ra te d to a ssist

a b u se c o u n s e lin g se rv ic e s , an d th e

w ith the re so lu tio n o f th ese p ro b lem s.

re in fo rc e m e n t o f n o n s u b s ta n c e -u s e -r e la te d

T h e C o n se n su s P a n e l b e lie v e s th a t th ese

p o sitiv e life c h a n g e s an d fo u n d th a t the latte r

th e ra p e u tic a p p ro a c h e s a re p o te n tia lly u se fu l fo r

re su lte d in th e m o s t s ig n ific a n t re d u c tio n in

clie n ts w ith s u b s ta n c e a b u se d is o rd e rs and

s u b s ta n c e u se e v e n a fte r re in fo rc e m e n t

sh o u ld b e in tro d u ce d to o ffe r n e w k n o w le d g e

c o n tin g e n c ie s e n d ed .

and te ch n iq u es fo r tre a tm e n t p ro v id e rs to

T h e s o lu tio n -fo c u s e d th e ra p y m o d e l h a s b ee n

c o n sid er. T h is c h a p te r p re s e n ts on e

u sed to re s p o n d to a ra n g e o f p ro b le m s and

s tra te g ic/ in te ra c tio n a l a p p ro a c h , s o lu tio n -

c o m p la in ts . R e se a rc h e rs B erg a n d M ille r w ere

fo cu se d th e ra p y , w h ic h h a s b e e n u sed in

the first to a p p ly th e m o d e l s p e c ific a lly to the

su b sta n ce a b u se tre a tm e n t. In fo rm a tio n on

tre a tm e n t o f a lc o h o l-re la te d p ro b le m s , b u t

w h en to u se s o lu tio n -fo c u s e d b rie f th e ra p y w ith

o th ers a lso h a v e u sed th e s e te c h n iq u e s fo r

s u b sta n ce a b u se c lie n ts, a ca s e stu d y u sin g

tre a tin g s u b s ta n c e a b u s e d is o r d e rs (B erg , 1995;

s tra te g ic/ in te ra c tio n a l a p p ro a c h e s w ith a

B e rg an d M ille r, 1 9 9 2 ; B e rg an d R e u ss, 1998;

s u b sta n ce -a b u sin g clie n t, an d th e g e n era l

R a tn e r an d Y a n d o li, 1 9 9 6 ). T h is tre a tm e n t

th eo ries that p ro v id e th e b a sis fo r

m o d e l is n o t n e c e s s a rily a u se fu l tre a tm e n t

s tra te g ic/ in te ra c tio n a l th e ra p ie s are

s tra te g y fo r all c lie n ts w ith s u b s ta n c e a b u se

d iscu sse d b elo w .

d is o rd e rs ; n o o n e m o d e l is. H o w e v e r, this
m o d e l is a "c o m p le x a n d v a rie d p a c k a g e of

Solution-Focused
Therapy for
Substance Abuse
W h ile th is ch a p te r co v e rs s e v e ra l stra te g ic and
in te ra ctio n a l th e o rie s an d p ra c tic e s, m o st o f the
w o rk cu rre n tly b e in g d o n e o n s u b s ta n c e a b u se
tre a tm e n t u ses a s o lu tio n -fo c u s e d a p p ro a ch .
S o lu tio n -fo cu se d th e ra p y is a lw a y s b rie f, an d to
d ate th e re h a s n o t b e e n a g re a t d e a l o f re se a rch
co m p a rin g it to o th e r m o d e ls.
R e se a rch b y Ig u c h i an d c o lle a g u e s su p p o rts
so m e o f the th e o re tica l c la im s m a d e by s o lu tio n 88

s tra te g ie s th a t c a n b e a p p lie d in an
in d iv id u a liz e d , e c le c tic fa s h io n to th o se see k in g
tre a tm e n t" fo r a m u ltifa c e te d a n d co m p le x
p ro b le m (B e rg a n d M ille r, 1 9 9 2 , p. xix). B erg
an d R e u ss d e lv e in to g re a te r d e ta il re g a rd in g the
a p p lic a tio n s o f s o lu tio n -fo c u s e d b rie f th e ra p y to
th e tre a tm e n t o f s u b s ta n c e a b u s e d is o rd e rs (B erg
an d R e u ss, 19 9 8 ).
O n e te c h n iq u e o f s o lu tio n -fo c u s e d th e ra p y is
to fo c u s o n th e e x c e p tio n s to th e c lie n t's
p ro b le m s . F o r e x a m p le , in p ro v id in g s o lu tio n fo cu se d b rie f th e ra p y fo r a c lie n t w ith a
s u b s ta n c e a b u s e d is o r d e r, th e th e ra p is t sh o u ld

B r ie f S tra teg ic/In tera c tio n a l T herapies

d irect the c lie n t's a tte n tio n to p e rio d s w h e n he

h e r s u b s ta n c e a b u s e a ffe c ts th o se sig n ific a n t

w as su b sta n ce fre e . T o id e n tify th e se p e rio d s,

a re a s o f c o n c e rn . T h e th e ra p is t h e lp s th e clie n t

the th e ra p ist m u s t liste n c a re fu lly to th e c lie n t's

so lv e th o se s ig n ific a n t p ro b le m s w h ile stro n g ly

re sp o n se s, th e n a sk the c lie n t to d is c u ss th o se

re in fo rc in g th e c lie n t's s u c c e s s . A fte r the in itial

p e rio d s. T h e p u rp o s e is to h e lp th e clie n t re a liz e

s e ssio n , the th e ra p is t k e e p s th e c lie n t fo c u se d on

th at h e can m a in ta in s o b rie ty an d h a s, in fa ct,

h o w h e r s itu a tio n is im p ro v in g b y a sk in g ,

d o n e so in th e p a st. T h e id ea o f fo cu sin g on the

" W h a t's b e tte r th is tim e ? "

e x ce p tio n to an y p re s e n tin g p ro b le m is a n a sp e ct
of s tra te g ic th e ra p y th a t h a s p a rtic u la r re le v a n ce
to the su b sta n c e a b u se r b e c a u se , as B e rg n o tes,
alm o st e v e ry s u b s ta n c e a b u s e r h a s h ad so m e
p erio d o f a b stin e n c e in m a n y ca se s th is p e rio d
m ay h a v e lasted m o n th s or y e a rs (B erg , 1995).

Compatibility of
Strategic/Interactional
Therapies and 12-Step
Programs

E x ce p tio n s to p re s e n tin g p ro b le m s m a y fall

in to tw o c a te g o rie s, d elib e ra te ex cep tio n s an d

S tra te g ic / in te ra c tio n a l a p p ro a c h e s ca n b e used

random ex cep tio n s (see F ig u re 5-1 fo r d e fin itio n s).

in c o n ju n c tio n w ith o th e r tre a tm e n ts , e v e n those

T h e m o re d e lib e ra te th e b e h a v io r on th e p a rt of
the clie n t, th e e a sie r it w ill b e fo r h e r to re p e a t it.

th a t re q u ire a lo n g e r te rm c o m m itm e n t.
S tra te g ic / in te ra c tio n a l th e ra p ie s a re g u id ed by
an in te n t to g e n e r a te a u n iq u e s e t o f te ch n iq u es,

B u t e v e n s u b s ta n c e -fre e p e rio d s th a t s ee m e d to

a p p ro a ch e s, or m o d a litie s th a t a re e ffe c tiv e fo r a

resu lt fro m o u tsid e in flu e n c e s (i.e., ra n d o m

e x ce p tio n s) can b e u sed to h e lp the c lie n t re a liz e

p a rtic u la r c lie n t. F o r s o m e c lie n ts, a

c o m b in a tio n o f b rie f th e ra p y w ith lo n g e r term

h er ow n ab ility to sta y sob er.

p a rtic ip a tio n in a n o th e r tre a tm e n t p ro g ra m ,

A s d iscu sse d a b o v e , a th e ra p ist u sin g a

s u ch as a se lf-h e lp g ro u p , w ill b e m o st effe ctiv e .

s o lu tio n -fo cu se d a p p ro a c h w o rk s c lo s e ly w ith

In sp ite o f s o m e th e o re tic a l d iffe ren ce s,

the clie n t to u n d e rsta n d th e c lie n t's o w n

s tra te g ic / in te ra c tio n a l a p p ro a c h e s ca n b e u sed

p e rsp e ctiv e o n h e r p ro b le m s. B y fo c u s in g on
th o se a re a s th e clie n t c o n s id e rs s ig n ific a n t (e.g .,

s u c c e s s fu lly in c o n ju n c tio n w ith 1 2 -S te p

p ro g ra m s . T h e s e a p p r o a c h e s , e sp e c ia lly

re la tio n sh ip s, w o rk , fin a n c ia l s e c u rity ), the

th e ra p ist assists th e c lie n t in u n d e rs ta n d in g how

id e n tify in g trig g e rs th a t ca n lea d to re la p se or

F ig u r e 5-1
D e lib e ra te a n d R a n d o m E x c e p tio n s to S u b s ta n c e A b u s e B e h a v io rs
D eliberate ex cep tio n s a re situ a tio n s in w h ic h a c lie n t h a s in te n tio n a lly m a in ta in e d a p e rio d o f s o b rie ty or
re d u ce d u se fo r w h a te v e r re a so n . F o r e x a m p le , a clie n t w h o d id n o t u se s u b s ta n c e s fo r a m o n th in ord er
to p ass a d ru g te st fo r a n e w jo b h a s m a d e a d e lib e ra te e x c e p tio n to h is ty p ic a l p a tte rn o f d a ily su b sta n ce
use. If h e is re m in d e d th a t h e d id d o th is in th e p a s t it w ill d e m o n s tra te th a t h e c a n re p e a t th e b eh a v io r.
R an dom ex cep tio n s a re o c c a s io n s w h e n a c lie n t re d u ce s u se o r a b sta in s b e c a u s e o f c irc u m sta n c e s th at
are a p p a re n tly b ey o n d h e r co n tro l. T h e c lie n t m a y sa y , fo r e x a m p le , th a t sh e w a s ju s t "fe e lin g g o o d " and
d id n o t feel the u rg e to u se a t a p a rtic u la r tim e b u t c a n n o t p o in t to an y in te n tio n a l b e h a v io rs o n h e r p art
th at en a b led h er to sta y so b er. T h is ty p e o f e x c e p tio n is m o re d iffic u lt fo r th e th e ra p is t to w o rk w ith b u t
can also b e u sed to h elp th e c lie n t p e rc e iv e h e r o w n e ffic a c y . In su ch in s ta n c e s th e th e ra p is t c a n a sk the
clie n t to try to p re d ic t w h e n s u c h a p e rio d o f "fe e lin g g o o d " m ig h t o c cu r a g a in , w h ic h w ill fo rce h e r to
b eg in th in k in g a b o u t th e b e h a v io rs th a t m a y h a v e h a d an e ffe c t o n c re a tin g th e ra n d o m e x ce p tio n .

89

C h ap ter 5

e x p lo rin g b a rrie rs th a t ca n p re v e n t the c lie n t

su p p o rt c h a n g e

fro m g o in g to A lc o h o lic s A n o n y m o u s (A A )
m e e tin g s or ca llin g h is sp o n so r, ca n b e a p p lied

to critica l p o in ts in m a in ta in in g so b rie ty . F or
e x a m p le , the th e ra p is t ca n h e lp th e c lie n t

H e a l th e fa m ily s y s te m so it c a n b e tte r

M a in ta in b e h a v io rs th a t w ill h e lp co n tro l
s u b s ta n c e u se

R e sp o n d to s itu a tio n s in w h ich th e c lie n t has

id e n tify th e " p a y o ff" fo r n o t a tte n d in g the

re tu rn e d to s u b s ta n c e u se a fte r a p e rio d of

m e e tin g and the k e y p la y e rs in th e sy ste m th a t

a b stin e n c e

m a in ta in s the c lie n t's su b sta n ce a b u se. E v e n a

clie n t w h o feels h e is p o w e rle ss o v e r s u b sta n ce

M o re s p e c ific a lly , s tra te g ic / in te ra c tio n a l

a p p ro a ch e s a re u se fu l in

ab u se w ith o u t th e h e lp o f a h ig h e r p o w e r can
re co g n iz e h e h a s s o m e co n tro l o v er th e ch o ice s

or c o n trib u te to s u b s ta n c e a b u se

th at lead to su b sta n c e a b u se.

So m e th e ra p ists fa m ilia r w ith 1 2 -S te p
p ro g ra m s m a y b e c o n c e rn e d th a t the
stra te g ic/ in te ra c tio n a l a p p ro a c h is o p p o sed to

L e a rn in g h o w th e c lie n t's re la tio n sh ip s d eter

S h iftin g p o w e r re la tio n sh ip s

A d d re s sin g fe a rs
M o st s tra te g ic / in te ra c tio n a l th e ra p ie s a sk a

v iew in g a d d ictio n as a d ise a se. T h e fo cu s on

clie n t to c o n s id e r th e q u e s tio n , "H o w d o y ou

e m p o w e rin g th e c lie n t m a y se e m in c o m p a tib le

u n d e rsta n d y o u r u s in g ? " (S o lu tio n -fo c u s e d

w ith the first step (i.e., " w e a d m itte d w e w e re

th e ra p y is an e x c e p tio n b e c a u se it c o n c e n tra te s

p o w e rle ss o v e r ..."). H o w e v e r, th e k e y to

in ste a d o n im p ro v in g th e s itu a tio n .) O fte n , as

th e ra p e u tic su c ce ss w ith th is a p p ro a c h is the

th e th e ra p is t a n d c lie n t e x p lo re th e c lie n t's

ab ility to w o rk w ith in a c lie n t's fra m e o f

u n d e rs ta n d in g o f th e a b u s e , c ritic a l re la tio n sh ip

re fe re n ce. T h e ra p is ts c a n a c k n o w le d g e th a t

issu es s u r fa c e e v e n w h e n th e c lie n t a p p e a rs to

a d d ictio n is a d ise a se b u t still u se the

b e iso la te d fro m fa m ily a n d frie n d s. E v e n if a

s tra te g ic/ in te ra c tio n a l a p p ro a c h to e n h a n ce

c lie n t s e e m s to h a v e n o e x is tin g fa m ily

clie n ts ' co p in g s k ills an d h elp th em to co n tro l

c o n n e c tio n s , th e fa m ily s o m e tim e s p la y s a role

the u s e -re la ted b e h a v io rs th a t c lie n ts m a y

in h e r s u b s ta n c e a b u s e . H e r fa m ily , o r h er

b elie v e are ra n d o m a n d s p o n ta n e o u s . S tra te g ic

re a c tio n to it, m a y h a v e in flu e n c e d h e r d e cisio n

th e ra p ists w h o d o n o t a c c e p t a d ise a se m o d e l

to b e g in u sin g o r h e r d e c is io n to sto p . M e ssa g e s

m ay tell a clie n t, "Y o u h a v e a d is o rd e r o f the

fro m th e fa m ily (in te rn a liz e d or a c tu a l) ca n also

p lea su re ce n te rs in y o u r b r a in ," an d w o rk w ith

p la y an o n g o in g ro le in th e c lie n t's ch o ic e to

the clie n t to fin d h e a lth ie r w a y s to a ctiv a te th o se

c o n tin u e u sin g .

"p le a s u re c e n te rs ."

When To Use Strategic/

Interactional Therapies

O n e th e ra p is t tre a te d a w o m a n w h o se e n tire
fa m ily a p p e a re d to h a v e a lc o h o l-re la te d
p ro b le m s a n d w h o b e lie v e d th a t e v e ry o n e
d ra n k , b u t a t d iffe re n t le v e ls . F o r th is clie n t, a
s tra te g ic / in te ra c tio n a l a p p r o a c h h e lp e d h e r

N o m a tte r w h ic h ty p e o f s tra te g ic / in te ra c tio n a l

b e c o m e a w a re o f n e w p o s s ib ilitie s , d ev elo p

th e ra p y is u se d , th is a p p ro a c h ca n h elp to

so cia l s k ills , a n d id e n tify s o b e r a c tiv itie s. Sh e

D efin e the situ a tio n s th a t c o n trib u te to

su b sta n ce a b u se in te rm s m e a n in g fu l to the
clien t

Id en tify ste p s n e e d e d to c o n tro l o r en d

su b sta n ce u se

lea rn ed to see th e w o rld as a ric h e r p la c e w ith

m a n y o p tio n s. T h e th e ra p is t in th is ca se c h o se
to b e d ire c tiv e a n d s h o w e d th e c lie n t the
p o ss ib ilitie s fo r c h a n g e th a t e x ist. T o m a n y
clie n ts w h o a re try in g to c h a n g e th e ir b e h a v io r,
it is re a s su rin g to b e lie v e th a t " th e r e is so m e o n e

90

B r ie f S tra teg ic/In teraction al T herapies

w h o k n o w s th e w a y ." T h e th e ra p is t u sin g th is

th e E rik s o n ia n m o d e l, a th e ra p is t m ig h t a sk the

stra te g ic / in te ra c tio n a l a p p ro a c h sh o u ld co n v e y

c lie n t to p ro je c t h e rs e lf in to th e fu tu re and

a sen se o f h o p e th a t b rid g e s th e c h a s m b e tw e e n

d e sc rib e w h a t it w ill b e lik e w h e n th e ch a n g e s

w h a t is and w h a t c o u ld b e and s u p p o rt the

ju s t d isc u sse d h a v e b e e n m a d e , or ta lk a b o u t a

clie n t th ro u g h th e ch a n g e p ro c e s s w ith re sp ect.

"fu tu r e s e lf" w h o h a s re s o lv e d c u rre n t p ro b lem s

T h e s tra te g ic / in te ra c tio n a l a p p ro a ch ca n also

an d fo r w h o m c u rre n t fe a rs a re n o lo n g e r an

h elp b re a k th ro u g h a sta le m a te in a re la tio n sh ip

issu e. S u c h s tra te g ie s a re u se fu l in co n fro n tin g

th a t b lo ck s h e a lin g , p a rtic u la rly if th e re h a s b ee n

c o m m o n fe a rs a n d h e lp in g c lie n ts see b ey o n d

a p o w e r stru g g le th a t h a s le ft b o th p a rtie s

th em .

e x h a u sted an d w ith a n a p p a re n tly re stricte d

ra n g e o f o p tio n s. In a p o w e r s tru g g le , e a ch
p e rso n sa y s sh e is rig h t an d th e o th e r is w ro n g ;

Duration of Therapy and

Frequency of Sessions

o n e o f th e m m u s t g iv e in. W h e n th e

M o st fo rm s o f s tra te g ic / in te ra c tio n a l th era p ies

stra te g ic/ in te ra c tio n a l a p p ro a c h is a p p lie d to

are b rie f b y th e d e fin itio n u se d in th is TIP .

p o w e r s tru g g le s it ca n h e lp to "o p e n up the

S tra te g ic / in te ra c tio n a l th e ra p ie s n o rm a lly

s y s te m ," w o rk in g to c h a n g e th e c lie n ts '

re q u ire 6 to 10 s e s s io n s , w ith 6 co n sid e re d

p e rce p tio n s o f e a c h o th e r an d th eir re la tio n sh ip

ty p ica l. S e ss io n s a re u s u a lly w e e k ly , an d it is

and e n a b le th em to see a b ro a d ra n g e o f o p tio n s.

n o t a d v is a b le to h a v e m o re th a n tw o sessio n s

B o th p a rtie s are a ssiste d in s e e in g th e m s e lv e s as

p e r w e e k . T h is ty p e o f th e ra p y o fte n in v o lv e s

stro n g , ca p a b le , an d in co n tro l. B e c a u se the

a s s ig n in g " h o m e w o r k " fo r th e c lie n t to o b serv e

su b sta n ce a b u se r ty p ic a lly fe e ls h e lp le ss,

h o w sp e c ific c h a n g e s in b e h a v io r a ffe ct the

in a d e q u a te , an d c o n d e s c e n d e d to w a rd , the

p ro b le m , an d tim e is n e e d e d to d e te rm in e h ow a

th e ra p ist o ften h a s to re b a la n c e th e p o w e r

n e w s tra te g y is w o rk in g a n d see h o w the sy stem

stru ctu re to p ro m o te m o re e ffe c tiv e in te ra c tio n s.

is a ffe c te d b y th e ch a n g e .

F o r e x a m p le , in a s itu a tio n w h e re one

In s o lu tio n -fo c u s e d b rie f th e ra p y , th e c lie n t is

p a rtn e r p u sh e s th e o th e r to sto p d rin k in g , the

e n c o u ra g e d to d e te rm in e th e le n g th o f tim e

p a rtn e r w h o h a s b e e n d rin k in g m a y feel

n e e d e d b e tw e e n s e ssio n s. T h is a p p ro a c h h elp s

co n tro lle d and d e m e a n e d a n d th e re fo re m a y

the c lie n t ta k e o w n e rs h ip o f th e p ro c e s s and

w ith d raw in a p a ssiv e m a n n e r or re a c t w ith an

re c o g n iz e h is p o w e r to c o n tro l c h a n g e (re a lizin g

e x p lo siv e te m p e r. H e th e n g ets d ru n k to fu rth e r

th a t o n e h a s th e p o w e r to c h o o s e o fte n is the

e x p ress h is a n g e r or to g e t e v e n . T h e p a rtn e r s'

s o lu tio n itself).

re sp ectiv e b e h a v io rs m a in ta in th e p ro b le m . T h e
th e ra p ist w o rk s to h e lp e a ch p a rtn e r p e rc e iv e
the o th er m o re p o sitiv e ly . A s th is is
a cco m p lish e d , e a c h p e rs o n b e c o m e s m o re
re ce p tiv e to n e w s o lu tio n s. T h e th e ra p is t th en
h elp s the p a rtn ers id e n tify sp e c ific c h a n g e s they
can m ak e , th u s d is m a n tlin g th e old sy s te m and

Applicability to Different
Types of Clients
In s tra te g ic / in te ra c tio n a l a p p ro a c h e s, clie n ts are
tra d itio n a lly d e fin e d a s c u sto m e rs , c o m p la in e rs,
or v isito rs. C u s to m e rs a re c lie n ts w h o sta te that
th e y h a v e a p ro b le m , th e y ca n n o t c o p e w ith the

lay in g the fo u n d a tio n fo r a n ew o n e th a t can

p ro b le m o n th e ir o w n , an d th e y n e ed the

su p p o rt d iffe re n t b e h a v io ra l ch o ice s.

th e ra p is t's h elp . S tra te g ic / in te ra c tio n a l

T h e s tra te g ic / in te ra c tio n a l a p p ro a c h is a lso

an a p p ro p ria te w a y to a d d re s s a c lie n t's fe a r o f
ch an g e. O fte n , c lie n ts fe e l th a t "s o m e th in g
w o rs e " m a y h a p p e n w h e n th e y q u it u sin g . In

a p p ro a ch e s a re p a rtic u la rly h e lp fu l fo r th e latter

tw o ty p e s o f c lie n ts th o se w h o th in k so m eo n e
e lse s h o u ld c h a n g e to re s o lv e th e p re sen tin g
p ro b le m (c o m p la in e rs ) a n d th o se w h o see their

91

C h ap ter 5

p re sen ce in tre a tm e n t as in v o lu n ta ry (v isito rs).

w h e n it is d iffic u lt to u se th is a p p ro a c h d irectly

S tra te g ic/ in te ra c tio n a l th e ra p ie s o ffe r th ese

w ith th e c lie n t, it m a y still b e an e ffe ctiv e

k in d s o f clie n ts a w a y to m a k e e ffe c tiv e c h a n g e s

m o d a lity to u se w ith fa m ily m e m b e r s to h elp

w ith in th eir o w n fra m es o f re fe re n ce .

th e m c h a n g e b e h a v io rs th a t s u p p o rt th e c lie n t's

For e x a m p le , c o n s id e r a c lie n t w h o fe e ls h er
b oss o v e rre a cte d to h e r su b sta n ce a b u se and

s u b s ta n c e a b u s e (F isc h e t a l., 19 8 2 ).
F o r o th e r p o p u la tio n s , th e a p p r o a c h m a y

b e lie v e s sh e sh o u ld n o t h a v e b e e n fo rced to

h a v e to b e a d a p te d to w o rk e ffe c tiv e ly . T h e

en te r tre a tm e n t to re ta in h er jo b . In ste a d of

th e ra p ist m a y h a v e to u se s u p p o rtiv e p ro p s su ch

w o rk in g to try to co n v in c e th e c lie n t she really

as h a n d o u ts o f th e a g re e d -u p o n p la n o f a ctio n

d o es h a v e a p ro b le m , th e th e ra p ist ca n m a k e

a n d a list o f g o a ls to h e lp k e e p th e c lie n t on

p ro g re ss w o rk in g w ith in h e r v ie w o f the

track . S tra te g ic / in te ra c tio n a l s tra te g ie s c a n be

situ atio n , p e rh a p s b y sa y in g , " S o y o u r b o ss

s im p lifie d fo r p e o p le w h o h a v e a c o g n itiv e

th in k s y ou h a v e a p ro b le m . W h a t w o u ld it tak e

im p a irm e n t. B e ca u se th is a p p r o a c h w o rk s w ith

to g et h im o ff y o u r b a c k ? " T h e a s s u m p tio n th a t

the c lie n t's la n g u a g e a n d fu n c tio n a l lev el, a

the clie n t w a n ts to b e fre e o f th e p ro b le m s

c lie n t w ith a c o g n itiv e d is a b ility m a y b e a b le to

cau sed b y th is o th er p e rso n g iv e s th e th e ra p ist

id e n tify an d m e e t g o a ls a p p r o p ria te to h e r skills

so m e th in g to fo cu s on w ith o u t c h a lle n g in g the

an d a b ilitie s. M a n y th e ra p is ts b e lie v e th a t th e

clie n t's v ie w o f the situ a tio n .

s o lu tio n -fo c u s e d a p p r o a c h is u se fu l w ith clie n ts

M o st clie n ts w ith su b sta n c e a b u se d iso rd e rs

w h o h a v e s c h iz o p h re n ia , a n d re s e a rc h su p p o rts

can b e v ie w e d as "h id d e n c u s to m e r s " w h o

its e ffe c tiv e n e s s w ith s o m e c lie n ts w h o h a v e

d esire so m e so rt o f ch a n g e in th eir b e h a v io r,

serio u s m e n ta l illn e s s e s (S a le e b e y , 1996;

ev en if they are n o t w illin g to a rtic u la te th a t fact

S o lo m o n , 19 9 2 ).

(B erg , 1995). G iv e n th at, th e th e ra p is t's ta sk is to

m ak e the " c o m p la in e r " or " v is ito r " a w a re that

Case Study

h e is in fa ct a "c u s to m e r " o f th e th e ra p is t's

serv ices.

F ig u re 5 -2 p re s e n ts a p o rtio n o f a d ia lo g
b e tw e e n a c o u n s e lo r a n d a c lie n t, a 4 5 -y e a r-o ld

92

When M ight a Strategic/

Interactional Approach Not
Be the Best?

re a l e sta te a g e n t w h o w a s tre a te d 4 y e a rs a g o in

E rik so n ia n a p p ro a c h e s m a y be c o n tra in d ic a te d

p o ly s u b s ta n c e a b u se (c o c a in e an d alco h o l).

a n in p a tie n t tre a tm e n t p ro g ra m an d th e re a fte r

a tte n d e d a 1 2 -S te p g ro u p to h e lp h im sto p his

fo r clie n ts w ith se v e re d iso rd e rs. C lien ts w h o

A fte r e x p e rie n c in g 3 c le a n an d s o b e r y e a rs, he

h a v e p e rso n a lity d is o rd e rs (A xis II) m a y ju m p

b e g a n to u se a g a in . T h e c lie n t sta rte d g a m b lin g ,

q u ick ly fro m o n e su g g e s tio n to a n o th e r w ith o u t

th en u sin g c o c a in e an d a lc o h o l w h ile g a m b lin g .

a clea r sen se o f h o w to m a k e u se o f th e ra p e u tic

H is re a l e sta te lic e n s e is n o w in je o p a rd y

su g g e stio n s. B e c a u se th e y fe e l a n e ed to sta y in

b e c a u se o f c u sto m e r c o m p la in ts an d re p o rts to

th e rap y th ey m a y re s is t so lu tio n s th a t w o u ld

the S ta te L ic e n s in g B o a rd . H e w a s re c e n tly

b rin g an en d (a lb e it a su c c e s s fu l on e) to th e ir

co n v ic te d fo r a se co n d tim e fo r d riv in g u n d e r

re la tio n sh ip w ith th e th e ra p ist. C lie n ts w ith

th e in flu e n c e (D U I), a n d h is w ife a n d fa m ily

im p aired b rain fu n ctio n as a re su lt o f s u b sta n ce

m o v e d o u t. T h e c lie n t tells th e th e ra p is t th a t his

ab u se m ay n o t b e g o o d c a n d id a te s fo r this

re n e w e d a b u se o f s u b s ta n c e s w a s th e re s u lt o f

a p p ro a ch e ith er. (F o r th e se clie n ts, a m o re

the g a m b lin g . U n lik e th e n e g a tiv e fe e d b a ck

d irectiv e a p p ro a c h is h e lp fu l.) H o w e v e r, ev en

fro m fa m ily , c o lle a g u e s , a n d o th e r p ro fe ss io n a ls ,

B r ie f S tra teg ic/In tera c tio n a l T herapies

F ig u r e 5 -2
S t r a t e g i c /I n t e r a c t i o n a l T h e r a p y in P r a c tic e : A C a s e S tu d y
C o n v e r s a t io n

O b s e r v a t io n s

C lien t: T h in g s w e re g o in g g re a t. I w a s g o in g to a lot
o f m e e tin g s. I fe lt life w a s g e ttin g b e tte r. I w as
g ettin g a lo n g w ith m y k id s. G e ttin g in to u c h w ith
the sp iritu a l p a rt o f the p ro b le m . I d o n 't k n o w w h a t
h ap p e n e d .

T herapist: W h a t led y o u to g o g a m b lin g ?

C lient: I g u e ss I'd b e e n g a m b lin g fo r a fe w m o n th s

T h e fi r s t trig g er (b o red o m ) h as been id en tified ; this

b efo re I g o t h ig h . I w a s b o re d .

w ill h a v e to be refram ed a s trea tm en t p rog resses.

T h erap ist: W h a t is the e x p e rie n c e o f g a m b lin g lik e?

C lient: I re a lly fe e l aliv e.

T herapist: W h e n d id y o u first u se a g a in ?

C lient: I sp e n t to o m u ch m o n e y on g a m b lin g , and m y

A n im p o rta n t in tera c tio n a l elem en t su rfaces.

w ife y elled at m e the sa m e w a y sh e u sed to w h en I

S om etim es the th in g s th at sp o u ses o r sig n ifica n t

g o t h ig h on co ca in e . I w o n a w h o le lo t, re a lly . It

o th ers d o o r sa y can eith er rein fo rce th e clien t's

w a s n 't fair.

su b sta n ce a b u se o r h elp h im o u t o f the problem .

T herapist: W h a t d o y o u d o w h en y o u r w ife g e ts a n g ry
at you fo r s p e n d in g m o n ey ?

C lien t: I ju s t sa y , "Y e a h , y o u 're r ig h t." A n d th en I go

aw ay. T h e n sh e h a ssle s m e so m e m o re. T h e re are
tim es I b lo w up, b u t n o rm a lly I ju s t try to le t it go by.

T herapist: S o u n d s lik e w h e n y o u w e re g a m b lin g , y ou

N o n ju d g m en ta l la n g u a g e is u sed to en ter th e c lie n ts

w ere e x cite d . So I d o n 't g e t it w h a t w e n t w ro n g ?

fr a m e o f referen c e/w o rld -v iew . It is best i f the clien t is

W h y d id y o u n eed th e co c a in e , to o? Is it p o ss ib le

a b le to d efin e th e su b s ta n ce a b u se a s a p ro b lem he

g a m b lin g w a s n 't e n o u g h ?

ivan ts to o v er co m e ra th er than h a v e th e therap ist

d efin e this f o r the clien t.

C lient: I g u e ss I ju s t n e ed e d m o re o f th e h ig h , you
kn ow . M y w ife and I w e re fig h tin g m o re. T h e
p re ssu re w as g e ttin g to m e. I g u e ss th a t's w h en I
started on the c o ca in e .

T herapist: H ow d id th a t co c a in e w o rk fo r y ou ?
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C h ap ter 5

F ig u re 5 -2 (c o n tin u e d )
S t r a t e g i c /I n t e r a c t i o n a l T h e r a p y in P r a c tic e : A C a s e S tu d y
O b s e r v a tio n s

C o n v e r s a t io n
C lien t: I w a s e x c ite d . I fe lt re a lly p o w e rfu l.

T herapist: W h a t w e n t w ro n g ? W h a t led y o u sta rt

u sin g a lco h o l, too?

C lien t: I g o t sca re d . I w a s up fo r 3 d ay s. T h e a lco h o l

H ere the th era p ist g e ts so m e u n d er sta n d in g o f the

h elp ed m e co m e d o w n an d sleep .

seq u en ce o f th e clien t's su b s ta n c e abu se.

T h erap ist: S o u n d s sca ry to m e. H o w d id y o u g e t

T h e th era p ist v a lid a tes th e clien t's ex p erien ce, rather

th ro u g h th a t sca re d p e rio d ? Y o u to le ra te d it

than criticiz in g the clien t's b eh av ior.

s o m e h o w fo r 3 d ay s.

C lien t: It w as k in d o f a b la n k , m o stly . I fe lt I h a d to
fix it so m e h o w . T h a t's w h en I sta rte d d rin k in g .

T h erap ist: H o w d id y o u k n o w a lco h o l w o u ld w o rk ?

C lien t: I'v e u sed it to b rin g m e d o w n b efo re .

T herapist: I h e a r th a t y ou re a liz e d so m e th in g n e ed e d

T h e th era p ist is p o in tin g ou t th at the clien t's action

to b e d o n e , an d y o u k n e w y o u n e e d e d so m e th in g to

w as an a ttem p t a t reg u la tion , th o u g h not a lon g -term

slo w you d o w n , a n d y o u to o k actio n .

solu tion . T h e sta tem en t rem in d s th e clien t that h e is

in co n tro l a n d m a k in g ch oices. It rea ffirm s the
clien t's stren g th a n d c o p in g sk ills th e clien t m ad e an
a d a p tiv e resp o n se to a d ifficu lt situ a tio n an d m ay
m ake a d ifferen t ch o ice n ex t tim e.

T herapist: So h o w is th is a p ro b le m fo r y o u n o w ?

T his q u estion brin g s th e c lien t b a c k to d efin in g the

p ro b lem f o r h im self, ra th er than lettin g the th erap ist
o r so m eo n e else (sp o u se, boss, p ro b a tio n officer, etc.)
d efin e it f o r him .

C lien t: W ell, I lo st m y fa m ily , a lm o s t lo s t m y

T his " h op eless a n d h elp less" sta n ce sh o u ld be shifted.

b u sin ess, an d I'm fa cin g a n o th e r D U I.

S o lu tio n -fo cu sed a n d M R I a p p ro a c h e s w ou ld try to

p ro m o te effec tiv e stra teg ies a n d elim in a te in effectiv e
on es. A n E rikson ian m ig h t ch a llen g e the clien t to
co m p a re his p o sitiv e a n d n eg a tiv e se lf-im a g e (i.e., the
w ay it fe e ls to g o to A A a n d stay so b er v ersu s h o w it
fe e ls a fter g e ttin g h igh).

94

B r ie f S tra teg ic/In tera c tio n a l T herapies

F ig u r e 5 -2 (c o n tin u e d )
S t r a t e g i c /I n t e r a c t i o n a l T h e r a p y in P ra c tic e : A C a s e S tu d y
C o n v e r s a t io n

O b s e r v a t io n s

T herapist: So w h e re d o y o u w a n t to g o n o w ? W h y are

T his th era p ist is u sin g a stra teg ic a p p ro a ch to sh ift the

you h ere?

clien t o f f h elp les sn ess to a se lf-m o tiv a tio n a l sta tem en t:

" I really n eed to c h a n g e m y life ."

C lien t: I w a n t to g e t so b er a g a in . I w e n t b a ck to A A ,
bu t now I c a n 't sta y so b er m o re th a n a day.

T herapist: W h e n y ou w e re d e te rm in e d to sta y so b er,

you w e re su cce ssfu l. W h a t's d iffe re n t a b o u t the w ay
y o u 're try in g to d o th is n o w ?

C lien t: W ell, n o w , I'll lea v e the m e e tin g and go g et

high.

T herapist: A n d h o w is th a t w o rk in g fo r y ou ?

C lient: It's n o t w o rk in g ! I ju s t s ta rt fe e lin g w o rse

a b o u t m y se lf. I'v e b e e n th ro u g h so m u c h a lre a d y . I
really ju s t n eed to stop .

T herapist: It so u n d s to m e lik e y ou h a v e in c re d ib le

H ere is a m a k e it o r b reak it" p o in t in treatm en t.

in n er stre n g th . W h a t k e e p s y o u g o in g ?

T h e th erap ist is se ek in g a key th at w ill m o v e the clien t

C lien t: I d o n 't w a n t to d ie.

his w ife back, h is co n cern a b o u t h is jo b ). In this case,

to a ction (e.g ., h is lo v e o f h is ch ild ren , h is d esire to g et

th e th era p ist h as ju s t lea rn ed th at th e clien t fe a r s he

w ill d ie as a resu lt o f h is use.

T herapist: It so u n d s lik e y o u h a v e a v e ry stro n g ,

S om e th erap ists w o u ld ca ll the co m p eten t s e lf the

c o m p e te n t sid e th a t w a n ts th e b est fo r y ou and w a n ts

"reco v ery s e lf."

to live. L e t's u se th a t c o m p e te n t p a rt o f y ou to g e t
b a ck on track and re b u ild y o u r life. W h a t d o you
think?

C lient: I w o u ld lik e that.

T herapist: L e t's b e g in b y fig u rin g o u t w h e re y o u are

T h e " read in ess ru ler" is an e ffec tiv e w ay to d eterm in e

n o w . O n a scale o f 1 to 10, o n w h ic h " 1 " is the w o rst

the clien t's rea d in ess to c h a n g e a n d id en tify n ext

you co u ld fe e l an d " 1 0 " is "c le a n , so b er, and

steps. T h e th era p ist is u sin g this tech n iq u e to id en tify

su c c e s s fu l," w h e re a re y o u n o w ?

a b a selin e to m ea su re p ro g r ess a n d fo c u s the clien t in

the d irection o f ch a n g e a n d p rog ress.
95

C h ap ter 5

F ig u re 5 -2 (c o n tin u e d )
S t r a t e g i c /I n t e r a c t i o n a l T h e r a p y in P r a c tic e : A C a s e S tu d y
C o n v e r s a t io n

O b s e r v a tio n s

C lien t: W e ll, n o w I fe e l lik e a n " 8 , " b u t I k n o w it's

te m p o ra ry . W h e n I g o b a c k h o m e, I'll p ro b a b ly g et
b a ck to a " 2 " rig h t aw ay .

T herapist: T h a t's g o o d b e c a u se slo w ch a n g e is m o re

A t this p o in t, th e th era p ist is read y to d efin e som e

im p o rta n t th a n fa s t ch a n g e . Y o u re a lly c a n 't co u n t on

k in d o f a ctio n a n d seek co m m itm e n t to ch an g e. T he

fa st ch a n g e to la st. So if y o u d id slip b a ck to a " 2 ,"

resp o n se is a ls o in ten d ed to e n c o u r a g e th e clien t by

w h a t w o u ld it tak e to m o v e y o u to a " 3 " ?

id en tify in g sm all, fe a s ib le step s

C lien t: I g u e ss m o re o f w h a t I k n o w w o rk s or w h a t
used to w o rk , a n y w a y . G o in g to m e e tin g s or ca llin g
m y sp o n so r. T h a t k in d o f th in g .

T h erap ist: S o u n d s g o o d . Y o u sa id n o w y o u g o to A A

T h e th era p ist is lo o k in g f o r ex ce p tio n s : tim es w hen

m e e tin g s an d g e t h ig h a fte rw a rd . W h a t d id y o u do

so m eth in g th e clien t d id w o rk ed a n d h e ex p erien ced

a fte rw a rd s w h e n y o u d id n 't d o th at, w h e n y ou

su ccess.

stay ed so b er?

C lien t: W e n t h o m e. W a tch e d T V . H ad fu n w ith m y

w ife; s o m e tim e s w e m a d e lo v e. N o w th a t s h e 's n o t
th ere, I really d rea d the e v e n in g s. T h e y a re so e m p ty .
I ju s t go b a ck an d sta re a t th e ce ilin g .

T h erap ist: So w h e n y o u d o n 't h a v e th in g s to

T he th erap ist is refra m in g the p ro b lem to open the

do, you g e t an tsy .

d o o r to a solu tion .

C lien t: Y eah . I g u e ss so. I g e t lo n e so m e .

T herapist: Y es, it is d iffic u lt to g o h o m e to an e m p ty

T he th erap ist is a ck n o iv led g in g th e d ifficu lty , bu t also

p lace. B u t it so u n d s lik e y o u h a v e n o t g iv e n up on

p o in tin g o u t the p o sitiv e d irectio n im p licit in the

p e o p le. P e o p le are still im p o rta n t to y ou . Y o u w a n t

clien t's statem en t. T h e th erap ist em p a th iz es w ith the

h u m a n c o n ta ct to ca re a b o u t p e o p le an d h a v e th e m

clien t, v a lid a tin g his ex p erien ces a n d fe e lin g s , bu t also

care a b o u t you .

p o in tin g o u t th e p o sitiv e d irectio n im p licit in the

clien t's statem en t.

C lien t: If n o b o d y 's a ro u n d , I feel e m p ty . I g e t b o red .

T h en I w a n t to u se. I w a n t to m a k e so m e th in g
h ap p en .

B r ie f S tra teg ic /In tera ctio n a l T herapies

F ig u r e 5 -2 (c o n tin u e d )
S t r a t e g i c /I n t e r a c t i o n a l T h e r a p y in P r a c tic e : A C a s e S tu d y
C o n v e r s a t io n
T herapist: A re y o u b o re d n o w ?

O b s e r v a t io n s
T h is q u estion g iv e s th e th era p ist in form atio n on h ow
the clien t fe e ls a n d acts w h en b o red a n d can h elp the

C lien t: S o rt of. N o t re a lly h e re all th e w a y , y ou

th erap ist reco g n iz e sig n a ls o f b o red o m in the fu tu re.

kn ow w h a t I m e a n ? S o rt o f e m p ty .

S o m etim es th e th era p ist w ill h a v e g re a t p a rticip a tio n ,

a n d the clien t w ill still d es c rib e h im s e lf a s bored. It is
also im p o rta n t to a scerta in w h e th e r the bored om
resu lts fr o m d ep ressio n o r a se n se o f em p tin ess. A
b etter u n d ersta n d in g o f w h a t "bored " m ean s w ill
en a b le the th erap ist to h elp th e clien t fig u r e ou t
"w hat's d ifferen t" a n d fi n d a solu tion .

T herap ist: T h a t's in te restin g . D e sp ite the fa c t th at

T h e th erap ist is fr a m in g th e clien t's self-im a g e

you feel e m p ty , y ou ca n still fu n c tio n . I th in k th ere

p o sitiv ely , su g g e stin g a c h a n g e in th e w a y the clien t

is so m e th in g in te rn a lly p o w e rfu l in y o u th a t h a s n o t

now sees h im self.

co m e ou t. F or s o m e re a so n , it h a s b e e n s u p p re sse d .
M y g u ess is th at th e b o re d o m c o m e s w h e n y ou
su p p ress th a t sid e o f you .

C lien t: Y o u k eep ta lk in g a b o u t th is p o w e rfu l sid e. I

A n a tu ra l resp on se fr o m a clien t w h o is m ostly

d o n 't g e t it. I lost e v e ry th in g . W h e re 's th is g re a t

fo c u s in g on n eg a tiv e p er cep tio n s a n d ex p erien ces. The

p o w e r I'm su p p o se d to h a v e?

th erap ist's fo c u s co n tin u es to be on sh iftin g the client's

p ercep tio n to p o sitiv e stren g th s a n d co n stru ctiv e

T herapist: I th in k it's rig h t h e re le t's see if w e can

action .

b rin g it o u t a b it. T e ll m e a b o u t a tim e w h en y ou fe lt

tre m e n d o u s p le a su re an d co n tro l, b u t y o u w e re
sob er.

C lient: W ell, I h a v e to go p re tty fa r b a ck . W h e n I

w as ten, th o u g h , I re m e m b e r p la y in g b a se b a ll and
h ittin g th is h o m e ru n. I re a lly h it th a t b all.

T herapist: S o m e tim e th is w e e k if y o u 're w illin g to

A t this p o in t, th e th era p ist m ig h t en co u ra g e the clien t

try s o m e th in g , an d o n ly if y o u 're w illin g , try to

to fe e l th at v ib ra tio n a n d run a cro ss the bases in his

b rin g b a ck th a t e x p e rie n c e . T a k e n o te o f w h a t it w as

m in d o r a sk w h eth er th e a c tiv ity m en tion ed is on e the

like and h o w d iffic u lt it w a s to g e t th ere.

clien t co u ld d o in h is p resen t life. T h e th erap ist cou ld

su g g est h ere th at a local recreation cen ter, o r a n o th er

C lient: O k ay . M a y b e I'll try th at.

w ay o f b ein g p h y sica lly a ctiv e, w o u ld be an op tion fo r

resto rin g the sen se o f p o w er an d co n tro l as w ell as
co n n ec tin g w ith p eop le.

97

C h ap ter 5

F ig u r e 5 -2 (c o n tin u e d )
S t r a t e g i c /I n t e r a c t i o n a l T h e r a p y in P r a c tic e : A C a s e S tu d y
T herapist: I'm su re th e re h a v e b e e n a n u m b e r o f

T h e th erap ist sh o u ld m a k e the clien t w o rk here. I f the

th in g s in y o u r life th a t y o u 'v e d o n e rig h t, o th e rw ise

clien t is blan k, h e co u ld be a sk ed to f r e e associate. In a

y o u w o u ld n 't h a v e su rv iv e d all o f the d ifficu ltie s

g ro u p settin g , o th ers co u ld g iv e su g g estio n s.

y o u 'v e h ad . It w o u ld h elp if y o u co u ld th in k a b o u t
th o se s u cce ssfu l or e ffe c tiv e b e h a v io rs.

C lien t: I ca n try.

T h erap ist: N ow th a t w e 'v e id e n tifie d th a t y o u h a v e

all this s tre n g th in sid e o f y o u a n d you still d o
h o w d o w e u se it?

C lien t: I g u e ss if I co u ld g o to A A an d sta y so b er
w h en I g et h o m e, th a t w o u ld a t le a st b e a start.

T herapist: W h a t d o y o u th in k is g o in g to h a p p e n at
AA?

C lien t: It's g o in g to b e g o o d to sit th e re an d k n o w

P art o f w h at's h a p p en in g is th at th e ex tern a l an d

I'm n o t h id in g .

in tern a l p re ssu re resu ltin g fr o m th e sh a m e is bein g

red u ced ; co n seq u en tly , th e fe e lin g a b o u t g o in g is
ch an g in g .

the th e ra p ist, u sin g s tra te g ic / in te ra c tio n a l

T h is c a s e stu d y is an e x a m p le o f h o w a b rie f

ap p ro a ch e s, p ra ise s th e c lie n t fo r c o m in g b a ck to

s tra te g ic / in te ra c tio n a l th e ra p is t m ig h t w o rk

treatm en t: "L o o k a t w h a t y o u h a v e d on e!

w ith a c lie n t w h o h a s p re v io u s ly b e e n su cce ssfu l

Y o u 're in th is c h a ir in ste a d o f still o u t th e re ."

a t c o n tro llin g h is s u b s ta n c e a b u s e p ro b le m b u t

T h e th e ra p ist a ssu re s th e clie n t th a t re la p se is

h a s re la p se d . T h e a p p r o a c h d e s c rib e d is a

p a rt o f the re co v e ry p ro ce s s an d s u g g e sts th a t

g e n e ric s tra te g ic / in te ra c tio n a l a p p ro a c h and

the e x p e rie n ce c a n b e see n as e d u c a tio n a l. In

d o e s n o t re p re s e n t a p u re m o d e l o f an y o n e ty p e

co n tra st to e m p h a s iz in g the c lie n t's fa ilu re , the

o f s tra te g ic / in te ra c tio n a l th e ra p y . B e c a u se the

th e ra p ist sen d s the m e ssa g e , " Y o u 'r e a su rv iv o r,

c lie n t h a s re la p se d , an im p o r ta n t g u id in g

n o t a v ic tim ." T h e th e ra p ist a ffirm s the c lie n t's

p rin c ip a l is to d is c o v e r w h a t h a s c a u se d h im to

ab ility to sta y s o b e r a n d b eg in s to see k w a y s to

d e v ia te fro m th o se b e h a v io rs , th o u g h ts, and

e m p h a siz e an d d raw o n th e c lie n t's stre n g th s.

a c tiv itie s th a t h a d p re v io u s ly b e e n e ffe c tiv e in

T h e th e ra p ist see k s to u n d e rsta n d the e v e n ts

co n tro llin g h is s u b s ta n c e a b u se . T h e th e ra p ist

th a t led up to re n e w e d u se b u t a lso s ea rch es fo r

m u s t th e n a s s is t th e c lie n t e ith e r to re tu rn to

the b e h a v io rs th a t p re v io u s ly h e lp ed the clie n t

th o se th in g s th a t h a v e b e e n w o rk in g b e fo re or to

stay a b stin e n t fo r 3 y ears.

a d d or re p la c e th e m w ith s tra te g ie s th a t are

m o re e ffe c tiv e .

98

B r ie f S tra teg ic/In tera ctio n a l T herapies

Strategic/Interactional
Therapies
T h e p rim a ry s tre n g th o f s tra te g ic / in te ra c tio n a l
ap p ro a ch e s is th a t th ey sh ift th e fo cu s fro m the
clie n t's w e a k n e sse s to th e c lie n t's s tre n g th s . T h e
th e ra p is t's task is to h e lp th e c lie n t id e n tify ,
re co g n ize , an d u se th e se stre n g th s to m a k e the
ch an g e s the clie n t see s as b e n e fic ia l.
S tra te g ic/ in te ra c tio n a l th e ra p ie s a re b a se d on
th ree p rim a ry th e o re tica l a ssu m p tio n s:

stra te g ic th e ra p is t b e lie v e s th a t a p o sitiv e

ch a n g e to o n e p a rt o f a s y s te m w ill p o sitiv e ly
a ffe ct th e re st o f th e sy ste m . T h is a p p ro a ch is
d is tin c t fro m a s tru c tu ra l v ie w o f sy stem s,
h o w e v e r; w h e re a s th e s tru c tu r a lis t see s th e need
to c o n s id e r an d try to c h a n g e d y sfu n c tio n a l
a s p e cts o f th e la rg e r fa m ily s tru c tu re , the
s tra te g ic th e ra p is t d o e s n o t n e c e s s a rily p o sit a
s y s te m w id e d y s fu n c tio n o n ly th e e x is te n c e of
in effectiv e in tera ctio n s w ith in th e sy stem .
A stra te g ic a p p ro a c h a c c e p ts the fa c t th at
c lie n ts m a y n o t a lw a y s p ro v id e a c cu ra te

1. T h e se th e ra p ie s tak e a co n stru ctiv ist v ie w of

re ality . T h e y a sse rt th a t re a lity is
d e term in e d b y in d iv id u a l p e rc e p tio n s ,
w h ich are in flu e n c e d b y cu ltu ra l,
s o cio p o litica l, a n d p s y c h o lo g ic a l fa cto rs.
2. T h e se th e ra p ie s s tre ss th e im p o rta n c e of
attrib u tio n o f m e a n in g . A c c o rd in g to th is
th e o retica l a p p ro a ch , it is th e m e a n in g w e
a ttrib u te to situ a tio n s th a t d e te rm in e s
w h eth er a p ro b le m e x ists. In th is m o d e l, an
im p o rta n t th e ra p e u tic g o a l is to u n d e rsta n d
the m e a n in g s th a t c lie n ts a ttrib u te to
e v e n ts o fte n re fe rre d to as th e c lie n t's
"fra m e o f r e fe r e n c e " a n d to u se this
k n o w le d g e to p ro m o te c o n s tru c tiv e ch a n g e .
T h is can in v o lv e h e lp in g c lie n ts to c o n s tru c t
a d iffe re n t m e a n in g th a t is m o re u se fu l to
th em in the re c o v e ry p ro cess.
3. T h e se th e ra p ie s fo c u s on h u m a n in te ra c tio n s
and th e p ro b le m s th a t e v o lv e fro m
in e ffe ctiv e w a y s o f co p in g w ith situ a tio n s.
T h e re is a lw a y s s o m e e le m e n t o f so cia l
in te ra ctio n in th e d e v e lo p m e n t,
m a in te n a n c e , an d ch a n g e p ro c e s s fo r an y
p ro b lem . By ta k in g th e se in te ra c tio n s in to
acco u n t, the th e ra p is t c a n b e tte r su p p o rt the

in fo rm a tio n a b o u t th e re a l n a tu re o f th eir
p ro b le m s. It is p o ss ib le to w o rk w ith th e clie n t's
v ie w o f w h a t is h a p p e n in g a n d m a k e p ro g re ss,
e v e n if th a t v ie w is o n ly p a rtia lly " c o r r e c t." For
e x a m p le , c o n s id e r a c lie n t w h o e n te rs th e ra p y
c o m p la in in g , "M y b o s s d riv e s m e to d rin k ." In
a c o g n itiv e or c o n fro n ta tio n a l a p p ro a c h , the
th e ra p is t m ig h t striv e to c h a n g e th is w a y of
lo o k in g a t re a lity . T h e th e ra p is t u sin g a fo rm of
s tra te g ic / in te ra c tio n a l th e ra p y m ig h t sa y th a t
th is a p p ro a c h re p re s e n ts th e c lie n t's v ie w o f the
w o rld a n d , ra th e r th a n c o r re c tin g or a lte rin g it in
s o m e w a y , th e th e ra p is t c a n m a k e m o re p ro g re ss
b y w o rk in g w ith in th a t fra m e o f re fe re n c e to
a c c o m p lis h stra te g ic o b je ctiv e s . T h e th e ra p ist
m ig h t a sk , " I f y o u r b o s s is d riv in g y o u to d rin k ,
h o w d o e s th a t h a p p e n a n d w h a t ca n y o u d o
a b o u t th a t? " T h e th e ra p is t im p lie s th a t th e clie n t
m u s t b e m o re e ffe c tiv e in in te ra c tio n s w ith his
b o ss, an d th is b e c o m e s a tre a tm e n t issu e. By
w o rk in g w ith in th e c lie n t's fra m e o f re fe re n ce ,
th e th e ra p is t c a n d e fin e w h a t th e c lie n t m ig h t d o
to c h a n g e k e y in te ra c tio n s th a t c o n trib u te to
s u b s ta n c e a b u s e , w ith o u t b u y in g in to the
p re m ise th a t it is o n ly h is b o s s ' b e h a v io r th a t
m u s t ch a n g e .

clie n t th ro u g h th e ch a n g e p ro c e ss.
A b asic te n e t o f th is a p p ro a ch is th e a sse rtio n

Initial Session

that h u m a n p ro b le m s ca n b e u n d e rsto o d by

T h e first q u e s tio n th a t a th e ra p is t u sin g a

ap p ly in g the p rin cip le s o f h u m a n sy stem s.

s tra te g ic / in te ra c tio n a l a p p ro a c h sh o u ld a sk is,

P ro b lem s d o n o t e x is t in a v a cu u m ; th ey e x ist

"W h y a re y o u h e r e ? " T h e first se s s io n sh o u ld be

b eca u se o f re la tio n sh ip s w ith o th e rs. T h e

s p e n t try in g to u n d e rs ta n d th e c lie n t's p ro b lem .

99

C h ap ter 5

H o w e v e r, d iffe re n t m o d e ls (d isc u sse d la te r in

T h e th e ra p is t c o u ld c o n tin u e to d ev elo p

this se ctio n ) u se d iffe re n t ta ctics to e x p lo re the

e ffe c tiv e s tra te g ie s a n d in c re a se th e ir use.

n atu re o f the p ro b le m , as fo llo w s:

S h e co u ld u se a ffirm a tio n s , c o n tin u e to use

sca lin g q u e s tio n s , an d " jo in " w ith th e clie n t

T h e th e ra p ist u sin g E rikson ian th erap y seek s

b y a c k n o w le d g in g h o w d iffic u lt it is to

to d efin e the c lie n t's p ro b le m in th e clie n t's

c h a n g e an d re b u ild h is life.

term s an d p ro b e th e w a y sh e u n d e rsta n d s
the p ro b le m (i.e., the " f r a m e " ). C o m p a re d to

c lie n t's m o tiv a tio n to c h a n g e an d c o n tin u e to

o th er s tra te g ic in te ra ctio n a l m o d e ls, the

a sk th e c lie n t w h a t h e th in k s w ill h a p p e n if

E rik so n ia n a p p ro a c h m o v e s m o re q u ick ly to

c h a n g e s ta k e p la c e . T h is te c h n iq u e

actio n , see k s to e ffe c t ch a n g e m o re q u ick ly ,

d e m o n s tra te s re s p e c t fo r th e c lie n t's v a lu es.

and p la ces g re a te r e m p h a sis on the

u n co n scio u s p ro ce s s e s u n d e rly in g ch a n g e .

th e c lie n t's s u b s ta n c e a b u s e a n d h e lp h im to
d e te rm in e h o w h e c a n h a n d le th e m

d efin in g g o a ls. T h ro u g h o u t th e se ssio n , the

d iffe re n tly . T h e th e ra p is t s h o u ld a sk the

w o rd " p r o b le m " is a v o id e d .

clie n t a b o u t w a y s h e h a s s u cc e s s fu lly

T h e th e ra p ist u sin g the M R I m od el se e k s to

h a n d le d s tre s so rs in th e p a s t an d e x p a n d on

d efin e the p ro b le m in th e c lie n t's te rm s and

th o se su c c e s s e s .

u n d e rsta n d th e " f r a m e " in a m a n n e r sim ila r

to the E rik s o n ia n a p p ro a ch . H o w e v e r, this

T h e th e ra p is t c o u ld u se im a g e s an d sy m b o ls
to h e lp th e c lie n t se e th e p ro b le m in a h e lp fu l

m o d a lity fo cu se s on m o d ify in g in effe ctiv e

w a y . F o r e x a m p le , th e c lie n t m ig h t fin d a

so lu tio n s th a t h a v e b e e n p re v io u sly

n e w jo b a n d th ro w h im s e lf co m p le te ly in to it.

atte m p ted .

T h e th e ra p is t c o u ld c o n tin u e to g a th e r
in fo rm a tio n a b o u t th e s tre s so rs th a t trig g er

T h e th e ra p ist u sin g so lu tio n -fo cu sed b r ie f

therapy sp e n d s m o st o f th e first se ssio n

T h e th e ra p is t s h o u ld a lso b e a w a re o f the

T h e th e ra p is t c o u ld te ll h im th a t h e is a

T h e th e ra p ist u sin g H aley 's p ro b lem -so lv in g

sh in in g sta r: " Y o u 'r e sh in in g b rig h t rig h t

therapy p a y s sp e cia l a tte n tio n to g a in in g an

n o w . W h a t ca n y o u d o to k e e p s h in in g ? "

u n d e rs ta n d in g o f p o w e r issu es in

T h is s ta rts a d is c u ss io n a b o u t h o w to last

re la tio n sh ip to th e p ro b le m (e.g ., w h o

lo n g e r, w o rk sm a rte r, a ch ie v e m o re , and use

co n tro ls k ey d ecisio n s).

re stra in t.

Later Sessions

T h e th e ra p is t m ig h t a lso fo c u s o n a ssistin g

T h e c lie n t's c o n tin u e d b e lie f in h is ow n

the c lie n t to im p ro v e o th e r a sp e c ts o f h is life.

O n ce the th e ra p ist h a s e n c o u ra g e d a p e rso n

w ith a su b sta n ce a b u se d is o rd e r to tak e fu rth e r

s tre n g th an d b a sic g o o d n e s s s h o u ld b e

step s to w ard ch a n g e , th e s u b s e q u e n t sessio n s

s u p p o rte d . T h e th e ra p is t s h o u ld h e lp h im

w ill fo cu s on id e n tify in g an d su p p o rtin g

see h im s e lf as a n in d iv id u a l w h o w an ts

a d d itio n a l ste p s in th e sa m e d ire ctio n . T h e

w h a t's b e s t fo r b o th h im s e lf an d h is fa m ily .

fo llo w in g are e x a m p le s o f te c h n iq u e s th a t m ig h t
be used in th e re m a in in g se ssio n s w ith th e c lie n t
in th is ca se stu d y .

O n e e ffe c tiv e s tra te g y is to e n c o u ra g e the

c lie n t to a d o p t a " h e lp e r " ro le in so m e a rea of
h is life . T h is sh ifts th e fo c u s fu rth e r fro m h is

S et up a te rm in a tio n p o in t. T h e th e ra p ist
co u ld a sk th e clie n t to d e sc rib e th e sig n s th a t
th in g s are g e ttin g b e tte r fo r h im , or ask,
"W h a t th in g s w ill y o u b e d o in g d iffe re n tly ? "

100

v ie w o f h im s e lf as a h e lp le s s, in co m p e te n t
a d d ic t to a stro n g , ca rin g , c o m p e te n t p e rs o n
w h o ca n h e lp o th e rs. T h is c lie n t's

B r ie f S tra teg ic /In tera ctio n a l T herapies

p a rticip a tio n in A A m ig h t g iv e h im th e

e m p h a s iz e u n c o n s c io u s fa c to rs in c h a n g e and

o p p o rtu n ity to h elp o th e rs in th is m a n n er.

th e im p o rta n c e o f in d ire c t w a y s to sh ift

A s the en d o f the th e ra p e u tic p ro c e ss n e a rs,

the th e ra p ist h e lp s th e c lie n t p re p a re fo r the
fu tu re. F o llo w in g a re su g g e s tio n s fo r h o w the
th e ra p ist can do this.

P repare the clien t to m ain tain p o sitiv e ch an g e

m e a n in g s a n d b e h a v io r. H is a p p ro a c h is activ e,
b u ild in g on c lie n ts ' re s o u rc e s to h e lp th e m attain
th eir g o a ls. T h e th e ra p is t a n d c lie n t c o o p e ra te in
b u ild in g an a w a re n e s s o f th e c lie n t's ex p erien ce
and an u n d e rs ta n d in g o f its m ean in g . T o g e th e r,
th ey b u ild a c o n te x t fo r c h a n g e .

throu gh d ifficu lt tim es. It is u se fu l to co n v e y

the id ea th at th e le a rn in g c u rv e is n e v e r a

E rik s o n 's in te rv e n tio n s e m p h a s iz e the

fo llo w in g :

stra ig h t slo p e ; ra th e r, it is a cu rv y lin e, w ith

p eak s and d ip s. T h e re w ill b e slip s. It is

im p a sse , re fra m in g th e p ro b le m , and ta k in g a

u n rea listic to e x p e c t p e rfe c tio n . L ife w ill

first step to w a rd s o lv in g it

c o n tin u o u sly h a v e "u p s and d o w n s " the

g o al is n o t to m a k e th in g s e v e n b u t to co p e

u n iq u e re s p o n s e th a t b u ild s a b rid g e fo r

Id en tify w h at the p o ten tia l n ext stressors an d

le a rn in g ; th e th e ra p is t u se s th e c lie n t's

ch allen g es w ill be. W o rk th ro u g h th e

m e ta p h o rs (e .g ., if th e c lie n t se e s re co v ery as

fo llo w in g q u e stio n w ith the clie n t: "G iv e n

a ro a d , th e n th e th e ra p is t ca n s p e a k of

w h at w e 'v e le a rn e d , h ow w o u ld y o u co p e

b rid g e s or o f s m o o th in g th e w a y , th u s

w ith the n e x t s tre s s o r/ c h a lle n g e ? "

a c tiv a tin g th e c lie n t's im a g in a tio n in the

D ev ote som e tim e to p re p a rin g the clien t f o r

s e rv ic e o f th e c h a n g e p ro c e s s )

ch an g es to the en v iron m en t. F o r e x a m p le , h ow
w ill sig n ific a n t p e o p le in h is life re a c t to h is

n e ed s

A sk the clien t to lo o k in to the fu t u r e at the en d o f

the treatm en t p erio d a n d tell the th erap ist w h ere

A n o rien ta tio n to w a rd th e fu t u r e (e.g .,

d e p re s s io n is se e n as th e re s u lt o f fo cu sin g on

he in ten ds to be at a certain tim e (th is is an

p a s t a s s o c ia tio n s ; as th e c lie n t w o rk s to w ard

E rikson ian ap p roa ch ). T h e th e ra p ist co u ld ask

c h a n g e an d b e g in s to a c c o m p lis h g o a ls, she

fo r a sp e cific d a te w h en the c lie n t e x p e c ts to

lets g o o f d e p re s s io n )

g e t th e re and a sk the c lie n t to c a ll the

th e ra p ist o n th a t d a te . T h is p ro c e s s sets up

T h e sy m p to m as a c o m m u n ic a tio n th a t
c o n v e y s in fo r m a tio n a b o u t d e v e lo p m e n ta l

ch a n g e in b e h a v io r?

M eta p h o r as in d ire c t in te rv e n tio n a w ay to

h e lp th e c lie n t re trie v e re s o u rc e s an d cre a te a

e ffe ctiv e ly w ith th e se u p s an d d o w n s.

S u g g estion as a m e a n s o f b y p a ss in g an

A cq u irin g n e w sk ills to m e e t the

r e q u ire m e n ts o f n e w s itu a tio n s (su ch as the

an e x p e cta tio n o f p ro g re ss and

d iffe re n t w a y s o f s o c ia liz in g a s s o c ia te d w ith

a cco u n ta b ility .

a b stin e n c e ) a n d to h a n d le d e v e lo p m e n ta l

Ericksonian Therapy
A ll fo rm s o f stra te g ic / in te ra c tio n a l th e ra p ie s

ta sk s

T h e cu re c o n c e p tu a liz e d a s th e lo ss o f the

h av e th eir ro o ts in the w o rk o f M ilto n E rik so n ,

s y m p to m an d as th e d e v e lo p m e n t o f new

an in n o v a tiv e p s y c h o th e ra p is t w h o w a s o n e of

re la tio n a l p a tte rn s th a t a llo w a cre a tiv e

the first th e o rists to s u g g e s t the im p o rta n c e of

re s p o n s e to th e e n v iro n m e n t

w o rk in g w ith in th e c lie n t's " f r a m e ." W ith h is

W h ile E rik s o n w a s a b le to w o rk w ith

u n iq u e u se o f h y p n o th e ra p y h e fo ste re d rap id

v irtu a lly all c lie n ts u sin g th e se te ch n iq u e s, h is

ch an g e s in his clie n ts, o fte n in an in d ire c t

w o rk h a s b e e n e sp e c ia lly u se fu l in h e lp in g

fash ion . T h ro u g h th is w o rk h e c a m e to

p e o p le le t g o o f tra u m a , b re a k th ro u g h a

101

C h ap ter 5

B erg an d M ille r re la te th e "c e n tr a l

re sista n ce to ch a n g e , an d a lte r o b s e s s iv e co m p u lsiv e , p h o b ic, or a d d ic tiv e b eh a v io r.

Solution-Focused Brief Therapy

p h ilo s o p h y " o f s o lu tio n -fo c u s e d th e ra p y in the

fo llo w in g th ree ru le s (B e rg an d M ille r 1992,
p. 17):

S o lu tio n -fo cu se d b rie f th e ra p y w a s d ev elo p e d

by S te v e D e S h a z e r and h is c o lle a g u e s at the
B rief F am ily T h e ra p y C e n te r in M ilw a u k e e ,
W isco n sin . In s o lu tio n -fo c u s e d b rie f th e ra p y ,

1.

" I f it a in 't b ro k e , d o n 't fix it!"

2.

O n ce y o u k n o w w h a t w o rk s , d o m o re o f it!

3.

If it d o e s n 't w o rk , th e n d o n 't d o it a g a in do
so m e th in g d iffe re n t!

the e m p h a sis is p la ced on b u ild in g e x ce p tio n s to

the p re se n tin g p ro b le m and m a k in g rap id

S o lu tio n -fo c u s e d in te rv ie w in g stra te g ie s

tra n sitio n s to id e n tify in g an d d e v e lo p in g

in clu d e th e fo llo w in g (b a se d o n G io rla n d o and

s o lu tio n s in trin sic to the c lie n t or p ro b lem

S c h illin g , 1 9 9 6 ), p re s e n te d in a ty p ic a l seq u en ce .

(C o o p er, 1995 ). B a sic ten e ts o f th is a p p ro a ch

T h e s e s tra te g ie s ca n b e a p p lie d a t d iffe re n t

in clu d e the fo llo w in g :

p o in ts in th e th e ra p e u tic p ro c e s s as a p p ro p ria te .

F o cu sin g on c o m p e te n c e ra th e r th an
p a th o lo g y

h a p p e n e d a n d [y o u r c o n d itio n ] w e re

F in d in g a u n iq u e s o lu tio n fo r e a ch p e rso n

su d d e n ly n o t a p ro b le m fo r y o u , h o w w o u ld

U sin g e x c e p tio n s to th e p ro b le m to o p en the

y o u r life b e d iffe r e n t? ").

d o o r to o p tim ism

A sk a b o u t e x c e p tio n s (e .g ., " A r e th e re e v e r
tim e s y o u se e p ie c e s o f th e m ira c le ? ").

U sin g p a st su cc e s s e s to fo ste r c o n fid e n ce

L o o k in g to the c lie n t as th e e x p e rt

U sin g g o a l-s e ttin g to ch a rt a p a th to w a rd

an d th e d e sire d p ro b le m -fre e sta te (e.g.,

ch an g e

"W h a t is th e d iffe re n c e b e tw e e n th e tim es

S h a rin g the re s p o n s ib ility fo r ch a n g e w ith

w h e n y o u c a n see p ie c e s o f th e m ira c le and

the clie n t

th e tim e s w h e n y o u c a n s e e o n ly th e

T h e b a sic te n e ts o f th e s o lu tio n -fo c u s e d

m o d e l are fa irly sim p le ; th ey are the sa m e w h en

w o rk to w a rd th e " m ir a c le ," h e r c o n fid e n ce in

h e r a b ility to c h a n g e , an d th e ste p s n e ed e d to

co n cern s. A th e ra p ist u ses th e se sa m e p rin c ip le s

im p ro v e th e s itu a tio n fro m o n e ra tin g on the

fo r an in d iv id u a l clie n t, fa m ily , or g ro u p . T h e

p ro b lem , n o t on d is co v e rin g th e c a u se or o rig in s

sca le to th e n e x t h ig h e st.

T ry ta k in g " tim e -o u ts " an d s u g g e s t to the

clie n t "W h ile I ste p o u t, I w a n t y o u to th in k

o f the p ro b le m . A c c o rd in g to G io rla n d o and

o f th e n e x t s m a lle s t ste p y o u co u ld ta k e that

S ch illin g ,

w o u ld b rin g y o u to th e n e x t n u m b e r on the

The innovative perspective of solution-focused

therapy shifts the emphasis from problems to
solutions, empowering the client to access her

U se sc a lin g to d e te rm in e h o w w e ll th e c lie n t
th in k s th in g s a re g o in g , h o w w illin g sh e is to

they are fo r tre a tin g o th e r m e n ta l h e a lth

th e ra p ist e m p h a s iz e s fin d in g so lu tio n s to a

E x p lo re d iffe re n c e s b e tw e e n c u rre n t sta tu s

p ro b le m ? ").

used fo r tre atin g s u b s ta n c e a b u se d is o rd e rs as

s c a le ."

A ffirm c lie n t c o m p e te n c ie s (e .g ., tell the

internal resources, strengths, and past

successes, with therapist and client working

clie n t, " I a m im p re s se d y o u a re sittin g in th at

collaboratively to achieve change in a shorter

time than that required by traditional schools
of psychotherapy (Giorlando and Schilling,

th r o u g h " ). M a n y o f th e se c lie n ts h a v e n e v e r

1996).

102

A sk th e "m ir a c le q u e s tio n " (i.e., " I f a m iracle

ch a ir a g a in a fte r w h a t y o u ju s t w e n t

h a d th is s u c c e s s a c k n o w le d g e d b efo re .

B r ie f S tra teg ic/In tera c tio n a l T herapies

S u g g e st ta sk s th a t th e c lie n t ca n p e rfo rm to

w o rk . H o w e v e r, th e th e ra p is t n o te s th a t she

im p ro v e h e r s itu a tio n (e .g ., a sk h e r to do

b e g a n u sin g a fte r th e d e a th o f h e r sp o u se and

s o m e th in g a c h ie v a b le th a t w o u ld p ro v id e

th e re fo re h y p o th e s iz e s th a t th e s u b sta n ce

u sefu l in fo rm a tio n or m o v e h e r c lo se r to the

a b u se is re la te d to h e r d e e p g rief. T h e

"m ir a c le " sh e h a s ch o se n ).

c h a lle n g e fo r th e th e ra p is t is to w o rk w ith the

c lie n t's p o sitio n in a w a y th a t a llo w s fo r a

The MRI Therapeutic Model

m o re u se fu l u n d e rs ta n d in g o f the p ro b lem ,

T h e M e n ta l R e se a rc h In s titu te 's b rie f th e ra p y

an d th e re fo re fo r n e w , m o re e ffe ctiv e

m o d e l is b a se d on th e b e lie f th a t p ro b le m s
d ev elo p fro m , an d a re m a in ta in e d b y , th e w a y

so lu tio n s.

th at n o rm a l life d iffic u ltie s are p e rc e iv e d and

h a n d led (F isch e t al., 19 8 2 ). N o rm a l d ifficu ltie s

an d w h a t w o u ld b e th e s ig n s o f ch a n g e ?

b eco m e p ro b le m s w h e n an in d iv id u a l

R ev iew a ttem p ted so lu tio n s. W h a t h a s the

clie n t d o n e to try to s o lv e th e p ro b le m ?

co n tin u a lly m is h a n d le s a s itu a tio n , u sin g the

sam e in e ffe ctiv e a p p ro a c h e a ch tim e. A c lie n t's

S tate g o a ls . W h a t b e h a v io rs a re to b e ch a n g ed

W h a t h a s w o rk e d , a n d w h a t h a s n o t w o rk e d ?

R efra m e th e situ a tio n . H e lp th e c lie n t ch a n g e

b e lie f sy ste m ca n ca u se h im to d e v e lo p

h is p e rc e p tio n o f h im s e lf, o th e rs in v o lv e d , or

in e ffe ctiv e a p p ro a c h e s to p ro b le m s th a t re s u lt in

th e p ro b le m s itu a tio n so th a t n e w o p tio n s

m a in ta in in g or e v e n e x a c e rb a tin g th e d iffic u lty .

ca n a p p e a r.

T h e m o re th e c lie n t u ses an in e ffe c tiv e so lu tio n

D ev elo p seco n d o rd e r ch an g e. H e lp th e clie n t

to so lv e a p ro b le m , th e m o re th e p ro b le m is

g e n e ra te m o re e ffe c tiv e so lu tio n s th a t lea d in

re in fo rce d an d m a in ta in e d . T h e s o lu tio n lie s in

a d iffe re n t d ire c tio n fro m th e in e ffe c tiv e

h e lp in g the clie n t c h a n g e h is p e rc e p tio n o f the

o n e s e ith e r b y m o d ify in g a tte m p ted

p ro b lem , th e n e ith e r m o d ify th e a tte m p te d

so lu tio n s or b y d e v e lo p in g n e w o n es. In the

so lu tio n so it h a s a g re a te r c h a n c e o f su c ce s s or

c a se o f a clie n t w h o h a s tried to co n tro l h er

d ev ise a m o re e ffe c tiv e s o lu tio n . T h e s e n ew

d rin k in g b y o b s e s s in g o v e r h e r n e ed to stop

so lu tio n s (g e n e ra lly re fe rre d to as secon d o rd er

d rin k in g , th e th e ra p is t m ig h t p e rc e iv e th at

chan ge) w o rk b e s t if th e y a re s u ffic ie n tly

e v e ry tim e sh e th in k s a b o u t co n tro llin g h er

d iffe re n t fro m th e in e ffe c tiv e , p re v io u sly

d rin k in g s h e a c tiv a te s h e r fe a rs th a t sh e is

atte m p ted so lu tio n s.

w e a k a n d o u t o f c o n tro l. T h e m o re she

In e a ch se ssio n , p ra c titio n e rs u sin g th e M R I

o b s e s s e s o v e r c o n tro llin g h e r d rin k in g the

b rie f th e ra p y m o d e l sh o u ld try to d o the

m o re o v e rw h e lm e d sh e b e c o m e s a b o u t the

fo llo w in g :

im p o s s ib ility o f th e ta sk . T h e th e ra p ist

w o u ld try to h e lp th is c lie n t to sto p o b sessin g

D efin e the p rob lem in b eh av iora l term s. F or

o v er th is ta sk a n d in s te a d v ie w th e situ a tio n

e x a m p le , a c lie n t m a y sa y , " I fe e l co m p e lle d

to jo in th e o th ers a t w o rk in d rin k in g ,

as m a n a g e a b le a n d c h a n g e a b le in a ste p -w ise

a lth o u g h as a re s u lt I h a v e s u c h a 's h o rt fu s e '

fa sh io n . T h e th e ra p is t w o u ld h e lp h e r see

th at I g et in fig h ts an d e v e n h u rt m y w ife ."

th a t sh e h a s b e e n s tro n g a n d ca p a b le in oth er

D eterm in e h o w the clien t u n d ersta n d s the

a sp e c ts o f h e r life a n d th a t s h e ca n m a k e use

problem . W h a t is h e r " fr a m e o f re fe re n c e " or

o f th e se s tre n g th s an d c o m p e te n c ie s to

"p o s itio n " ? It is im p o rta n t to u n d e rsta n d

h a n d le h is d rin k in g p ro b le m .

h ow th e clie n t v ie w s h e r p ro b le m an d w h a t

P lan f o r m a in ten a n c e o f th e n ew beh av iors.

attitu d e s sh e h a s to w a rd th e p ro b le m . For

S u p p o rt c o n tin u e d im p ro v e m e n t b y

e x a m p le , a c lie n t m ig h t in s is t th a t h e r

p re p a rin g th e c lie n t to m e e t fu tu re ch a lle n g e s

su b sta n ce a b u se is th e re s u lt o f p re s s u re s at

a n d crises.
103

C h ap ter 5

T h e sp eed w ith w h ic h a th e ra p is t is a b le to
m o v e th ro u g h th e se ste p s w ill d ep en d on the

o rd er. T h e th e ra p is t s h o u ld try to a n sw e r

c lie n t's p a rticu la r p ro b le m , o v era ll

q u e stio n s s u c h as, "W h a t fu n ctio n d o e s the

d ev elo p m en t, c o g n itiv e c a p a c itie s, an d h is stag e

s y m p to m s e rv e in s ta b iliz in g the fa m ily ? " and ,

o f re a d in e ss to ch a n g e .

"W h a t is th e c e n tra l th e m e a ro u n d w h ich the

Haley's Problem -Solving Therapy

p ro b le m is o r g a n iz e d ? "
H a le y 's a p p ro a c h a s s u m e s th a t su b sta n ce

Ja y H aley w ro te th a t "th e r a p y c a n b e called

a b u se b y a fa m ily m e m b e r is a s y m p to m of a

stra te g ic if the th e ra p is t in itia te s w h a t h a p p e n s

fa m ily 's d e s ire to a v o id c o n fro n tin g

d u rin g th e th e ra p y an d d esig n s a p a rtic u la r

d y s fu n c tio n a l fa m ily d y n a m ic s. T h e in d iv id u a l

a p p ro a ch fo r e a ch p ro b le m " (H a le y , 1973, p. 17).

is n o t n e c e s s a rily re s p o n s ib le fo r h a v in g cre a te d

T o d o th is th e th e ra p is t w ill h a v e to id e n tify

the s y m p to m (w h ic h w o u ld fit in w e ll w ith a

so lv a b le p ro b le m s, d esig n in te rv e n tio n s to

d ise a se c o n c e p t a d d ic tio n ). A c c o rd in g to

re so lv e th em , c o rre ct th o se in te rv e n tio n s b ased

H a le y 's m o d e l, a w ife m a y d rin k to a v o id

on re sp o n se s fro m the clie n t, and e v a lu a te the

e x p re s s in g h e r ra g e a t h e r h u sb a n d fo r h a v in g

e ffe ctiv e n e ss o f the th e ra p y .

an a ffa ir. T h e h u sb a n d im p lic itly u n d e rsta n d s

H a le y 's p ro b le m -s o lv in g th e ra p y e m p h a siz e s

th a t by c o n fro n tin g h is w ife 's d rin k in g , a

o b ta in in g a c le a r sta te m e n t o f the p ro b le m an d

c o n fro n ta tio n m ig h t e n s u e o v e r h is in fid e lity

an a ccu ra te p ictu re o f the in te ra ctio n a l

an d th a t co u ld d e s tro y th e m a rria g e . T h is

s eq u en ce s th a t m a in ta in it. M o re o v e r,

a p p ro a c h re c o m m e n d s n e g o tia tin g a p a th to

sy m p to m s (i.e., p re s e n tin g d y s fu n c tio n s) or

c h a n g e b y ch a n g in g th e fa m ily p a tte rn th at

p ro b le m b e h a v io rs serv e a fu n ctio n in fa m ilie s

m ilita te s a g a in st it. T h e th e ra p is t co u ld w o rk

and ca rry m e ta p h o ric a l in fo rm a tio n a b o u t

w ith th e fa m ily to se t g o a ls a n d d e s ig n a

h ie ra rch ica l d y s fu n c tio n (H a le y , 19 8 7 ). T h ro u g h

s tra te g ic se rie s o f d ire c tiv e s to m e e t th e se g o als,

o b serv in g the c lie n t's s y m p to m a tic b e h a v io r, the

u su a lly in v o lv in g a c h a n g e in th e s e q u e n c e s of

th e ra p ist can o fte n u n d e rsta n d the u n d e rly in g

in te ra ctio n th a t m a in ta in th e p ro b le m . In the

p ro b lem m e ta p h o ric a lly . F o r e x a m p le , if a ch ild

a b o v e e x a m p le , th e w ife 's d rin k in g s e rv e s to

ru n s a w ay it can in d ica te th a t th e fa m ily is

sta b iliz e th e fa m ily an d a v o id th e re a l issu e s of

"ru n n in g a w a y " fro m c o n fro n tin g an issu e. T h is

the w ife 's a n g e r an d th e h u s b a n d 's in fid e lity .

b eh a v io r o ften sig n a ls a s o lu tio n as w ell, ca llin g

T h e th e ra p is t w o u ld w o rk w ith th e w ife to

a tte n tio n to w h a t n e ed s to b e c h a n g e d .

e x p re s s h e r a n g e r in a w a y o th e r th a n d rin k in g ,

T o m ap o u t a fa m ily 's o rg a n iz a tio n , the

th e ra p ist sh o u ld o b se rv e co m m u n ic a tio n

104

s e q u e n c e s w h o ta lk s to w h o m , an d in w h a t

and d e fin e th e issu e as o n e o f tru s t in the

m a rria g e .

6 Brief Humanistic and

Existential Therapies

u m a n istic and e x iste n tia l

h u m a n n a tu re as b a s ic a lly g o o d , w ith an

p sy c h o th e ra p ie s u se a w id e ra n g e o f

in h e re n t p o te n tia l to m a in ta in h e a lth y ,

ap p ro a c h e s to ca se co n c e p tu a liz a tio n ,

m e a n in g fu l re la tio n s h ip s a n d to m a k e ch o ice s

th e rap e u tic g o a ls, in te rv e n tio n s tra te g ie s, and

th a t are in th e in te re s t o f o n e s e lf an d o th ers. T h e

re sea rch m e th o d o lo g ie s . T h e y a re u n ite d b y an

h u m a n istic th e ra p is t fo c u s e s o n h e lp in g p e o p le

e m p h a sis on u n d e rs ta n d in g h u m a n e x p e rie n c e

fre e th e m s e lv e s fro m d is a b lin g a s s u m p tio n s and

and a fo cu s o n th e c lie n t ra th e r th a n the

a ttitu d e s so th e y ca n liv e fu lle r liv es. T h e

sy m p to m . P sy ch o lo g ic a l p ro b le m s (in clu d in g

th e ra p is t e m p h a s iz e s g ro w th an d self-

su b sta n ce a b u se d iso rd e rs) are v ie w e d as the

a c tu a liz a tio n ra th e r th a n c u rin g d ise a se s or

resu lt o f in h ib ite d a b ility to m a k e a u th e n tic,

a lle v ia tin g d is o rd e rs . T h is p e rs p e c tiv e ta rg ets

m e a n in g fu l, and se lf-d ire c te d c h o ice s a b o u t how

p re s e n t c o n s c io u s p ro c e s s e s ra th e r th an

to live. C o n s e q u e n tly , in te rv e n tio n s a re a im ed

u n c o n sc io u s p ro c e s s e s a n d p a s t ca u se s, b u t like

at in cre a sin g clie n t s e lf-a w a re n e ss an d self-

the e x is te n tia l a p p ro a c h , it h o ld s th a t p e o p le

u n d e rsta n d in g .

h a v e a n in h e r e n t c a p a c ity fo r re s p o n s ib le self-

W h e re a s the k ey w o rd s fo r h u m a n istic

d ire ctio n . F o r th e h u m a n is tic th e ra p ist, n ot

th e rap y are a cce p ta n ce an d g ro w th , th e m a jo r

b e in g o n e 's tru e s e lf is th e so u rce o f p ro b lem s.

th em es o f e x is te n tia l th e ra p y a re c lie n t

T h e th e ra p e u tic re la tio n sh ip s e rv e s as a v eh icle

resp on sibility and fr e e d o m . T h is c h a p te r b ro a d ly

or c o n te x t in w h ic h th e p ro c e s s o f p sy ch o lo g ica l

d efin e s so m e o f th e m a jo r c o n c e p ts o f th e se tw o

g ro w th is fo ste re d . T h e h u m a n istic th e ra p ist

th e ra p e u tic a p p ro a ch e s an d d e s c rib e s h o w they

trie s to c re a te a th e ra p e u tic re la tio n sh ip th a t is

can be a p p lie d to b rie f th e ra p y in th e tre a tm e n t

w a rm an d a c c e p tin g an d th a t tru sts th a t the

o f su b sta n ce a b u se d iso rd e rs. A s h o rt ca se

c lie n t's in n e r d riv e is to a c tu a liz e in a h e a lth y

illu stra te s h o w e a c h th e o ry w o u ld a p p ro a c h the

d irectio n .

c lie n t's issu es. M a n y o f th e c h a ra c te ris tic s o f

T h e e x is te n tia lis t, on th e o th e r h a n d , is m o re

th ese th e ra p ie s h a v e b e e n in c o rp o ra te d in to

in te re ste d in h e lp in g th e c lie n t fin d

o th er th e ra p e u tic a p p ro a ch e s su ch as n a rra tiv e

p h ilo s o p h ic a l m e a n in g in th e fa ce o f a n x ie ty by

th erap y .

c h o o s in g to th in k an d a c t a u th e n tic a lly and

H u m a n istic an d e x is te n tia l a p p ro a c h e s sh a re

re sp o n sib ly . A c c o rd in g to e x is te n tia l th e ra p y ,

a b e lie f th at p e o p le h a v e th e c a p a city fo r self-

the ce n tra l p ro b le m s p e o p le fa ce a re em b e d d ed

a w a ren e ss and ch o ice . H o w e v e r, the tw o

in a n x ie ty o v e r lo n e lin e ss , iso la tio n , d esp a ir,

sch o o ls co m e to th is b e lie f th ro u g h d iffe re n t

an d , u ltim a te ly , d e a th . C re a tiv ity , lov e,

th eo ries. T h e h u m a n istic p e rs p e ctiv e v ie w s

a u th e n ticity , a n d fre e w ill a re re c o g n iz e d as

105

C h ap ter 6

p o te n tia l a v e n u es to w a rd tra n sfo rm a tio n ,

fa cilita te th e ra p e u tic ra p p o rt, in c re a se self-

en a b lin g p e o p le to liv e m e a n in g fu l liv es in the

a w a re n e ss, fo cu s o n p o te n tia l in n e r re so u rces,

fa ce o f u n certa in ty an d su ffe rin g . E v e ry o n e

an d e sta b lis h th e c lie n t as th e p e rs o n re sp o n sib le

su ffe rs lo sses (e.g ., frie n d s d ie, re la tio n sh ip s

fo r re c o v e ry . T h u s, c lie n ts m a y b e m o re lik e ly to

en d ), and th ese lo sses c a u se a n x ie ty b eca u se

see b e y o n d th e lim ita tio n s o f s h o rt-te rm

they are re m in d e rs o f h u m a n lim ita tio n s and

tre a tm e n t an d e n v is io n re c o v e ry as a life lo n g

in ev ita b le d eath . T h e e x is te n tia l th e ra p ist

p ro c e s s o f w o rk in g to re a c h th e ir fu ll p o ten tia l.

re co g n iz e s th a t h u m a n in flu e n c e is sh a p e d by

B e c a u se th e se a p p ro a c h e s a tte m p t to a d d ress

b io lo g y , c u ltu re , an d lu ck . E x iste n tia l th e ra p y

the u n d e rly in g fa c to rs o f s u b s ta n c e a b u se

assu m e s the b e lie f th a t p e o p le 's p ro b le m s co m e

d iso rd e rs, th e y m a y n o t a lw a y s d ire c tly c o n fro n t

fro m n o t e x e rc isin g ch o ice an d ju d g m e n t

s u b s ta n c e a b u s e itself. G iv e n th a t th e s u b sta n ce

e n o u g h or w ell e n o u g h to fo rg e m e a n in g in

a b u se is th e p rim a ry p re s e n tin g p ro b le m and

th eir liv es, an d th a t e a ch in d iv id u a l is

sh o u ld re m a in in th e fo re g ro u n d , th ese

re sp o n sib le fo r m a k in g m e a n in g o u t o f life.

th e ra p ie s a re m o s t e ffe c tiv e ly u sed in

O u tsid e fo rces, h o w e v e r, m a y c o n trib u te to th e

c o n ju n c tio n w ith m o re tra d itio n a l tre a tm e n ts fo r

in d iv id u a l's lim ite d a b ility to e x e rc ise ch o ice

s u b s ta n c e a b u s e d is o rd e rs . H o w e v e r, m a n y of

and liv e a m e a n in g fu l life. F o r th e e x iste n tia l

the u n d e rly in g p rin c ip le s th a t h a v e b e e n

th e ra p ist, life is m u c h m o re o f a c o n fro n ta tio n

d e v e lo p e d to s u p p o rt th e se th e ra p ie s ca n be

w ith n e g a tiv e in te rn a l fo rc e s th a n it is fo r the

a p p lie d to a lm o s t a n y o th e r k in d o f th e ra p y to

h u m a n istic th e ra p ist.

fa c ilita te th e c lie n t-th e r a p is t re la tio n sh ip .

In g e n era l, b rie f th e ra p y d e m a n d s the ra p id

fo rm a tio n o f a th e ra p e u tic a llia n c e co m p a re d
w ith lo n g -te rm tre a tm e n t m o d a litie s. T h e se
th e rap ie s a d d ress fa cto rs s h a p in g s u b sta n ce
ab u se d iso rd e rs, su ch as la ck o f m e a n in g in

M a n y a s p e c ts o f h u m a n istic a n d e x is te n tia l

o n e 's life, fe a r o f d ea th or fa ilu re , a lie n a tio n

a p p ro a c h e s (in c lu d in g e m p a th y , e n c o u ra g e m e n t

fro m o th ers, an d sp iritu a l e m p tin e ss.

o f a ffe c t, r e fle c tiv e lis te n in g , a n d a c c e p ta n ce of

H u m a n istic an d e x is te n tia l th e ra p ie s p e n e tra te

th e c lie n t's su b je c tiv e e x p e rie n c e ) a re u se fu l in

at a d ee p e r lev el to issu es re la ted to s u b sta n ce

an y ty p e o f b rie f th e ra p y s e s s io n , w h e th e r it

ab u se d iso rd e rs, o fte n se rv in g as a c a ta ly s t for

in v o lv e s p s y c h o d y n a m ic , stra te g ic , or c o g n itiv e -

see k in g a lte rn a tiv e s to su b s ta n c e s to fill th e void

b e h a v io ra l th e ra p y . T h e y h e lp e sta b lis h ra p p o rt

the clie n t is e x p e rie n c in g . T h e c o u n s e lo r 's

and p ro v id e g ro u n d s fo r m e a n in g fu l

em p a th y and a cc e p ta n c e , as w ell as th e in sig h t

e n g a g e m e n t w ith a ll a s p e c ts o f th e tre a tm e n t

g ain ed by the c lie n t, c o n trib u te to th e c lie n t's

p ro cess.

re co v ery b y p ro v id in g o p p o rtu n itie s fo r h er to

106

Using Humanistic and

Existential Therapies

W h ile th e a p p ro a c h e s d is c u ss e d in this

m a k e n ew e x is te n tia l c h o ic e s, b e g in n in g w ith an

c h a p te r e n c o m p a ss a w id e v a r ie ty o f th e ra p e u tic

in fo rm ed d e cisio n to u se or a b sta in fro m

in te rv e n tio n s , th e y a re u n ite d b y an e m p h a sis on

su b sta n ce s. T h e s e th e ra p ie s c a n ad d fo r the

liv ed e x p e rie n c e , a u th e n tic (th e ra p e u tic )

c lie n t a d im e n s io n o f se lf-re s p e c t, self-

re la tio n sh ip s , an d re c o g n itio n o f th e su b je c tiv e

m o tiv a tio n , an d s e lf-g ro w th th a t w ill b etter

n a tu re o f h u m a n e x p e rie n c e . T h e re is a fo cu s on

fa cilita te h is tre a tm e n t. H u m a n istic and

h e lp in g th e c lie n t to u n d e rs ta n d th e w a y s in

e x iste n tia l th e ra p e u tic a p p ro a ch e s m a y be

w h ich re a lity is in flu e n c e d b y p a s t e x p e rie n ce ,

p a rticu la rly a p p ro p ria te fo r s h o rt-te rm

p re s e n t p e rc e p tio n s , a n d e x p e c ta tio n s fo r the

s u b sta n ce ab u se tre a tm e n t b e ca u se th e y ten d to

fu tu re. S c h o r d e s c rib e s th e p ro c e s s th ro u g h

B r ie f H u m a n is tic a n d E x isten tial T herapies

w h ich o u r e x p e rie n c e s a ssu m e m e a n in g as

c o n tin u a tio n o f re c o v e ry (e .g ., to g e t so m e o n e

ap p ercep tion (S ch o r, 19 9 8 ). B e co m in g a w a re of

w h o in s is ts on re m a in in g h e lp le s s to a cce p t

this p ro ce ss y ie ld s in s ig h t an d fa c ilita te s the

re s p o n s ib ility ). N a r ra tiv e th e ra p y m a y b e used

ab ility to ch o o se n e w w a y s o f b e in g an d actin g .

to h elp th e c lie n t c o n c e p tu a liz e tre a tm e n t as an

F or m a n y clie n ts, m o m e n ta ry circ u m sta n c e s

o p p o rtu n ity to a s s u m e a u th o rs h ip an d b e g in a

and p ro b le m s s u rro u n d in g su b s ta n c e a b u se m a y

"n e w c h a p te r " in life . G esta lt a p p ro a c h e s ca n

see m m o re p re ssin g , an d n o tio n s o f in te g ra tio n ,

a lso b e u sed th r o u g h o u t th e ra p y to fa c ilita te a

s p iritu a lity , an d e x is te n tia l g ro w th m a y b e too

g e n u in e e n c o u n te r w ith th e th e ra p is t an d the

rem o te fro m th e ir im m e d ia te e x p e rie n ce to be

c lie n t's o w n e x p e rie n c e . T ra n sp erso n a l th e ra p y

effe ctiv e . In su ch in sta n c e s, h u m a n istic an d

ca n e n h a n c e s p iritu a l d e v e lo p m e n t b y fo cu sin g

e x isten tia l a p p ro a c h e s ca n h e lp c lie n ts fo cu s on

on th e in ta n g ib le a s p e c ts o f h u m a n e x p e rie n c e

the fa ct th a t th ey d o, in d e e d , m a k e d ecisio n s

an d a w a re n e s s o f u n re a liz e d sp iritu a l ca p a city .

a b o u t su b sta n ce a b u se an d a re re s p o n s ib le fo r

T h e se a p p ro a c h e s in c re a se se lf-a w a re n e ss ,

th eir o w n re co v ery .

w h ic h p ro m o te s s e lf-e s te e m an d a llo w s fo r m o re
c lie n t re s p o n s ib ility , th u s g iv in g th e c lie n t a

Essential Skills

se n se o f c o n tro l an d th e o p p o rtu n ity to m a k e

By th eir very n a tu re , th e se m o d e ls d o n o t rely

ch o ice s. A ll o f th e se a p p r o a c h e s ca n b e u sed to

on a co m p re h e n siv e se t o f te c h n iq u e s or

su p p o rt th e g o a ls o f th e ra p y fo r su b s ta n c e a b u se

p ro ced u res. R a th e r, th e p e rs o n a l p h ilo s o p h y o f

d iso rd e rs.

the th e ra p ist m u s t b e c o n g ru e n t w ith the

a p p ro a ch e s. T h e th e ra p is t m u s t b e w illin g an d

Duration of Therapy and

Frequency of Sessions

ab le to e n g ag e th e clie n t in a g e n u in e and

A lth o u g h m a n y a s p e c ts o f th e se a p p ro a c h e s are

au th en tic fa s h io n in o rd e r to h e lp the c lie n t

fo u n d in o th e r th e ra p e u tic o rie n ta tio n s , co n cep ts

m ak e m e a n in g fu l ch a n g e . S e n s itiv ity to

lik e e m p a th y , m e a n in g , a n d c h o ic e lie a t the

" te a c h a b le " or " th e r a p e u tic " m o m e n ts is

v e ry h e a rt o f h u m a n istic a n d e x is te n tia l

essen tial.

th e ra p ie s. T h e y a re p a rtic u la rly v a lu a b le for

th e o retica l u n d e rp in n in g s a s s o c ia te d w ith th ese

When To Use Brief Hum anistic and

Existential Therapies

b rie f tre a tm e n t o f s u b s ta n c e a b u se d iso rd e rs

b e ca u se th e y in c re a s e th e ra p e u tic ra p p o rt and
e n h a n c e c o n s c io u s e x p e rie n c e an d a c c e p ta n c e of

T h e se a p p ro a ch e s ca n b e u se fu l a t all sta g e s of

re s p o n s ib ility . E p is o d ic tre a tm e n t co u ld be

re co v ery in cre a tin g a fo u n d a tio n o f re s p e c t fo r

d e sig n e d w ith in th is fra m e w o rk , w ith the

clie n ts and m u tu a l a c ce p ta n c e o f th e sig n ific a n ce

tre a tm e n t p la n fo c u s in g on th e c lie n t's ta sk s and

o f th eir e x p e rie n c e s. T h e re a re, h o w e v e r, so m e

e x p e rie n c e b e tw e e n se s s io n s . H u m a n istic and

th e rap e u tic m o m e n ts th a t len d th e m s e lv e s m o re

e x is te n tia l th e ra p ie s a s s u m e th a t m u ch g ro w th

read ily to o n e or m o re sp e c ific a p p ro a c h e s. T h e

a n d c h a n g e o c cu r o u ts id e th e m e e tin g s . W h en

d etails o f th e sp e cific a p p ro a c h e s a re laid ou t

fo cu se d on b ro a d e r p ro b le m s , th e se th e ra p ie s

la ter in th is ch a p te r. C lien t-c en tered th e ra p y , fo r

ca n b e life lo n g jo u rn e y s o f g ro w th and

e x a m p le , can b e u sed im m e d ia te ly to e sta b lish

tra n sfo rm a tio n . A t th e sa m e tim e , fo c u sin g on

ra p p o rt and to cla rify issu es th ro u g h o u t the

sp e cific s u b s ta n c e a b u se iss u e s ca n p ro v id e a

session . E x isten tial th e ra p y m a y b e u se d m o st

fra m e w o rk fo r c h a n g e a n d m o re d iscre te g oals.

e ffe ctiv e ly w h e n a c lie n t is a b le to acce ss

T h e s e te c h n iq u e s w ill a lso w o rk w e ll in

e m o tio n a l e x p e rie n ce s or w h en o b sta cle s m u st

c o n ju n c tio n w ith o th e r ty p e s o f th e ra p y .

be o v erco m e to fa c ilita te a c lie n t's e n try in to or

107

C h ap ter 6

Initial Session

m o tiv a tio n th a t th e c lie n t fe e ls a fte r th e first

T h e o p en in g se ssio n is e x tre m e ly im p o rta n t in

se s s io n is d e te rm in e d la rg e ly b y th e d e g re e of

b rie f th e ra p y fo r b u ild in g an a llia n ce ,

sig n ific a n c e e x p e rie n c e d d u rin g th e in itia l

d e v e lo p in g th e ra p e u tic ra p p o rt, an d c re a tin g a

th e ra p e u tic e n c o u n te r. A n e g a tiv e e x p e rie n ce

clim a te o f m u tu a l re sp e ct. A lth o u g h the

m a y k e e p a h ig h ly m o tiv a te d c lie n t fro m co m in g

a p p ro a ch e s d iscu sse d in th is c h a p te r h a v e

b a c k , w h e re a s a p o sitiv e e x p e rie n c e m a y in d u ce

d iffe re n t w ay s o f a d d re ssin g the c lie n t's

a p o o rly m o tiv a te d c lie n t to re c o g n iz e the

p ro b lem s, the o p e n in g s e ssio n sh o u ld a tte m p t

p o te n tia l fo r tre a tm e n t to b e h e lp fu l.

the fo llo w in g :

S ta rt to d e v e lo p the a llia n c e

E m p h a siz e th e c lie n t's fre e d o m o f ch o ice and

p o te n tia l for m e a n in g fu l ch a n g e

H u m a n istic an d e x is te n tia l a p p ro a c h e s are

A rticu la te e x p e c ta tio n s an d g o a ls o f th e ra p y

c o n s is te n t w ith m a n y te n e ts o f 1 2 -S te p

(how g o a ls a re to b e re a ch e d )

p ro g ra m s. F o r e x a m p le , e x is te n tia l and

D ev e lo p in g th e a llia n c e ca n b e u n d e rta k e n

h u m a n istic th e ra p is ts w o u ld e m b ra c e the

th ro u g h re fle ctiv e liste n in g , d e m o n stra tin g

s ig n ific a n c e stre s se d b y th e "s e r e n ity p r a y e r " to

resp ect, h o n e sty , an d o p e n n e s s ; e licitin g tru st

a ccep t th e th in g s th a t c a n n o t b e c h a n g e d , the

and c o n fid e n ce ; and a p p ly in g o th er p rin cip le s

co u ra g e to c h a n g e w h a t ca n b e c h a n g e d , an d the

th at e m e rg e fro m th e se th e ra p ie s. T h e th e ra p is t's

w isd om to k n o w th e d iffe re n c e . H o w e v e r, so m e

au th en tic m a n n e r o f e n c o u n te rin g the c lie n t ca n

w o u ld a rg u e a g a in s t th e d e g re e to w h ich

set the to n e fo r an h o n e st, c o lla b o ra tiv e

A lc o h o lic s A n o n y m o u s (A A ) id e n tifie s the

th e ra p e u tic re la tio n sh ip . E m p h a s iz in g fre e d o m

p e rs o n 's " d is e a s e " as a ce n tra l c h a ra c te r tra it, or

o f ch o ice and p o te n tia l fo r m e a n in g fu l ch a n g e

the w a y in w h ic h s o m e m ig h t in te rp re t the

m ay be d e e p e n e d by a fo cu s on th e c u rre n t

n o tio n o f " p o w e r le s s n e s s ." T h e p rin c ip le s of

d ecisio n (h o w e v e r it h a s b e e n re a c h e d ) to

e x is te n tia lis m , fre e ch o ic e , a n d fre e w ill m ay

p a rticip a te in the o p e n in g se ssio n . E x p e c ta tio n s

a p p e a r in c o m p a tib le w ith th e 1 2 -S te p

and g o als can b e a rticu la te d th ro u g h stra te g ic

p h ilo s o p h y o f a c c e p ta n c e a n d s u rre n d e r. Y et,

q u e stio n s or c o m m e n ts lik e, "W h a t m ig h t be

s u ch s u r re n d e r m u s t re s u lt fro m c o n sc io u s

a cco m p lish e d in tre a tm e n t th a t w o u ld h e lp y ou

d e c isio n s o n an in d iv id u a l's p a rt. T h e A A

liv e b e tte r " or "Y o u n o w fa ce th e ch o ice o f how

c o n c e p t o f rig o ro u s s e lf-a s s e s s m e n t o f

to p a rticip a te in y o u r o w n s u b s ta n c e a b u se

a c c e p tin g o n e 's o w n p e rs o n a l lim ita tio n s and

re c o v e ry ."

c o n tin u a lly c h o o s in g a n d re c h o o sin g to act

B eca u se o f tim e c o n stra in ts in h e re n t in

a c co rd in g to c e rta in p rin c ip le s as a w a y o f liv in g

a p p ro a ch e s to b rie f s u b s ta n c e a b u se tre a tm e n t,

life a re c o m p a tib le w ith b o th e x is te n tia l and

the e a rly p h a s e o f th e ra p y is cru cia l. U n le ss the

h u m a n istic p rin c ip le s .

th e ra p ist su c c e e d s in e n g a g in g th e c lie n t d u rin g

this e arly p h a se , the tre a tm e n t is lik e ly to b e less
effe ctiv e . "E n g a g in g " in clu d e s h e lp in g the
c lie n t in cre a se m o tiv a tio n fo r o th er a sp e cts of
s u b sta n ce ab u se tre a tm e n t su ch as g ro u p
th erap y . M o re o v e r, th e p a tte rn s o f in te ra ctio n

108

Com patibility of Hum anistic

And Existential Therapies and
12-Step Program s

Research O rientation
T h e p re d o m in a n t re s e a rc h s tra te g y or
m e th o d o lo g y in s o c ia l s c ie n c e is ro o te d in th e
n a tu ra l sc ie n c e or r a tio n a l-e m p ir ic a l
p e rs p e c tiv e . S u c h a p p ro a c h e s g e n e ra lly a tte m p t

e sta b lish e d d u rin g th e e a rly p h a se ten d to

to id e n tify a n d d e m o n s tra te c a u sa l re la tio n sh ip s

p e rsist th ro u g h o u t th e ra p y . T h e d e g re e of

b y iso la tin g sp e c ific v a r ia b le s w h ile co n tro llin g

B r ie f H u m a n istic a n d E x isten tia l T herapies

fo r o th er v a ria b le s su ch as p e rs o n a l d iffe re n ce s

q u a n tifia b le d a ta , it e m p h a s iz e s n a rra tiv e

am o n g th e ra p ists as w ell as clie n ts. F or

d e s c rip tio n s o f e x p e rie n c e . Q u a lita tiv e

e x a m p le , v a ria tio n s in b e h a v io r or o u tc o m e s are

u n d e rs ta n d in g v a lu e s u n iq u e n e ss and

o ften q u a n tifie d , m e a s u re d , an d s u b je c te d to

d iv e r sity th e " little s to r ie s " (L y o ta rd , 1 9 8 4 ) as

sta tistica l p ro c e d u re s in o rd e r to iso la te the

m u c h as g e n e r a liz a b ility or g ra n d e r

re se a rch e r fro m th e d a ta an d e n s u re o b je c tiv ity .

e x p la n a tio n s . G e n e ra lly , th is a p p ro a ch assu m e s

S u ch stra te g ie s a re p a rtic u la rly u se fu l fo r

th a t o b je c tiv ity , s u ch as is p re s u m e d in ra tio n al

in v e stig a tin g o b s e rv a b le p h e n o m e n a lik e

e m p iric a l m e th o d s , is illu s o ry . F or the

b eh av io r. T ra d itio n a l a p p ro a c h e s to

q u a lita tiv e re s e a rc h e r a n d th e th e ra p ist, the

u n d e rsta n d in g h u m a n e x p e rie n c e an d m e a n in g ,

g o a ls a re th e sa m e : o p e n n e s s to th e o th er, activ e

h o w e v e r, h av e b ee n c ritic iz e d as an in s u ffic ie n t

p a rtic ip a tio n , an d a w a re n e s s o f o n e 's ow n

m e an s to u n d e rs ta n d in g th e liv ed re a lity o f

s u b je c tiv ity , ra th e r th a n illu so ry o b je ctiv ity .

h u m a n e x p e rie n ce . V o n E c k a rts b e rg n o ted ,

In te rs u b je c tiv e d ia lo g p ro v id e s a m e a n s of

"S c ie n c e aim s fo r an id e a l w o rld o f d e p e n d e n t

co m p a rin g s u b je c tiv e e x p e rie n c e s in o rd e r to

and in d e p e n d e n t v a ria b le s in th e ir c a u sa l

fin d c o m m o n a lity an d d iv e rg e n c e as w ell as to

in te rco n n e cte d n e ss q u ite a b stra cte d and

a v o id re s e a r c h e r b ias.

re m o v ed fro m p e rs o n a l e x p e rie n c e o f the

B e ca u se h u m a n istic an d e x is te n tia l th era p ies

e v e ry d a y life -w o rld " (V o n E c k a rts b e rg , 1983,

e m p h a s iz e p s y c h o lo g ic a l p ro c e s s an d the

p. 199). S im ila rly , B le w e tt a rg u e d , "T h e

th e ra p e u tic re la tio n sh ip , a lte rn a tiv e re sea rch

im p o rta n ce o f h u m a n e x p e rie n c e re la tiv e to

s tra te g ie s m a y b e re q u ire d in o rd e r to

b e h a v io r is b e y o n d q u e stio n fo r e x p e rie n c e

u n d e rsta n d th e n e c e s s a ry a n d s u fficie n t

e x te n d s b ey o n d b e h a v io r ju s t as fe e lin g e x te n d s

c o n d itio n s fo r th e ra p e u tic c h a n g e . F or e x a m p le ,

b ey o n d the co n c e p ts o f la n g u a g e " (B lew ett,

C a rl R o g e rs "p r e s e n te d a c h a lle n g e to

1969, p. 22). T h u s, tra d itio n a l m e th o d o lo g ic a l

p s y c h o lo g y to d e s ig n n e w m o d e ls o f scie n tific

a p p ro a ch e s see m ill-su ite d fo r u n d e rsta n d in g

in v e s tig a tio n c a p a b le o f d e a lin g w ith the in n er,

the m e a n in g o f h u m a n e x p e rie n c e and the

su b je c tiv e e x p e rie n c e o f th e p e r s o n " (C o rey ,

p ro cess by w h ich s e lf-u n d e rs ta n d in g m a n ife sts

19 9 1 , p. 218 ).

itself in the c o n te x t o f a th e ra p e u tic re la tio n sh ip .

the u se o f v e rb a tim tra n sc r ip ts o f co u n se lin g

A h u m a n istic scie n c e or q u a lita tiv e

S o m e 5 0 y e a rs a g o , h e p io n e ered

s e ssio n s a n d e m p lo y e d a u d io a n d v id e o tap in g

a p p ro a ch , w h ic h h a s its ro o ts in

o f s e s s io n s lo n g b e fo re s u c h p ro c e d u re s b eca m e

p h e n o m e n o lo g y , is c la im e d to b e m o re

s ta n d a rd p ra c tic e in re s e a rc h a n d su p e rv isio n .

a p p ro p ria te fo r the c o m p le x itie s an d n u a n ce s of

u n d e rsta n d in g h u m a n e x p e rie n c e (G io rg i, 1985).
T h e p e rso n a l and u n iq u e c o n s tru c tio n of
m e a n in g , th e im p o rta n c e o f su ch su b tle tie s as

The Humanistic
Approach to Therapy

"th e re la tio n s h ip " an d th e " f i t " in th e ra p y , and

H u m a n istic p s y c h o lo g y , o fte n re fe rre d to as the

sh ifts in in te rn a l sta te s o f c o n s c io u s n e s s c a n be

"th ir d fo r c e " b e s id e s b e h a v io ris m and

q u an tified and m e a su re d o n ly in th e b ro a d e s t of

p s y c h o a n a ly s is, is c o n c e rn e d w ith h u m a n

term s. A m o re su b tle s c ie n c e is re q u ire d to

p o te n tia l an d th e in d iv id u a l's u n iq u e p e rso n a l

d escrib e h u m a n s an d th e th e ra p e u tic p ro ce ss.

e x p e rie n c e . H u m a n istic p s y c h o lo g is ts g e n erally

R ath er th an p re d ic tio n , co n tro l, an d

d o n o t d e n y th e im p o rta n c e o f m a n y p rin cip le s

rep lica tio n o f resu lts, a h u m a n istic sc ie n c e

o f b e h a v io ris m an d p s y c h o a n a ly s is. T h e y valu e

a p p ro a ch e m p h a s iz e s u n d e rs ta n d in g and

th e a w a re n e s s o f a n te c e d e n ts to b e h a v io r as w ell

d escrip tio n . In ste a d o f s ta tis tic a l a n a ly sis of

as th e im p o rta n c e o f ch ild h o o d e x p e rie n c e s and

109

C h ap ter 6

u n co n scio u s p s y c h o lo g ic a l p ro c e sse s.

N eg o tia tio n o f a co n tra ct b y fo rm a lly or

H u m a n istic p s y c h o lo g is ts w o u ld a rg u e,

in fo rm a lly a s k in g , " W h e r e d o w e g o fro m

h o w e v e r, th a t h u m a n s a re m o re th a n the

h ere?"

co lle ctio n o f b e h a v io rs or o b je cts o f u n c o n sc io u s

fo rces. T h e re fo re , h u m a n istic p s y c h o lo g y o ften

is d escrib e d as h o listic in th e se n se th a t it ten d s
to b e in clu siv e an d a c c e p tin g o f v a rio u s
th e o re tica l tra d itio n s and th e ra p e u tic p ra c tic e s.
T h e e m p h a sis fo r m a n y h u m a n istic th e ra p ists is
the p rim a cy o f e sta b lish in g a th e ra p e u tic
re la tio n sh ip th a t is c o lla b o ra tiv e , a cc e p tin g ,
au th en tic, and h o n o rs th e u n iq u e w o rld in
w h ich the clie n t liv es. T h e h u m a n istic a p p ro a ch
is also h o listic in th a t it a ssu m e s an
in te rre la te d n e ss b e tw e e n th e c lie n t's
p sy ch o lo g ica l, b io lo g ica l, so cia l, an d sp iritu a l
d im en sio n s. H u m a n istic p s y c h o lo g y assu m e s
that p e o p le h a v e an in n a te c a p a city to w a rd self-

T h e s e c h a ra c te ris tic s m a y p ro v e u se fu l at all

sta g e s o f s u b s ta n c e a b u s e tre a tm e n t. F or
e x a m p le , e m p h a s iz in g th e ch o ic e o f se e k in g h elp
as a sig n o f c o u ra g e ca n o c c u r im m e d ia te ly ;
p la cin g re s p o n s ib ility a n d w is d o m w ith the
clie n t m a y fo llo w . R e sp e c t, e m p a th y , and
a u th e n tic ity m u s t re m a in th r o u g h o u t the
th e ra p e u tic re la tio n sh ip . P la c in g w is d o m w ith
th e clie n t m a y b e u s e fu l in la te r sta g e s o f
tre a tm e n t, b u t a c lie n t w h o is c u rre n tly u sin g or
re c e n tly s to p p e d (w ith in th e la st 3 0 d a y s) m ay
n o t b e a b le to m a k e re a s o n a b le ju d g m e n ts a b o u t
h is w e ll-b e in g o r fu tu re.

u n d e rsta n d in g and p s y c h o lo g ic a l h e a lth .

So m e o f the k e y p ro p o n e n ts o f th is a p p ro a ch
in clu d e A b ra h a m M a slo w , w h o p o p u la riz e d the
c o n c e p t o f "s e lf-a c tu a liz a tio n ," C a rl R o g e rs, w h o

D em o n stra tio n o f a u th e n tic ity b y se ttin g a to n e

o f g e n u in e , a u th e n tic e n c o u n te r

E a ch th e ra p y ty p e d is c u ss e d b e lo w is
d is tin g u is h e d fro m th e o th e rs b y h o w it w o u ld
re sp o n d to th e c a s e s tu d y p re s e n te d in
F ig u re 6-1.

fo rm u la te d p e rs o n -c e n te re d th e ra p y , an d F ritz
P eris, w h o se G e sta lt th e ra p y fo c u se d o n the

Client-Centered Therapy

w h o le n e ss o f an in d iv id u a l's e x p e rie n c e a t any

C a rl R o g e rs ' c lie n t-c e n te re d th e ra p y a ssu m e s

g iv en m o m en t. S o m e o f the e sse n tia l

th a t th e c lie n t h o ld s th e k e y s to re c o v e ry b u t

ch a ra cte ristics o f h u m a n istic th e ra p y are

n o tes th a t th e th e ra p is t m u s t o ffe r a re la tio n sh ip

E m p ath ic u n d ersta n d in g o f th e c lie n t's fra m e of

in w h ic h th e c lie n t ca n o p e n ly d is c o v e r an d test

re fe re n ce an d su b je c tiv e e x p e rie n c e

h is o w n re a lity , w ith g e n u in e u n d e rs ta n d in g

R espect fo r th e c lie n t's c u ltu ra l v a lu e s an d

an d a c c e p ta n c e fro m th e th e ra p is t. T h e ra p is ts

fre e d o m to e x e rc ise ch o ice

m u s t cre a te th re e c o n d itio n s th a t h e lp clie n ts

E xploration o f p ro blem s th ro u g h an a u th en tic

ch a n g e :

and co lla b o ra tiv e a p p ro a c h to h e lp in g th e

1.

U n c o n d itio n a l p o sitiv e re g a rd

c lie n t d e v e lo p in sig h t, c o u ra g e , and

2.

A w a rm , p o sitiv e , an d a c c e p tin g a ttitu d e

re sp o n sib ility

th a t in c lu d e s n o e v a lu a tio n or m o ra l

E xploration o f g o a ls an d ex p ecta tio n s, in clu d in g

ju d g m e n t

a rticu la tio n o f w h a t th e clie n t w a n ts to

3.

A c c u ra te e m p a th y , w h e re b y th e th e ra p ist

a cco m p lis h an d h o p e s to g a in fro m tre a tm e n t

c o n v e y s a n a c c u ra te u n d e rs ta n d in g o f th e

C larification o f the h elp in g role b y d e fin in g the

c lie n t's w o rld th ro u g h sk ille d , a ctiv e

th e ra p is t's ro le b u t re s p e c tin g th e self

liste n in g

d e te rm in a tio n o f the clie n t

A ssessm en t an d en h a n cem en t o f clien t m otiv ation

b o th co lla b o ra tiv e ly an d a u th e n tica lly

110

A c c o rd in g to C a rso n , th e clie n t-c e n te re d

th e ra p is t b e lie v e s th a t

B r ie f H u m a n istic a n d E x isten tial T herapies

F ig u re 6-1
A C a s e S tu d y
T his case stu d y w ill be referred to th ro u g h o u t this ch ap ter. It w ill p ro v id e an e x a m p le to w h ich ea ch type o f
h u m an istic or ex isten tia l th erap y w ill be a p p lied .
S a n d ra is a 3 8 -y e a r-o ld A fric a n -A m e ric a n w o m a n w h o h a s a b u s e d a n u m b e r o f s u b s ta n c e s , in clu d in g
c o ca in e , h e ro in e , a lco h o l, an d m a riju a n a o v er th e p a st 15 y e a rs. S h e le ft h ig h s c h o o l a n d w a s a
p ro stitu te fo r 5 y e a rs. L a te r sh e fo u n d a jo b as a sa le s cle rk at a h o m e fu rn ish in g s sto re. S a n d ra h ad
tw o ch ild re n in h e r e a rly tw e n tie s , a d a u g h te r w h o is n o w 15, an d a so n , a g e d 18. B e c a u se o f h er
su b sta n ce a b u se p ro b le m s, th e y liv e w ith o th e r re la tiv e s w h o a g re e d to ra ise th e m . S a n d ra h a s b e e n in
tre a tm e n t re p e a te d ly an d h a s re m a in e d s u b s ta n c e fre e fo r th e la st 5 y e a rs, w ith s e v e r a l m in o r rela p se s.
She has b e e n m a rrie d fo r 2 y e a rs, to S te v e , a ca rp e n te r; h e is s u b s ta n c e fre e a n d s u p p o rts h e r a tte m p ts
to stay a w ay fro m su b sta n ce s.
L a st m o n th sh e b e ca m e s y m p to m a tic w ith A ID S . S h e h a s b e e n H IV -p o s itiv e fo r 5 y e a rs b u t h a d n ot
d ev elo p e d an y illn e sse s re la ted to th e d ise a se. S a n d ra h a s p ra c tic e d s a fe sex w ith h e r h u sb a n d w h o
knew o f h e r H IV sta tu s. R e c e n tly , a fte r le a rn in g fro m th e p h y s ic ia n a t h e r c lin ic a b o u t h e r H IV
s y m p to m s, sh e b e g a n to " s h o o t u p ," w h ich led h e r b a ck in to tre a tm e n t. O u t o f fe a r, s h e c a m e to the
tre a tm e n t ce n te r an d a sk ed to see a c o u n s e lo r a t th e c lin ic o n e d a y a fte r w o rk . S h e is w o rrie d a b o u t her
m a rria g e an d th a t h e r h u sb a n d w ill b e d e v a s ta te d b y th is n e w s. S h e is a fra id sh e is n o lo n g e r stro n g
e n o u g h to sta y a w a y fro m d ru g s sin ce d is c o v e rin g th e o n s e t o f A ID S . S h e is a lso c o n c e rn e d a b o u t h er
ch ild re n an d h e r jo b . U n c e rta in o f h o w sh e w ill k e ep on liv in g , sh e is a lso te rrifie d o f d y in g .

E ach in d iv id u a l e x ists in a p riv a te w o rld of

u n c o n d itio n a l n a tu re o f th e th e ra p is t's

e x p e rie n ce in w h ich th e in d iv id u a l is the

a cc e p ta n c e . T h is ty p e o f th e ra p y a im s n o t to

cen ter.

in te rp re t th e c lie n t's u n c o n s c io u s m o tiv a tio n or

T h e m o st b asic striv in g o f an in d iv id u a l is

c o n flicts b u t to re fle c t w h a t th e c lie n t fe e ls, to

to w ard the m a in te n a n ce , e n h a n c e m e n t, and

o v e rc o m e re s is ta n c e th r o u g h c o n s is te n t

a ctu a liz a tio n o f th e self.

a cc e p ta n c e , a n d to h e lp re p la c e n e g a tiv e

A n in d iv id u a l re a cts to s itu a tio n s in te rm s o f

a ttitu d e s w ith p o sitiv e o n es.

the w a y h e p e rc e iv e s th e m , in w a y s

R o g e rs ' te c h n iq u e s a re p a rtic u la rly u se fu l for

c o n siste n t w ith h is s e lf-c o n c e p t and v iew of

the th e ra p is t w h o is try in g to a d d re s s a

the w o rld .

s u b s ta n c e -a b u s in g c lie n t's d e n ia l an d m o tiv a te

A n in d iv id u a l's in n e r te n d e n c ie s a re to w a rd

h e r fo r fu rth e r tre a tm e n t. F o r e x a m p le , the

h e alth an d w h o le n e ss; u n d e r n o rm a l

te ch n iq u e s o f m o tiv a tio n a l in te rv ie w in g d raw

co n d itio n s, a p e rs o n b e h a v e s in ra tio n a l and

h e a v ily o n R o g e ria n p rin c ip le s (se e T IP 35,

co n s tru ctiv e w a y s an d c h o o s e s p a th w a y s

E n h a n cin g M o tiv a tion f o r C h a n g e in S u b sta n ce

to w ard p e rs o n a l g ro w th a n d self-

A b u se T rea tm en t [C S A T , 1 9 9 9 c ], fo r m o re

a ctu a liz a tio n (C a rso n , 1992).

in fo rm a tio n on m o tiv a tio n a l in te rv ie w in g ).

A clie n t-ce n te re d th e ra p is t fo c u se s on the

Response to the case study

clie n t's se lf-a c tu a liz in g co re an d th e p o sitiv e

A c lie n t-c e n te re d th e ra p is t w o u ld e n g a g e in

fo rces of the clie n t (i.e., the sk ills th e clie n t has

re fle c tiv e lis te n in g , a c c e p tin g th e c lie n t and her

used in th e p a st to d ea l w ith ce rta in p ro b le m s).

p a st, an d c la rify in g h e r c u rre n t situ a tio n and

T h e c lie n t sh o u ld a lso u n d e rsta n d the

fe e lin g s. A s S a n d ra d e v e lo p e d tru s t in the

111

C h ap ter 6

th erap ist, h e w o u ld b e g in to e m p h a s iz e h er

p s y c h o lo g ic a l g ro w th h a v e e m p h a s iz e d u sin g

p o sitiv e ch a ra c te ris tic s an d h e r p o te n tia l to

sto ry te llin g an d m y th o lo g y to e n h a n c e self-

m ak e m e a n in g fu l c h o ic e s to b e c o m e th e p e rso n

a w a re n e ss (se e C a m p b e ll, 1 9 6 8 ; F e in ste in and

she w an ts to (an d ca n ) b e c o m e . A n o th e r g o a l of

K rip p n e r, 1 9 9 7 ; M id d e lk o o p , 1989).

th e rap y w o u ld b e to h e lp h er d e v e lo p su ffic ie n t

P a rk e r a n d H o rto n a rg u e th a t " S tu d ie s in a

in sig h t so th a t sh e ca n m a k e c h o ic e s th a t re flect

v a rie ty o f d is c ip lin e s .. .h a v e s u g g e s te d th a t all

m o re clo sely th e v a lu e s an d p rin c ip le s to w h ich

c o g n itio n is in h e r e n tly m e ta p h o r ic a l" an d n o te

sh e asp ires. F or e x a m p le , sh e m a y w a n t to tell

"th e v ita l ro le th a t s y m b o lis m p la y s in

h e r h u sb a n d a b o u t h e r s y m p to m s and try to

p e r c e p tio n " (P a rk e r an d H o rto n , 1 9 9 6 , p. 83).

stre n g th e n h e r m a rria g e .

T h e a u th o rs o ffe r th e "p e r s p e c tiv e th a t the

If S a n d ra b e g a n to fe e l g u ilt a b o u t h e r p a st as

u n iv e rse is m a d e up o f s to rie s ra th e r th a n

a p ro stitu te , the th e ra p ist w o u ld d em o n stra te

a to m s " an d s u g g e st, " M y th a n d ritu a l are

a p p re cia tio n o f h e r stru g g le to a cc e p t th a t a sp e ct

v e h ic le s th ro u g h w h ic h th e v a lu e -im p re g n a te d

o f h e rself, h ig h lig h tin g th e fa c t th a t sh e d id

b e lie fs a n d id e a s th a t w e liv e b y , a n d fo r, are

e v e n tu a lly ch o o s e to lea v e it. H e m a y n o te th a t

p re s e rv e d an d tr a n s m itte d " (p. 8 2). F ro m this

she d id the b e s t sh e co u ld a t th a t tim e an d

p e rs p e c tiv e , n a rr a tiv e s re v e a l a d e e p e r tru th

u n d e rsco re h e r c u rre n t c o m m itm e n t to c h o o se a

a b o u t the m e a n in g s o f o u r e x p e rie n c e th a n a

b etter life. S a n d ra w o u ld b e s u p p o rte d and

fa c tu a l a c c o u n t o f th e e v e n ts th e m se lv e s. A s

acce p te d , n o t criticiz e d . S h e w o u ld be

F e in ste in an d K rip p n e r n o te , "P e rs o n a l

en co u ra g ed to e x p re s s h e r fe a r o f d ea th an d the

m y th o lo g ie s g iv e m e a n in g to th e p a st,

e ffe ct this fe a r h a s on h er. T h is m ig h t b e the first

u n d e rs ta n d in g to th e p re s e n t, an d d ire c tio n to

tim e in h e r life th a t s o m e o n e h a s b e e n

the fu tu r e " (F e in ste in an d K rip p n e r, 1997, p.

u n co n d itio n a lly a c c e p tin g o f h e r or fo c u se d on

138).
W h e n p e o p le tell a n d re te ll th e ir life sto rie s

h er stre n g th s ra th e r th a n h e r fa ilin g s. Sh e
ap p a re n tly h a s th e a b ility to s o lv e p ro b lem s,

(w ith th e h e lp o f a th e ra p is t), th e s to rie s e v o lv e

w h ich is re flected by h e r re tu rn to th e ra p y and

in to in c re a sin g ly m e a n in g fu l an d h e a lin g

h er in sig h t a b o u t n e e d in g h e lp . By b ein g

c o n s tru c tio n s . A s n a rra tiv e th e ra p ists liste n to

u n d e rsto o d and a c c e p te d , h e r s e lf-e s te e m and

th e s to rie s c lie n ts te ll, th e y a s s is t th e m by

sen se o f h o p e w o u ld in c re a se and h e r sh a m e

id e n tify in g a lte rn a tiv e w a y s o f u n d e rsta n d in g

w o u ld d e cre a se . S h e w o u ld fe e l s u p p o rte d in

e v e n ts in th e ir liv e s. T h u s, th e y h e lp clie n ts to

m a k in g critica l c h o ic e s in h e r life an d m o re

a ssu m e a u th o rs h ip o f th e ir liv es in o rd e r to

co n fid e n t to re su m e h e r re c o v e ry .

re w rite th e ir s to rie s b y b re a k in g p a tte rn s an d

Narrative Therapy
N a rra tiv e th e ra p y e m e rg e s fro m so cia l
co n stru ctiv ism , w h ic h a ssu m e s th a t e v e n ts in
life are in h eren tly a m b ig u o u s, an d the w a y s in
w h ich p e o p le c o n s tru c t m e a n in g are la rg ely

d e v e lo p in g n e w so lu tio n s. N a rra tiv e th e ra p y

h e lp s c lie n ts re s o lv e th e ir p ro b le m s by

in th e ir liv es h a v e a s s u m e d s ig n ifica n c e

in clu d in g th e ir re la tio n sh ip s , a re sh a p e d by
la n g u a g e and th e k n o w le d g e an d m e a n in g
co n ta in e d in th e sto rie s th ey h e a r and tell a b o u t
th eir liv es. R e c e n t a p p ro a c h e s to u n d e rsta n d in g

112

A llo w in g th e m to d is ta n ce th e m s e lv e s fro m
im p o v e r is h in g s to rie s b y g iv in g n ew

in flu e n ced b y fa m ily , c u ltu re , an d so ciety .

N a rra tiv e th e ra p y a ssu m e s th a t p e o p le 's liv es,

H e lp in g th e m b e c o m e a w a re o f h o w e v e n ts

m e a n in g to th e ir p a s t

H e lp in g th e m to see th e p ro b le m of
su b s ta n c e a b u s e as a s e p a ra te , in flu e n tia l
e n tity ra th e r th a n an in s e p a ra b le p a rt o f w h o
th ey a re (n o te th e d is c re p a n c y b e tw e e n this

B r ie f H u m a n is tic a n d E x isten tial T herapies

and the A A m e m b e r 's sta te m e n t, "M y n a m e

p o sitiv e a s p e c ts a n d p o te n tia l re s o u rc e s

is Ja n e , and I am an a lc o h o lic ")

o c c u rrin g in p e o p le 's n a rr a tiv e s th a t ca n be

C o lla b o ra tiv e ly id e n tify in g e x c e p tio n s to self-

e n h a n c e d , as w e ll as d e fic its th a t m u s t be

d efea tin g p a tte rn s

o v erco m e .

E n co u ra g in g th e m to c h a lle n g e d e stru c tiv e

In an e ffo rt to b e u n d e rs to o d , clie n ts

cu ltu ra l in flu e n c e s th ey h a v e in te rn a liz e d

s o m e tim e s tell a sto ry as a w a y o f e d u ca tin g the

C h a lle n g in g clie n ts to re w rite th e ir o w n liv es

th e ra p ist to th e ir c u ltu re or life sty le . T h e re fo re ,

a cco rd in g to a lte rn a tiv e an d p re fe rre d scrip ts

it is e s s e n tia l fo r th e th e ra p is t to a p p re c ia te the

N a rra tiv e th e ra p y ca n b e a p o w e rfu l

a p p ro ach fo r e n g a g in g clie n ts in d e sc rib in g th eir
liv es and p ro v id in g th e m w ith o p p o rtu n itie s to
gain in sig h t in to th eir life sto rie s and to ch a n g e
th o se " s c r ip ts " th ey fin d la ck in g . S to ry te llin g is
a w ay of a rticu la tin g a s u b je c tiv e , e x p e rie n tia l
tru th, and it is im p o rta n t fo r th e th e ra p ist an d
clie n t to b e co m e a w a re of th e sig n ific a n c e o f th e
story b ein g told and its p o te n tia l th e ra p e u tic
valu e.
N a rra tiv e a p p ro a c h e s to p s y c h o lo g ic a l
h ealin g h av e b ee n u sed a cro ss v a rio u s c u ltu re s
for th o u sa n d s o f y e a rs (K a tz , 19 9 3 ), b u t they
h av e o ften b ee n o v e rlo o k e d by m a in s tre a m
m e n tal h e a lth p ro fe ssio n a ls. C o n te m p o ra ry

u n iq u e in flu e n c e s (p o s itiv e an d n e g a tiv e ) o f the

c lie n t's sp e cific c u ltu ra l e x p e rie n c e s and
id e n tity . O fte n th e s e s to rie s d o n o t c o n stitu te
sh a rin g in its u su a l m e a n in g . W h e n liste n in g to
th e m , o n e m a y se n se th a t th e se sto rie s h a v e b een
to ld re p e a te d ly o v e r th e y e a rs. It is th ro u g h this
se n se o f s to r y te llin g as o ra l h is to ry th a t w e
re v e a l o u r v a lu e s, e x p e c ta tio n s , h o p e s , and fears.
F or th e th e ra p is t, a sto ry p ro v id e s in s ig h t in to
the c lie n ts ' re s p o n s e s , th e ir n e ed to a ct on th e
re s p o n s e s , an d th e ir d e s ire to b e h e a rd or
u n d e rsto o d . A sto ry ca n b e c o m e a w a y fo r a
c lie n t to b e c o m e b o th p a rtic ip a n t an d o b serv e r
in o rd e r to fin d n e w s o lu tio n s or b re a k d ow n
b a rrie rs.

a p p ro a ch e s to n a rra tiv e th e ra p y re c o g n iz e the

Response to the case study

im p o rta n ce o f u n d e rsta n d in g h o w h u m a n

T h e th e ra p is t m a y in itia lly a sk S a n d ra to

e x p e rien ce b e co m e s m e a n in g fu l. A p e rs o n 's life

d e sc rib e s o m e o f the im p o r ta n t tra n sitio n a l

is in flu e n ced by the n a rra tiv e s h e c o n stru cts,

m o m e n ts in h e r life. T h e s e m a y in c lu d e

w h ich are in tu rn in flu e n c e d b y the n a rra tiv e s of

e x a m p le s o f lo ss o f in n o c e n c e o c cu rrin g e a rly in

th o se aro u n d h im . T h u s, th e ra p y is v ie w e d as a

h e r life, h e r e x p e rie n c e o f s c h o o l, c ircu m sta n ce s

co lla b o ra tiv e a tte m p t to in c re a se c lie n ts '

an d in flu e n ce s s u r ro u n d in g p ro s titu tio n and

a w a ren e ss o f the w a y s in w h ic h e v e n ts in th eir

d ru g u se, th e e x p e rie n c e o f b e in g su p p o rte d by

liv es b e co m e sig n ific a n t. In e ffe ct, the th e ra p ist

h e r h u sb a n d , an d in te rn a l re s o u rc e s th at

says, " L e t's b e cu rio u s a b o u t y o u r story

e n a b le d h e r to e n te r tre a tm e n t a n d m a in ta in

to g e th e r."

so b rie ty . T h e th e ra p is t w o u ld a sk q u e stio n s

T h e n a rra tiv e a p p ro a c h o ften in v o lv e s p o sin g

a b o u t e x p e c ta tio n s sh e fe lt fro m fa m ily , so ciety ,

q u e stio n s in a w ay th a t situ a te s the p ro b le m as

and h e rself. S h e m a y b e a sk ed q u e stio n s like,

an e x te rn a l in flu e n ce. "W h e n th e p ro b le m is

"H o w d id a d d ic tio n in te rfe re w ith y o u r

e x te rn a liz ed , it's as if the p e rs o n ca n p e e k ou t

a tte m p ts to b e a g o o d m o th e r " or "H o w h a s fear

fro m b eh in d it" (N ich o ls an d Schw 'artz, 1998, p.

c o n trib u te d to y o u r re c e n t re la p se an d fe e lin g s

412). In s u b sta n ce a b u se tre a tm e n t, fo r e x a m p le ,

o f h o p e le s s n e s s ? " P o sitiv e a sp e c ts o f h er story

a clien t m ig h t b e a sk ed , "H o w h a s su b sta n ce

a n d e x c e p tio n s to d e s tru c tiv e a sp e c ts o f her

ab u se in flu e n ced y o u r life ? " or "H a v e th ere

n a rra tiv e co u ld b e id e n tifie d b y a sk in g

b een tim es w h en y ou d id n o t a llo w a d d ictio n to

q u e stio n s lik e , " W e r e th e re tim e s th a t y ou d id n 't

take o v e r ? " S u ch q u e stio n s ca n h e lp id e n tify

a llo w a d d ic tio n to m a k e ch o ic e s fo r y o u ? " and

113

C h ap ter 6

"H o w h as y o u r a b ility to a c c e p t lo v e and

T h is a p p ro a c h a lso re c o g n iz e s th e p o te n tia l fo r

s u p p o rt fro m y o u r h u sb a n d h e lp e d y o u ? "

g ro w th in h e r e n t in " p e a k " e x p e rie n c e s and

T h e fo cu s o f th e ra p e u tic d ia lo g co u ld then

o th er sh ifts in c o n s c io u s n e s s . A lth o u g h

sh ift to w ard d e v e lo p in g a lte rn a tiv e s to h o p eless

g ro u n d e d in p s y c h o lo g ic a l th e o ry , tra n sp e rso n a l

asp ects o f p e rs o n a l an d cu ltu ra l e x p e cta tio n s . It

p ra c titio n e rs a lso ten d to in c o rp o ra te

w o u ld b e h e lp fu l to re m in d h e r th a t re c e n t

p e rs p e c tiv e s fro m a n c ie n t w is d o m tra d itio n s.

T h e p ra c tic e o f tra n sp e rs o n a l th e ra p y is

a d v a n ce s in m e d ic a l tre a tm e n ts m e a n th a t A ID S
m a y n o t b e th e d e a th se n te n c e it w a s on ce

d e fin e d m o re b y its o r ie n ta tio n a n d sco p e ra th er

th o u g h t to b e. O th e r im p o rta n t q u e stio n s can

th an b y a p a rtic u la r s e t o f te c h n iq u e s or

h elp h e r to b e g in to c re a te a n a lte rn a tiv e story :

m e th o d s (B o o rste in , 1 9 8 0 ). W ittin e s u g g e s ts fiv e

"A s y o u b e g in to u n d e rsta n d th e p o sitiv e and

p o stu la te s fo r a tra n sp e rs o n a l p s y c h o th e ra p y

n e g a tiv e in flu e n c e s in y o u r life, w h a t q u a litie s

(W ittin e , 1989):

m u st you p o ss e s s in o rd e r to re m a in so b er and

1. T ra n s p e rs o n a l p s y c h o th e r a p y is an

d ev elo p b e tte r re la tio n sh ip s w ith y o u r h u sb a n d

a p p ro a c h to h e a lin g an d g ro w th th a t

and c h ild re n ? " S h e m a y n e ed h e lp re p la cin g

r e c o g n iz e s th e c e n tra lity o f th e s e lf in the

th ese sto rie s w ith m o re p o sitiv e n a rra tiv e s a b o u t

h e rself. A s S a n d ra ta lk s a b o u t th e p e o p le and

th e ra p e u tic p ro ce s s .
2.

e v e n ts in h er life, su ch as h e r ch ild h o o d an d h er
ch ild re n , sh e ca n d is co v e r s o m e o f h e r fe e lin g s,

all le v e ls o f th e s p e c tru m o f id e n tity (i.e.,

as w ell as the p e rs o n a l m e a n in g in h e r story .

Sh e can e x p e rie n c e a g re a t d ea l o f h e a lin g

e g o ic, e x is te n tia l, tra n sp e rs o n a l).

3. T ra n s p e rs o n a l p s y c h o th e r a p y is a p ro ce ss of

th ro u g h the th e ra p is t's fe e d b a c k an d q u e stio n s

a w a k e n in g fro m a lim ite d p e rs o n a l id e n tity

th at u n co v e r th e d e sire s an d e m o tio n s b e n e a th
h er story . A c o n tin u e d fo c u s on id e n tify in g ,

to e x p a n d e d u n iv e rs a l k n o w le d g e o f self.
4.

p ra cticin g , or e v e n im a g in in g c h a n g e s in h er

a w a re n e s s a n d in tu itio n in th e p ro c e s s of

w ay s o f liv in g .

a w a k e n in g .
5.

In tra n sp e rs o n a l p s y c h o th e r a p y , the
th e ra p e u tic re la tio n sh ip is a v e h ic le fo r the

T ra n s p e rs o n a l p s y c h o lo g y e m e rg e d as a "fo u r th

p ro c e s s o f a w a k e n in g in b o th c lie n t and

fo r c e " in p s y ch o lo g y in th e la te 1 9 6 0 s and h a s

th e ra p ist.

stro n g ro o ts in h u m a n istic an d e x iste n tia l

In te g ra tin g in s ig h ts an d p ra c tic e s in

p sy ch o lo g ie s, Ju n g ia n a n a ly sis, th e E a s t-W e s t
d ialo g , an d a n c ie n t w isd o m tra d itio n s.

e v e ry d a y life is th e g o a l o f e v e ry th e ra p y .

T ra n sp e rso n a l th e ra p y m a y b e th o u g h t o f as a

B rin g in g th e tra n sp e rs o n a l d im e n s io n to the

b rid g e b e tw e e n p s y c h o lo g ic a l an d sp iritu a l

fo re fro n t m a y in v o lv e th e fo llo w in g :

p ractice.

A tra n sp e rso n a l a p p ro a c h e m p h a siz e s

in clu d in g , th e eg o . It a c k n o w le d g e s the h u m a n

g ro w th o f th e in d iv id u a l (R o w a n , 1993)

sp iritu a l q u e st an d re c o g n iz e s the h u m a n
striv in g fo r u n ity , u ltim a te tru th , an d p ro fo u n d
fre e d o m . It cu ltiv a te s in tu itiv e w a y s o f k n o w in g
th at c o m p le m e n t ra tio n a l an d se n so ry m o d es.

E x p lo ra tio n o f " in n e r v o ic e s " in c lu d in g th o se

o f a h ig h e r s e lf th a t p ro v id e s g u id a n c e for

d e v e lo p m e n t o f the in d iv id u a l b e y o n d , b u t

114

T ra n s p e rs o n a l p s y c h o th e r a p y m a k e s u se of
th e h e a lin g re s to ra tiv e n a tu re o f su b je c tiv e

sto ry can b e g in th e p ro ce s s o f d e v e lo p in g n ew

Transpersonal Therapy

T ra n s p e rs o n a l p s y c h o th e r a p y v a lu e s
w h o le n e s s o f b e in g a n d s e lf-re a liz a tio n on

R e fin e m e n t o f in tu itio n or n o n ra tio n a l

k n o w in g

P ra c tic e o f c re a tiv ity in " f o r m a l" (art) or

in fo rm a l (p e rso n a l re la tio n sh ip s ) e n c o u n te rs

B r ie f H u m a n is tic a n d E x isten tial T herapies

M e d ita tio n

Response to the case study

L o v in g serv ice

A s th e e x is te n tia lis ts re m in d u s, th e re is n o th in g

C u ltiv a tio n o f m in d fu ln e s s

lik e d e a th to riv e t o u r a tte n tio n . A g lim p se of

U se o f d re a m s an d im a g ery

d e a th fo r e x a m p le , s e e in g th e a fte rm a th o f a

T h ese te ch n iq u e s m a y b e ta u g h t and
su p p o rte d e x p lic itly in th e th e ra p y sessio n . A t
tim es, a th e ra p ist m a y d ire c tly cu ltiv a te sh ifts in
c o n scio u sn e ss (e .g ., th ro u g h m e d ita tio n [W eil,
1972], or im a g in a l w o rk [Jo h n so n , 1 9 8 7 ]),
p ro v id in g im m e d ia te in s ig h t an d in s p ira tio n
th at m ay n o t b e a v a ila b le th ro u g h m o re
c o n v e n tio n a l m e a n s (H a rt, 1998). T h is m ay
p ro v id e clie n ts w ith a sk ill th e y ca n p ra c tic e on
th eir ow n ; in itia tin g su ch a c tiv ity re p re s e n ts a
p o te n tia l fo r b rie f in te rv e n tio n .
T ra n s p e rs o n a l th e ra p y re c o g n iz e s th e n eed
fo r b asic p s y c h o lo g ic a l d e v e lo p m e n t to b e
in te g rate d w ith s p iritu a l g ro w th (N e lso n , 1994).
W ith o u t su ch in te g ra tio n th e re is d a n g e r of
"s p iritu a l b y p a s s in g ," w h ere issu e s o f b a sic
p sy ch o lo g ica l fu n c tio n in g are a v o id e d in the
n am e o f s p iritu a l d e v e lo p m e n t. In o th e r w o rd s,
the b asic p s y c h o lo g ic a l w o rk s h o u ld b e
u n d e rta k e n first.
S u b sta n ce a b u se d is o rd e rs m a y b e seen
b ro a d ly as an a tte m p t to fill a s p iritu a l v o id .
T h ey m ay a lso b e u n d e rsto o d as a m e a n s fo r the
ego to d efen d its e lf a g a in st a n a tu ra l d riv e fo r
g ro w th . If g ro w th w e re to o ccu r, th e e g o m ig h t
find its d o m in a n c e re lin q u is h e d . A d d ic tio n , lik e
sp iritu a lity , also ra ises q u e stio n s o f s u rre n d e r
(M ay , 1991): fo r e x a m p le , to w h a t an d to w h o m
do w e s u rre n d e r? In a c u ltu re a n d a p s y c h o lo g y
th at are d o m in a te d b y issu e s o f ra tio n a l ego
co n tro l, w h a t is th e ro le o f c o n s tru c tiv e
su rren d e r (re g u la rly d e sc rib e d in s p iritu a l
tra d itio n s)? H ow d o e s c o n s tru c tiv e su rre n d e r
b eco m e d e s tru c tiv e an d d isto rte d in su b sta n ce
d e p en d e n cy ? In a d d itio n , s u b s ta n c e a b u se m a y
b e u n d e rsto o d as a m e a n s fo r sh iftin g o u t o f a
n o rm a l w a k in g sta te o f c o n s c io u s n e s s . T h is m a y
b e an a tte m p t to fu lfill an in n a te d riv e (W eil,
1972) fo r n o n ra tio n a l c o n sc io u sn e ss.

serio u s ca r c ra s h re m in d s th e w itn e s s o f h ow
v a lu a b le life is, b rin g in g u p o th e r issu es as w ell.
S a n d ra is n o w c o n fro n te d w ith d ea th d u e to
A ID S . T h is o p p o rtu n ity to fa c e d e a th an d life
s q u a re ly p ro v id e s a c h a n c e to re c o n s id e r and
re p rio ritiz e h e r life . In fa ct, it co u ld b e arg u ed
th a t th e b e s t c a ta ly s t to b rie f th e ra p y m a y b e a
d e a th se n te n c e p re c ise ly b e c a u se it h a s the
p o te n tia l to w a k e u p a n in d iv id u a l. In m a n y
re sp e c ts, h e lp in g th e c lie n t w a k e fro m h a b itu a l,
m e c h a n ic a l ro u tin e s th a t a re o fte n b a se d on eg o
p ro te c tio n a n d m o v e to w a rd a n a p p re c ia tio n
th a t th e in d iv id u a l is n o t b o u n d to or d efin e d by
a lim ite d e g o , is th e g o a l o f tra n sp e rs o n a l
th e ra p y . T h is ca n b e s e e n as a tra n sfo rm a tio n of
id e n tity .
M a n y in s p irin g in s ta n c e s o f p e o p le fa cin g
d ea th , in c lu d in g d e a th th r o u g h A ID S , h a v e
s h o w n th a t e m e rg e n t s p iritu a lity ca n ch a n g e the
q u a lity a n d d ire c tio n o f e x is te n c e v e ry q u ick ly .
F o r tre a tm e n t, th e b a sic s h a rin g o f th ese
e x p e rie n c e s w ith a g ro u p o f o th e rs in a sim ila r
p re d ic a m e n t o fte n q u ic k ly m o v e s th e c lie n t
b e y o n d is o la tio n an d a se n se o f s e lf-se p a ra te n e s s
to c o n n e c t in tim a te ly w ith o th e rs w h o
u n d e rsta n d h e r s itu a tio n . T h is c o m m u n ity m ay
n o t o n ly b rin g c o m fo rt a n d s u p p o rt b u t a lso a
d ee p se n se o f c o m m u n io n w ith h u m a n ity . In
th is in s ta n c e , b re a k in g th r o u g h th e sh e ll of
iso la tio n m a y e n a b le S a n d ra to b e g in to m a k e
n e w c o n n e c tio n s w ith h e r fa m ily a n d w ith
h e rse lf. A se n se o f in te rc o n n e c tio n , a c e n tra l
p o stu la te a n d e x p e rie n c e in th e w is d o m
tra d itio n s, m a y re p la c e h e r p e rc e iv e d iso la tio n .
S a n d ra m a y u se th is o p p o rtu n ity o f fa cin g
p o ss ib le d e a th to b e g in to e n c o u n te r an d let go
o f su ch fe e lin g s a s g u ilt, s h a m e , d isa p p o in tm e n t,
an d a n g e r th a t h a v e k e p t h e r life less sa tisfy in g
th a n it co u ld b e. A c c e s s in g th e im a g in a l
th ro u g h a rt or d re a m s , fo r e x a m p le , ca n p ro v id e
115

C h ap ter 6

a cle a r and sy m b o lic e x p re s s io n o f u n reso lv ed

are n o t as im p o rta n t as re su lts).

issu es. T h e u se o f ritu a ls or rite s-o f-p a ssa g e

in sp ire d by th e w is d o m tra d itio n s ca n p ro v id e
so m e ca ta ly s t fo r sh iftin g h e r co n s cio u s n e s s
th ro u g h fo rg iv e n e s s an d re le a se .
T h e th e ra p ist m a y e n g a g e in a w id e v a rie ty
o f m e th o d s (e.g ., im a g e ry , art, or d re a m w o rk ,
m e d ita tio n , ritu a ls), b u t th e h e a rt o f th e w o rk is
in the sim p le an d h u m a n e sp iritu a lity th a t is
em b o d ie d b y th e th e ra p is t's lo v in g p re se n c e
alon g w ith th e th e ra p is t's o p e n n e ss to e x p lo re
the fu ll ra n g e o f h u m a n e x p e rie n c e d irectly . F or
S an d ra, this e x p e rie n c e m a y b e se e n as an
o p p o rtu n ity fo r p ra c ticin g lo v e an d fo rg iv e n e ss,
m o v in g ou t fro m b e h in d rig id se lf-se p a ra te n e s s ,
facin g fe a rs, an d tra n sfo rm in g h e r s e lf
d efin itio n .

Gestalt Therapy
G e sta lt th eo ry h o ld s th a t th e a n a ly sis o f p arts
can n e v e r p ro v id e a n u n d e rs ta n d in g o f the
w h o le. In a th e ra p e u tic settin g , this a p p ro a ch
o p p o ses the n o tio n th a t h u m a n b e in g s ca n b e
u n d e rsto o d e n tire ly th ro u g h a ra tio n a l,
m e ch a n istic, sc ie n tific p ro c e ss. T h e p ro p o n e n ts
o f G e sta lt th e ra p y in s is t th a t th e e x p e rie n tia l
w o rld o f a clie n t ca n b e u n d e rsto o d on ly
th ro u g h th a t in d iv id u a l's d ire c t e x p e rie n c e and
d escrip tio n . G e sta lt th e ra p ists se e k to h elp th eir
clie n ts g ain a w a re n e ss o f th e m s e lv e s and th e
w o rld . D is c o m fo rt arises fro m le a v in g e le m e n ts
an d e x p e rie n ce s o f th e p sy c h e in c o m p le te
p rim a rily p a s t re la tio n sh ip s a n d in tra p sy c h ic
co n flicts th at are u n re so lv e d , w h ich P eris ca lls
"u n fin ish e d b u s in e s s '' (P eris, 19 6 9 ). A cco rd in g
to G e sta lt th e o ry

116

T h e in d iv id u a l's in n e r e x p e rie n c e is ce n tral.

F o r G e s ta lt th e ra p is ts th e "p o w e r is in the

p r e s e n t" (P o ls te r an d P o lste r, 1 9 7 3 ). T h is m e an s
th a t the " n o w " is th e o n ly p la c e w h e re
a w a re n e s s , re s p o n s ib ility , a n d c h a n g e ca n occu r.
T h e re fo re , th e p ro c e s s o f th e ra p y is to h e lp the
c lie n t m a k e c o n ta c t w ith the p re s e n t m o m en t.
R a th e r th a n s e e k in g d e ta ile d in te lle c tu a l
a n a ly sis, th e G e s ta lt th e ra p is t lo o k s to c re a te a
"s a fe e m e r g e n c y " in th e th e ra p e u tic e n c o u n te r.
P e ris ' in v o c a tio n to " lo s e y o u r m in d an d co m e
to y o u r s e n s e s " im p lie s th a t a fe e lin g -le v e l,
" h e r e an d n o w " e x p e rie n c e is th e o p tim a l
c o n d itio n fo r th e ra p e u tic w o rk . T h is m a y be
a c c o m p lis h e d in a fa irly s h o rt a m o u n t o f tim e by
e x p lic itly a s k in g c lie n ts to p a y a tte n tio n (e.g.,
"W h a t a re y o u a w a re o f n o w ? H o w d o es y o u r
fe a r fe e l to y o u ? "). T h e th e ra p is t m a y p o in t out
h o w th e c lie n t c o u ld b e a v o id in g th e p re se n t
m o m e n t th ro u g h in a u th e n tic " g a m e s " or w ay s
o f re la tin g s u c h a s "ta lk in g a b o u t" fe e lin g s
ra th e r th a n e x p e rie n c in g th e m d ire ctly . C lien ts
m a y b e a sk e d to e x a g g e ra te c e rta in e x p re ssio n s
(e .g ., p o u n d in g a fist) or ro le -p la y ce rta in
in te rn a l d ia lo g s (e .g ., th ro u g h an e m p ty ch a ir
te c h n iq u e ). T h e s e m a y all se rv e th e g o a l of
h e lp in g c lie n ts m o v e in to th e im m e d ia c y o f th eir
e x p e rie n c e ra th e r th a n r e m a in in g d is ta n t fro m it
th ro u g h in te lle c tu a liz a tio n o r s u b s ta n c e ab u se.
T h e te rm co n ta ct in G e s ta lt re fe rs to m e e tin g
o n e s e lf an d w h a t is o th e r th a n o n e se lf. W ith o u t
a p p ro p ria te c o n ta c t a n d c o n ta c t b o u n d a rie s
th e re is n o re a l m e e tin g o f th e w o rld . In ste a d ,
on e re m a in s e ith e r e n g u lfe d b y th e w o rld on on e

T h e o rg a n ism sh o u ld b e see n as a w h o le

h a n d or, o n th e o th e r h a n d , d is ta n t fro m the

(p h y sica l b e h a v io r is an im p o rta n t

w o rld a n d p e o p le .

co m p o n e n t, as is a c lie n t's m e n ta l and

H o w is m o re im p o rta n t th a n w h y (i.e., ca u se s

S u b s ta n c e a b u se in te rru p ts th e flo w o f w h at

e m o tio n a l life).

P eris c a lle d "o r g a n is m ic s e lf-r e g u la tio n ." T h e

B ein g in th e " h e r e an d n o w " (i.e., b ein g

re s u lt is th a t in d iv id u a ls d o n o t a ch ie v e

a w a re o f p re s e n t e x p e rie n c e ) is o f p rim a ry

sa tisfa c tio n o f th e ir n e e d s a n d c a n re m a in

im p o rta n ce .

u n a w a re o f w h a t th e ir n e e d s are. T h e su b sta n ce

B r ie f H u m a n istic a n d E x isten tial T herapies

ab u ser m a y d isto rt or th w a rt the n a tu ra l c y cle at

c o n ta c t n o w ? W h a t is th e s e n sa tio n in y o u r

an y o f the fo llo w in g p o in ts:

b o d y a t th is m o m e n t? ").

E x p e rie n cin g th e n eed

M o b iliz a tio n o f e n erg y

C o n tact

S a tisfa ctio n

W ith d ra w a l

R est

S a n d ra m a y a lso id e n tify c e rta in issu e s su ch

as s u b s ta n ce a b u s e , re la tio n sh ip d iffic u ltie s, and
the th re a t o f d e a th fro m A ID S th a t se e m to
d o m in a te h e r life. T h e th e ra p is t m ig h t in v ite her
to n a m e an d e x p lo re th e s e n sa tio n th a t the
th o u g h t o f d e a th , fo r e x a m p le , b rin g s ; p e rh a p s
th is in v o lv e s a se n se o f a v o id , o r fe e lin g cold

T re a tm e n t in v o lv e s b rin g in g a w a re n e ss to

an d d a rk , or a fe e lin g o f e n g u lfm e n t. S h e th en

e ach o f th ese d im e n sio n s an d the c lie n t's

m a y b e a sk ed to b e c o m e th e se s e n sa tio n s for

stra te g ies o f a v o id a n c e .

e x a m p le , th e th e ra p is t m a y a sk h e r to b e "th e

S u b sta n ce a b u se m a y a lso b e u n d e rsto o d as

v o id " an d e n c o u ra g e h e r to s p e a k as if sh e w ere

" in tr o je c tio n " in w h ic h th e c lie n t a tte m p ts to

th a t v o id . T h is m a y th e n o p e n p o ss ib ilitie s fo r a

"s w a llo w w h o le " or "d r in k in " h is e n v iro n m e n t

d ia lo g w ith th e v o id th ro u g h a c tin g o u t the

w ith o u t c o n ta ct an d d is crim in a tio n . T h is ty p e of

o p p o site p o la rity : s e p a ra te n e s s a n d ch o ice . T h is

clie n t b y p a sse s an d b lo c k s o th er e x p e rie n c e s

m ig h t in v o lv e u s in g an e m p ty ch a ir te c h n iq u e in

th a t m ig h t e n a b le c o n ta c t an d th e d e v e lo p m e n t

w h ic h th e c lie n t w o u ld lite ra lly m o v e in to the

o f d iscrim in a tio n . P eris m a in ta in s th a t su ch a

c h a ir o f th e " v o id ," s p e a k as if sh e w e re th at,

clie n t see k s im m e d ia te co n flu e n c e w ith o u t

an d th e n m o v e in to an o p p o s ite c h a ir and

p re p a ra to ry co n ta ct. T h is p a tte rn o f in te ra ctio n

re sp o n d in a d ia lo g . A th e ra p is t co u ld also

exte n d s to o th er re la tio n sh ip s (b e sid e s the

e x p lo re h e r in tro je c tio n th r o u g h q u e stio n s su ch

su b sta n ce ) as w ell.

as, "H o w is th is v o id d iffe re n t or th e sa m e as

In o rd e r fo r th is w o rk to p ro c e e d , the

fro m th e fe e lin g o f a lc o h o l or in re la tio n sh ip s

th e ra p ist m u st m a in ta in a fin e -tu n e d , p re se n t-

w ith y o u r c h ild re n or h u s b a n d ? " S h e m ig h t also

m o m e n t im m e d ia c y , e v e n se rv in g as a

u se th is sa m e te c h n iq u e to d ia lo g w ith fa m ily

"r e s o n a n c e c h a m b e r " (P o lste r an d P o lster, 1973)

m e m b e rs, or c e rta in a s p e c ts o f h e rself.

fo r the c lie n t's e x p e rie n c e . T h e y , to o, m u s t be

S a n d ra s e e m s to h a v e a g re a t d ea l of

ab le to m a k e an d su s ta in c o n ta c t w ith th e clie n t

"u n fin is h e d b u s in e s s " th a t in v o lv e s

and w ith th eir o w n re a ctio n s.

u n e x p re sse d fe e lin g s (e .g ., a n g e r, lo n g in g , hu rt).

Response to the case study

E x p e rim e n ta tio n w ith th e se s e n sa tio n s m ay

T h e G e sta lt th e ra p ist b e g in s w ith S a n d ra 's

cu rre n t e x p e rie n ce o f th e w o rld , s ta rtin g w ith
a w a ren e ss an d a tte n tio n . T h e th e ra p is t m ay
sim p ly h elp h e r b e c o m e a w a re o f b a sic sig h ts,
so u n d s, so m a tic re a c tio n s, fe e lin g s , and
th o u g h ts as w ell as w h a t h e r a tte n tio n d rifts to.
T h e im m e d ia te c o n ta c t b e tw e e n th e ra p is t and
clie n t is a c o m p o n e n t o f th e " n o w " w h e re th ese
sen satio n s are e x p lo re d d irectly . T h e th e ra p ist
m ig h t n o tice an d a sk a b o u t h er sty le o f ey e

b e g in to fre e h e r to e x p re s s an d m e e t th ese
fe e lin g s m o re d ire c tly . A ll o f th is w o rk
e n c o u ra g e s S a n d r a 's e x p e rim e n ta tio n w ith new
w a y s o f re la tin g b o th d u rin g an d o u tsid e o f the
se s s io n in o rd e r to m o v e in to th e " h e r e and
n o w " an d w o rk to w a rd th e re s o lu tio n of
" u n fin is h e d b u s in e s s ."

The Existential Approach

To Therapy

co n tact, or h er fid g e tin g b o d y , or s tre a m o f

th o u g h ts (e.g ., "W h a t is it lik e to m a k e ey e

T h e e x is te n tia l a p p r o a c h to th e ra p y e m p h a siz es
th e fo llo w in g six p ro p o s itio n s :
117

C h ap ter 6

1.

2.

3.

4.

A ll p e rso n s h a v e th e c a p a c ity fo r self-

h u m a n istic a p p ro a c h e s a n d te ch n iq u e s. Y a lo m ,

a w a ren e ss.

fo r e x a m p le , p e rc e iv e s th e th e ra p is t as a "fe llo w

A s fre e b ein g s, e v e ry o n e m u st a c c e p t the

tr a v e le r " th ro u g h life , an d h e u ses e m p a th y and

re sp o n sib ility th a t c o m e s w ith fre e d o m .

s u p p o rt to e lic it in s ig h t a n d c h o ic e s. H e

E ach p e rso n h a s a u n iq u e id e n tity th a t can

stro n g ly b e lie v e s th a t b e c a u se p e o p le e x ist in the

on ly b e k n o w n th ro u g h re la tio n sh ip s w ith

p re s e n c e o f o th e rs, th e re la tio n a l c o n te x t of

oth ers.

g ro u p th e ra p y is an e ffe c tiv e a p p ro a c h (Y a lo m ,

E ach p e rs o n m u st c o n tin u a lly re cre a te

1980).

h im self. T h e m e a n in g o f life an d of
e x iste n ce is n e v e r fix e d ; ra th e r, it c o n sta n tly

in d ic a te in d iv id u a ls w ith low le v e ls o f p e rce iv e d

ch an g e s.

m e a n in g in life m a y b e p ro n e to s u b s ta n c e a b u se

5.

A n x iety is p a rt o f th e h u m a n co n d itio n .

as a c o p in g m e c h a n is m . F ra n k l firs t o b serv e d

6.

D eath is a b a sic h u m a n c o n d itio n th a t g iv e s

this p o ss ib ility a m o n g in p a tie n t d ru g a b u sers in

sig n ifica n c e to life.

G e rm a n y d u rin g th e 1 9 3 0 s (F ra n k l, 1959).

T h e co re q u e stio n a d d re sse d in e x iste n tia l

th e ra p y is "H o w d o I e x is t? " in th e fa ce of
u n certa in ty , c o n flic t, or d ea th . A n in d iv id u a l
ach iev es a u th e n tic ity th ro u g h c o u ra g e an d is
th u s ab le to d efin e an d d isc o v e r h is o w n
m e a n in g in th e p re s e n t an d th e fu tu re. T h e re
are im p o rta n t c h o ic e s to b e m a d e (e.g ., to h a v e
tru e fre e d o m an d to ta k e re s p o n s ib ility fo r o n e 's
life, o n e m u st fa ce u n ce rta in ty an d g iv e up a
false sen se o f secu rity ).
A co re ch a ra c te ris tic o f th e e x is te n tia l v ie w is
that an in d iv id u a l is a "b e in g in th e w o rld " w h o
h as b io lo g ica l, so cia l, an d p s y c h o lo g ic a l n eed s.
B ein g in the w o rld in v o lv e s th e p h y sica l w o rld ,
the w o rld o f re la tio n sh ip s w ith o th e rs, an d o n e 's
ow n re la tio n sh ip to s e lf (M a y an d Y a lo m , 1995,
p. 265). T h e " a u th e n tic " in d iv id u a l v a lu e s
sy m b o liz a tio n , im a g in a tio n , and ju d g m e n t and
is ab le to u se th e se to o ls to co n tin u a lly cre a te
p e rso n a l m e a n in g .
E x iste n tia l th e ra p y fo cu se s o n sp e cific
co n c ern s ro o te d in th e in d iv id u a l's e x isten ce.
T h e co n te m p o ra ry e x is te n tia l p s y c h o th e ra p is t,
Irv in Y a lo m , id e n tifie s th e se c o n c e rn s as d eath ,
isolation , fr e e d o m , an d em p tin ess. E x iste n tia l
th e ra p y fo cu se s o n th e a n x ie ty th a t o ccu rs w h en
a clie n t co n fro n ts th e c o n flic t in h e re n t in life.
T h e ro le o f th e th e ra p is t is to h elp th e clie n t
fo cu s on p e rs o n a l re s p o n s ib ility fo r m a k in g
d ecisio n s, an d the th e ra p is t m a y in te g ra te so m e
118

P re lim in a ry o b s e r v a tio n s a n d re s e a rc h

N ic h o lso n a n d c o lle a g u e s fo u n d in p a tie n t d ru g

a b u se rs h a d s ig n ific a n tly lo w e r lev els of
m e a n in g in life w h e n c o m p a re d to a g ro u p of
m a tc h e d , n o n a b u sin g c o n tro l su b je cts
(N ic h o ls o n et al., 1 9 9 4 ). S h e d le r a n d B lo ck
p e rfo rm e d a lo n g itu d in a l s tu d y an d fo u n d th at
lo w e r le v e ls o f p e rc e iv e d life m e a n in g a m o n g
y o u n g c h ild re n p re c e d e d s u b s ta n c e a b u se
p a tte rn s in a d o le s c e n c e (S h e d le r an d B lo ck ,
1990).
In th e c o n te x t o f tre a tin g s u b s ta n c e a b u se
d iso rd e rs, th e e x is te n tia l th e ra p is t o fte n serv e s
as a c o a c h h e lp in g th e c lie n t c o n fro n t th e a n x ie ty
th a t te m p ts h im to a b u s e su b s ta n c e s. T h e c lie n t
is th e n fo cu s e d o n ta k in g re s p o n s ib ility and
m a k in g h is o w n c h o ic e s to re m a in su b sta n ce
free. If h e c h o o s e s to a v o id th e a n x ie ty th ro u g h
su b s ta n c e s, h e c a n n o t m o v e fo rw a rd to fin d
tru th a n d a u th e n tic ity . T h e c h a lle n g e fo r the
e x is te n tia l th e ra p is t is to h e lp th e c lie n t m a k e
p e rs o n a l d e c is io n s a b o u t h o w to liv e, d ra w in g
u p o n c re a tiv ity a n d lo v e , in s te a d o f lettin g
o u tsid e e v e n ts d e te rm in e b e h a v io r.

Time and Existential Therapy

A lth o u g h e x is te n tia l th e ra p y m a y n o t h a v e b ee n
d e sig n e d fo r p ra c tic e in a tim e -lim ite d fa sh io n ,
its u n d e rly in g p rin c ip le s re la tin g to th e c lie n t's
stru g g le fo r m e a n in g in th e fa c e o f d ea th ca n b e
a p p lie d to a tim e -lim ite d se ttin g . B rie f th e ra p y

B r ie f H u m a n istic a n d E x isten tial T h erapies

(no m a tte r w h a t the m o d a lity ) m u s t b e

an d w a y s o f d e a lin g (o r n ot d e a lin g ) w ith

co n cern e d w ith th e "h e r e an d n o w ." B oth

ch o ice s a b o u t s u b s ta n c e a b u se . T h e fo c u s in her

e x iste n tia l an d b rie f th e ra p ie s a re a lso co n c e rn e d

th e ra p y w o u ld b e o n c h o o s in g th e life sh e w an ts

w ith the lim ita tio n s o f tim e. H o y t s u g g e sts th a t

to liv e. T h e th e ra p is t w o u ld a s s is t h e r in d ealin g

in b rie f th e ra p y tim e sh o u ld a lw a y s b e an issu e

c o n s tru c tiv e ly w ith a n x ie ty so th a t she ca n find

fo r d iscu ssio n , and the th e ra p is t sh o u ld m a k e a

m e a n in g in th e re s t o f h e r life. T h is co u ld be

p o in t o f re m in d in g the c lie n t o f his u se o f tim e

a c c o m p lis h e d b y e n g a g in g h e r in th e stru g g le to

and the tim e s c h e d u le d fo r te rm in a tin g th e ra p y

a ssu m e a u th o rs h ip o f h e r c h o ice s . S h e m a y be

(H o y t, 1995).

e n c o u ra g e d to " p la y o u t" s c e n a rio s o f ch o ice s

M a n n 's m o d e l o f tim e -lim ite d p s y c h o th e ra p y

sh e fa c e s a n d a c k n o w le d g e th e a c c o m p a n y in g

(M an n , 1973; M a n n an d G o ld m a n , 1994),

fe a rs an d a n x ie tie s. S h e m ig h t b e a sk ed , "W h a t

alth o u g h b a se d in p a rt o n p s y c h o d y n a m ic

k e e p s y o u fro m s h a rin g y o u r fe a rs w ith y o u r

th eory, also u ses a n e x is te n tia l a p p ro a c h to th e

h u sb a n d , a n d a c c e p tin g th e p o ss ib ility o f his

p rim a cy o f tim e. In M a n n 's a p p ro a c h , th e tim e

s u p p o r t? " or "Im a g in e y o u rs e lf e x p re s s in g you r

lim ita tio n o f b rie f th e ra p y is e m p h a s iz e d to h elp

lo v e fo r y o u r c h ild re n an d re g re t fo r the

the c lie n t co n fro n t issu es o f s e p a ra te n e s s and

m is ta k e s y o u h a v e m a d e ." T h u s, th e th e ra p ist

iso la tio n . T h is fa c ilita te s th e c lie n t's b e c o m in g

w o u ld h e lp h e r u n d e rs ta n d th a t m a k in g d ifficu lt

en g a g ed in an d re s p o n s ib le fo r th e p ro c e s s o f

ch o ice s in th e fa ce o f d e a th is a c tu a lly a w a y to

reco v ery .

fin d in te g rity , w h o le n e s s , a n d m e a n in g .

Response to the case study

A n e x iste n tia l th e ra p is t m a y h e lp S a n d ra
u n d e rsta n d th a t h e r d ia g n o sis o f A ID S fo rces
h er to co n fro n t the p o ss ib ility o f d e a th an d ,
co n se q u e n tly , fa ce th e re s p o n s ib ilitie s th ru st
up on h e r b y life. T h e th e ra p is t c o u ld a c c o m p lish
this b y h e lp in g h e r u n d e rsta n d th a t h e r life (like
ev e ry o n e e ls e 's ) is fin ite. T h e re fo re , sh e is
ch a lle n g e d to fo rg e m e a n in g fro m h e r life and
m ak e d ifficu lt d e c is io n s a b o u t h e r re la tio n sh ip s

T h e te a c h in g s o f th e e x is te n tia l th e ra p ist,
Y a lo m , ca n b e a u se fu l re s o u rc e in d ea lin g w ith
issu es re la te d to d e a th , sin ce h e h a s w o rk e d w ith
te rm in a lly ill c a n c e r p a tie n ts fo r m a n y y ears,
h e lp in g th e m to u se th e ir cris is a n d th e ir d a n g er
as an o p p o rtu n ity fo r c h a n g e (Y a lo m , 1998).
Y a lo m e x p la in s th a t a lth o u g h d e a th is a p rim a ry
s o u rc e o f a n x ie ty fo r a c lie n t, in c o rp o ra tin g
d e a th in to life c a n e n rich life a n d a llo w o n e to
liv e m o re p u rp o s e fu lly .

119

7 Brief Psychodynamic Therapy

s y ch o d y n a m ic th e ra p y fo cu se s on

m o d e ra te s e v e rity o f s u b s ta n c e a b u se. It is also

u n co n scio u s p ro c e s s e s as th ey are

im p o rta n t th a t th e p s y c h o d y n a m ic th e ra p ist

m a n ife ste d in the c lie n t's p re s e n t

k n o w a b o u t th e p h a r m a c o lo g y o f a b u sed d ru g s,

b eh av io r. T h e g o a ls o f p s y c h o d y n a m ic th e rap y

the s u b c u ltu re o f s u b s ta n c e a b u se , an d 12-S tep

are clien t se lf-a w a re n e ss and u n d e rs ta n d in g of

p ro g ra m s.

the in flu e n ce o f th e p a st on p re s e n t b e h a v io r. In

P sy c h o d y n a m ic th e ra p y is th e o ld e st o f the

its b rie f fo rm , a p s y c h o d y n a m ic a p p ro a c h

m o d e rn th e ra p ie s. A s s u c h , it is b a se d in a

e n a b les the clie n t to e x a m in e u n re so lv e d

h ig h ly d e v e lo p e d a n d m u ltifa c e te d th e o ry of

co n flicts and s y m p to m s th a t a rise fro m p a st

h u m a n d e v e lo p m e n t a n d in te ra c tio n . T h is

d y sfu n ctio n a l re la tio n sh ip s and m a n ife st

c h a p te r d e m o n s tra te s h o w ric h it is fo r

th e m se lv es in th e n eed an d d e sire to a b u se

a d a p ta tio n an d fu rth e r e v o lu tio n b y

su b stan ce s.

c o n te m p o ra ry th e ra p is ts fo r sp e c ific p u rp o se s.

Se v e ra l d iffe re n t a p p ro a c h e s to b rie f

T h e m a te ria l p re s e n te d in th is c h a p te r p ro v id e s

p sy ch o d y n a m ic p s y c h o th e ra p y h a v e e v o lv e d

a q u ick g la n c e a t th e u s e fu ln e s s an d th e co m p le x

fro m p sy c h o a n a ly tic th e o ry and h a v e b e e n

n a tu re o f th is ty p e o f th e ra p y .

clin ica lly ap p lie d to a w id e ra n g e of

p sy ch o lo g ica l d iso rd e rs. A g ro w in g b o d y o f

Background

re sea rch su p p o rts the e ffic a c y o f th ese

a p p ro a ch e s (C rits-C h ris to p h , 1 9 9 2 ; M e sse r and
W a rre n , 1995).
S h o rt-te rm p s y c h o d y n a m ic th e ra p ie s ca n
co n trib u te to th e a rm a m e n ta riu m o f tre a tm e n ts
fo r su b sta n ce ab u se d iso rd e rs. B rief
p sy ch o d y n a m ic th e ra p ie s p ro b a b ly h a v e the
b e s t ch a n ce to b e e ffe c tiv e w h e n th ey are
in te g ra te d in to a re la tiv e ly c o m p re h e n siv e
su b sta n ce a b u se tre a tm e n t p ro g ra m th a t
in clu d e s d ru g -fo c u se d in te rv e n tio n s su ch as
re g u lar u rin a ly sis, d ru g c o u n s e lin g , an d , for
o p io id -d e p e n d e n ts, m e th a d o n e m a in te n a n c e
p h a rm a co th e ra p y . B rie f p s y c h o d y n a m ic '
th e rap ie s are p e rh a p s m o re h e lp fu l a fte r
ab stin e n ce is w e ll e sta b lis h e d . T h e y m a y be
m o re b e n e ficia l fo r c lie n ts w ith n o g re a te r th an

T h e th e o ry s u p p o rtin g p s y c h o d y n a m ic th era p y
o rig in a te d in an d is in fo rm e d b y p sy c h o a n a ly tic
th e o ry . T h e re a re fo u r m a jo r sc h o o ls of
p s y c h o a n a ly tic th e o ry , e a c h o f w h ich has
in flu e n c e d p s y c h o d y n a m ic th e ra p y . T h e fo u r
s c h o o ls are: F re u d ia n , E g o P sy c h o lo g y , O b je ct
R e la tio n s, a n d S e lf P sy c h o lo g y .
F re u d ia n p s y c h o lo g y is b a se d o n the th e o rie s
first fo rm u la te d b y S ig m u n d F re u d in th e e a rly
p a rt o f th is c e n tu ry a n d is s o m e tim e s re fe rre d to
as the d riv e or s tru c tu r a l m o d e l. T h e e sse n c e of
F re u d 's th e o ry is th a t se x u a l an d a g g re ssiv e
e n e rg ie s o rig in a tin g in th e id (o r u n co n scio u s)
a re m o d u la te d by th e eg o, w h ic h is a set of
fu n ctio n s th a t m o d e ra te s b e tw e e n th e id and
e x te rn a l re a lity . D e fe n se m e c h a n is m s are

121

C h ap ter 7

co n stru ctio n s o f the e g o th a t o p e ra te to

a p p e a r to th e u se r to b e c a p a b le o f cu rin g the

m in im iz e p a in an d to m a in ta in p sy c h ic

ce n tra l d e fe c t in the self.

e q u ilib riu m . T h e su p ereg o, fo rm e d d u rin g

la ten cy (b etw e en ag e 5 an d p u b e rty ), o p e ra te s to

[T]he ingestion of the drug provides him with

the self-esteem which he does not possess.

co n tro l id d riv e s th ro u g h g u ilt (M esse r and

Through the incorporation of the drug, he

W arren , 1995).
E go P sy ch o lo g y d e riv e s fro m F re u d ia n

supplies for him self the feeling of being

accepted and thus of being self-confident; or
he creates the experience of being merged with

p sy ch o lo g y . Its p ro p o n e n ts fo cu s th eir w o rk on

the source of pow er that gives him the feeling

e n h a n cin g and m a in ta in in g eg o fu n c tio n in

of being strong and worthw hile (Blaine and

a cco rd a n ce w ith th e d e m a n d s o f re a lity . Ego

P sy ch o lo g y s tre sse s the in d iv id u a l's c a p a city fo r

Julius, 1977, pp. vii-viii).

E a ch o f the fo u r sc h o o ls o f p s y c h o a n a ly tic

d efen se , a d a p ta tio n , and re a lity te stin g (P in e,

th e o ry p re s e n ts d is c re te th e o rie s o f p e rs o n a lity

1990).

fo rm a tio n , p s y c h o p a th o lo g y fo rm a tio n , an d

O b je ct R e la tio n s p s y ch o lo g y w a s first

c h a n g e ; te c h n iq u e s b y w h ic h to c o n d u c t

articu la te d b y se v e ra l B ritish a n a ly sts, a m o n g

th e ra p y ; an d in d ic a tio n s an d c o n tra in d ic a tio n s

th em M e la n ie K lein , W .R .D . F a irb a irn , D .W .

fo r th e ra p y . P sy c h o d y n a m ic th e ra p y is

W in n ico tt, an d H a rry G u n trip . A c c o rd in g to

d is tin g u is h e d fro m p s y c h o a n a ly s is in sev era l

this th eo ry, h u m a n b ein g s a re a lw a y s sh a p e d in

p a rtic u la rs , in c lu d in g th e fa c t th a t

re latio n to the sig n ific a n t o th e rs su rro u n d in g

p s y c h o d y n a m ic th e ra p y n e e d n o t in c lu d e all

them . O u r s tru g g le s an d g o a ls in life fo cu s on

a n a ly tic te c h n iq u e s a n d is n o t co n d u c te d by

m a in ta in in g re la tio n s w ith o th e rs, w h ile at the

p s y c h o a n a ly tic a lly tra in e d a n a ly sts.

sam e tim e d iffe re n tia tin g o u rse lv e s fro m o th ers.

P sy c h o d y n a m ic th e ra p y is a lso c o n d u cte d o v er a

T h e in te rn a l re p re s e n ta tio n s o f s e lf an d o th ers

sh o rte r p e rio d o f tim e an d w ith less fre q u e n cy

acq u ire d in ch ild h o o d a re la te r p la y e d o u t in

th a n p s y c h o a n a ly s is.

ad u lt re la tio n s. In d iv id u a ls re p e a t old o b je ct

S e v e ra l o f th e b r ie f fo rm s o f p s y c h o d y n a m ic

re la tio n sh ip s in a n e ffo rt to m a s te r th em and

th e ra p y a re c o n s id e re d le ss a p p ro p ria te fo r use

b eco m e freed fro m th e m (M esse r an d W a rre n ,

w ith p e rs o n s w ith s u b s ta n c e a b u s e d iso rd e rs,

1995).

p a rtly b e c a u se th e ir a lte re d p e rc e p tio n s m a k e it

S e lf P sy ch o lo g y w a s fo u n d e d b y H ein z

d iffic u lt to a c h ie v e in s ig h t a n d p ro b le m

K o h u t, M .D ., in C h ica g o d u rin g th e 1950s.

re s o lu tio n . H o w e v e r, m a n y p s y c h o d y n a m ic

K o h u t o b se rv e d th a t the s e lf re fe rs to a p e rs o n 's

th e ra p ists w o rk w ith s u b s ta n c e -a b u s in g clie n ts,

p e rce p tio n o f h is e x p e rie n c e o f h is self,

in c o n ju n c tio n w ith tra d itio n a l d ru g an d a lco h o l

in clu d in g th e p re se n c e or la ck o f a se n se o f se lf

tre a tm e n t p ro g ra m s or as th e s o le th e ra p is t fo r

estee m . T h e s e lf is p e rc e iv e d in re la tio n to the

clie n ts w ith c o e x is tin g d is o rd e rs , u sin g fo rm s of

e sta b lis h m e n t o f b o u n d a rie s a n d the

b rie f p s y c h o d y n a m ic th e ra p y d e s c rib e d in m o re

d iffe re n tia tio n s o f s e lf fro m o th e rs (o r th e la ck of

d eta il b elo w .

b o u n d a rie s an d d iffe re n tia tio n s ). "T h e

e x p la n a to ry p o w e r o f the n ew p s y c h o lo g y o f the
se lf is n o w h e re as e v id e n t as w ith re g a rd t o .. .th e
a d d ic tio n s " (B la in e and Ju liu s, 1 9 7 7 , p. vii).
K o h u t p o stu la te d th a t p e rso n s su ffe rin g fro m

122

Introduction to Brief
Psychodynamic Therapy
T h e h e a lin g a n d c h a n g e p ro c e s s e n v is io n e d in

s u b sta n ce a b u se d is o rd e rs a lso s u ffe r fro m a

lo n g -te rm p s y c h o d y n a m ic th e ra p y ty p ic a lly

w e a k n e ss in th e c o re o f th e ir p e rs o n a litie s a

re q u ire s a t le a s t 2 y e a rs o f se s s io n s . T h is is

d e fe ct in th e fo rm a tio n o f th e " s e lf ." S u b sta n ce s

b e c a u se th e g o a l o f th e ra p y is o fte n to ch a n g e an

B r ie f P sy ch o d y n a m ic T herapy

a sp ect o f o n e 's id e n tity o r p e rs o n a lity or to

B a rb e r, 19 9 1 ). F o r e x a m p le , s o m e b rie f

in te g ra te k ey d e v e lo p m e n ta l le a rn in g m isse d

p s y c h o d y n a m ic m o d e ls fo c u s m a in ly on

w h ile th e clie n t w a s stu c k a t a n e a rlie r s ta g e of

s y m p to m re d u c tio n (H o ro w itz , 1 9 9 1 ), w h ile

e m o tio n a l d e v e lo p m e n t.

o th ers ta rg e t th e r e s o lu tio n o f th e O e d ip a l

P ra ctitio n e rs o f b rie f p s y c h o d y n a m ic th e ra p y

c o n flic t (D a v a n lo o , a s in te rp re te d b y L a ik in et

b elie v e th a t so m e c h a n g e s ca n h a p p e n th ro u g h a

al., 19 9 1 ). T h e len g th o f th e ra p y is u su a lly

m o re rap id p ro c e ss or th a t an in itia l sh o rt

re la ted to th e a m b itio u s n e s s o f th e th e ra p y

in te rv e n tio n w ill sta rt an o n g o in g p ro c e s s of

g o a ls. M o st th e ra p is ts a re fle x ib le in te rm s of

ch a n g e th at d o e s n o t n e ed the c o n s ta n t

the n u m b e r o f s e s s io n s th e y re c o m m e n d fo r

in v o lv e m e n t o f th e th e ra p ist. A ce n tra l c o n c e p t

clin ic a l p ra c tic e . O fte n th e n u m b e r o f sessio n s

in b rie f th e rap y is th a t th e re s h o u ld b e o n e m a jo r

d e p e n d s o n a c lie n t's c h a ra c te ris tic s , g o a ls, and

fo cu s fo r the th e ra p y ra th e r th a n th e m o re

th e issu e s d e e m e d c e n tra l b y th e th e ra p ist.

tra d itio n a l p s y c h o a n a ly tic p ra c tic e o f a llo w in g

the c lie n t to a sso c ia te fre e ly an d d iscu ss
u n co n n e cte d issu es (M a la n , 19 7 6 ). In b rie f
th e rap y , th e ce n tra l fo c u s is d e v e lo p e d d u rin g
the in itia l e v a lu a tio n p ro c e ss, o c c u rrin g d u rin g
the first se ssio n or tw o. T h is fo cu s m u s t be
ag re ed on b y the c lie n t an d th e ra p ist. T h e
ce n tra l fo cu s sin g le s o u t th e m o st im p o rta n t
issu es an d th u s c re a te s a s tru ctu re an d id e n tifie s
a g o al fo r th e tre a tm e n t. In b rie f th e ra p y , the
th e ra p ist is e x p e c te d to be fa irly a c tiv e in
k e ep in g th e se ssio n fo c u se d on th e m a in issu e.
H av in g a cle a r fo cu s m a k e s it p o ss ib le to do
in te rp re tiv e w o rk in a re la tiv e ly s h o rt tim e
b eca u se the th e ra p is t o n ly a d d re s s e s the
circu m scrib e d p ro b le m a rea . W h e n u sin g b rie f
p sy ch o d y n a m ic a p p ro a c h e s to th e ra p y fo r the
tre a tm e n t o f s u b s ta n ce a b u se d is o rd e rs , the
ce n tra l fo cu s w ill a lw a y s b e th e s u b s ta n c e a b u se
in a sso cia tio n w ith th e co re co n flic t. F u rth e r, the
su b sta n ce ab u se an d th e co re c o n flic t w ill
alw a y s b e co n c e p tu a liz e d w ith in an
in te rp e rso n a l fra m e w o rk .
T h e n u m b e r o f s e ssio n s v a rie s fro m on e
a p p ro a ch to a n o th er, b u t b rie f p s y c h o d y n a m ic
th e rap y is ty p ic a lly c o n s id e re d to b e n o m o re
th an 25 se ssio n s (B a u er an d K o b o s, 19 8 7 ). C ritsC h risto p h an d B a rb e r in clu d e d m o d e ls a llo w in g
up to 40 sessio n s in th e ir re v iew o f s h o rt-te rm
d y n am ic p sy ch o th e ra p ie s b e c a u se o f the
d iv erg en ce in the sc o p e o f tre a tm e n t an d the

Psychodynamic
Psychotherapy for
Substance Abuse
S u p p o rtiv e -e x p re s s iv e (S E ) p s y c h o th e ra p y
(L u b o rsk y , 1 9 8 4 ) is o n e b rie f p sy c h o d y n a m ic
a p p ro a c h th a t h a s b e e n a d a p te d fo r u se w ith
p e o p le w ith s u b s ta n c e a b u s e d iso rd e rs. It has
b e e n m o d ifie d fo r u se w ith o p ia te d e p e n d e n ce
in c o n ju n c tio n w ith m e th a d o n e m a in te n a n c e
tre a tm e n t (L u b o rsk y et al., 1 9 7 7 ) an d fo r co cain e
u se d is o rd e rs (M a rk an d F a u d e , 19 95 ; M a rk and
L u b o rs k y , 1 9 9 2 ). T h e re h a v e b e e n m a n y stu d ies
o f th e u se o f S E th e ra p y fo r s u b s ta n c e a b u se
d iso rd e rs, re s u ltin g in a s ig n ific a n t b o d y of
e m p iric a l d a ta o n its e ffe c tiv e n e s s in tre a tin g
th e se p ro b le m s (see b e lo w ).
M a rk an d F a u d e a s s e rte d th a t a lth o u g h th eir
th e ra p e u tic a p p r o a c h w a s d e v is e d sp e cific a lly
fo r c o c a in e -d e p e n d e n t clie n ts , th e se p e o p le o ften
h a v e m u ltip le d e p e n d e n c ie s , an d th is a p p ro a ch
c a n b e u se d to tre a t a v a r ie ty o f su b sta n c e a b u se
d iso rd e rs. H o w e v e r, c lie n ts s h o u ld be
re a s o n a b ly s ta b le in te rm s o f th e ir su b sta n c e
a b u se b e fo re b e g in n in g th is ty p e o f th e ra p y
(M a rk a n d F a u d e , 19 9 5 ).
M a rk a n d F a u d e th e o riz e d th a t su b sta n c e s of
a b u se s u b s titu te a "c h e m ic a l r e a c tio n " in p la ce
o f e x p e rie n c e s a n d th a t th e s e ch e m ica lly
in d u ce d e x p e rie n c e s c a n b lo c k th e im p a c t of

ty p es o f g o a ls a d d re sse d (C rits-C h ris to p h and

223

C h ap ter 7

o th er e x te rn a l e v e n ts. T h e p e rs o n w ith a

su b sta n ce a b u se d is o rd e r w ill th e re fo re h a v e a

m y s e lf."

"tre m e n d o u s ly im p o v e ris h e d an d im p a ired

ca p a city to e x p e rie n c e ," a n d tra d itio n a l
p s y ch o th e ra p y m ig h t h a v e to b e a u g m en ted
w ith te ch n iq u e s th a t fo cu s o n in cre a sin g a
c lie n t's ab ility to e x p e rie n c e (M a rk and F a u d e,
1995, p. 297).
E ffe ctiv e SE th e ra p y d e p e n d s on a p p ro p ria te
u se o f w h a t is te rm e d th e co re con flictu a l
relation sh ip th em e (C C R T ), a c o n c e p t first
in tro d u ced b y L e s te r L u b o rsk y . A cc o rd in g to
L u b o rsk y , a C C R T is a t th e c e n te r o f a p e rs o n 's

"T h e y 'r e ju s t w a itin g fo r m e to m a k e a fo o l o f

F o r m a n y p e o p le w ith s u b s ta n c e a b u se
d iso rd e rs, a lc o h o l or d ru g u se is a w a y o f selfm e d ic a tin g a g a in st fe e lin g s o f lo w se lf-w o rth
an d low s e lf-e s te e m th a t re fle c t th e c lie n t's RS.
A n e g a tiv e R O re in fo rc e s a n e g a tiv e R S an d can
lea d to th e d e c e p tiv e a n d m a n ip u la tiv e b e h a v io r
th a t is s o m e tim e s o b s e rv e d in th is p o p u la tio n .
T h e c lie n t's R S is b a se d o n th e in d iv id u a l's
s o m a tic e x p e rie n c e s , a c tio n s , an d p e rc e iv e d
n e e d s. F o llo w in g a re e x a m p le s o f sta te m e n ts
th a t co u ld re fle c t a c lie n t's c o re RS:

p ro b lem s. T h e C C R T d e v e lo p s fro m e a rly

ch ild h o o d e x p e rie n c e s , b u t th e c lie n t is u n a w a re

" I 'm so s tu p id an d g u llib le ."

o f it and h o w it d e v e lo p e d . It is a ssu m e d that

" I c a n 't d o a n y th in g r ig h t."

the clie n t w ill h a v e b e tte r co n tro l o v er b eh a v io r

" I f I d id n 't u se d ru g s, I w o u ld lo se m y
m in d ."

if he k n o w s m o re a b o u t w h a t h e is d o in g on an
u n co n scio u s lev el. T h is k n o w le d g e is a cq u ire d

" I c a n 't h e lp m y s e lf."

b y b e tte r u n d e rs ta n d in g o f c h ild h o o d

" I 'm n o t a v e ry n ic e or h o n e s t p e rs o n ."

e x p e rie n ce s (B o h a rt an d T o d d , 19 8 8 ). T h e C C R T

w ish ; it re fle c ts w h a t th e c lie n t y e a rn s fo r, w ish e s

w h ich re p re se n ts a p e rs o n 's p re d o m in a n t

fo r, or d e sire s. T h e c lie n t's " w is h " is la rg ely

e x p e cta tio n s or e x p e rie n c e s o f o th e r s ' in te rn a l

b a se d on in d iv id u a l p e rs o n a lity sty le. T h o se

and e x te rn a l re a ctio n s to h e rse lf, an d a co re

w ith s u b s ta n c e a b u se d is o rd e rs o fte n h a v e a

resp on se o f the s e lf( R S ) , w h ic h re fe rs to a m o re or

w ish to c o n tin u e u sin g th e s u b s ta n c e w ith o u t

less c o h e re n t c o m b in a tio n o f so m a tic

h a v in g to e n d u re th e c o n s e q u e n c e s . P u t a n o th er

e x p e rie n ce s, a ffects, a ctio n s, co g n itiv e sty le, s e lf

w a y , th e y w o u ld lik e to b e a c c e p te d (o r lo v e d or

e stee m , an d se lf-re p re s e n ta tio n s .

a p p re c ia te d ) as th e y a re, w ith o u t h a v in g to g iv e

M o st p e o p le w ith su b s ta n ce a b u se d iso rd e rs

up th e p le a s u re th e y g e t fro m th e ir u se

h av e p a rticu la rly n e g a tiv e e x p e c ta tio n s of

(L e v e n so n e t al., 1 9 9 7 ). M a n y p e o p le w h o hav e

o th e rs' a ttitu d e s to w a rd th em (th a t is, th e R O ),

s u b s ta n c e a b u s e d is o r d e rs h a v e m u c h in v e sted

alth o u g h it re m a in s u n cle a r w h ich c a m e first

in d e n y in g th a t th e y re a lly h a v e a p ro b le m , in

this re sp o n se or th e su b s ta n c e a b u se d iso rd er.

p o rtra y in g th e m s e lv e s as h e lp le s s v ictim s, and

E ith er w ay , the tw o b e c o m e m u tu a lly

in d is c la im in g th e ir ro le in th e b e h a v io r th a t h as

re in fo rcin g . F o llo w in g a re e x a m p le s of

b ro u g h t th e m in to tre a tm e n t.

s ta te m e n ts th a t re fle c t the c o re R O o f a p erso n

124

A th ird c o m p o n e n t o f C C R T is a p e rs o n 's

d ev elo p s o u t o f a co re resp o n se fr o m o th ers (R O ),

O n c e th e ra p y h a s b e e n in itia te d , the th e ra p ist

w ith a s u b s ta n c e a b u se d iso rd e r:

an d c lie n t c a n w o rk to g e th e r to p u t th e clie n t's

"E v e ry b o d y h a te s m e ."

g o a ls in to th e C C R T fra m e w o rk a n d e x p lo re the

" I am ju s t b e in g u s e d ."

m e a n in g , fu n c tio n , an d co n s e q u e n c e o f h er

"P e o p le la u g h at m e ."

su b sta n c e a b u s e , lo o k in g in p a rtic u la r a t h ow

"N o on e u n d e rs ta n d s h o w I fe e l.''

the R O an d R S h a v e c o n trib u te d to the p ro b lem .

"E v e ry b o d y w a n ts m e to b e so m e th in g I'm

T h e C C R T fra m e w o rk a lso ca n b e u sed to

n o t."

id e n tify p o te n tia l o b s ta c le s in th e re co v e ry

B r ie f P sy ch o d y n a m ic T herapy

p ro cess as the th e ra p is t an d c lie n t e x p lo re the

m o n th s a g o . A t the b e g in n in g o f tre a tm e n t, she

clie n t's a n ticip a te d re s p o n s e s fro m o th ers and

to ld C h ris to p h e r th a t sh e w a s g o in g to re q u e st

fro m h e rs e lf an d d isc u ss h o w th e se p e rc e p tio n s

m e d ic a tio n fro m h e r p h y s ic ia n fo r h er b a ck p ain.

w ill ch a n g e w h en sh e sto p s a b u sin g su b sta n c e s.

A fte r h e r e ig h th s e s s io n , w ith h e r re lu cta n t

T h e C C R T c o n c e p t a lso ca n h elp c lie n ts d ea l

a g re e m e n t, C h ris to p h e r in fo rm e d th e p h y sicia n

w ith re la p se , w h ic h is re g a rd e d by v irtu a lly all

th a t sh e w a s in tre a tm e n t fo r c o c a in e

e x p e rts in the field as an in te g ra l and n a tu ra l

d e p e n d e n c e . C h ris to p h e r a sk ed th e p h y s icia n to

p art o f re co v e ry . R e la p se o ffe rs th e c lie n t and

find a m e d ic a tio n o th e r th a n d ia z e p a m (V a liu m )

the SE th e ra p ist th e o p p o rtu n ity to e x a m in e how

fo r S te lla 's b a c k p a in .

the R O and R S ca n serv e as trig g e rs an d to

S te lla b e g a n th e 1 9 th s e s s io n c o m p la in in g

d ev ise stra te g ie s to a v o id th e se trig g e rs in th e

th a t e v e r sin ce th e p h y s ic ia n fo u n d o u t sh e w as

fu tu re. F in ally , S E th e ra p y is c o n d u c iv e to c lie n t

a d ru g u se r, h e h a s tre a te d h e r d iffe re n tly . "H e

p a rticip a tio n in a se lf-h e lp g ro u p su ch as

th in k s I'm a s c u m b a g d ru g a d d ic t," sh e said .

A lco h o lics A n o n y m o u s , or it ca n b e u sed a s a

C h ris to p h e r a c te d u n c h a ra c te ristic a lly : he

m e ch a n ism to e x a m in e a c lie n t's u n w illin g n e ss

o ffe re d so m e a d v ic e . H e s u g g e s te d th a t Stella

to p a rticip a te in th e se g ro u p s.

c o n s id e r te llin g h e r p h y s ic ia n h o w sh e feels

Stella and Christopher:

A Case Study

a b o u t his tre a tm e n t. T h e in te rv e n tio n strik in g ly

a ltered th e m o o d an d p ro d u c tiv ity o f the
s e ssio n . A fte r a b rie f e x p re s s io n o f s y m p a th y for

T h e case stu d y in th is se c tio n c a m e fro m the

h e r p o sitio n , h e fo c u s e d o n h e r e x tre m e d istress

N ID A C o lla b o ra tiv e C o c a in e S tu d y (M a rk and

o v e r th e p h y s ic ia n 's tre a tm e n t. H e a tte m p ted to

F au d e, 1997; a d a p te d w ith p e rm is sio n ). S E is

e x p la in th e in te n sity o f h e r re a c tio n in term s of

the th e ra p e u tic a p p ro a c h u sed .

p ro je ctio n : th a t sh e re s p o n d e d so s tro n g ly

W h ile d e p e n d e n t an d im p u lsiv e , S te lla , a 28y e ar-o ld c o c a in e -d e p e n d e n t w o m a n , w o u ld be

b e c a u se o f h e r n e g a tiv e v ie w o f h e rself.
M a tte rs g o t w o rs e as th e s e s s io n c o n tin u ed .

seen u n d e r m a n y c irc u m sta n c e s as w a rm and

S te lla re la te d a seco n d n e g a tiv e in c id e n t w h en

op en. S h e a p p e a rs to be the k in d o f p e rs o n w h o

sh e d e scrib e d h e r tre a tm e n t b y th e p h y sic ia n in

w ears h e r h e a rt on h e r sle e v e , b u t it is a b ig

a g ro u p th e ra p y s e s s io n . T h e g ro u p th e ra p ist

h e a rt n o n e th e le ss, c a p a b le o f ca rin g fo r o th ers

re s p o n d e d , "W e ll, y o u m a n ip u la te d o c to rs !"

w ith lo y a lty an d c o m p a s sio n . In a d d itio n , sh e

S te lla h a d b e e n fu rio u s.

has a te n a city o f sp irit; d e sp ite a h o rrific

p e rso n a l h isto ry sh e co m p le te d h er tra in in g as a

C h ris to p h e r e n c o u ra g e d h e r to sa y m o re.
S te lla b e c a m e fru s tra te d a t C h ris to p h e r's lack of

m e d ica l te ch n ic ia n and h a s w o rk e d in that

u n d e rs ta n d in g an d e x p la in e d th a t a g a in , sh e felt

ca p a city fo r m u c h o f the la st 4 y ea rs. H er

sh e w a s b e in g tre a te d lik e a " s c u m b a g ," this

th e ra p ist, C h ris to p h e r, is a w e ll-tra in e d

tim e b y th e g ro u p th e ra p is t. C h ris to p h e r

p s y ch o d y n a m ica lly o rie n te d th e ra p ist. H e is an

su g g e s te d th a t S te lla m ig h t te ll b o th the

in te llig e n t, serio u s, and m e a su re d p e rso n ,

p h y s ic ia n and th e g ro u p th e ra p is t h o w sh e felt.

w h o se w e ll-m e a n in g n a tu re c o m e s th ro u g h

T h e te n s io n in th e s e s s io n d is a p p e a re d , and

u n d er m o st circ u m sta n c e s d e sp ite h is n a tu ra l

S te lla re m a rk e d th a t sh e h a s a lw a y s h ad tro u b le

reserv e.

stic k in g up fo r h e rself.

Stella h as a h isto ry o f p o ly s u b s ta n c e a b u se,

In s u p e rv is io n , C h ris to p h e r re a liz e d

in clu d in g the a b u se o f p re s c rip tio n d ru g s, b o th

im m e d ia te ly th a t h e w a s in d ire c tly lettin g Stella

an x io ly tics and o p io id s. S h e w o rk e d as a

k n o w th a t h e u n d e rs to o d an d a g re ed w ith her.

m e d ica l te ch n ic ia n u n til sh e in ju red h e r b a ck 3

125

C h ap ter 7

D ia g n o stica lly sp e a k in g , S te lla h a s a

b o rd erlin e p e rso n a lity d iso rd e r as d efin e d by

in tw o w a y s. In th e first s e s s io n , S te lla told

the D iag n ostic an d S ta tistica l M a n u al o f M en ta l

C h ris to p h e r th a t sh e h a d ta k e n

D isorders, 4 th E d itio n [D S M -IV ] (A m e rica n

c h lo rd ia z e p o x id e fo r s e v e r a l d a y s b e fo re th eir

P sy ch ia tric A sso c ia tio n , 19 9 4 ). W h e n sh e w as

a p p o in tm e n t, to re lie v e h e r a n x ie ty . S h e p o in te d

b etw ee n 6 an d 8 y ea rs old , S te lla 's m a te rn a l

o u t th a t it h a d b e e n p re s c rib e d b y a d o cto r.

g ra n d fa th e r s e x u a lly ab u sed h er. H er p a re n ts

P re s u m a b ly , C h ris to p h e r w o u ld h a v e k n o w n

d iv o rced w h en sh e w a s 10, an d sh e liv ed w ith

th e re su lts o f h e r d ru g s c re e n , w h ic h w a s p a rt of

h er m o th e r, w h o w a s o ften d ru n k and

th e p ro g ra m . S h e th u s c o n fe s s e d b e fo re b ein g

p h y sica lly a b u siv e. S te lla said sh e w a s c lo se r to

c o n fro n te d b y d ru g s c re e n re su lts. H e r cla im

h er fa th er, w h o m sh e d e scrib e d as g en tle. H e

th a t the p re s c rip tio n w a s le g itim a te fa c ilita te d

ap p e a re d to o th ers as w e a k and in effe ctu a l.

h e r d e n ia l th a t sh e h a s a n y th in g to b e co n c ern e d

A t ag e 15, S te lla ra n o ff w ith a b o y frie n d w h o

w as also h e r p im p . A fte r 2 w e e k s sh e re tu rn ed

ab ou t.
S e c o n d , S te lla a n n o u n c e d h e r in te n tio n to ask

h o m e, w as u n a b le to lea v e h e r m o th e r, an d w as

h er p h y s ic ia n fo r d ia z e p a m , a c o m m o n ly a b u sed

d ia g n o sed as h a v in g a g o ra p h o b ia , fo r w h ich she

m e d ic a tio n . By c o n ta c tin g h e r p h y sic ia n ,

took c h lo rd ia z e p o x id e (L ib riu m ). T w o y ears

C h ris to p h e r re p la y e d a c o m m o n sc e n a rio in her

later sh e ran aw a y w ith a n o th e r m a n , a

life: sh e sig n a ls th a t s o m e o n e s h o u ld tak e

p a rticu la rly sa d istic p im p . F o r 5 y e a rs sh e w as

c o n tro l o r ca re fo r h e r, th e n re s e n ts it w h e n they

too te rrified to lea v e h im . It w a s d u rin g this

d o, fe e lin g th a t sh e is b e in g tre a te d lik e a

p erio d th a t sh e sta rte d u sin g c o ca in e .

"s c u m b a g d ru g a d d ic t." S h e ca n c re a te the

T h e co ca in e b o th "d is c la im s a c tio n " and

la rg e ly illu s o ry se n se o f b e in g c a re d fo r w h en

a ffirm s h e r " b a d n e s s ." H er c o ca in e u se en a b led

so m e o n e tre a ts h e r as a h e lp le s s in c o m p e te n t.

her to avo id e x a m in in g w h y sh e sta y ed w ith her

W a s th is h o w C h ris to p h e r w a s tre a tin g h er

b o y frie n d and sim u lta n e o u s ly a ffirm e d h er

w h en h e c a lle d h e r p h y s ic ia n ?

b ad n ess. So, sh e d e se rv e s h er fate. S h e w o u ld

W h e n C h ris to p h e r s u g g e s te d th a t sh e tell the

use th e co ca in e to c le a r h er p a in fu l fe e lin g s and

p h y s ic ia n a n d th e g ro u p th e ra p is t h o w sh e felt

feel "s tr o n g an d in d e p e n d e n t," th en "fe e l lik e a

a b o u t th e w a y th e y h a d tre a te d h e r, h is w o rd s

big b a b y fo r h a v in g to u se th e d r u g s ." Sh e

m a y h a v e g iv e n a d v ic e , b u t h is c o m m u n ic a tio n

th o u g h t o f h e rs e lf as a "b ig b a b y ," fo r re tu rn in g

a c tu a lly c o n v e y e d a g re e m e n t w ith S te lla 's

to h er m o th e r at ag e 15 and fo r b e in g u n a b le to

p o sitio n th a t s h e h a d b e e n u n fa irly tre a te d .

leav e h er c u rre n t b o y frie n d . H er re a c tio n s to

co cain e are ty p ica l; a b rie f su rg e or a " h ig h ,"

S te lla e x p e rie n c e d C h ris to p h e r's a g re e m e n t

an d su p p o rt th ro u g h h is in te rv e n tio n .

fo llo w ed by a cra sh . H o w e v e r, th e se ty p ica l

H o w e v e r, w h a t c o u ld h a v e m a d e th is a m o re

re a ctio n s a lso fit h er co re th em e: sh e w a n ts to be

p o w e rfu l th e ra p e u tic in te ra c tio n w o u ld h a v e

lo v ed an d ca re d fo r b u t b e lie v e s sh e w ill be

b e e n e ith e r fo r C h ris to p h e r to d ire ctly

th w arte d an d e x p lo ite d b y o th e rs b e c a u se o f th is

a c k n o w le d g e h is m is g iv in g s a b o u t h a v in g tak en

w ish . H er re s p o n s e th e n is to u se d ru g s, w h ich

c h a rg e an d c o n ta c te d th e p h y s ic ia n or to exp lo re

m a k e s h e r fe e l s tro n g an d in d e p e n d e n t fo r a

h o w S te lla c a m e to h e a r h is in itia l o b liq u e n e s s as

b rie f tim e an d a lso m a k e s h e r see h e rs e lf as

g iv in g h e r w h a t sh e w a n te d h is ca re and

d ese rv in g o f b e in g th w a rte d an d e x p lo ite d ,

su p p o rt.

w h ich h as h a p p e n e d re p e a te d ly in in te rp e rso n a l
co n te x ts in h er life.

126

S te lla 's d ru g u se b e c a m e a p a rt o f th e th e rap y

B r ie f P sy ch o d y n a m ic T herapy

Research on the Efficacy of

Supportive-Expressive Therapy

a s s o c ia te d w ith s ig n ific a n t p ro g re ss . D ro p o u t

It is on ly sin ce the 1 9 80 s th a t p sy c h o so c ia l

ra te s w e re h ig h , an d o v e ra ll a b stin e n c e in b o th

co m p o n e n ts o f th e tre a tm e n t o f su b s ta n c e a b u se

g ro u p s d id n o t a p p e a r to d iffe r fro m th a t

d iso rd e rs h a v e b e c o m e th e su b je c t o f sc ie n tific

e x p e c te d fro m s p o n ta n e o u s re m iss io n . T h e

in v e stig a tio n . M o st re s e a rc h on the e ffic a c y of

m a in c o n c lu s io n s w e re th a t th e la ck o f tre a tm e n t

p s y ch o th e ra p y fo r th e tre a tm e n t o f su b sta n c e

e ffe c ts m a y h a v e re s u lte d b e c a u se th ese

ab u se d iso rd e rs h a s c o n c lu d e d th a t it c a n b e an

tre a tm e n ts d id n o t o ffe r e n o u g h fre q u e n c y and

e ffe ctiv e tre a tm e n t m o d a lity (W o o d y et al.,

in te n sity o f c o n ta c t to b e e ffe c tiv e fo r co ca in e -

1994). C o m p a riso n s a m o n g sp e c ific m o d e ls of

d e p e n d e n t p e o p le in th e in itia l sta g e s o f

th e rap y h a v e b e c o m e th e fo cu s o f m u ch in terest.

re c o v e ry . T h is s tu d y h a d a t le a s t tw o fla w s,

A s m e n tio n e d a b o v e , S E p s y c h o th e ra p y h a s

w e e k ly th e ra p y , o f e ith e r ty p e , w a s n o t

h o w e v e r. O n e w a s th a t th e th e ra p is ts w e re n o t

b ee n m o d ified fo r u se w ith m e th a d o n e -

w e ll-tra in e d in S E th e ra p y ; th e re fo re , it is

m a in ta in e d o p ia te d e p e n d e n ts an d fo r c o c a in e

q u e s tio n a b le w h e th e r or n o t th e tre a tm e n t they

d ep en d e n ts. In SE th e ra p y , th e c lie n t is h elp ed

p ro v id e d w a s a c tu a lly SE th e ra p y . T h e oth er

to id e n tify an d ta lk a b o u t co re re la tio n sh ip

w a s th a t th e th e ra p y w a s p ro v id e d in a

p attern s and h o w th e y re la te to s u b s ta n c e a b u se.

m u n ic ip a l o ffic e b u ild in g w h e re c o u rts and

O n e stu d y co m p a re d S E th e ra p y an d c o g n itiv e -

so cia l se rv ic e s w e re a d m in is te re d , th u s this

b e h a v io ra l th e ra p y w ith sta n d a rd d ru g

s ettin g la c k e d m a n y fe a tu re s o f tra d itio n a l

co u n selin g fo r o p ia te d e p e n d e n ts in a

s u b s ta n c e a b u s e tre a tm e n t se ttin g s.

m e th a d o n e m a in te n a n c e p ro g ra m . C lie n ts w e re

M o re re ce n tly , a la rg e m u ltis ite stu d y o f 4 87

offered o n ce -w e e k ly th e ra p y fo r 6 m o n th s.

p e rs o n s re c e iv in g tre a tm e n t c o m p a re d SE

A d d in g p ro fe ss io n a l p s y c h o th e ra p ie s (e ith er SE

th e ra p y w ith c o g n itiv e th e ra p y an d d ru g

or c o g n itiv e -b e h a v io ra l) to d ru g c o u n s e lin g

c o u n s e lin g fo r c o c a in e d e p e n d e n c e (C rits-

b en e fite d clie n ts w ith h ig h e r le v e ls of

C h ris to p h et al., 1 9 9 7 ). E a ch o f th e th ree

p sy ch o p a th o lo g y m o re th a n u sin g d ru g

c o n d itio n s in c lu d e d , in a d d itio n to the

c o u n se lin g a lo n e. H o w e v e r, d ru g co u n s e lin g

in d iv id u a l tre a tm e n t, a s u b s ta n c e a b u se

alon e w a s h e lp fu l fo r c lie n ts w ith lo w e r lev els o f

c o u n s e lin g g ro u p . A fo u rth c o n d itio n re ce iv e d

p sy ch o p a th o lo g y (W o o d y e t al., 19 8 3 ). A n o th e r

g ro u p co u n s e lin g w ith o u t a d d itio n a l in d iv id u a l

stu d y in v o lv in g th ree m e th a d o n e p ro g ra m s w as

th e ra p y . T h is s tu d y w a s a th e o re tic a l

a lso p o sitiv e re g a rd in g th e e ffic a c y o f SE

d e s c e n d a n t o f th e m e th a d o n e s tu d ie s m e n tio n e d

th e rap y (W o o d y et al., 19 9 5 ). In this stu d y ,

e a rlie r. It w a s h y p o th e siz e d th a t S E and

clien ts re ce iv in g S E th e ra p y re q u ire d less

c o g n itiv e th e ra p y m ig h t b e m o re e ffe c tiv e th an

m e th a d o n e th an th o se w h o re c e iv e d on ly

in d iv id u a l d ru g co u n s e lin g fo r c lie n ts w ith

sta n d a rd su b sta n ce a b u se c o u n s e lin g , an d a fter

h ig h e r le v e ls o f p s y c h ia tric s e v e rity . T h e resu lts

6 m o n th s o f tre a tm e n t th e se c lie n ts m a in ta in e d

sh o w e d th a t e a c h ty p e o f tre a tm e n t w as

th eir g a in s or s h o w e d c o n tin u in g im p ro v e m e n t.

a s s o c ia te d w ith s ig n ific a n tly re d u c e d co ca in e

G ain s te n d ed to d is s ip a te in th o se w h o re ce iv e d

use. H o w e v e r, fo r th is p o p u la tio n o f o u tp a tie n t

d ru g c o u n se lin g o n ly (W o o d y et al., 1995).

c o c a in e -d e p e n d e n t c lie n ts , d ru g co u n se lin g w as

O n e stu d y co m p a re d SE p s y c h o th e ra p y w ith

m o re s u c c e s s fu l a t re d u c in g su b s ta n c e use th an

stru ctu ral fa m ily th e ra p y fo r the tre a tm e n t of

S E or c o g n itiv e th e ra p y (C rits-C h ris to p h et al.,

co cain e d e p e n d e n c e (K a n g et al., 1 9 91 ; K le in m a n

1999). O n e im p lic a tio n o f th is fin d in g is th at

et al., 1990). B o th ty p e s o f th e ra p y w e re o ffe red

d ru g -fo c u s e d in te rv e n tio n s a re p e rh a p s the

on ce a w e e k . T h e re se a rch e rs fo u n d th a t o n ce127

C h ap ter 7

o p tim al a p p ro a ch fo r p ro v id in g tre a tm e n t fo r
su b sta n ce a b u se d is o rd e rs (S trea n , 1994).
W h a t th is m e a n s fo r p ra c titio n e rs of
p s y ch o d y n a m ic a lly o rie n te d tre a tm e n ts is th a t
in ad d itio n to p ro v id in g th e m o re d y n a m ic

A lth o u g h th e re is s o m e d is a g re e m e n t in the
d e ta ils, th is ty p e o f b rie f th e ra p y is g e n e ra lly
th o u g h t m o re s u ita b le fo r th e fo llo w in g ty p e s of
c lien ts:

in te rv e n tio n s, it is im p o rta n t to a lso in c o rp o ra te

d irect, d ru g -fo c u se d in te rv e n tio n s . T h is ca n b e

w ith th e ir s u b s ta n c e a b u s e d is o rd e r

acco m p lish e d b y on e th e ra p is t c o m b in in g b o th

p ro v id in g d y n a m ic th e ra p y an d an a lc o h o l and
d ru g co u n se lo r p ro v id in g d irect, d ru g -fo cu se d
co u n selin g . It ca n b e a rg u ed th a t th is is w h y SE

T h o se w h o d o n o t n e e d or w h o h a v e
c o m p le te d in p a tie n t h o s p ita liz a tio n or

m o d e ls or, in a co m p re h e n siv e tre a tm e n t

p ro g ra m fo r s u b s ta n c e u sers, o n e th e ra p ist

T h o se w h o h a v e c o e x is tin g p s y c h o p a th o lo g y

d e to x ific a tio n

T h o se w h o se re c o v e ry is sta b le

T h o se w h o d o n o t h a v e o rg a n ic b ra in
d a m a g e or o th e r lim ita tio n s d u e to th eir
m e n ta l c a p a c ity

th e ra p y w as so h e lp fu l in th e m e th a d o n e
stu d ies. In th o se stu d ie s, p s y c h o d y n a m ic
th e rap y w as w e ll in te g ra te d in to a
c o m p re h e n siv e m e th a d o n e m a in te n a n c e
p ro g ra m . In o th er w o rd s, in a d d itio n to the

Psychodynamic Concepts
Useful in Substance
Abuse Treatment

d y n am ic th e ra p y , clie n ts re c e iv e d s u b sta n ce
ab u se d iso rd e r co u n s e lin g a lo n g w ith

P sy c h o d y n a m ic th e o rie s e n d e a v o r to p ro v id e

m e th a d o n e (W o o d y et al, 1998).

c o h e re n t e x p la n a tio n s fo r in tra p s y c h ic and

O n e stu d y c o n d u cte d a sm a ll, c o n tro lle d trial

in te rp e rs o n a l w o rk in g s. B e c a u s e o f the

co m p a rin g SE th e ra p y to a b rie f (o n e-se ssio n )

im p o rta n c e o f th is a p p ro a c h in th e d e v e lo p m e n t

in te rv e n tio n fo r m a riju a n a d ep e n d e n c e . T h e SE

o f m o d e rn th e ra p y , th e te c h n iq u e s th a t ste m

a p p ro a ch w as a d a p te d fo r u se in tre a tm e n t of

fro m th e se th e o rie s a re in e v ita b ly u se d in an y

ca n n a b is d ep e n d e n c e (G re n y e r et al., 1995) and

ty p e o f p s y c h o th e r a p y , w h e th e r or n o t it is

w as o ffe red o n ce a w e e k fo r 16 w e e k s. R esu lts

id e n tifie d as " p s y c h o d y n a m ic ." F o r e x a m p le ,

sh o w ed th at b o th in te rv e n tio n s w e re h e lp fu l b u t

p e o p le w h o h a v e w o rk e d w ith th o se w h o h av e

SE th e rap y p ro d u c e d s ig n ific a n tly la rg e r

su b s ta n c e a b u s e d is o rd e rs a re fa m ilia r w ith

re d u ctio n s in c a n n a b is u se, d e p re ssio n , and

" d e n ia l," e v e n if th e y a re n o t a w a re th a t th is

an x iety , an d in cre a se s in p s y c h o lo g ic a l h e a lth

p ro c e s s is o n e o f th e p s y c h o d y n a m ic d efen se

(G ren y e r et al., 19 9 6 ). T h e a u th o rs co n c lu d e d

m e c h a n is m s . C o u n s e lo rs w h o se c lie n ts h a v e an

th a t SE th e rap y co u ld b e an e ffe c tiv e tre a tm e n t

im m e d ia te an d s tro n g n e g a tiv e re a c tio n to them

fo r ca n n a b is d e p e n d e n c e .

o ften b e n e fit fro m a n u n d e rs ta n d in g o f the

c o n c e p t o f " tr a n s fe r e n c e ." It a lso is h e lp fu l fo r

128

Clients Most Suitable for

Psychodynamic Therapy

h o p e le s s a n d c o n fu s e d a fte r a se ssio n to

B rie f p sy ch o d y n a m ic th e ra p y is m o re

u n d e rsta n d h o w " c o u n te r tr a n s fe r e n c e " co u ld be

a p p ro p ria te fo r so m e ty p e s o f c lie n ts w ith

a t w o rk . T h e re fo re , c o u n s e lo r s w h o tre a t clie n ts

su b sta n ce a b u se d is o rd e rs th a n o th ers. F or

w ith s u b s ta n c e a b u s e d is o rd e rs c a n b e n e fit fro m

an a lc o h o l an d d ru g c o u n s e lo r w h o is le ft fe e lin g

so m e, p s y c h o d y n a m ic th e ra p y is b est

u n d e rs ta n d in g th e b a sic c o n c e p ts o f g e n e ra l

u n d e rta k e n w h en th ey a re w ell a lo n g in

p s y c h o d y n a m ic th e o ry d is c u ss e d in th is sectio n ,

re co v ery an d re ce p tiv e to a h ig h e r lev el o f self-

e v e n if th e y d o n o t u se a s tric tly p s y c h o d y n a m ic

k n o w le d g e.

in te rv e n tio n .

B r ie f P sy ch od y n a m ic T herapy

The Therapeutic Alliance

p a rtic ip a tio n a n d o f d rin k in g b e h a v io r d u rin g

T h e a llia n ce th a t d e v e lo p s b e tw e e n th e ra p ist

tre a tm e n t a n d a t 1 2 -m o n th fo llo w u p , th o u g h the

and clie n t is a v e ry im p o rta n t fa c to r in

a m o u n t o f v a ria n c e e x p la in e d w a s sm all

su cce ssfu l th e ra p e u tic o u tco m e s (L u b o rsk y ,

(C o n n o rs e t al., 1 9 9 7 ). A m o n g c o c a in e -

1985). T h is is tru e re g a rd le ss o f th e m o d a lity of

d e p e n d e n t p a tie n ts , a n o th e r s tu d y fo u n d th at

th erap y . T h e p s y c h o d y n a m ic m o d e l h a s a lw a y s

p a tie n ts ' ra tin g s o f th e th e ra p e u tic a llia n ce

v ie w e d the th e r a p is t-c lie n t re la tio n sh ip as

p re d ic te d th e le v e l o f c u rre n t d ru g u se a t 1

ce n tra l an d th e v e h icle th ro u g h w h ich ch a n g e

m o n th b u t n o t a t 6 m o n th s (B a rb e r e t al., 1999).

occu rs. O f all the b rie f p s y c h o th e ra p ie s ,

T h e a llia n ce a t 1 m o n th , h o w e v e r, p re d icted

p sy ch o d y n a m ic a p p ro a c h e s p la c e the m o st

im p ro v e m e n t in d e p re s s iv e s y m p to m s a t 6

em p h asis on th e th e ra p e u tic re la tio n sh ip and

m o n th s. T h e s e fin d in g s s u g g e s t th a t th e

p ro v id e the m o st e x p lic it an d c o m p re h e n siv e

th e ra p e u tic a llia n c e e x e rts a m o d e ra te b u t

e x p la n a tio n s o f h o w to u se th is re la tio n sh ip

s ig n ific a n t in flu e n c e on o u tc o m e in th e

e ffe ctiv e ly . L u b o rsk y an d c o lle a g u e s a re a m o n g

tre a tm e n t o f s u b s ta n c e a b u s e d iso rd e rs. T h e

th o se w h o h a v e d o c u m e n te d th e p ro fo u n d e ffe ct

s p e c ific o u tc o m e s m e a s u re d v a ry fro m stu d y to

th at the th e r a p is t-c lie n t re la tio n sh ip h a s o n the

s tu d y b u t in c lu d e le n g th o f p a rtic ip a tio n in

su cce ss o f tre a tm e n t, h o w e v e r b rie f (L u b o rsk y et

tre a tm e n t, re d u c tio n in d ru g u se, an d re d u ctio n

al., 1985).

in d e p re s s iv e s y m p to m s .

T h e p sy ch o d y n a m ic m o d e l o ffe rs a
sy ste m a tic e x p la n a tio n o f h o w the th e ra p e u tic
re la tio n sh ip w o rk s and g u id e lin e s fo r h o w to
use it fo r p o sitiv e c h a n g e an d g ro w th . In all
p s y ch o d y n a m ic th e ra p ie s, th e first g o a l is to
e sta b lish a "th e r a p e u tic a llia n c e " b e tw e e n
th e ra p ist an d clie n t. In m o st ca ses, the
d e v e lo p m e n t o f a th e ra p e u tic a llia n c e is p a rtia lly
a p ro cess o f the p a s s a g e o f tim e. T h e m o re
sev ere the c lie n t's d iso rd e r, th e m o re tim e it w ill
take. T h e ca p a b ilitie s o f the th e ra p is t to b e
h o n e st an d e m p a th ic an d o f th e c lie n t to be
tru stin g are also fa cto rs. A th e ra p e u tic a llia n c e
re q u ire s in tim a te s e lf-d is c lo su re o n th e p a rt o f
the clie n t and an e m p a th ic an d a p p ro p ria te
re sp o n se on the p a rt o f the th e ra p ist. H o w e v e r,
in b rie f p s y ch o d y n a m ic th e ra p y th is a llia n ce
m u st be e sta b lish e d as so o n as p o ss ib le , and
th erap ists c o n d u c tin g th is s o rt o f th e ra p y m u st
be ab le to e sta b lis h a tru stin g re la tio n sh ip w ith
th eir c lie n ts in a sh o rt tim e.
O n e stu d y o f the th e ra p e u tic a llia n ce an d its
re la tio n sh ip to a lc o h o lism tre a tm e n t fo u n d th a t
fo r alco h o lic o u tp a tie n ts, ra tin g s o f th e
th e rap e u tic a llia n ce by th e p a tie n t or th e ra p is t

D evelopm ental Level

P sy c h o d y n a m ic th e o ry e m p h a s iz e s th a t the
c lie n t's le v e l o f fu n c tio n in g s h o u ld d eterm in e
the n a tu re o f a n y in te rv e n tio n . In F re u d ia n
p s y c h o a n a ly tic th e o ry , s u b s ta n c e a b u se is
co n s id e re d a s y m p to m a s s o c ia te d w ith the oral
or m o st p rim itiv e sta g e o f d e v e lo p m e n t and
re p re s e n ts an a tte m p t to e s ta b lis h a n e e d g ra tify in g s y m b io tic s ta te (L e e d s and
M o rg e n ste rn , 1 9 9 6 ). A n a ly tic th e o rists w ith in
th e O b je c t R e la tio n s s c h o o l h o ld th a t su b sta n ce s
sta n d in fo r th e fu n c tio n s u s u a lly a ttrib u te d to
th e p rim a ry m a te rn a l (o r ca re -g iv in g ) o b ject. A s
a re su lt, th e s u b s ta n c e a b u s e r re la te s to the
su b sta n ce b a se d o n th e d is tu rb e d p a tte rn of
re la tin g th a t h e e x p e rie n c e d w ith th e m a te rn a l
o b je c t (K ry sta l, 1 9 7 7 ). T h is w o u ld b e c o n sid ere d
a v a ria n t o f b o rd e r lin e p s y c h o p a th o lo g y , w h ich
is v ie w e d as a fa irly s e v e re d is tu rb a n c e o f eg o
fu n ctio n in g a n d o b je c t re la tio n s. It is fo r this
re a so n th a t s u b s ta n c e -a b u s in g c lie n ts w e re and
p e rh a p s s till a re o fte n c o n s id e re d u n su ita b le fo r
p s y c h o a n a ly s is a n d a lso u n su ita b le fo r m a n y of
th e s h o rt-te rm a n a ly tic m o d e ls th a t in v o lv e a

w ere sig n ifica n t p re d ic to rs o f tre a tm e n t

129

C h ap ter 7

v e ry fo cu se d an d a c tiv e u n c o v e rin g o f the

T h e se o p tio n s in c lu d e le a rn in g to s e p a ra te h is

u n co n scio u s.

re a c tio n s to th e s u p e rv is o r fro m h is fe e lin g s

C o n te m p o ra ry a n a ly tic th e o rists w h o

a b o u t h is fa th e r, w o rk in g th ro u g h h is fe e lin g s

co n cern th e m se lv e s w ith su b s ta n c e a b u se

a b o u t h is fa th e r (o f w h ic h h e m a y n o t h a v e b ee n

d iso rd e rs ty p ic a lly d o n o t fo cu s o n th e id ea th a t

p re v io u s ly a w a re ), a c tiv e ly c h o o s in g a lte rn a tiv e

a d d ictio n is lin k e d to a d e v e lo p m e n ta lly

b e h a v io rs to d rin k in g w h e n h e fe e ls b a d (e.g.,

p rim itiv e lev el o f eg o fu n c tio n in g , a lth o u g h th ey

a tte n d in g a 1 2 -S te p m e e tin g ), a n d a cce p tin g

m a y e n d o rse it. O n e re a so n is th a t th is id ea

g re a te r re s p o n s ib ility fo r h is fe e lin g s an d

lea d s to a ra th e r p e s sim is tic b e lie f re g a rd in g the

b e h a v io rs.

o u tco m e o f a n a ly tic tre a tm e n ts fo r su b sta n ce

A b ro a d e r d e fin itio n o f in s ig h t, a lso

ab u se d iso rd e rs. A n o th e r re a so n is th a t it d o es

p ro m o te d b y b rie f p s y c h o d y n a m ic th e ra p ie s, is

n o t co n trib u te h e lp fu l in fo rm a tio n to the

sim p ly an y re a liz a tio n a b o u t o n e s e lf, o n e 's in n er

th e ra p e u tic a p p ro a ch , an d it ca n im p e d e the

w o rk in g s, or o n e 's b e h a v io r. F o r e x a m p le , a

d e v e lo p m e n t o f a n e m p a th ic an d re sp e c tfu l

c lie n t w h o s a y s, " t h e o n ly e m o tio n I re a lly fe e l is

th e ra p e u tic a llia n ce . F u rth e rm o re , th e re is

a n g e r ," h a s o p e n e d th e d o o r to u n d e rs ta n d in g

in cre a sin g e m p iric a l e v id e n c e fo r th e id ea th a t

th e e ffe c t o th e rs h a v e o n h e r, a n d v ice v e rsa .

s ev ere su b sta n c e a b u se is la rg e ly d riv e n by

Sh e c a n th e n b e g in to d e v e lo p a lte rn a tiv e

b io b e h a v io ra l fo rces an d th a t in d iv id u a l

b e h a v io rs to th o se th a t p re v io u s ly fo llo w e d

p sy ch o lo g ica l fa cto rs are o f le sse r im p o rta n ce

a u to m a tic a lly fro m h e r a n g e r (su ch as d rin k in g ),

(B ab o r, 1991). A lth o u g h a n a ly tic th e o rie s h a v e

as w e ll as to u n d e rs ta n d w h y h e r e m o tio n a l

ten d ed to ig n o re th is (L e ed s an d M o rg e n ste rn ,

r e p e rto ire is so lim ite d .

1996), it h as b e c o m e in c re a sin g ly a p a rt o f the

In s ig h t in v o lv e s b o th th o u g h ts a n d fe e lin g s.

k n o w le d g e b a se in u n d e rs ta n d in g s u b sta n ce

A p u re ly in te lle c tu a l e x e rc ise w ill n o t lea d to

a b u se d iso rd e rs.

b e h a v io r c h a n g e . T ru e in s ig h t in v o lv e s a
p o w e rfu l e m o tio n a l e x p e rie n c e as w e ll as a

130

Insight

co g n itiv e c o m p o n e n t a n d le a d s to a g re a te r

A n o th e r critica l u n d e rly in g c o n c e p t of

a c c e p ta n c e o f re s p o n s ib ility fo r fe e lin g s and

p s y ch o d y n a m ic th e o ry an d o n e th a t ca n b e of

b e h a v io r. In tre a tin g s u b s ta n c e a b u se d iso rd e rs,

g re a t b e n e fit to all th e ra p is ts is th e c o n c e p t of

it is im p o r ta n t to re c o g n iz e th a t in s ig h t a lo n e is

in sig h t. P sy ch o d y n a m ic a p p ro a c h e s re g a rd

o ften n o t s u ffic ie n t to c re a te c h a n g e . S u b sta n ce s

in sig h t as a p a rtic u la r k in d o f se lf-re a liz a tio n or

of a b u se a re p o w e rfu l b e h a v io ra l re in fo rc e rs and

s e lf-k n o w le d g e , e sp e c ia lly re g a rd in g the

th e th e ra p is t n e e d s to h e lp th e c lie n t c o u n te r the

c o n n e ctio n s o f e x p e rie n c e s an d c o n flic ts in the

s tro n g co m p u ls iv e d e s ire fo r th e m . T h u s, in

p ast w ith p re s e n t p e rce p tio n s and b e h a v io r and

a d d itio n to in s ig h t, it c o u ld b e h e lp fu l to o ffer

the re co g n itio n o f fe e lin g s or m o tiv a tio n s th a t

p s y c h o e d u c a tio n a n d m a k e b e h a v io ra l

h a v e b e e n re p re sse d . In s ig h t c a n co m e th ro u g h

in te rv e n tio n s , w h ic h m ig h t in c lu d e e n c o u ra g in g

a su d d en fla sh o f u n d e rs ta n d in g or fro m

a tte n d a n c e an d p a rtic ip a tio n in se lf-h e lp

g ra d u a l a cq u isitio n o f se lf-k n o w le d g e . S o, fo r

p ro g ra m s a n d re q u irin g re g u la r te stin g by

e x a m p le , a clie n t w h o fe e ls d e p re sse d an d a n g ry

u rin a ly sis a n d / o r B re a th a ly z e r . M a n y

and s u b s e q u e n tly d rin k s c o m e s to re a liz e th a t

th e ra p is ts w h o c o n d u c t s u b s ta n c e a b u se

h is fe e lin g s to w a rd h is fa th e r a re stim u la te d by

tre a tm e n t fro m a p s y c h o d y n a m ic p e rs p e c tiv e

an e m o tio n a lly a b u siv e s u p e rv is o r at w o rk . T h is

a re c o m fo rta b le c o m b in in g in s ig h t-o rie n te d

ty p e o f re a liz a tio n g iv e s th e c lie n t n ew op tio n s.

th e ra p y w ith co n c re te , b e h a v io ra l in te rv e n tio n s.

Defense Mechanisms and Resistance

In psychoanalytic theory, defense mechanisms
bolster the individual's ego or self. Under the
pressure of the excessive anxiety produced by an
individual's experience of his environment, the ego
is forced to relieve the anxiety by defending itself.
The measures it takes to do this are referred to as
"defense mechanisms." All defense mechanisms
have two characteristics in common: they deny,

Sidestepping rather than confronting defenses

Demonstrating the denial defense while

interacting with the client to show her how
it works
Figure 7-1 defines the most common mechanisms

clients use to defend themselves from painful feelings

or to resist change.

distort, or falsify reality, and they operate

Transference

unconsciously. Some defense mechanisms are

Effective use of the therapeutic relationship depends on

adaptive and support the mature functioning of the

an understanding of transference. Transference is the

individual, while others are maladaptive and

process of transferring prominent characteristics of

hinder the individual's growth. Generally the

unresolved conflicted relationships with significant

defenses hamper the process of exploration in

others onto the therapist. For example, a client whose

therapy, and for this reason they are often

relationship with his father is deeply conflicted may

confronted in the more expressive models of

find himself reacting to the therapist as if he were the

analytic therapy. However, in more supportive

types of therapy, adaptive defenses are supported,
and even the maladaptive defenses may not be
confronted until the therapist has enabled the client
to replace them with a more constructive means of
coping.
In the treatment of substance abuse disorders,
defenses are seen as a means of resisting changechanges that inevitably involve eliminating or at least

client's father. The opening session in psychodynamic

therapy usually involves the assessment of transference
so that it may be incorporated into the treatment
strategy. Strean found that, "all patients-regardless of
the setting in which they are being treated, of the
therapeutic modality, or the therapist's skills and years
of experience-will respond to interventions in terms of
the transference" (Strean, 1994, p. 110).
An initial goal of brief psychodynamic therapy is to

reducing drug use. Mark and colleagues noted that

foster transference by building the therapeutic

two defenses frequently seen in those with substance

relationship. Only then can the therapist help the client

abuse disorders are denial and grandiosity (Mark

begin to understand her reasons for abusing substances

and Luborsky, 1992). Particularly with this group of

and to consider alternative, more positive behavior. A

clients, handling defenses can degenerate into an

longer term goal-necessitated by the brevity of the

adversarial interaction, laden with accusations; for

process-is to increase the client's motivation and

example, when a therapist admonishes the client by

participation in other modalities of treatment for

saying, "You are in denial" (Mark and Luborsky,

substance abuse disorders.

1992). They recommend avoiding ineffective

adversarial interactions around the client's use of

Etiology

defenses by using the following strategies:

Four contemporary analytic theorists have offered

Working with the client's perceptions of reality

valuable psychodynamic perspectives on the etiology

rather than arguing

Asking questions

of substance abuse disorders.

C h ap ter 7

G iv e n th is u n d e rs ta n d in g , W u r m s e r 's m a in

W u rm se r, a tra d itio n a l d riv e th e o rist,

su g g e sts th a t th o se w ith s u b s ta n c e a b u se

fo cu s is th e a n a ly sis o f th e s u p e re g o . H e

d iso rd e rs s u ffe r fro m o v e rly h a rsh and

b e lie v e s th a t a m o ra lis tic sta n ce to w a rd the

d estru ctiv e su p e re g o s th a t th re a te n to

s u b s ta n c e -a b u s in g b e h a v io r is

o v erw h e lm the p e rso n w ith ra g e an d fear.

c o u n te rp ro d u c tiv e a n d th a t s u b s ta n c e a b u se rs'

A b u sin g su b sta n c e s is an a tte m p t to flee fro m

p ro b le m s c o n s is t o f to o m u c h , ra th e r th a n too

su ch d a n g e ro u s a ffects. T h e se a ffe cts a re the

little , s u p e re g o . W u r m s e r re c o m m e n d s th a t the

resu lt o f co n flic t b e tw e e n the e g o an d su p e re g o ,

th e ra p is t p ro v id e a s tro n g e m o tio n a l p re sen ce

b ro u g h t a b o u t b y the h a rs h n e s s o f the su p e re g o .

a n d a w a rm , a c c e p tin g , fle x ib le a ttitu d e .

F ig u re 7-1
D e fen se M e c h a n is m s

D en ial. P re te n d in g th a t a th re a te n in g situ a tio n d o es n o t e x is t b e c a u se th e s itu a tio n is to o d istre ssin g

to co p e w ith . A ch ild c o m e s h o m e, and n o o n e is th ere. H e sa y s to h im s e lf, " T h e y a re h e re . I'll find
th em s o o n ."

D isp lacem en t. F e elin g s an d th o u g h ts d irecte d to w a rd o n e p e rs o n o r o b je c t a re d ire cte d to w a rd

a n o th er p e rso n . F o r e x a m p le , an e m p lo y e e h a s fe e lin g s o f a n g e r to w a rd h is b o s s b u t is u n a w a re of
th ese fe e lin g s b e c a u se o f h is in te rn a l c o n flic t o v er a c k n o w le d g in g th em . In ste a d h e b e c o m e s
d is p ro p o rtio n a te ly a n g ry at h is w ife o v er a m in o r p ro b le m a t h o m e.

G ran diosity. A lth o u g h n o t o n e o f the o rig in a lly id e n tifie d a n a ly tic d e fe n s e s , g ra n d io s ity is fre q u e n tly
e m p lo y e d b y s u b s ta n c e a b u sers (M a rk an d L u b o rsk y , 19 9 2 ). G ra n d io s ity d e fe n d s a g a in st
u n co n scio u s low s e lf-e s te e m by in v o k in g s e lf-d e c e p tiv e , o v e rly p o sitiv e o p in io n s a b o u t o n e se lf. A n
e x a m p le o f g ra n d io s ity in a su b s ta n c e -a b u s in g c lie n t is th e c lie n t w h o in s is ts th a t h e ca n m a in ta in
co n tro l o f d ru g u se d e sp ite th e fa c t th a t h e w a s u sin g an in c re a sin g ly la rg e a m o u n t o f d ru g s w ith
in cre a sin g fre q u e n c y . T h is e x a m p le ca n b e see n as d e n ia l as w e ll b e c a u s e d e n ia l in v o lv e s d e n y in g or
m in im iz in g th e c o n s e q u e n c e s o f the a d d ictio n . H o w e v e r, the g ra n d io s ity is e v id e n t in th e u s e r's
u n rea listic b e lie f th a t h e is in co n tro l o f h is d ru g u se w h e n it w o u ld se e m th a t h is u se is c o m p u lsiv e
and cle a rly o u t o f c o n tro l a t th is p o in t.

Id en tification w ith th e a g g resso r. T h e a c tiv ity o f d o in g u n to s o m e o n e e ls e w h a t a ro u se d a n x ie ty w h en

it w as d o n e to o n e se lf. A c h ild h a s a to n sille c to m y . S h e th e n p u ts o n a toy s te th o s c o p e an d g o es
aro u n d p re te n d in g to tak e o u t th e to n sils o f h e r p la y m a te s.

In trojection . T h e in d iv id u a l "ta k e s in s id e " h im s e lf w h a t is th re a te n in g . F o r e x a m p le , a c h ild feels

s tro n g a n x ie ty a b o u t lo sin g a p a re n t's lo v e w h en th e la tte r a d m o n is h e s h e r fo r n o t c le a n in g h er
ro om . T o co p e w ith th e a n x ie ty sh e te lls h e rself, " Y o u are a b ad g ir l."

Isolation . P a in fu l id e a s a re se p a ra te d fro m fe e lin g s a s s o cia te d w ith th e m . T o fa ce th e fu ll im p a c t of

sex u a l or a g g re ssiv e th o u g h ts and fe e lin g s, th e id e a s and a ffects a re k e p t a p a rt. F o r e x a m p le , the
th o u g h t o f sh o u tin g o b s ce n itie s in a c h u rc h is k e p t s e p a ra te fro m all th e ra g e a b o u t b e in g in ch u rch .
T h u s, in iso la tio n the in d iv id u a l m ay h a v e fle e tin g th o u g h ts o f an a g g re s siv e or se x u a l n a tu re
w ith o u t an y e m o tio n a l a cco m p a n im e n t.

P rojection . T h is is th e o p p o site o f in tro je c tio n ; an in to le ra b le id e a or fe e lin g is a scrib e d to so m e o n e

else. For e x a m p le , it co u ld b e h y p o th e siz e d th a t b e c a u se the la te S e n a to r Jo s e p h M c C a rth y co u ld n o t
to le ra te h is o w n h o m o s e x u a l w ish e s, h e s p e n t m u ch tim e c o m p ilin g lists o f m e n in th e S ta te
D e p a rtm e n t w h o , a c c o rd in g to M cC a rth y , w e re h id in g th e ir h o m o s e x u a lity .

132

B r ie f P sy ch o d y n a m ic T herapy

F ig u r e 7-1 (c o n tin u e d )
D e fe n se M e c h a n is m s

R eaction fo r m a tio n . A p a in fu l id ea or fe e lin g is re p la c e d b y its o p p o s ite . A y o u n g g irl, fo r e x a m p le ,

w h o c a n n o t to le ra te h e r h a te fu l fe e lin g s to w a rd h e r n e w b a b y b ro th e r k e e p s s a y in g , " I lo v e m y new
b ro th e r!"

R eg ression . A re tre a t to an e a rlie r fo rm o f b e h a v io r an d p s y c h ic o rg a n iz a tio n b e c a u se o f a n x ie ty in

th e p re sen t. F or e x a m p le , u n d e r th e im p a c t o f a n x ie ty stirre d up b y w is h e s to m a s tu rb a te , a
te e n a g e r re tu rn s to an e a rlie r fo rm o f b e h a v io r an d re s u m e s s u c k in g h is th u m b .

R epression . A n a tte m p t to e x c lu d e fro m a w a re n e s s fe e lin g s a n d th o u g h ts th a t e v o k e a n x ie ty . In

re p re ssio n , th e fe e lin g s an d th o u g h ts m a y h a v e b e e n e x p e rie n c e d c o n s c io u s ly a t o n e tim e , or the
re p re ssiv e w o rk m a y h a v e sto p p e d id e a s an d fe e lin g s fro m e v e r re a ch in g co n s c io u s n e s s . For
e x a m p le , an in d iv id u a l m a y h a v e c o n s c io u s ly e x p e rie n c e d h a te fu l fe e lin g s to w a rd a p a re n t or
s ib lin g b u t, b e c a u se o f th e a n x ie ty e v o k e d , b lo ck e d th e fe e lin g s fro m a w a re n e s s . O r to p ro te c t
h e rs e lf fro m fe e lin g th e u n p le a s a n tn e s s an d d re a d o f h a te an d a n g e r, a w o m a n n e v e r a llo w s any
h o stile th o u g h ts or fe e lin g s to re a ch c o n s c io u s n e s s .

U n doin g. T ry in g to re m o v e a n o ffe n siv e act, e ith e r b y p re te n d in g it w a s n o t d o n e or b y a to n in g for

it. F or e x a m p le , a b o ss h a te s an e m p lo y e e an d w ish e s to fire h im . In s te a d h e p ro m o te s the
e m p lo y e e , th e re b y d im in is h in g in h is m in d w h a t h e th in k s h e h a s d o n e .

A d ap ted fr o m : S tre a n , 1994, p p . 1 3 -1 5 .

K h a n tz ia n th e o riz e s th a t d e ficits, ra th e r th a n

c o n tin u e s to b e a p o p u la r th e o ry a lth o u g h m o st

co n flicts, u n d e rlie th e p ro b le m s o f th o se w ith

re s e a rc h e rs a n d th e ra p is ts n o w w o u ld sa y th a t

su b sta n ce ab u se d iso rd e rs. T h a t is, w e a k n e s s or

th is c a n o ffe r o n ly p a rtia l a n s w e rs to the

in a d e q u a cie s in th e e g o or s e lf a re at th e ro o t of

q u e stio n s o f h o w a b u s e rs d e v e lo p d ru g

the p ro b lem . K h a n tz ia n an d c o lle a g u e s

p re fe re n c e s a n d w h a t th e m e a n in g is o f su ch

d ev elo p e d M o d ifie d D y n a m ic G ro u p T h e ra p y

p re fe re n c e s. It is im p o r ta n t to c o n s id e r the

(M D G T ) to a d d re ss th e se issu e s in a g ro u p

so c ia l an d p h y s ic a l e n v iro n m e n ta l c o n te x t of

th e rap y fo rm a t, an d th is a p p ro a ch h a s so m e

su b s ta n c e a b u s e as w e ll. T h a t is, w h a te v e r

e m p irica l su p p o rt. K h a n tz ia n p u t fo rth th e self-

d ru g s are m o st re a d ily a v a ila b le in a p e rs o n 's

m e d ica tio n h y p o th e sis , w h ic h e ss e n tia lly sta te s

c o m m u n ity an d w h a t h is p e e rs a n d a sso cia tes

th at su b sta n ce a b u sers w ill u se su b s ta n c e s in an

a re u sin g a lso h a v e a s tro n g in flu e n c e o n a

a tte m p t to m e d ic a te sp e c ific d istre s s in g

u s e r's d ru g p re fe re n c e .

p sy ch ia tric s y m p to m s (K h a n tz ia n , 19 8 5 ). It

K ry s ta l o ffe rs tw o p o ss ib le th e o rie s o f the

fo llo w s, th en , th a t su b s ta n c e -d e p e n d e n t p e rso n s

e tio lo g y o f s u b s ta n c e a b u s e d iso rd e rs. O n e is

w ill e x p ress a s tro n g p re fe re n c e fo r a p a rtic u la r

b a se d on a n o b je c t-r e la tio n s c o n c e p tu a liz a tio n .

d ru g o f ch o ice to m e d ic a te th eir p a rtic u la r se t o f

In th is th e o ry , th e s u b s ta n c e a b u s e r e x p e rie n c e s

sy m p to m s. For e x a m p le , th o se d e p e n d e n t on

th e s u b s ta n c e as th e p rim a ry m a te rn a l ob ject.

o p io id s are th o u g h t to b e m e d ic a tin g in te n se

T h e s u b s ta n c e a b u s e r re la te s to th e su b sta n ce in

an g er an d a g g re s sio n th a t th e ir e g o s a re u n a b le

th e sa m e m a la d a p tiv e re la tio n sh ip p a tte rn s th at

to co n tain . C o c a in e -d e p e n d e n t p e o p le are

sh e e x p e rie n c e d d e v e lo p m e n ta lly w ith the

b elie v e d to b e s e e k in g re lie f fro m in te n se

m o th e r. T h e se c o n d th e o ry fo c u s e s o n the

d ep ressio n or e m o tio n a l la b ility (as in b ip o la r

s u b s ta n c e a b u s e r 's d is tu rb e d a ffe c tiv e fu n ctio n s,

d iso rd ers) or a tte n tio n d e ficit d iso rd e r. T h is

k n o w n as a le x ith y m ia . It is th o u g h t th a t

133

C h ap ter 7

in d iv id u a ls w ith a le x ith y m ia d o n o t re c o g n iz e

u r g e " to a b u se s u b s ta n c e s a n u rg e th a t ca n

the co g n itiv e a sp e cts o f fe e lin g sta te s. In ste a d ,

ta k e p re c e d e n c e o v e r e v e ry o th e r a sp e c t o f life.

they e x p e rie n c e an u n c o m fo rta b le , g lo b a l sta te

F u rth e rm o re , th e s y m p to m (su b sta n c e a b u se) is

o f te n sio n in re sp o n se to all a ffe c tiv e stim u li.

o fte n c o n s id e re d p le a s u ra b le b y th e c lie n t, in

T h u s they see k to re lie v e th is d is c o m fo rt w ith

c o n tra s t to th e s y m p to m s o f o th e r p s y c h o lo g ica l

su b stan ce s.

d iso rd e rs (su c h as a n x ie ty or d e p re s s io n ). T h u s,

M cD o u g a ll v ie w s s u b s ta n c e a b u se as a
p s y ch o s o m a tic d iso rd e r. It is a w a y o f d ea lin g

as p a rt o f an o v e ra ll tre a tm e n t p la n th a t in clu d e s

w ith d istress th a t in v o lv e s e x te rn a liz in g and

s o m e k in d o f d ru g c o u n s e lin g an d p o ssib ly

m a k in g p h y sic a l w h a t is e ss e n tia lly a

o th er in te rv e n tio n s as w e ll, s u ch as m e d ic a tio n s

p sy ch o lo g ica l d istu rb a n ce . S u b s ta n c e a b u se

a n d fa m ily th e r a p y " (L e v e n s o n e t al., 1997,

then is the h a b itu a l u se o f a n e x te rn a liz in g

p. 125).

d efen se a g a in st p a in fu l or d a n g e ro u s a ffects.
M cD o u g a ll s u g g e sts th a t th e se p a in fu l a ffects
are the re sp o n se to d ee p u n ce rta in ty a b o u t o n e 's
rig h t to ex ist, o n e 's rig h t to a s e p a ra te id e n tity ,

Integrating Psychodynam ic
Concepts Into Substance Abuse
Treatm ent

and o n e 's rig h t to h a v e c o n tro l o v e r o n e 's b o d y

M a n y o f th e c o n c e p ts a n d p rin c ip le s u sed in

lim its an d b e h a v io r. T h e a b u se o f d ru g s is p a rt

p s y c h o d y n a m ic th e ra p y w ith c lie n ts w h o h av e

o f a "fa ls e s e lf" th a t th e in d iv id u a l cre a te s to

s u b s ta n c e a b u s e d is o rd e rs a re s im ila r to th o se

w ard o ff th e se p a in fu l fe e lin g s.

u sed w ith c lie n ts w h o h a v e o th e r p s y c h ia tric

S o m e critics h a v e a rg u ed th a t a m a jo r

d iso rd e rs. H o w e v e r, m o s t th e ra p is ts a g re e that

lim ita tio n o f th o se p s y c h o a n a ly tic th e o rie s is

p e o p le w ith s u b s ta n c e a b u se d is o rd e rs co m p rise

th at they d o n o t m a k e a llo w a n c e s fo r the

a sp e c ia l p o p u la tio n o n e th a t o fte n re q u ires

b io lo g ica l b a se s o f s u b s ta n c e a b u se d iso rd e rs

m o re s tru c tu re an d a c o m b in e d tre a tm e n t

(B ab o r, 1991). H o w e v e r, c o n te m p o ra ry

a p p ro a c h if tre a tm e n t is to b e s u cc e ssfu l. T o

p s y ch o a n a ly tic th e o rists a c k n o w le d g e th a t

e ffe c tiv e ly tre a t th e se c lie n ts , it is im p o rta n t to

b io lo g y p la y s a ro le in b e h a v io rs re la ted to

co m b in e sk ill in th e p ro v isio n o f th e m o d e l of

su b sta n ce a b u se. B u t th e u n a n sw e re d q u e stio n

th e ra p y w ith k n o w le d g e o f th e g e n e ra l fa cto rs in

re m ain s w h e th e r b io lo g ic a l or p s y c h o lo g ic a l

th e tre a tm e n t o f s u b s ta n c e a b u se d iso rd e rs.

facto rs co m e first: W h y d o e s a p e rs o n start u sin g

T h e s e in c lu d e k n o w le d g e o f th e p h a rm a c o lo g y

s u b sta n ce s? A n a ly tic c o n c e p ts a re u se fu l h e re ,

an d th e in to x ic a tio n a n d w ith d ra w a l e ffe c ts of

in th at th e y ca n b e sa id to fa cilita te the

d ru g s, fa m ilia rity w ith th e s u b c u ltu re of

re so lu tio n o f p ro b le m s th a t c o n trib u te to

s u b s ta n c e a b u se a n d w ith s u b s ta n c e -d e p e n d e n t

e m o tio n a l d istre ss a n d to h elp e x p lo re the

life sty le s, a n d k n o w le d g e o f se lf-h e lp p ro g ra m s.

co n n e ctio n am o n g in te rp e rs o n a l p a tte rn s,

It a lso h e lp s to fe e l c o m fo rta b le w o rk in g w ith

e m o tio n s, and s u b s ta n c e a b u se.

s u b s ta n c e a b u s e rs a n d fo r o n e 's th e ra p e u tic sty le

L ev en so n an d c o lle a g u e s o ffe r su ch a th eo ry

to e x p re s s a c c e p ta n c e o f a n d e m p a th y fo r the

(L e v e n so n et al., 19 9 7 ). T h e y d e sc rib e a

clie n t. In m o d ify in g S E p s y c h o th e r a p y fo r use

b io p sy ch o so cia l c o n c e p tu a liz a tio n o f s u b sta n ce

w ith c lie n ts w ith s u b s ta n c e a b u s e d iso rd e rs,

a b u se d iso rd e rs th a t ca n , in p a rt, b e a d d resse d

L u b o rsk y a n d c o lle a g u e s id e n tifie d ce rta in

b y b rie f p s y c h o d y n a m ic th e ra p y . In th is m o d e l,

e m p h a se s th a t a re p a rtic u la rly im p o rta n t

s u b sta n ce a b u se d iso rd e rs a re p a rticu la rly

(L u b o rsk y e t al., 1 9 7 7 ,1 9 8 9 ). T h e s e e m p h a se s,

d ifficu lt to tre a t b e c a u se , u n lik e o th er

liste d b e lo w , a re re le v a n t fo r a p p ly in g o th er

p s y ch o lo g ica l d iso rd e rs, th e re is a "p rim a ry

134

"[p s y c h o d y n a m ic ] th e ra p y s h o u ld b e co n sid ere d

B r ie f P sy ch o d y n a m ic T herapy

ty p es o f p s y c h o th e ra p y to su b s ta n c e -d e p e n d e n t

th e e x te n t to w h ic h th e y u se e x p re s s iv e or

clie n ts as w ell.

s u p p o rtiv e te c h n iq u e s , fo c u s o n a cu te or c h ro n ic

M u ch o f the th e ra p is t's tim e an d e n e rg y are

re q u ired to in tro d u c e a n d e n g a g e th e c lie n t
in tre a tm e n t.

T h e tre a tm e n t g o a ls m u st b e fo rm u la te d
e arly an d k e p t in sig h t.

T h e th e ra p ist m u s t p a y c a re fu l a tte n tio n to

d e v e lo p in g a g o o d th e ra p e u tic a llia n ce and
s u p p o rtin g th e clie n t.

T h e th e ra p ist m u s t sta y a b re a s t o f th e c lie n t's

c o m p lia n ce w ith th e o v e ra ll tre a tm e n t
p ro g ra m (if th e c lie n t is in v o lv e d in a
co m p re h e n siv e tre a tm e n t p ro g ra m ). T h is
in clu d e s su ch th in g s as th e c lie n t's
a tte n d a n ce a t all fa ce ts o f th e p ro g ra m ,
su b m issio n to re g u la r u rin a ly s is , a n d u se o f
an y d ru g s.

If the c lie n t is re c e iv in g s u b s titu tio n th e ra p y ,

su ch as m e th a d o n e m a in te n a n c e , a tte n tio n
sh o u ld b e g iv e n to th e tim e o f th e c lie n t's
d aily d o se an d w h e n , in re la tio n to the
d o sin g , the c lie n t fe e ls th e ra p y is b est
co n d u cte d .
T h e ra p is ts w h o se o rie n ta tio n s a re n o t

p ro b le m s , h a v e a g o a l o f s y m p to m a tic ch a n g e or
p e rs o n a lity c h a n g e , an d p a y a tte n tio n to
in tra p s y c h ic or in te rp e rs o n a l d y n a m ics.
In te rp e rs o n a l p s y c h o th e r a p y is in clu d e d
b e c a u se it is o n e o f th e im p o r ta n t an d b e tte r
re s e a rc h e d th e ra p e u tic a p p ro a c h e s fo r tre a tin g
s u b s ta n c e a b u se d is o rd e rs . It is co n s id e re d by
s o m e to b e a p s y c h o d y n a m ic m o d e l, b u t th ere
a re c o n flic tin g o p in io n s o n th is. T h is lis t is n o t
e x h a u s tiv e ; n u m e ro u s o th e r, p e rh a p s less w ell
k n o w n , a p p ro a c h e s or m o d ific a tio n s o f these
a p p ro a ch e s a re n o t m e n tio n e d . M a n y o f th ese
a p p ro a c h e s h a v e d e v e lo p e d fro m clin ica l
e x p e rie n c e , an d s o m e a re n o t w e ll re se a rch e d , if
th e y a re re s e a r c h e d a t a ll. F ig u re 7 -2
s u m m a riz e s th e le n g th o f tre a tm e n t, fo cu s, and
m a jo r te c h n iq u e s o f v a rio u s m o d e ls o f b rie f
p s y c h o d y n a m ic th e ra p y .

M ann's Tim e-Lim ited

Psychotherapy (TLP)
T h e g o a l o f tre a tm e n t in T L P is to d im in ish as
m u c h as p o ss ib le th e c lie n t's n e g a tiv e se lf-im a g e
th ro u g h re s o lu tio n o f th e c e n tra l issu e (M an n ,

p s y ch o d y n a m ic m a y s till fin d th e s e te c h n iq u e s

19 9 1 ). S y m p to m s a re re d u c e d or e lim in a te d as a

an d a p p ro a ch e s u se fu l. T h e ra p is ts w h o se

b y p ro d u c t o f th e p ro c e s s . T L P w o rk s v ia tw o

a p p ro a ch e s are p s y c h o d y n a m ic w ill b e m o re

m a in c o m p o n e n ts o f th e tre a tm e n t: th e

su cce ssfu l if th e y a lso h a v e a k n o w le d g e o f the

th e ra p is t's id e n tific a tio n o f th e c e n tra l issu e and

g e n eral fa cto rs in th e tre a tm e n t o f su b sta n c e

th e s e ttin g o f th e te rm in a tio n d a te a t the sta rt of

a b u se d iso rd e rs an d c o n d u c t p s y c h o th e r a p y in a

tre a tm e n t. T h e c e n tra l issu e is a lw a y s

w ay th a t c o m p le m e n ts th e fu ll ra n g e o f se rv ice s

c o n c e p tu a liz e d in te rm s o f th e c lie n t's ch ro n ic

th at clie n ts w ith s u b s ta n ce a b u s e d is o rd e rs

a n d p re s e n tly e n d u re d p a in , re s u ltin g fro m

re ce iv e in a re la tiv e ly c o m p re h e n siv e p ro g ra m .

p a in fu l life e x p e rie n c e s . T h is p a in is a p riv a te ly

h e ld , a ffe c tiv e s ta te m e n t a b o u t h o w th e c lie n t

Models of Brief
Psychodynamic Therapy

fe e ls a b o u t h im s e lf. C h a n g e c o m e s a b o u t
th ro u g h th e id e n tific a tio n an d e x p lo ra tio n o f the
p a in fu l fe e lin g s a b o u t h im s e lf a n d th ro u g h the

T e n m a jo r a p p ro a c h e s to s h o rt-te rm

fe e lin g s o f lo ss s u r ro u n d in g te rm in a tio n . T h is

p s y ch o d y n a m ic p s y c h o th e ra p y a re b rie fly

m o d e l h a s a se t tre a tm e n t le n g th o f 12 sessio n s

s u m m a riz ed in th is se c tio n (fo r m o re d eta iled

an d p ro m o te s w o rk in g th ro u g h o f te rm in a tio n

in fo rm a tio n , se e C r its -C h ris to p h a n d B a rb e r,

issu es.

1991). T h e se a p p ro a c h e s d iffe r d e p e n d in g on
135

C h ap ter 7

Sifneos' Short-Term AnxietyProvoking Psychotherapy (STAPP)

D avanloo's Intensive Short-Term

D ynam ic Psychotherapy (ISTDP)

S T A P P is a fo ca l, g o a l-o rie n te d p s y ch o th e ra p y

In IS T D P , th e ra p e u tic te c h n iq u e s a re u sed to

th at is u su a lly p ra c tic e d in 12 to 15 se ssio n s and

p ro v o k e e m o tio n a l e x p e rie n c e s a n d , th ro u g h

so m e tim e s fe w e r (N ielsen and B a rth , 1991).

th is, to fa c ilita te c o r re c tiv e e m o tio n a l

D u rin g the first se ssio n , th e th e ra p is t an d clie n t

e x p e rie n c e s o r th e p o sitiv e re e n a c tm e n ts , in

ag ree on a cle a r p s y ch o d y n a m ic fo cu s, ra th er

th e ra p y , o f p a s t c o n flic tu a l re la tio n sh ip s (L aik in

like a tre a tm e n t co n tra c t. T h e fo ci th a t re sp o n d

e t al., 1 9 9 1 ). C h a n g e c o m e s a b o u t b y b rin g in g to

b est to S T A P P a re u n re so lv e d O e d ip a l co n flicts,

c o n s c io u s n e s s th e se p a s t u n re s o lv e d co n flicts

b u t lo ss, s e p a ra tio n issu es, an d g rie f m a y a lso be

th ro u g h in te n se e m o tio n a l e x p e rie n c e s ,

acce p ta b le . C h a n g e co m es a b o u t th ro u g h the

re e x p e rie n c in g th e m in a m o re c o g n itiv e w ay,

clie n t's le a rn in g to re so lv e an e m o tio n a l co re

an d lin k in g th e m to cu rre n t s y m p to m s and

p ro b lem , e sse n tia lly p ro b le m s o lv in g . R e so lv in g

p ro b le m a tic in te rp e rs o n a l p a tte rn s. E x ten siv e

the p ro b lem p ro m o te s a fe e lin g o f w e ll-b e in g

use o f a n a ly sis o f th e tra n sfe re n c e re la tio n sh ip

and a c o rre sp o n d in g p o sitiv e ch a n g e in attitu d e .

also h e lp s to b rin g th e u n re s o lv e d c o n flicts to

F ig u r e 7 -2
B rie f P s y c h o d y n a m ic T h e r a p y
T herapy

Length of

(Theorist)

Treatm ent

T im e -L im ite d

12 sessio n s

M ajor T ech n iq u es

Focus

C e n tra l issu e re la ted to

P sy ch o th e ra p y

co n flic t a b o u t loss

(M an n )

(lifelo n g so u rc e o f p a in ,

in te rp re ta tio n s o f th e ce n tra l issu e

In te rp re ta tio n a ro u n d e a rlie r

T e rm in a tio n

a tte m p ts to m a s te r it,
an d c o n c lu sio n s d ra w n

F o rm u la tio n , p re s e n ta tio n , and

lo sse s

fro m it re g a rd in g the
c lie n t's se lf-im a g e )
S h o rt-T e rm

U su a lly 12

U n re so lv e d co n flic t

E a rly tra n sfe re n c e in te rp re ta tio n

A n x ie ty -P ro v o k in g

to 15

d efin e d d u rin g the

C o n fro n ta tio n /c la rific a tio n / in te r

P sy ch o th e ra p y

s e ssio n s

e v a lu a tio n

In te n siv e S h o rt-

5 to 3 0 se s

E x p e rie n cin g an d

T e rm D y n am ic

sio n s; up to

lin k in g in te rp e rso n a l

P sy ch o th e ra p y

4 0 sessio n s

c o n flicts w ith im p u lse s,

E a rly tra n sfe re n c e in te rp re ta tio n

(L aik in , W in sto n ,

fo r sev ere

fe e lin g s, d e fe n se s, and

A n a ly s is o f c h a ra c te r d e fe n se s

and M cC u llo u g h )

p e rso n a lity

a n x iety

S u p p o rtiv e : c re a tin g th e ra p e u tic

p re ta tio n s

(N ielsen and B arth )

R e le n tle s s c o n fro n ta tio n of

d e fe n s e s

d iso rd e rs
SE T h e ra p y

16 fo r m a jo r

F o cu s on th e co re

(L u b o rsk y and

d e p re ssio n ,

c o n flictu a l re la tio n sh ip

M ark )

3 6 fo r

th em e

co c a in e
d ep e n d e n c e

a llia n c e th ro u g h sy m p a th e tic
lis te n in g

E x p re ssiv e : fo rm u la tin g an d in te r
p re tin g th e C C R T ; re la tin g sy m
p to m s to th e C C R T a n d e x p la in in g
th e m as c o p in g a tte m p ts

236

B r ie f P sy ch o d y n a m ic T herapy

F ig u re 7 -2 (c o n tin u e d )
B rief P s y c h o d y n a m ic T h e r a p y
Therapy

Length of

(Theorist)

T reatm en t

M ajor T ech n iq u es

Focus

V a n d e rb ilt T im e -

25 to 30

C h a n g e in in te rp e rso n a l

L im ited D y n a m ic

s e ssio n s

fu n c tio n in g , e sp e cia lly

P sy ch o th e ra p y

ch a n g e in c y clica l

(B in d er an d S tru p p )

m a la d a p tiv e p a tte rn s

T ra n s fe re n c e a n a ly sis w ith in an
in te rp e rs o n a l fra m e w o rk

R e c o g n itio n , in te rp re ta tio n o f the

c y c lica l m a la d a p tiv e p a tte rn and
fa n ta sie s a s s o c ia te d w ith it

B rief A d a p tiv e

U p to 4 0

M a la d a p tiv e and

M a in te n a n c e o f fo cu s

P sy ch o th e ra p y

s e ssio n s

in fle x ib le p e rso n a lity

In te rp re ta tio n o f th e tra n sfe re n ce

(P ollack ,

tra its an d e m o tio n s and

R e c o g n itio n , ch a lle n g e ,

F le g e n h e im e r, and

c o g n itiv e fu n c tio n in g ,

in te rp re ta tio n s , an d re s o lu tio n of

W in sto n )

e sp e c ia lly in the

e a rly re s is ta n c e

in te rp e rs o n a l d o m a in

H ig h le v e l o f th e ra p is t a ctiv ity

S e lf-e s te e m b o o ste rs: re a ssu ra n ce ,

D y n am ic S u p p o rtiv e

U p to 40

In c re a se se lf-e ste e m ,

P sy ch o th e ra p y

s e ssio n s

a d a p tiv e sk ills, an d e g o

(P in sk e r, R o se n th a l,

fu n ctio n s

an d M cC u llo u g h )

p ra is e , e n c o u ra g e m e n t

R e d u c tio n o f a n x ie ty

R e sp e c t a d a p tiv e d efen se s,
c h a lle n g e m a la d a p tiv e on es

C la rific a tio n s , re fle c tio n s,

in te rp re ta tio n s

R a tio n a liz a tio n s , re fra m in g , ad v ice

M o d e lin g , a n ticip a tio n , an d

re h e a rs a l

S e lf P sy ch o lo g y
(B ak er)

A n a ly s is o f th e m irro rin g ,

12 to 30

C h a n g e in tra p s y c h ic

se ssio n s, n o t

p a tte rn s. In c o rp o ra te

id e a liz in g , a n d m e rg e r

rig id ly

m o re d iv e rse

tra n sfe re n c e s

a d h e red to

re p re s e n ta tio n s o f o th ers

S u p p o rtiv e , e m p a th ic

E x p lo ra tio n , c la rific a tio n ,

an d c h a n g e s in
in fo rm a tio n p ro ce ssin g
In te rp e rso n a l

T im e

E lim in a tin g or re d u cin g

P sy ch o th e ra p y

lim ite d ; fo r

the p rim a ry s y m p to m ;

e n c o u ra g e m e n t o f a ffe c t, a n a ly sis

(K le rm an )

s u b sta n ce

im p ro v e m e n t in h a n d lin g

o f c o m m u n ic a tio n , u se o f th e

a b u se, the

c u rre n t in te rp e rs o n a l

th e ra p e u tic re la tio n sh ip and

trials h a v e

p ro b lem a rea s,

b e h a v io r-c h a n g e te ch n iq u e s

b e e n 3 and 6

p a rtic u la rly th o se

m o n th s

a sso c ia te d w ith s u b s ta n c e
a b u se

S ou rces: C rits -C h ris to p h an d B a rb e r, 1991; K le rm a n an d W e is s m a n , 1 9 9 3 ; R o u n s a v ille a n d C a rro ll, 1993.

137

C h ap ter 7

the c lie n t's co n s c io u s n e s s so th a t they ca n th en

"c y c lic a l m a la d a p tiv e p a tte r n ," w h ic h in clu d e s

be e x p lo red an d re so lv e d .

fo u r c a te g o rie s o f in fo rm a tio n :

SE Psychoanalytic Psychotherapy

A cts o f th e s e lf to w a rd o th e rs

E x p e c ta tio n s a b o u t o th e r s ' re a ctio n s

T h is m o d e l o f d y n a m ic th e ra p y ca n b e o ffe re d as
an o p en -en d e d or a tim e -lim ite d a p p ro a ch
(L u b o rsk y , 198 4 ; L u b o rsk y an d M a rk , 1991).
T h e term "s u p p o r tiv e " re fe rs to th e te c h n iq u e s

A cts o f o th e rs to w a rd th e se lf

A cts o f th e s e lf to w a rd th e s e lf (in tro je ctio n )

T h e th e o ry o f c h a n g e is th a t th e ra p y is a set

aim ed at d irectly m a in ta in in g th e c lie n t's lev el

o f in te rp e rs o n a l tra n sa c tio n s th ro u g h w h ich the

o f fu n ctio n in g th a t is, "s u p p o r tin g " th e clien t.

c lie n t le a rn s an d is th e n a b le to c h a n g e th e

T h e term "e x p r e s s iv e " re fe rs to te c h n iq u e s th a t

m a la d a p tiv e in te rp e rs o n a l p a tte rn s in h e r life.

in ten d to fa cilita te th e c lie n t's e x p re s s io n of

A n a ly s is o f th e tra n sfe re n c e r e la tio n s h ip an d the

p ro b le m s and c o n flicts an d th e ir u n d e rsta n d in g .

th e ra p e u tic re la tio n sh ip as a m o d e l fo r h e a lth ie r

T h e ra p ists u sin g th is a p p ro a ch w ill

re la tio n sh ip s a re im p o r ta n t c o m p o n e n ts o f the

D ev e lo p a g o o d th e ra p e u tic a llia n ce

F o rm u la te an d re sp o n d to ce n tra l
re la tio n sh ip p a tte rn s

U n d e rsta n d and re sp o n d to h o w the

s y m p to m fits in to th e ce n tra l re la tio n sh ip
p a ttern

A tten d to an d re sp o n d to co n c e rn s a b o u t
s e p a ra tio n (th era p y te rm in a tio n )

M a k e in te rp re ta tio n s th a t a re a p p ro p ria te to
the c lie n t's le v e l o f a w a re n e ss

R e co g n iz e th e c lie n t's n e ed to te st the

th e ra p e u tic re la tio n sh ip (in tra n sfe re n c e
term s)

F ram e the s y m p to m s as p ro b le m -s o lv in g or
co p in g a tte m p ts

th e ra p y .

Short-Term Dynam ic Therapy of

Stress Response Syndromes
T h is a p p ro a c h to b rie f d y n a m ic th e ra p y w as
d e v e lo p e d fo r u se w ith c lie n ts w h o a re d ea lin g
w ith re c e n t s tre s s fu l e v e n ts , s u ch as tra u m a tic
e x p e rie n c e s o r th e d e a th o f a lo v e d o n e
(H o ro w itz , 1 9 9 1 ). T h e th e ra p is t e sta b lis h e s a
w o rk in g a llia n c e w ith th e c lie n t an d th e n , u sin g
te c h n iq u e s a p p r o p ria te to th e c lie n t's sta te o f
m in d an d c o n tro l p ro c e s s e s, h e lp s th e c lie n t to
in te g ra te th e life e v e n t an d its m e a n in g in to his
sch e m a (a sch e m a is o n e 's w a y o f u n d e rsta n d in g
o n e se lf in re la tio n to o th e rs). T h e th e ra p ist
fo ste rs th is p ro c e s s o f in te g ra tio n an d

C h a n g e co m es a b o u t th ro u g h th ree cu ra tiv e

u n d e rs ta n d in g b y fo c u s in g a tte n tio n , co rre ctin g

facto rs: a p o sitiv e h e lp in g re la tio n sh ip , g a in s in

d isto rtio n s, m a k in g lin k a g e s , a n d c o u n te ra c tin g

se lf-u n d e rsta n d in g , an d in te rn a liz a tio n o f th ese

d e fe n s iv e a v o id a n c e . F o r re s e a rc h , th is m o d e l is

gains.

o ffe re d a s a 1 2 -se ssio n th e ra p y , b u t it ca n a lso be

The Vanderbilt Approach to TimeLimited Dynamic Psychotherapy

(TLDP)

138

u sed as an o p e n -e n d e d th e ra p y in c lin ic a l
p ra ctice .

T h e p rim a ry g o a l o f th is th e ra p y is to fo ster

Brief Adaptive
Psychotherapy (BAP)

p o sitiv e ch a n g e in in te rp e rs o n a l fu n c tio n in g ,

B A P is a s h o rt-te rm a n a ly tic m o d e l d e v e lo p e d to

w h ich w ill th e n h a v e b e n e fic ia l e ffe c ts o n the

tre a t c lie n ts w ith p e rs o n a lity d is o rd e rs , a lth o u g h

m o re circ u m sc rib e d s y m p to m s (B in d e r and

it is a p p lica b le to o th e r g ro u p s o f c lie n ts as w ell

S tru p p , 1991). In te rp e rso n a l p ro b le m s are

(P o lla c k et a l., 1 9 9 1 ). T h e th e o ry o f c h a n g e is

co n c e p tu a liz e d in a sp e c ific fo rm a t term ed the

th a t th ro u g h co g n itiv e a n d a ffe c tiv e

B r ie f P sy ch o d y n a m ic T herapy

u n d e rsta n d in g o f the o rig in s an d o p e ra tio n s of

E m p a th y

the m a la d a p tiv e p a tte rn , th e c lie n t ca n ch a n g e

T h e c o n c e p t o f th e s e lfo b je c t

and c o n s tru c t m o re a d a p tiv e p a tte rn s. T h e

T h e im p o r ta n c e o f th e s e lf in m o tiv a tin g
b e h a v io r

te ch n iq u es u sed in c lu d e m a in te n a n c e o f a fo cu s,
m u ch w o rk o n tra n sfe re n c e , an d a h ig h lev el of

r e s to rin g s e lf-c o h e s io n

a ctiv ity on th e p a rt o f th e th e ra p ist. T h e m a jo r

m a la d a p tiv e p a tte rn is an in te rp e rs o n a l p a ttern ,
and it is e x p lo red in the p re s e n t, in th e p a st, an d
in the c lie n t-th e ra p is t re la tio n sh ip . T h e se th ree
areas are re p e a te d ly lin k e d to o n e a n o th er. T h e
m a x im u m n u m b e r o f se ssio n s o ffe re d is 4 0 ,
w h ich P o lla ck an d c o lle a g u e s p o in t o u t is m o re
than so m e o f th e o th e r b rie f m o d e ls b e c a u se of
the h ig h e r lev el o f p s y c h o p a th o lo g y o f th e
clien ts.

Dynamic Supportive Psychotherapy

S u p p o rtiv e th e ra p y is w id ely p ra c tice d c lin ica lly
b u t h isto rica lly is d e fin e d m a in ly by th e a b se n ce
o f e x p re ssiv e or in te rp re tiv e c o m p o n e n ts of
p s y ch o a n a ly tic th e ra p ie s (P in sk e r et al., 19 9 1 ). It
e v o lv e d as th e p s y c h o d y n a m ic a lly b a se d
th e rap y u sed fo r lo w e r fu n c tio n in g or m o re
frag ile clie n ts fo r w h o m th e e x p re s s iv e w o rk of
th e rap y m ig h t b e to o d is tre s s in g . T h e th e ra p ist
h as a co h e siv e p s y c h o d y n a m ic fo rm u la tio n of
the clie n t b u t o n ly s h a re s p a rts o f it in a m a n n e r
in te n d e d to fo ste r th e c lie n t's a d a p tiv e
fu n ctio n in g . T h e g o a ls o f s u p p o rtiv e th e ra p y
are to a m e lio ra te s y m p to m s an d to m a in ta in ,
resto re , or im p ro v e s e lf-e s te e m , a d a p tiv e sk ills,
and eg o fu n ctio n . C h a n g e c o m e s a b o u t fro m
lea rn in g and fro m id e n tific a tio n w ith or
in tro je c tio n o f an a c c e p tin g th e ra p ist w ith w h o m
the clie n t h as a g o o d re la tio n sh ip . T h e
te ch n iq u es u sed in c lu d e re d u c in g a n x ie ty ,
re sp ectin g d e fe n se s, c la rific a tio n , lim itin g

T h e ro le o f s y m p to m s as th e c lie n t's w a y of

In th is b rie f s e lf-p s y c h o lo g ic a l th e ra p y
a p p ro a ch , o n e or tw o g o a ls a re e sta b lish e d
c o lla b o ra tiv e ly in th e in itia l s e ssio n s. T h e
d u ra tio n o f tre a tm e n t ty p ic a lly is 20 to 30
s e ssio n s, w ith fe w e r o r m o re as n e e d e d . A
s e lfo b je c t is s o m e th in g o r so m e o n e e lse th a t is
e x p e rie n c e d a n d u se d as if it w e re p a rt o f o n e 's
o w n s e lf (B a k e r, 1 9 9 1 ). F o r e x a m p le , a ch ild is
d e p e n d e n t o n th e p a r e n t's lo v e a n d p ra ise to
d e v e lo p a se n se o f s e lf-w o r th a n d self-este e m .
In th a t w a y , th e c h ild in te rn a liz e s a p a rt o f the
p a re n t as th e s e lfo b je c t. T h e th e o ry o f ch a n g e is
th a t u n d e rs ta n d in g , fo llo w e d b y in te rp re ta tio n ,
le a d s to c h a n g e . S u c c e s s in th e ra p y re q u ire s th at
d y s fu n c tio n a l in tra p s y c h ic stru c tu re s b e
ch a n g e d a n d / o r th a t c o m p e n s a tin g n ew
s tru c tu re s b e a d d e d .

Interpersonal Psychotherapy (IPT)

IP T w a s d e v e lo p e d in itia lly a s a tim e -lim ite d ,
w e e k ly p s y c h o th e r a p y fo r n o n b ip o la r,
n o n p s y c h o tic , d e p re s s e d c lie n ts (K le rm a n et al.,
19 8 4 ). It h a s s in c e b e e n s u m m a riz e d in a
m a n u a l fo r re s e a rc h a n d m o d ifie d fo r tre a tm e n t
o f o th er ty p e s o f d e p re s s io n (d y s th y m ia ), o th er
p o p u la tio n s (a d o le sc e n ts a n d c o u p le s ), and
o th er p ro b le m s (s u b s ta n c e a b u s e d iso rd e rs and
b u lim ia ). T h e g o a ls o f th is a p p ro a c h are
p rim a rily s y m p to m re d u c tio n an d im p ro v e m e n t
in in te rp e rs o n a l fu n c tio n in g . T h e m a in
te c h n iq u e s in c lu d e th e fo llo w in g :

co n fro n ta tio n an d in te rp re ta tio n , e n h a n c in g s e lf

estee m , re fra m in g , o ffe rin g e n c o u ra g e m e n t,

c lie n t is g iv e n th e " s i c k " ro le.

ad v isin g , an d m o d e lin g .

T h e c lie n t is e d u c a te d a b o u t th e p ro b le m , its

T h e in te rp e rs o n a l c o n te x t o f th e p ro b le m and

A Self-Psychological Approach
T h e e sse n tia l a sp e c ts o f th e th e o ry o f S e lf
P sy ch o lo g y (B a k er, 19 9 1 ) in clu d e the fo llo w in g :

T h e p ro b le m is e x p lic itly d ia g n o s e d an d the

ca u se s, a n d th e tre a tm e n ts a v a ila b le.

its d e v e lo p m e n t a re id e n tifie d .
139

C h ap ter 7

S tra te g ie s fo r d ea lin g w ith th e in te rp e rso n a l

e ffic a c y o f 12 s e ssio n s o f w e e k ly in d iv id u a l

co n te x t e m e rg e an d a re tried by th e clie n t

p s y c h o th e ra p y , w ith o u t a d ju n c tiv e

(p ro b le m so lv in g ).

p h a r m a c o th e ra p y , as th e so le tre a tm e n t fo r 42
s u b je c ts w h o w e re ra n d o m ly a ss ig n e d to e ith er

Other Research

IP T or R P . R a te s o f a ttritio n w e re s ig n ific a n tly

h ig h e r fo r IP T th a n fo r R P , w ith o n ly 38 p e rce n t

In a d d itio n to S u p p o rtiv e -E x p re s siv e

p sy ch o th e ra p y , b o th IP T an d M G D T h a v e b ee n
stu d ied as th e ra p ie s fo r u se in th e tre a tm e n t of
su b sta n ce a b u se d iso rd e rs.
IP T has b ee n e v a lu a te d as an a d ju n c tiv e
tre a tm e n t fo r a fu ll-s e rv ic e m e th a d o n e clin ic
(R o u n sa v ille et al., 1983). T h is w a s a
co lla b o ra tiv e re se a rc h p ro je c t th a t p a ra lle le d a
stu d y by W o o d y an d c o lle a g u e s (W o o d y et al.,
1983). S e v e n ty -tw o m e th a d o n e -m a in ta in e d ,
o p ia te -d e p e n d e n t su b je c ts w h o w e re d ia g n o sed
w ith a p sy ch ia tric d is o rd e r (e.g ., d e p re ssio n )
w ere ra n d o m ly a ssig n e d to o n e o f tw o tre a tm e n t
co n d itio n s, e a ch la stin g 6 m o n th s. T h e
tre a tm e n ts w e re IP T o ffe re d o n ce a w e e k an d
low co n ta ct, co n s is tin g o f o n e 2 0 -m in u te
m e e tin g p e r m o n th , w h e n s y m p to m s an d so cia l
fu n ctio n in g w e re re v ie w e d . B o th g ro u p s a lso
re ce iv e d tre a tm e n t as u su a l in the m e th a d o n e m a in te n a n ce p ro g ra m th a t in clu d e d a w e e k ly
9 0 -m in u te s e ssio n o f g ro u p co u n se lin g . T h e
m a in fin d in g s w e re th a t it w a s e x tre m e ly

of th o se in IP T c o m p a re d to 6 6 p e rc e n t o f th o se
in R P c o m p le tin g th e 1 2 -w e e k c o u rs e o f
tre a tm e n t (R o u n s a v ille a n d C a rro ll, 19 9 3 ). O n
m o st o u tco m e m e a s u re s th e re w e re no
s ig n ific a n t d iffe re n c e s b e tw e e n th e tw o
tre a tm e n t c o n d itio n s ; b o th w e re a s s o c ia te d w ith
fa v o ra b le o u tc o m e s . H o w e v e r, fo r c lie n ts w ith
m o re se v e re p s y c h ia tric s y m p to m s o r m o re
s e v e re d ru g u se, th o se w h o re c e iv e d R P w ere
m o re lik e ly to b e c o m e a b stin e n t th a n th o se w h o
re c e iv e d IP T. C lie n ts w ith m o re sev ere
su b s ta n c e a b u s e d is o rd e rs m a y re q u ire the
g re a te r s tru c tu re an d d ir e c tio n o ffe re d b y the
re la p se p re v e n tio n a p p ro a c h (R o u n s a v ille and
C a rro ll, 1 9 9 3 ). T h is is e n tire ly c o n s is te n t w ith
the o b s e r v a tio n th a t s u b s ta n c e -fo c u s e d
in te rv e n tio n s a re p e rh a p s th e o p tim a l a p p ro a ch
fo r tre a tin g s u b s ta n c e a b u s e d is o rd e rs (S train ,
1999). B a sed on the ra th e r m o d e s t e m p irica l
su p p o rt, R o u n s a v ille a n d C a rro ll su g g e ste d that
the ro le o f IP T in th e tre a tm e n t o f su b sta n c e
a b u se d is o rd e rs m ig h t b e th e fo llo w in g :

d ifficu lt to re cru it and re ta in c lie n ts in the

p ro g ra m an d th a t a lth o u g h b o th tre a tm e n ts
w e re a sso cia ted w ith sig n ific a n t clin ica l

T o in tro d u c e c lie n ts in to tre a tm e n t

T o tre a t c lie n ts w ith lo w e r le v e ls o f s u b sta n ce

a b u se

im p ro v e m e n ts d u rin g the 6 -m o n th p e rio d , th ere

w as e sse n tia lly no a d v a n ta g e to IP T o v er low

T o tre a t c lie n ts w h o d id n o t b e n e fit fro m

T o c o m p le m e n t o th e r o n g o in g tre a tm e n t

o th er m o d a litie s

co n tact. T h is stu d y w a s d o n e in a p ro g ra m in
w h ich clie n ts w e re s u sp e n d e d a fte r 3 m o n th s if

m o d a litie s

they co n tin u e d to u se illicit d ru g s, thu s

p ro v id in g a p o te n t b e h a v io ra l in te rv e n tio n . For
the co n tro l g ro u p , c lie n ts w e re fo rced to d o w ell
or lea v e th e p ro g ra m .
A seco n d stu d y (C a rro ll et al., 1991)

T o h e lp c lie n ts m a in ta in an d s o lid ify g a in s

fo llo w in g th e e s ta b lis h m e n t o f stab le
a b stin e n ce
K h a n tz ia n an d c o lle a g u e s d e v e lo p e d M G D T

co m p a re d IP T w ith R e la p se P re v e n tio n (R P ), a

to a d d re ss th e c h a ra c te ro lo g ic a l u n d e rp in n in g s

co g n itiv e -b e h a v io ra l th e ra p y (M a rla tt and

o f s u b s ta n c e a b u s e d is o rd e rs (K h a n tz ia n et al.,

G o rd o n , 1985) fo r the tre a tm e n t o f a m b u la to ry

1990). T h e g ro u p h a s fo u r m a in g o als:

co ca in e -u sin g clie n ts. T h is stu d y e v a lu a te d the

140

B r ie f P sy ch o d y n a m ic T herapy

1. T h e d e v e lo p m e n t o f a ffe c t to le ra n ce

T h is a p p ro a c h h a s s h o w n e ffic a c y fo r ab u se

2. T h e b u ild in g o f s e lf-e s te e m

in re s e a rc h , b u t th e re s e a rc h w a s n o t

3. T h e d iscu ssio n an d im p ro v e m e n t of

c o m p a ra tiv e , so it is n o t k n o w n h o w e ffe ctiv e

in te rp e rso n a l re la tio n sh ip s

this a p p ro a c h is in c o n tra s t to o th e r a p p ro a ch e s

4. T h e d e v e lo p m e n t o f a p p ro p ria te s e lf-c a re
stra te g ies

141

8 Brief Family Therapy

u b sta n ce a b u se d is o rd e rs d o n o t d ev elo p

F a m ily in v o lv e m e n t is o fte n c ritic a l fo r

in iso la tio n . F o r m a n y in d iv id u a ls w ith

su c c e ss in tre a tin g m a n y s u b s ta n c e a b u se

su b sta n ce a b u se d iso rd e rs, in te ra c tio n s

d is o rd e rs m o st o b v io u sly in c a s e s w h ere

w ith the fa m ily o f o rig in , as w e ll as th e c u rre n t

e le m e n ts o f th e fa m ily a re in a d v e rte n tly

fam ily , se t the p a tte rn s an d d y n a m ic s fo r th e ir

re in fo rc in g o r s u p p o rtin g th e p ro b le m . In so m e

p ro b lem s w ith su b sta n c e s. F u rth e rm o re , fa m ily

c a se s, a n o th e r fa m ily m e m b e r h a s a d iffe re n t

m e m b er in te ra ctio n s w ith th e s u b s ta n ce a b u se r

a g e n d a fro m th e re s t o f th e fa m ily . F o r e x a m p le ,

can e ith er p e rp e tu a te an d a g g ra v a te th e p ro b le m

th e h u sb a n d o f a re c o v e rin g s u b s ta n c e a b u ser

or s u b s ta n tia lly a ssist in re s o lv in g it. F a m ily

m a y h a v e ta k e n o n a d d itio n a l ro le s in th e fa m ily

th e rap y is su g g e s te d w h e n the c lie n t e x h ib its

as a re s u lt o f th e v a c u u m le ft w h e n h is w ife w as

sig n s th a t s u b s ta n c e a b u se is stro n g ly in flu e n c e d

a b u sin g su b s ta n c e s. T h e h u sb a n d m a y be

by fam ily m e m b e r s ' b e h a v io rs or

u n w illin g to let h e r re s u m e h e r p la c e in the

co m m u n ica tio n s w ith th e m . F a m ily th e ra p y

fa m ily or sh a re c o n tro l o f th e fa m ily b u d g et, for

m ig h t b e c o n tra in d ic a te d if o th e r fa m ily

e x a m p le . U n le s s fa m ily th e ra p y ca n sh ift h is

m e m b ers are a ctiv e s u b s ta n c e a b u se rs, v io le n t,

p o sitio n , th e c lie n t's re c o v e ry is lik e ly to be

d en y th at the c lie n t's s u b s ta n c e a b u s e is

im p e d e d . W h e n th e w h o le fa m ily is in v o lv e d in

p ro b lem a tic, or re m a in e x c e s s iv e ly a n g ry .

th e ra p y , ch a n g e s a re fa s te r a n d e a sie r to

F am ily th e ra p y is o fte n u sed to e x a m in e

facto rs th at m a in ta in a c lie n t's s u b s ta n c e a b u se
b eh a v io r. T o u n d e rsta n d th e se fa c to rs, the

m a in ta in . In a d d itio n , th e c lie n t g a in s a b u ilt-in

su p p o rt sy stem .
C o m p le x in te ra c tio n s b e tw e e n fa m ily

th e ra p ist c o n s id e rs th e fa m ily 's v a rio u s

d y n a m ic s an d s u b s ta n c e a b u s e h a v e lo n g b een

s tru ctu ra l e le m e n ts an d h o w th e y c o n trib u te to

re c o g n iz e d (L e w is, 1 9 3 7 ). W h a le n su g g e ste d

the s u b sta n ce a b u se. T h e s e e le m e n ts m ig h t

sp o u s a l p s y c h o p a th o lo g y w a s a co n trib u tin g

in clu d e the p o w e r h ie ra rch y , ro le s, ru les,

fa c to r in th e o n s e t an d m a in te n a n c e o f s u b sta n ce

a lig n m e n ts, an d c o m m u n ic a tio n p a tte rn s w ith in

a b u se (W h a le n , 1 9 5 3 ). Ja c k s o n a rg u ed on the

the fam ily . T h ro u g h fa m ily th e ra p y , the

b a sis o f in te rv ie w s w ith m e m b e r s o f A l-A n o n

clin icia n ca n h e lp th e fa m ily id e n tify

th a t th e d e p re s s io n , a n x ie ty , an d d istre ss see n so

d y sfu n ctio n a l a re a s, a d ju st its h ie ra rc h y , ch a n g e

o fte n in fa m ily m e m b e rs o f s u b s ta n c e a b u sers

v a rio u s ro le s th a t m e m b e rs p la y , ch a n g e

ste m fro m , ra th e r th a n c a u se s u b s ta n ce a b u se

d y sfu n ctio n a l ru le s, a lte r d y sfu n ctio n a l

d iso rd e rs (Ja c k so n , 19 5 4 ).

a lig n m e n ts b e tw e e n fa m ily m e m b e rs, an d

C o n tra ry to w h a t h a d lo n g b e e n th e p o p u la r

re p lace d y sfu n ctio n a l c o m m u n ic a tio n s w ith

o p in io n , m o st in d iv id u a ls w ith su b sta n ce ab u se

clear, d irect, an d e ffe c tiv e co m m u n ica tio n .

d iso rd e rs m a in ta in c lo s e ties w ith th e ir fam ilies.

143

C hapter 8

R ese a rch h as c o n s is te n tly sh o w n th a t p e o p le

If p o ss ib le , an a p p r o p ria te ly tra in e d fa m ily

w ith su b sta n ce a b u se d iso rd e rs a re in clo ser

th e ra p is t s h o u ld b e a v a ila b le to c o n d u c t sessio n s

co n ta ct w ith th e ir fa m ilie s o f o rig in th a n the

in v o lv in g a c lie n t's fa m ily .

m e m b ers o f the g e n era l p o p u la tio n of

co m p a ra b le ag e (B e k ir et al., 1 9 9 3 ; D o u g la s,
1987).
A n u m b e r o f re v ie w s h a v e fo u n d stro n g
s u p p o rt fo r the u se o f fa m ily th e ra p y m e th o d s

L o n g -te rm fa m ily th e ra p y is n o t u su a lly

fo r su b sta n ce a b u se tre a tm e n t. R e c e n t re sea rch

n e c e s s a ry w ith in th e c o n te x t o f tre a tm e n t fo r

ev e n su g g e sts th a t fa m ily an d m a rita l tre a tm e n t

su b s ta n ce a b u s e d is o rd e rs . A n e x c e p tio n is

p ro d u ce s b e tte r m a rita l an d d rin k in g o u tco m es

lo n g -te rm re s id e n tia l tre a tm e n t, d u rin g w h ich

than n o n fa m ily m e th o d s (L o w in so n et al., 1997).

the in v o lv e m e n t o f th e c lie n t's fa m ily is h ig h ly

A t least o n e stu d y th a t c o m p a re d lo n g -te rm and

re c o m m e n d e d a n d o fte n is an in te g ra l p a rt o f

sh o rt-te rm fam ily th e ra p y (16 an d 8 ca se w o rk

th e th e ra p e u tic p ro c e s s . M a k in g re a l p ro g re ss

in te rv e n tio n s o v er an 8- an d a 4 -m o n th p e rio d ,

w ith a fa m ily o v er a lo n g p e rio d is ch a lle n g in g .

re sp ectiv ely ) fo u n d th a t sh o rte r s e rv ic e s w e re

S tu m b lin g b lo c k s , b a rrie rs , an d p a th o lo g y seem

o ften m o re b e n e fic ia l (G a rv in et al., 1976).

to e m e rg e . F a m ily m e m b e r s d ro p o u t and

H o w ev er, co m p a ra b le stu d ie s sp e c ifica lly on

re e n te r th e th e ra p e u tic p ro c e s s , an d it b e c o m e s

fam ily th e ra p y as a p p lie d to su b sta n ce a b u se

in cre a sin g ly d iffic u lt fo r the th e ra p is t to avo id

d iso rd e rs are lack in g .

m a k in g d e cis io n s . T h e fa m ily m a y try to

T h e H a rv a rd M e d ica l S ch o o l D e p a rtm e n t of

in c o rp o ra te the th e ra p is t in to th e fa m ily sy stem ,

P sy ch ia try su c c e s s fu lly u sed c o u p le s co u n se lin g

ro u tin e ly s e e k in g d ire c tio n in a crisis. B o u n d a ry

in the co n te x t o f tre a tm e n t fo r a lco h o l-

a n d p ro je c tio n issu e s m u s t b e a d d re s s e d . In

d e p e n d e n t clie n ts. S tu d ie s o f p a rtic ip a n ts in the

s h o rt-te rm fa m ily th e ra p y , th e b o u n d a ry

H arv a rd C o u n se lin g fo r A lc o h o lic s ' M a rria g e s

b e tw e e n th e th e ra p is t a n d th e fa m ily is m o re

P ro ject (P ro je ct C A L M ) sh o w e d th a t m o re th an

clea r. In g e n e ra l, it is e a s ie r to co n tin u e to h elp

50 p e rce n t o f h u sb a n d s w ith a lc o h o l a b u se

an in d iv id u a l w o rk w ith in the fa m ily sy stem

d iso rd e rs w h o p a rtic ip a te d re m a in e d a lco h o l

th ro u g h s u b s e q u e n t in d iv id u a l th e ra p y .

fre e in th e first y e a r a fte r tre a tm e n t, co m p a re d

S o m e tra d itio n a l a p p ro a c h e s e n c o u ra g e

w ith less th a n 3 0 p e rc e n t o f h u sb a n d s tre a te d in

clie n ts to w o rk o n th e m s e lv e s in iso la tio n fro m

in d iv id u a l th e ra p y . P a rticip a n ts in th e p ro g ra m

o th ers, b u t th e re a re v e ry fe w in s ta n c e s in w h ich

also h ad fe w e r m a rita l se p a ra tio n s. W ith the

the o p p o rtu n ity to w o rk w ith a c lie n t's fa m ily

ad d itio n o f a re la p se p re v e n tio n p ro g ra m , th e

fo r a t le a s t o n e o r a fe w s e s s io n s is n o t

resu lts im p ro v e d e v e n fu rth e r (R o tu n d a and

b e n e ficia l. O b v io u s ly , o n e s u c h e x c e p tio n is

O 'F a rre ll, 1997).

w h e n th e c lie n t is u n w illin g to p u rs u e th is

F am ily th e ra p y sh o u ld b e co n d u c te d b y a

144

Appropriateness of Brief
Family Therapy

a p p ro a ch . A n o th e r in s ta n c e b e s t d e a lt w ith

clin icia n w ith a g o o d u n d e rs ta n d in g o f fa m ily

in d iv id u a lly is w h e n th e c lie n t's s itu a tio n

sy stem s, d y s fu n c tio n a l fa m ily p a tte rn s, p o w e r

in v o lv e s issu e s o f s e p a ra tio n an d in d iv id u a tio n

stru g g le s, and c o m m u n ic a tio n . A lc o h o l and

a lth o u g h c o n jo in t fa m ily w o rk o fte n h elp s

d ru g c o u n se lo rs ca n lea rn to w o rk w ith fa m ilie s,

co m p le te th is p ro c e ss. P h y s ic a l, e m o tio n a l, or

e sp e cia lly if th e y d o n o t h o ld the fa m ily

se x u a l a b u s e o f th e c lie n t b y a fa m ily m e m b e r

re sp o n sib le fo r th e su b sta n c e a b u se.

m a y a lso ru le o u t fa m ily th e ra p y . S h o rt-te rm

B r ie f F am ily T herapy

fam ily th e ra p y is an o p tio n th a t co u ld b e u sed in

c o m m u n ity m e m b e r s, in c lu d in g h e a le rs or

the fo llo w in g circu m sta n c e s:

o th e rs w h o c a n h e lp p ro m o te or b lo ck ch a n g e .

W h en re so lv in g a sp e cific p ro b le m in the
fam ily and w o rk in g to w a rd a so lu tio n

W h en th e th e ra p e u tic g o a ls d o n o t re q u ire ind ep th , m u ltig e n e ra tio n a l fa m ily h is to ry , b u t

ra th er a fo cu s on p re s e n t in te ra c tio n s

W h e n th e fam ily as a w h o le ca n b e n e fit fro m

te ach in g an d c o m m u n ic a tio n to b e tte r
u n d e rstan d so m e a s p e c t o f th e su b sta n c e
a b u se d iso rd e r

Y o u n g c h ild re n , a lth o u g h n o t th e m o st p o w e rfu l

m e m b e rs o f th e fa m ily , o fte n h a v e h e lp fu l
p e rc e p tio n s to c o n trib u te to th e th e ra p y p ro cess.
In d e te rm in in g h o w a n d w h e n to in clu d e
c h ild re n , it is im p o r ta n t to c o n s id e r th e ir age
a n d th e n a tu re o f th e s u b je c t m a tte r th e fa m ily
w ill a d d re ss. P a re n ta l s e x u a l re la tio n s,
o b v io u sly , s h o u ld b e d is c u ss e d b y th e p a re n ts
alon e.
F a m ily th e ra p y a p p ro a c h e s h a v e b ee n

F am ily th e ra p y o ffe rs an o p p o rtu n ity to

e m p lo y e d w ith a v a r ie ty o f s p e c ific su b sta n c e -

F o cu s on th e e x p e c ta tio n o f c h a n g e w ith in

a b u sin g s u b p o p u la tio n s , in c lu d in g th o se w h o

th e fam ily (w h ic h m a y in v o lv e m u ltip le

a re d u a lly d ia g n o s e d (R e a d e t a l., 1 9 9 3 ; R eilly ,

a d ju stm e n ts)

1 9 9 1 ; R y g le w ic z , 1 9 9 1 ), V ie tn a m v e te ra n s w ith

T e st n e w p a tte rn s o f b e h a v io r

s u b s ta n c e a b u s e d is o r d e rs a n d p o sttra u m a tic

T e a ch h ow a fa m ily sy ste m w o rk s , and h ow

stre ss d is o rd e r (F a h n e s to c k , 1 9 9 3 ; M o y er, 1988),

the fam ily su p p o rts s y m p to m s an d m a in ta in s

o ld er a d u lts w ith s u b s ta n c e a b u se d iso rd e rs

n e ed e d ro les

(A m o d e o , 1 9 9 0 ; C ra w le y , 1 9 9 3 ; R a th b o n e -

E licit the stre n g th s o f e v e ry fa m ily m e m b e r

M c C u a n a n d H e d lu n d , 1 9 8 9 ), c o c a in e a b u sers

E x p lo re th e m e a n in g o f s u b s ta n c e a b u se

(O 'M a lle y a n d K o ste n , 1 9 8 8 ; R ic e -L ic a re and

w ith in th e fa m ily

D e la n e y -M c L o u g h lin , 1 9 9 0 ; S m o k o w s k i and

W o d a rsk i, 1 9 9 6 ), H IV -p o s itiv e c lie n ts w ith

A n o b v io u s p re re q u isite fo r fa m ily th e ra p y
w o u ld se e m to b e th e e x is te n c e o f a fa m ily .
H o w ev er, s o m e th e ra p ists, in c lu d in g H a ley ,

s u b s ta n c e a b u s e d is o r d e rs (B a rth et al., 1993),

an d s u b s ta n c e -a b u s in g p e rp e tra to rs o f d o m estic
v io le n c e (F la n z e r, 1 9 8 9 ; O 'S u lliv a n , 1989).

b elie v e it is p o ssib le to " c r e a te " a fa m ily by

d ra w in g on the c lie n t's n e tw o rk o f sig n ific a n t
co n tacts. A m o re im p o rta n t q u e stio n th an

Definitions of "Fam ily"

w h eth er th e clie n t is liv in g w ith a fa m ily is,

T h e te rm "fa m ily th e r a p y " e v o k e s im a g e s of

"C a n the c lie n t's p ro b le m b e se e n as h a v in g a

p a re n ts an d ch ild re n . H o w e v e r, as m e n tio n e d

re la tio n a l c o m p o n e n t (th a t is, in v o lv in g tw o or

a b o v e , fa m ily th e ra p y c a n in v o lv e a n e tw o rk

m o re p e o p le )? " R a th e r th a n sim p ly try in g to

b e y o n d th e im m e d ia te fa m ily , m a y in v o lv e on ly

id e n tify e x is te n t fa m ily m e m b e rs, th e ra p ists can

on e fa m ily m e m b e r in tre a tm e n t or a few

b eg in by c o n d u ctin g an a s s e s s m e n t o f the

m e m b e rs o f th e fa m ily s y s te m , o r m a y ev en

clie n t's so cia l n e tw o rk th a t w o u ld in clu d e

in c lu d e s e v e r a l fa m ilie s a t o n ce.

sig n ifica n t o th ers, frie n d s, e m p lo y e rs , and

N etw o rk th erap y v ie w s s u b s ta n c e a b u se

co w o rk e rs. T h e se p e o p le a re s ig n ific a n t and

d is o rd e rs fro m a c o g n itiv e -b e h a v io r a l

h e lp fu l in the c lie n t's life an d ca n b e im p o rta n t

p e rs p e c tiv e (G a la n te r, 1 9 9 3 ; G a la n te r et al., 1997;

e le m e n ts o f a c lie n t's re c o v e ry p ro g ra m .

K e lle r et a l., 19 9 7 ). In n e tw o rk th e ra p y ,

T h e d e fin itio n o f " f a m ily " a lso v a rie s in

s ig n ific a n t n o n fa m ily m e m b e r s, s u ch as frien d s,

d iffe ren t cu ltu re s an d situ a tio n s. F o r e x a m p le ,

e x te n d e d fa m ily m e m b e r s , c o u s in s , and

for a su b sta n ce a b u se r in a N a tiv e A m e ric a n

g ra n d p a re n ts , as w e ll as fa m ily m e m b e rs, are

gro u p , the n o tio n o f fa m ily m a y e x te n d to

145

C h ap ter 8

re g a rd ed as u se fu l re so u rce s a v a ila b le to a ssist

w o u ld o c c u r in s in g le -fa m ily th e ra p y . T y p ic a lly ,

the clien t.

fo u r or fiv e fa m ilie s p a rtic ip a te , o fte n a ch iev in g

In co n tra st, so m e ty p e s o f fa m ily sy stem s

therap y re g ard su b sta n c e a b u se as a sy m p to m of

m e a n in g fu l re s u lts ra p id ly (K a u fm a n an d
K a u fm a n , 19 7 9 ).
T h is a p p ro a c h h e lp s w ith b o u n d a ry settin g

an u n d e rly in g p a th o lo g y a t w o rk in th e fa m ily .
T h is a p p ro a ch see k s to re stru c tu re the fa m ily

an d r e e s ta b lis h m e n t o f th e p a r e n t-c h ild

and th e m a la d a p tiv e b e h a v io rs w h ic h c o n trib u te

h ie ra rch y . If a p a re n t is th e s u b s ta n c e a b u ser, a

to (or e n co u ra g e ) the c lie n t's s u b s ta n c e a b u se

fa m ily ro le re v e rs a l m a y h a v e o cc u rre d in w h ich

(K e lle r e t al., 1997).

th e c h ild re n h a v e ta k e n th e p a re n ta l ro le and

C on join t cou p les th erap y a d d re sse s co u p les

issu es w ith in th e fa m ily (E p ste in an d M cC ra d y ,

b e c o m e c a re ta k e rs . In th e ra p y a n d re co v e ry , it
is im p o r ta n t th a t th e se b o u n d a rie s b e re cla rifie d

1998; Z w e b e n et al., 1988). T y p ic a lly , co u p les

an d th a t th e c o r re c t p a r e n t-c h ild h ie r a rc h y be

carry o u t a ssig n m e n ts in d e a lin g w ith key

re e s ta b lis h e d . N o t c o m m u n ic a tin g is ty p ica l in

th e ra p e u tic th e m e s, s u c h as listin g th e fa cto rs

fa m ilie s u n d e rg o in g s u b s ta n c e a b u s e tre a tm e n t.

th a t a ttra cted e a c h p a rtn e r to th e o th er,

O n e o f th e g o a ls m u s t b e to re e s ta b lis h lin e s of

d iscu ssin g h ow the re la tio n sh ip co u ld re g a in

c o m m u n ic a tio n .
T h e d is a d v a n ta g e o f th is a p p ro a c h is th a t the

th at a ttra ctio n , an d lo o k in g a t e x p e c ta tio n s of

e ach p a rtn er, n e ed s fro m th e o th er p a rtn er, and

fa m ilie s in v o lv e d m a y n o t h a v e m u ch co m m o n

re sen tm e n ts. C o u p le s m a y n e ed to e x p lo re th eir

e x p e rie n c e ; a lso , s o m e fa m ilie s fe e l a sh a m e d in

id eas a b o u t g e n d e r ro le s w ith in the re la tio n sh ip ,

this s o rt o f e n c o u n te r an d a re n o t w illin g to

or th ey m ay h a v e to e x p lo re th e ir v ie w s on

sh a re th e ir e x p e rie n c e s . A t tim e s, th is a p p ro a ch

p a re n tin g , e sp e c ia lly in re g a rd to the

ca n le a d c lie n t fa m ilie s sim p ly to c o m p la in to

d iscip lin in g o f c h ild re n . T h e y m a y a lso b e ask ed

on e a n o th e r, w ith o u t b e in g m o tiv a te d to fin d

to sh a re w a y s in w h ic h th ey c o m m u n ic a te

n e w s o lu tio n s . O n e o f th e re s p o n s ib ilitie s o f the

d issa tisfa ctio n or n e g a tiv e fe e lin g s a b o u t the

th e ra p is t le a d in g th e g ro u p is to g u id e the

o n g o in g su b sta n c e a b u se.

fa m ily in e x p lo r in g a lte r n a tiv e s a n d ch o o sin g

M u ltifam ily g ro u p s a re o ften u sed in

a m o n g th e m .
M u ltip le fa m ily th e ra p y o ffe rs an

su b sta n ce a b u se tre a tm e n t fo r e d u ca tio n a l

p u rp o se s and as su p p o rt g ro u p s. T h e y ca n

o p p o rtu n ity to d e a l w ith fo u r c o n c e rn s fo r

e x p lo re w ay s to a tta in stra te g ic o b je ctiv e s

fa m ilie s in w h ic h s u b s ta n c e a b u s e h a s b e e n a

re le v a n t to e a ch fa m ily , o ffe r a n o p p o rtu n ity fo r

p ro b le m (B rill, 19 8 1 ):

sh a rin g k n o w le d g e , a d d re ss b o u n d a ry and
c o m m u n ica tio n issu es, an d e x p o se p a rtic ip a n ts
to new w a y s o f m a n a g in g c h a lle n g e s.

1.

In a d e q u a te in te rn a l fa m ily d e v e lo p m e n t

2.

F a m ily s y ste m s a n d ro le im b a la n c e

3.

S e le c te d s o c ia liz a tio n v a ria n c e s w ith in the

P a rticip a n ts re a liz e th e y are n o t a lo n e and are

fa m ily (i.e., d iffe re n c e s in th e d e sire and

h elp ed to m a in ta in th eir s u b s ta n c e -fre e life sty le

th ro u g h lea rn in g new c o p in g te c h n iq u e s and
w ay s to stop e n a b lin g su b sta n c e a b u se. T h e

a b ility o f fa m ily m e m b e r s to so c ia liz e )

4.

D y s fu n c tio n a l, in e ffe c tiv e fa m ily b e h a v io rs

th a t m a in ta in th e p ro b le m

th e ra p ist ca n a p p ly th e e x p e rie n c e s o f on e
fam ily to h elp a n o th er. A fte r o n e fa m ily

146

S o m e re s e a r c h e rs b e lie v e th a t m u ltip le

d escrib e s a s o lu tio n , th e th e ra p is t m a y ask

fa m ily th e ra p y is e sp e c ia lly u se fu l fo r fa m ilie s

a n o th er, "W o u ld th a t w o rk in y o u r fa m ily ? "

d ea lin g w ith s u b s ta n c e a b u s e d is o rd e rs

T h is a p p ro a ch ca n p ro m o te a c c o u n ta b ility fo r

(K a u fm a n an d K a u fm a n , 1 9 7 9 ). In fa m ilie s

m a in ta in in g a g re e m e n ts w ith less stre ss th an

w h e re o n e or m o re m e m b e r s h a v e a s u b sta n ce

B r ie f F a m ily T herapy

ab u se d iso rd e r, d e te rio ra tio n in th e fa m ily

in v o lv e m e n t w ith th e s u b s ta n c e u ser (A l-A n o n ,

s y stem is u su ally see n . M u ltip le fa m ily th e ra p y

1 9 7 9 ; B e p k o , 1 9 8 5 ). A s a re su lt, tre a tm e n t o ften

allow s a q u ick a sse s s m e n t o f th e d e te rio ra tio n

c o n sists o f a re fe rra l to A l-A n o n an d (less

and stim u la te s a c o n fro n ta tio n an d stra te g y to

fre q u e n tly ) s e p a ra te th e ra p y g ro u p s fo r fa m ily

rev e rse this p ro cess.

m e m b e rs th a t e x c lu d e th e s u b s ta n c e u ser

F u rth e rm o re , it is m o st u sefu l in re sid e n tia l

settin g s w h ere th e fa m ily is e a sily a cce ssib le ,
alth o u g h it h as a lso b e e n s u c c e s s fu lly u sed in

(F ra n k e l, 1 9 9 2 ; F rie d m a n , 1 9 9 0 ; M c C ra d y , 1989;
R e g a n e t al., 19 8 3 ).
F a m ily s y s te m s m o d e ls, o n th e o th e r h a n d ,

o u tp a tie n t s ettin g s. K a u fm a n an d K a u fm a n also

in ste a d o f fo c u s in g on in d iv id u a l p e rso n a lity

fo u n d th at it w o rk s b e s t w ith h ig h ly m o tiv a te d

d iso rd e rs, g e n e ra lly re g a rd s u b s ta n c e a b u se and

and in v o lv e d clie n ts and

d e p e n d e n c e as s y m p to m s o f d y s fu n c tio n a l

[R ]e d u ce s the in cid en ce o f p re m a tu re

in te rp e rs o n a l d y n a m ic s w ith in th e fa m ily

d ro p o u ts , a cts as a p re v e n tiv e m e a s u re for

(B o w en , 1 9 7 4 ; G o ra d e t al., 1971). F ro m this

o th e r fam ily m e m b e rs, b u ild s a su b cu ltu re th at

p e rs p e c tiv e , th e s u b s ta n c e a b u s e m e e ts a n eed

a cts a s a n e x te n d e d 'g o o d fa m ily ,' a n d cre a te s

a n d su p p o rts s tru c tu ra l fam ily c h a n g e s th at

o n s o m e le v e l fo r th e fa m ily a s a w h o le and

in te rd ict the re tu rn o f d ru g ab u se (K a u fm a n

in a d v e rte n tly re in fo rc e s th e s u b s ta n c e a b u se

an d K a u fm a n , 1 9 7 9 , p. 84).

(D a v is e t al., 1 9 7 4 ; S ta n to n , 19 7 7 ). C h a fe tz and
c o lle a g u e s , fo r e x a m p le , cite a fa m ily w h o

Theoretical Approaches

la u g h e d an d jo k e d to g e th e r w h ile th e fa th e r w as

M a n y th e ra p ists a re u n fa m ilia r w ith e ffe c tiv e

c o n tra s t to th e sa m e fa m ily 's ra th e r fla t affect

w ay s to u tiliz e s u p p o rtiv e fa m ily m e m b e rs and

d u rin g a s e s s io n w h e n th e fa th e r w a s so b er

in to x ic a te d d u rin g an e x p e rim e n ta l sessio n in

sig n ifica n t o th ers w h e n tre a tin g s u b s ta n c e a b u se

(C h a fe tz e t al., 1 9 7 4 ). T h e fa th e r 's a lc o h o l a b u se

d iso rd e rs (B ale, 1 9 9 3 ; F re n ch , 1 9 8 7 ; M cC ra d y ,

w a s se e n a s h a v in g b e c o m e n e c e s s a ry fo r this

1991). T h is m a y ste m in p a rt fro m re lia n c e on

fa m ily to e x p re s s th e ir p o s itiv e e m o tio n s . B ased

p o p u la r co n c e p ts d ra w n fro m th e tra d itio n a l

on sim ila r a n e c d o ta l e v id e n c e , m a n y fa m ily

"fa m ily d is e a s e " m o d e l, in w h ich fa m ily

tre a tm e n t a p p r o a c h e s h a v e e v o lv e d th a t seek to

m e m b ers o f the su b sta n c e u ser a re see n as

id e n tify th e sp e c ific ro le or fa m ily -le v e l

su ffe rin g fro m th e d ise a se o f "c o d e p e n d e n c y "

"a d a p tiv e fu n c tio n " se rv e d b y s u b s ta n c e ab u se,

(B eattie, 1987; C o u d e rt, 19 7 2 ). C e rm a k e v e n

w ith th e g o a l o f b o ls te rin g in te rp e rs o n a l

d efin e s co d e p e n d e n c y u sin g crite ria sim ila r to

fu n c tio n in g in th is a re a in o rd e r to re d u ce these

th o se u sed in th e D ia g n o stic a n d S ta tistica l

s e c o n d a ry g a in s fro m s u b s ta n c e a b u se fo r the

M an u al f o r M en tal D isord ers, 4 th E d itio n [D S M -

in d iv id u a l a n d th e fa m ily (B e p k o , 1 9 8 5 ; S ta n to n

IV ] (C erm ak , 19 8 6 ). A c c o rd in g to S ch u tt,
[T ]he w o m a n w h o lives w ith an a lco h o lic
d e v e lo p s an e n ab lin g illness. She co n sta n tly
sta n d s b e tw e e n the a lco h o lic an d h is crises,
thu s e n a b lin g an d co n d o n in g the fu rth e r u sa g e
of the d ru g (S ch u tt, 1 9 8 5 , p. 5).

a n d T o d d , 1 9 8 2 ; S te in g la s s e t a l., 19 7 7 ). S e v e ral
fa m ily tre a tm e n t m o d e ls a re d e s c rib e d b elo w .
S tra teg ic fa m ily th era p y (H a le y , 19 7 6 ) and the
re la te d M ila n s c h o o l o f fa m ily th e ra p y (S e lv in iP a la z z o li e t a l., 19 7 8 ) ta rg e t th e p o sitiv e
in te rp e rs o n a l a s p e c ts o f s u b s ta n c e a b u se

F ro m th is p e rs p e c tiv e , fa m ily m e m b e rs o f the

s p e c ific a lly , a c k n o w le d g in g d ire c tly its b en e fits

p e rso n w ith a su b s ta n c e a b u se d is o rd e r " e n a b le "

to th e fa m ily (e .g ., " W ith y o u r h u sb a n d

the s u b sta n ce ab u se to co n tin u e and so are

u n e m p lo y e d as a re s u lt o f h is d rin k in g , h e can

th o u g h t to n eed h e lp " d e ta c h in g " or

b e h o m e w h e n th e c h ild re n g e t o u t o f s c h o o l"),

d ise n g a g in g fro m th e ir o v e rre s p o n s ib le

as w e ll as th e n e g a tiv e c o n s e q u e n c e s th e fa m ily
147

C h ap ter 8

m ig h t fa ce if the su b sta n c e a b u se w e re to en d

a u th o rity an d d e fin e c le a re r in te rg e n e ra tio n a l

(Fisch et al., 1 9 8 2 ; H a le y , 1987). T o g e th e r w ith

b o u n d a rie s, e sp e c ia lly b e tw e e n th e se m e n and

su ch p a ra d o x ic a l in te rv e n tio n s as s u g g e stin g the

th e ir m o th e rs (S ta n to n a n d T o d d , 1982).

fam ily m ay n o t y e t b e re a d y to ch a n g e , th ese

in te rv e n tio n s o ften p ro v o k e "s p o n ta n e o u s "

fo c u se s o n fa m ily -o f-o rig in e m o tio n a l

g ro w th on the p a rt o f the fa m ily (W e e k s and

a tta c h m e n t p a tte rn s an d u n re so lv e d sep a ra tio n

L 'A b a te , 1979; W in n , 1995). S e e C h a p te r 5 in

issu es to m a k e se n se o f s u b s ta n c e a b u se

this T IP fo r m o re in fo rm a tio n on s tra te g ic and

d iso rd e rs. In ste a d o f w o rk in g th ro u g h th e

in te ra ctio n a l th e ra p ie s, w h ic h o fte n in v o lv e the

p a re n ta l g e n e r a tio n , h o w e v e r, a d u lts an d

fam ily d irectly .

a d o le s c e n ts a re h e lp e d to d iffe re n tia te and

S tru ctu ral fa m ily th erap y lo o k s b ey o n d the

d efin e th e m s e lv e s as in d iv id u a ls by

sp e cific fam ily d y n a m ic s a ro u n d su b sta n c e

a c k n o w le d g in g an d c u rta ilin g th e ir re sid u a l

ab u se d iso rd e rs to m o re g e n e ra l im b a la n ce s in

e m o tio n a l e n ta n g le m e n ts . A s a re su lt, s u b sta n ce

fam ily re la tio n sh ip s th a t m ig h t m a in ta in

a b u se is n o lo n g e r n e e d e d as a w a y to d en y th eir

su b sta n ce a b u se, s u c h as e x tre m e

fa m ily -o f-o rig in a tta c h m e n ts (B o w en , 1974).

d ise n g a g e m e n ts an d in a p p ro p ria te co a litio n s

C o n tex tu a l fa m ily th era p y (B o s z o rm e n y i-N a g y

b etw ee n fam ily m e m b e rs, e sp e c ia lly a cro ss

an d S p a rk , 1 9 7 3 ) is a n o th e r tra n sg e n e ra tio n a l

g e n e ra tio n a l lin e s (M in u ch in , 19 7 4 ). S a lv a d o re

fa m ily m o d e l th a t h a s b e e n a p p lie d in w o rk

M in u ch in h as h a d an e n o rm o u s im p a c t on b o th

w ith fa m ilie s a ffe c te d b y s u b s ta n c e a b u se

the th eo ry an d p ra c tic e o f s tru ctu ra l fa m ily

(F lo re s -O rtiz a n d B e rn a l, 1 9 8 9 ). T h is a p p ro a ch

th erap y , a lth o u g h m a n y o f h is c o n c e p ts h a v e

e m p h a s iz e s e th ic a l le g a c ie s an d u n c o n sc io u s

b ee n m o d ified as th ey h a v e b e e n in c o rp o ra te d

lo y a ltie s p a s s e d a lo n g fro m o n e g e n e ra tio n to

in to th e s p e ctru m o f m o d a litie s . M in u ch in

th e n e x t. F o r e x a m p le , th e a d o le s c e n t s u b sta n ce

stre sse d the im p o rta n c e o f th e h ie ra rc h y of

a b u s e r lo y a lly p ro v id e s h e r p a re n ts the

p o w e r w ith in th e fa m ily an d id e n tify in g

o p p o rtu n ity to v e n t u n re s o lv e d a n g e r le ft fro m

d y sfu n ctio n a l u ses o f p o w e r (e.g .,

th e ir o w n u p b rin g in g . T re a tm e n t h e lp s cla rify

"s c a p e g o a tin g "). It is im p o rta n t to u n d e rsta n d

the w a y s th e se u n c o n s c io u s " le d g e r s " are

b o th h e a lth y an d d y s fu n c tio n a l ro le s w ith in th e

p a sse d d o w n fro m g e n e r a tio n to g e n e ra tio n , and

fam ily: a lig n m e n ts, c o llu sio n s, and

p a re n ts a re e n c o u ra g e d to d ea l w ith th eir

co m m u n ica tio n p a ttern s. T h e s e k ey p o in ts are

c h ild h o o d iss u e s d ire ctly in ste a d o f a c tin g th em

ro u tin e ly e x p lo red in fa m ily th e ra p y , a lth o u g h

o u t th ro u g h th e ir o w n c h ild re n .

m a n y th e ra p ists w o u ld n o t fe e l c o m fo rta b le

O th e r fa m ily th e ra p y m o d e ls d e e m p h a siz e

"im p o s in g " th e ir o w n m o d e l o f h e a lth on a

th e s y s te m ic " f u n c tio n " o f th e s u b s ta n c e a b u se

fam ily an issu e th a t d id n o t tro u b le M in u ch in .

or fa m ily p a th o lo g y an d c o n c e n tr a te in stea d on

S tru ctu ra l th e ra p ists e x p lo re c u rre n t fa m ily

148

B ow en ian fa m ily th erap y (B o w e n , 1978) also

u tiliz in g fa m ily s tre n g th s an d e n lis tin g fa m ily

o rg a n iz a tio n , e s p e c ia lly h ie ra rc h y and in tim a cy ,

m e m b e rs as a g e n ts o f c h a n g e to m o tiv a te the

w h ile e n co u ra g in g th e fa m ily to lo o se n ru les

s u b s ta n c e u se r an d p ro v id e s u p p o rt fo r o n g o in g

an d e x p e cta tio n s th a t m ig h t b e lo c k in g th e

re c o v e ry (L id d le e t al., 1 9 9 2 ; M e y e rs e t al., 1998;

s u b sta n ce a b u se r in to a d y s fu n c tio n a l ro le

N o e l an d M c C ra d y , 1 9 9 3 ; S iss o n an d A z rin ,

(M in u ch in an d F ish m a n , 1 9 8 1 ; S ta n to n , 19 7 7 ). In

19 9 3 ). T h is is p a rtic u la rly th e ca se w ith m u ltip le

on e o f th e e a rlie st a p p lic a tio n s o f fa m ily th e ra p y

fa m ily th e ra p y m o d e ls an d fa m ily

fo r su b sta n ce a b u se d iso rd e rs, S ta n to n an d T o d d

p s y c h o e d u c a tio n a l g ro u p s (K a u fm a n an d

w o rk ed s u cce s s fu lly w ith fa m ilie s o f y o u n g

K a u fm a n , 1 9 7 9 ; K y m is s is et al., 1 9 9 5 ; O 'F a rre ll et

m a le h e ro in a d d icts to re e s ta b lis h p a re n ta l

al, 19 8 5 ). F ra n k e l d e s c rib e d c o n d u c tin g se p a ra te

B r ie f F am ily T herapy

g ro u p s fo r p a re n ts an d a d o le s c e n ts (F ra n k el,

u sin g a m o d ifie d v e rs io n (N o e l an d M cC ra d y ,

1992). S z a p o cz n ik an d co lle a g u e s a lso e x te n d e d

19 9 3 ) o f th e S p o u s e B e h a v io r Q u e stio n n a ire

the fam ily g ro u p m o d e l to p re v e n tio n w ith

(O rfo rd e t al., 1 9 7 5 ). S p o u s e s w e re tra in e d using

fam ilie s of a d o le sc e n ts at h ig h risk of

ro le -p la y in g a n d re h e a rs a ls to re in fo rce

d ev elo p in g a s u b s ta n c e a b u se d is o rd e r

a b stin e n c e an d d e c r e a s e a n y o f th e ir b e h a v io rs

(S z a p o cz n ik et al., 1989).
B ehavioral m arital th erap y (B M T ) m o d e ls

th a t co u ld trig g e r re n e w e d a lc o h o l
c o n s u m p tio n . S p o u s e s w e re a lso in stru c te d to

c o n c en tra te on te a c h in g an d p ra cticin g

let the d rin k e r e x p e rie n c e n e g a tiv e

gu id elin es fo r c le a r c o m m u n ic a tio n a n d c o n flic t

c o n s e q u e n c e s fro m d rin k in g an d to b e m o re

reso lu tio n , m a rita l e n h a n c e m e n t, an d su b sta n ce

asse rtiv e re g a rd in g th e im p a c t o f th e a lco h o l

ab u se-sp ecific co p in g sk ills s u c h as w a y s to

use.

h an d le re la p se p ro d u c tiv e ly . T h e B M T

T h e th ird ty p e o f tre a tm e n t in c lu d e d all of

co m p o n e n t w as d e v e lo p e d as p a rt o f the

th e tra in in g a b o v e , p lu s a B M T co m p o n e n t

P ro g ra m fo r A lco h o lic C o u p le s T re a tm e n t, a

(M c C ra d y et al., 19 8 6 ). E a c h c o u p le 's

re sea rch stu d y th a t re c e iv e d g o o d e m p iric a l

in te ra c tio n a l b e h a v io rs w e re in itia lly assesse d

s u p p o rt a fte r co n tro lle d tria ls (M c C ra d y , 1989).

u sin g th e L o c k e -W a lla c e M a rita l A d ju stm e n t

F o rty -fiv e p e o p le w ith a lc o h o l a b u s e d iso rd e rs

T e s t (L o ck e a n d W a lla c e , 1 9 5 9 ) an d A rea s of

and th eir s p o u se s w e re ra n d o m ly a ssig n e d to

C h a n g e Q u e s tio n n a ire (B irc h le r an d W e b b ,

on e o f th ree ty p es o f s p o u se in v o lv e m e n t d u rin g

1977). C o u p le s in th e B M T g ro u p w e re tau g h t

o u tp a tie n t tre a tm e n t (a p p ro x im a te ly 15

w a y s to e n rich th e ir re la tio n sh ip b y p la n n in g

sessio n s) an d th e n fo llo w e d o v e r a 2 -y e a r

an d c a rry in g o u t sh a re d fu n a ctiv itie s,

p eriod .

d e s ig n a tin g s p e c ia l " lo v e d a y s " to d em o n stra te

T h e first ty p e o f tre a tm e n t w a s M in im a l

th e ir a ffe ctio n , a n d p ra c tic in g g o o d

S p o u se In v o lv e m e n t (M S I), w h e re th e sp o u se

c o m m u n ic a tio n s s k ills w ith p la n n e d fa m ily

atte n d e d all se ssio n s b u t o n ly as an o b serv e r.

d is c u ss io n s , as w e ll as te c h n iq u e s fo r

C lie n t and clin ic ia n w o rk e d to g e th e r to p re p a re

p ro b le m s o lv in g a n d n e g o tia tio n . F in a lly , to

an in v e n to ry o f th e s u b s ta n c e a b u s e r's

o ffse t th e a b stin en c e v iolation effec t (a d e scrip tio n

in cen tiv es to c h a n g e an d a fu n c tio n a l a n a ly sis of

o f w h ich is in C h a p te r 4) (M a rla tt, 19 7 8 ), co u p les

the su b sta n ce a b u se b e h a v io r u tiliz in g th e T im e -

w e re c o a c h e d to re g a rd a n y re la p se th a t m ig h t

L ine F o llo w -B a c k In te rv ie w (S o b e ll e t al., 1980)

o cc u r as a n o p p o rtu n ity to s h a rp e n th e ir e ffo rts

and a D rin k in g P a tte rn s Q u e s tio n n a ire (Z itte r

ra th e r th a n g iv e u p . B o o s te r s e s s io n s w ere

and M cC ra d y , 19 9 3 ). D rin k in g -sp e cific

s o m e tim e s s c h e d u le d up to 6 m o n th s

in te rv e n tio n s g e a re d to th e c lie n t w e re th e n

p o sttre a tm e n t (N o e l a n d M c C ra d y , 1993).

tau g h t, in clu d in g a lc o h o l re fu sa l sk ills, lea rn in g

B a se d on fo llo w u p a s s e s s m e n ts a t 6 m o n th s,

to se lf-m o n ito r d rin k in g u rg es an d c o n s u m p tio n

c o u p le s in th e B M T g ro u p re p o rte d b etter

rates on a d a ily b a sis, re a rra n g in g c o n tin g e n c ie s

m a rita l s a tisfa c tio n an d re la p se d m o re slo w ly

to su p p o rt a b stin e n c e , re s tru ctu rin g irra tio n a l

a fte r tre a tm e n t th a n th e o th e r tw o g ro u p s.

co g n itio n s, p lu s d e v e lo p in g a lte rn a tiv e

C lie n ts w ith p a rtn e rs in th e B M T g ro u p w ere

re la x a tio n and a s s e rtiv e n e ss sk ills (M c C ra d y et

a lso m o re lik e ly th a n th o se w ith "M in im a l

al., 1986).

S p o u se In v o lv e m e n t" to c o m p le te tre a tm e n t

T h e seco n d o f th e th re e tre a tm e n t ty p es,

(M c C ra d y e t a l., 1 9 8 6 ). E ig h te e n m o n th s after

A lco h o l-F o cu se d S p o u se In v o lv e m e n t (A F S I),

tre a tm e n t, c o u p le s w h o h a d re c e iv e d B M T

in clu d ed th e sa m e d rin k in g -sp e c ific a sse ssm e n ts

re p o rte d e n jo y in g g re a te r re la tio n sh ip

and in te rv e n tio n s b u t a lso a sse sse d the c o u p le

s a tisfa c tio n w ith fe w e r m a rita l s e p a ra tio n s.

149

C h ap ter 8

In ad d itio n , the ra te o f a b stin e n c e a m o n g the

sy ste m s a v a ila b le in th e c o m m u n ity s u c h as

B M T co u p les h ad g ra d u a lly c o n tin u e d to

c h u rc h e s a n d sc h o o ls (P ia z z a a n d D elV a lle,

im p ro v e a fte r tre a tm e n t e n d ed ra th e r th an

1992).

d ro p p in g off, as o ccu rre d w ith the o th er tw o

is a b rie f s y s te m ic / fa m ily in te rv e n tio n an d

ab u se tre a tm e n t p ro g ra m s (M c C ra d y et al.,

th e ra p y m o d e l th a t h a s sh o w n g o o d re su lts

1991). In s u p p o rt o f th is p a rtic u la r fin d in g ,

th ro u g h tra in in g th e s ig n ific a n t o th e rs, g e n e ra lly

S to u t an d co lle a g u e s re p o rte d th e sa m e p a ttern

s p o u s e s , o f tre a tm e n t-re s is ta n t c lie n ts w ith

o f im p ro v e m e n t 2 y e a rs a fte r a sim ila r B M T trial

a lco h o l a b u se d is o r d e rs (H u n t a n d A z rin , 1973;

w ith a d iffe re n t sa m p le o f 2 2 9 clie n ts w ith

S iss o n a n d A z rin , 1 9 8 6 ,1 9 8 9 ). C R A p a rtic ip a n ts

a lco h o l u se d iso rd e rs (O 'F a rre ll an d C o w les,

lea rn to e n c o u ra g e s o b rie ty b y re in fo rcin g

1989).

a b stin e n c e w h ile a llo w in g th e d rin k e r to

A cco rd in g to N o e l an d M cC ra d y , th is lo n g

e x p e rie n c e n e g a tiv e c o n s e q u e n c e s fro m

term e ffe ctiv e n e s s s u g g e sts th a t m a rita l th e ra p y

in to x ica tio n . S ig n ific a n t o th e rs a lso le a rn to

m ay p re v e n t re la p se d u rin g e a rly re c o v e ry b y

id e n tify a tim e w h e n th e d rin k e r m ig h t be

s ta b iliz in g the su b s ta n c e u s e r's in te rp e rs o n a l

w illin g to e n te r tre a tm e n t, in c o n tra s t to th e

co n te x t (N o el an d M c C ra d y , 19 9 3 ). S im ila r B M T

c o n fro n ta tio n a l m e th o d s a d v o c a te d b y the

a p p ro a ch e s h a v e re c e n tly b e e n s u c c e s s fu lly

Jo h n s o n In s titu te (Jo h n so n , 1 9 8 6 ) an d U n ila te ra l

e m p lo y e d w ith m a le su b s ta n ce a b u sers and

F a m ily T h e ra p y m o d e ls (T h o m a s a n d A g er,

th eir p a rtn ers (F a ls -S te w a rt e t al., 1996) and

1993). C R A p a rtic ip a n ts a re p re p a re d to

a p p lied in re la p se p re v e n tio n (M c C ra d y , 1993)

c o n trib u te to th e tre a tm e n t p ro c e s s w h e n an d if

w ith b o o ste r s e ssio n s sp re a d o u t o v er the

th e d rin k e r a g re e s to th is. B e c a u s e d o m e stic

fo llo w in g y e a r (O 'F a rre ll et al., 19 9 3 ). A B M T

v io le n c e re m a in s a s ig n ific a n t risk th ro u g h o u t

a p p ro a ch sp e c ifica lly fo r fe m a le su b sta n ce

th is p ro c e s s , s p o u s e s a n d s ig n ific a n t o th e rs are

a b u sers is also b e in g stu d ie d (W e tc h le r e t al.,

h e lp e d to re c o g n iz e an d re s p o n d to w a rn in g

1993).

sig n s b y d e -e s c a la tin g c o n flic t a n d e n su rin g

N etw ork th erap y a p p ro a ch e s (F a v a z z a and

T h o m p so n , 19 8 4 ; G a la n te r, 19 9 3 ) re co g n iz e the

150

T h e c o m m u n ity rein fo rcem en t a p p ro a ch (C R A )

g ro u p s in th is stu d y an d m o st o th er su b sta n c e

th e ir o w n sa fe ty .
O n c e th e d rin k e r a g re e s to e n te r tre a tm e n t,

p o te n tia l su p p o rt fro m th o se o u tsid e the

th e s ig n ific a n t o th e r a tte n d s a ll fu rth e r sessio n s

im m e d ia te fa m ily , e sp e c ia lly in te rm s o f

a n d p a rtic ip a te s in c o m m u n ic a tio n -sk ills

co n d u ctin g e ffe c tiv e su b s ta n c e a b u se

tra in in g a n d re c ip ro c ity m a rr ia g e c o u n s e lin g "

in te rv e n tio n s. G a th e rin g to g e th e r th o se w h o

to d e v e lo p m u tu a lly re in fo rc in g b e h a v io rs

g e n u in e ly ca re a b o u t th e w e lfa re o f th e

(S isso n a n d A z rin , 1 9 8 9 ). T h e s ig n ific a n t o th er is

s u b sta n ce a b u ser, e sp e c ia lly frie n d s and

a lso a sk ed to m o n ito r th e d r in k e r 's d isu lfira m

e x te n d e d fa m ily m e m b e rs, h e lp s e n c o u ra g e the

u se (A n ta b u se ) o n a d a ily b a sis a n d to re sp o n d

s u b sta n ce a b u s e r to sto p u sin g a n d re m a in

a p p ro p ria te ly if th e d is u lfira m is n o t ta k e n

a b stin e n t. G a la n te r a lso p o in ts to the

(S isso n an d A z rin , 1 9 9 3 ). B e s id e s d isu lfira m and

im p o rta n ce o f th e in v o lv e m e n t o f A lco h o lics

m a rita l c o u n s e lin g , d rin k e rs in th e C R A

A n o n y m o u s (A A ) in n e tw o rk th e ra p y (G a la n te r,

p ro g ra m s re c e iv e jo b a n d s o c ia l sk ills c o u n se lin g

1993). S im ila rly , S e le k m a n h a s in v o lv e d p eer

as n e e d e d . It is w o rth n o tin g th a t s o m e C R A

g ro u p m e m b e rs in fa m ily th e ra p y w ith

s e ssio n s h a v e b e e n h e ld in th e fa m ily 's h o m e

a d o le sce n t s u b s ta n ce u se rs (S e le k m a n , 1991).

(H u n t a n d A z rin , 1 9 7 3 ), re c o g n iz in g the

P ia z z a and D e lV a lle h a v e d e v e lo p e d th e ra p e u tic

p o te n tia l fo r h o m e -b a s e d tre a tm e n ts (H e n g g e le r

in te rv e n tio n s th a t a ctiv e ly in c o rp o ra te la rg er

et al., 19 9 6 ).

B r ie f F a m ily T herapy

In a stu d y u tiliz in g th e C R A a p p ro a c h , 12

w e re ra n d o m ly a s s ig n e d to e ith e r th e C R A F T

sig n ifica n t o th ers o f tre a tm e n t-re sis ta n t clie n ts

p ro g ra m , a n A l-A n o n -o n ly g ro u p , or a Jo h n so n

w ith a lco h o l ab u se d iso rd e rs w e re ra n d o m ly

In stitu te in te rv e n tio n g ro u p (Jo h n so n , 1973,

d iv id ed to fo rm a C R A g ro u p o f s e v e n an d a

19 8 6 ). O f th e C R A F T p a rtic ip a n ts w ith alco h o l

co n tro l g ro u p o f fiv e w h o w e re re fe rre d to A l-

a b u se d is o rd e rs , 6 7 p e rc e n t w e n t in to tre a tm e n t,

A n on. O f the C R A g ro u p , six o f th e sev en

w h e re a s o n ly 13 p e rc e n t o f th e A l-A n o n g ro u p

re sista n t s p o u se s e n te re d tre a tm e n t, c o m p a re d

a n d 23 p e rc e n t o f th e Jo h n s o n In stitu te

w ith n o n e o f th e A l-A n o n g ro u p p a rtn e rs. T h e

in te rv e n tio n g ro u p e n te re d tre a tm e n t (M ey e rs et

p artn ers o f C R A p a rtic ip a n ts re d u c e d th eir

a l., 1998).

d rin k in g d ay s fro m 24 p e r m o n th to 11 b e fo re

C R A F T a lso w o rk s w ith s ig n ific a n t o th ers to

e n te rin g tre a tm e n t, an d th is ra te d ro p p e d to 2

im p ro v e th e ir s o c ia l a n d e m o tio n a l w e lfa re .

d rin k in g d ay s p e r m o n th o n ce th e c o u p le sta rte d

S ig n ific a n t o th e rs a re e n c o u ra g e d to d ecrea se

jo in t tre a tm e n t (S isso n an d A z rin , 19 8 6 ). (M o re

stre ss b y ta k in g c a re o f th e m s e lv e s an d m a k in g

in fo rm a tio n on th e C R A m o d e l ca n b e fo u n d in

c h a n g e s to e n h a n c e th e ir o w n w e ll-b e in g and

C h a p te r 4 o f th is T IP .)

p o sitiv e s o c ia l s u p p o rts . P a rtic ip a n ts in the

T h e C R A h a s b e e n m o d ifie d in to the

C R A F T p ro g ra m h a v e re p o rte d re d u c tio n s in

com m u n ity rein fo rcem en t an d fa m ily train in g

a n g e r, a n x ie ty , a n d d e p re s s io n , re g a rd le ss o f the

(C R A F T ) p ro ce d u re (M e y e rs e t al., 19 9 6 ) w ith

s u b s ta n c e u s e r 's tre a tm e n t sta tu s. A lth o u g h

clin ica l tria ls u n d e r w a y (M e y e rs et al., 19 9 8).

m u c h o f th e fo c u s o f th e C R A a n d C R A F T

T h is b rie f sy s te m ic in te rv e n tio n a n d th e ra p y

m o d e ls c e n te rs o n g e ttin g th e s u b s ta n c e a b u ser

m o d e l also w o rk s th ro u g h th e c o n c e rn e d o th er

in to tre a tm e n t, b o th p ro g ra m s e m p h a s iz e the

to a n a ly z e b e h a v io r p a tte rn s su rro u n d in g

im p o rta n c e o f o n g o in g fa m ily o r c o u p les

su b sta n ce a b u se. S u b s ta n c e a b u s e trig g e rs and

s e ssio n s e m p lo y in g c o m m u n ic a tio n sk ills

c o n se q u e n ce s a re so u g h t, as w e ll as

tra in in g an d m a rita l re c ip ro c ity co u n se lin g

in te rp e rso n a l cu es an d p o sitiv e c o n s e q u e n c e s

(M e y e rs e t al., 1 9 9 8 ; S iss o n a n d A z rin , 1986).

th a t s u p p o rt m o re a d a p tiv e , s o b e r b e h a v io rs.

F a m ily th e ra p y is o fte n a p p lie d in the

T h is an a ly sis ca n in c lu d e th e S p o u s e E n a b lin g

tre a tm e n t o f a d o le s c e n ts w ith s u b s ta n c e a b u se

In v e n to ry or th e S p o u se S o b rie ty In flu e n c e

d iso rd e rs, a n d m a n y s p e c ific fa m ily th e ra p y

In v e n to ry (T h o m a s et al., 19 9 4 ). T h e risk of

m o d e ls h a v e b e e n d e v e lo p e d fo r th is

d o m e stic v io le n ce is a sse sse d u sin g th e C o n flic t

p o p u la tio n . T h e s e o fte n w e a v e to g e th e r

T a ctics S cale (S tra u s, 19 7 9 ), an d stra te g ie s,

c o n c e p ts a n d te c h n iq u e s fro m d iffe re n t sch o o ls

in clu d in g a sa fe ty p la n , a re d e v e lo p e d .

o f fa m ily th e ra p y . M u ltid im en s io n a l fa m ily

C o m m u n ica tio n sk ills a re an im p o rta n t a s p e ct o f

th erap y (M D F T ) (L id d le et a l., 1 9 9 2 ) is a b rie f

this m o d e l. T h e b a sic ru le s ta u g h t a re to b e

fa m ily th e ra p y m o d e l th a t h a s d e m o n stra te d

b rie f, b e p o sitiv e , b e sp e c ific a n d cle a r, la b e l

s ig n ific a n t lo n g -te rm c lin ic a l e ffe c tiv e n e s s in

fe e lin g s, e x p re ss u n d e rs ta n d in g fo r th e o th e r's

tre a tin g a d o le s c e n t s u b s ta n c e a b u se an d co n d u ct

p e rsp e ctiv e , a c c e p t p a rtia l re s p o n s ib ility w h e n

d is o rd e rs d u rin g c o n tro lle d tria ls (S c h m id t e t al.,

in d icate d , an d o ffe r to h e lp (M e y e rs et al., 1998).

1 9 9 6 ). M D F T in te g ra te s s tru c tu ra l/ s tra te g ic

A tre a tm e n t s e ttin g is a lso lin e d up in

fa m ily th e ra p y (S ta n to n , 1 9 8 1 ; T o d d , 1986) w ith

a n ticip a tio n th a t the su b s ta n c e a b u s e r w ill a g ree

re s e a rc h fin d in g s o n a d o le s c e n t d e v e lo p m e n t

to a cce p t fu rth e r h elp a t s o m e p o in t.

(L id d le e t al., 19 9 2 ). T h e M D F T m o d e l is

In o n e p re lim in a ry s tu d y o f th e C R A F T

d e sig n e d to e n h a n c e a fa m ily 's a b ility to b u ffer

m o d el, 130 sig n ific a n t o th e rs o f tre a tm e n t-

a d o le s c e n ts a g a in st d e s tr u c tiv e p e e r a n d so cial

re sista n t c lie n ts w ith a lc o h o l a b u se d iso rd e rs

in flu e n c e s b y n u rtu r in g h e a lth y te en

151

C h ap ter 8

d e v e lo p m e n t th ro u g h s u p p o rtiv e ra th e r th a n

w a s a lso a re d u c tio n in re la te d co n d u c t

strictly a u th o rita ria n p a r e n t-c h ild re la tio n sh ip s.

d is o rd e rs a m o n g 68 p e rc e n t o f th e te en s w ith

In d iv id u a l se ssio n s w ith th e a d o le s c e n t are

s ig n ific a n t im p ro v e m e n ts s e e n in sch o o l

in te rsp erse d w ith fa m ily s e ssio n s to a llo w the

p e rfo rm a n c e (S c h m id t e t a l., 19 9 6 ). M o st

th e ra p ist an o p p o rtu n ity to fo rm a su p p o rtiv e

re m a rk a b ly , th e se p o sitiv e o u tc o m e s re m a in ed

re la tio n sh ip w ith th e teen and a ct as an

a t fo llo w u p 1 y e a r la te r (L id d le an d D a k o f,

in te rm e d ia ry b e tw e e n p a re n t(s) and ch ild .

199 5). B a sed on n o n p a rtic ip a n t ra te rs w h o

B esid es re la tio n sh ip issu es, the M D F T m o d e l

a sse sse d fa m ily th e ra p y v id e o ta p e s, the

re co g n ize s the d e v e lo p m e n ta l ta sk s fa ce d b y the

re d u c tio n s in s u b s ta n c e u se w e re s ig n ific a n tly

ad o lesce n t, su ch as le a rn in g to m a n a g e e m o tio n s

a sso c ia te d w ith im p ro v e m e n ts in th e p a r e n t-

and im p u lses, an d tries to sp e cific a lly a d d ress

a d o le s c e n t re la tio n sh ip (S c h m id t e t al., 1 9 9 6 ), a

them . T h e ra p y s o m e tim e s in clu d e s

p rim a ry g o al o f M D F T (L id d le e t al., 1992).

re p re se n ta tiv e s o f e x tra fa m ilia l s y ste m s su ch as

U n fo rtu n a te ly , d ro p o u t ra te s u sin g th e M D F T

sch o o l and p ro b a tio n a ry p e rs o n n e l as w ell as

tre a tm e n t m o d e l re a c h e d 28 p e rc e n t, an d on ly 69

p eers.

p e rc e n t o f th e p a re n ts w e re a s se sse d as m a k in g

R e co g n iz in g th a t m o st su b s ta n c e -a b u s in g
teen s and th eir p a re n ts a re lo ck e d in co n flic t, the
M D F T th e ra p ist w o rk s to fin d a c o m m o n

p ro g re ss in m o d ify in g th e ir p a re n tin g sty les

(L id d le an d D a k o f, 19 9 4 ).
T h e In s titu te o f M e d ic in e (IO M )

g ro u n d an d cre a te a c o n te x t w h e re a m o re

re c o m m e n d e d th a t b rie f c o u p le s th e ra p y be

tru stin g re la tio n sh ip ca n e m e rg e . A d o le sc e n ts

in c lu d e d as a tre a tm e n t o p tio n fo r all a lco h o l-

are ch a lle n g e d to id e n tify an d a rtic u la te th eir

a b u sin g c lie n ts , e s p e c ia lly fo r th o se still

ow n issu es an d g o a ls fo r th e ra p y and to tak e

e x p e rie n c in g o n ly m ild to m o d e ra te p ro b le m s

step s to a ch ie v e th ese. P a re n ts a re ch a lle n g e d to

(IO M , 19 9 0 ). B a sed on th e ir re v ie w o f the

listen to th eir teen s an d let th e p a r e n t-c h ild

tre a tm e n t o u tc o m e lite ra tu re , E d w a rd s and

re la tio n sh ip e v o lv e in to o n e o f m u tu a l re sp ect,

S te in g la s s re a c h e d a s im ila r c o n c lu sio n :

b a la n cin g th e p a re n ta l ta sk s o f g u id a n c e w ith

T h e w e ig h t o f the e v id e n c e ...s e e m s so stro n g at

su p p o rt. T h is in v o lv e s c h a rg in g b o th the

this p o in t as to s u p p o rt a re c o m m e n d a tio n th at

a d o lesce n t an d th e p a re n ts w ith re sp o n sib ility

fam ily in v o lv e m e n t, e sp e cia lly in clu sio n of

for ch a n g e w h ile co n v e y in g the cle a r e x p e c ta tio n

th at the fa m ily ca n a rriv e a t this p o in t of

n o n -a lc o h o lic fam ily m e m b e rs in the

a s s e s s m e n t p h a se o f tre a tm e n t, be b u ilt in as a
ro u tin e c o m p o n e n t o f a lco h o lism tre a tm e n t

re co n cilia tio n (L id d le et al., 19 9 2 ). See T IP 32,

p ro g ra m s (E d w a r d s a n d S tein g lass, 1 9 9 5 , p.

T reatm en t o f A d o lescen ts W ith S u b sta n ce U se

4 8 5 ).

D isorders (C S A T , 1 9 9 9 b ), fo r m o re in fo rm a tio n

T h e b rie f fa m ily th e ra p y a p p ro a c h e s

on fam ily th e ra p y fo r a d o le s c e n t su b sta n ce

re v ie w e d a b o v e h a v e all s h o w n p o sitiv e lo n g

users.

te rm o u tc o m e s in c o n tro lle d c lin ic a l trials.

In a d iv erse sa m p le o f fa m ilie s

T o g e th e r th e se a p p r o a c h e s d e m o n s tra te the

(a p p ro x im a te ly 4 5 p e rc e n t A fric a n -A m e ric a n or

p o te n tia l fo r b rie f fa m ily th e ra p y in su b sta n c e

H isp an ic), 16 sessio n s o f M D F T led 79 p e rc e n t of

a b u se tre a tm e n t.

the a d o le sce n ts to re d u ce th e ir a v e ra g e a lco h o l

and m a riju a n a u se fro m a d a ily to a w e e k ly
b asis. In a d d itio n , h a rd e r su b sta n c e u se
d ro p p ed fro m e v e ry o th e r m o n th to ze ro . O f

252

Using Brief Family

Therapies

th o se w h o re d u ce d th eir s u b s ta n ce u se, 30

In v o lv in g fa m ily m e m b e rs or c o n c e rn e d o th ers

p e rce n t d e cid e d o n c o m p le te a b stin e n c e . T h e re

in fa m ily th e ra p y c a n h a v e a n u m b e r o f b en e fits.

B r ie f F a m ily T herapy

T h e d y n a m ics o f th e fa m ily a re a lre a d y a fa cto r

w ritte n ou t. P e rm a n e n t c h a n g e s o fte n resu lte d

in the c lie n t's su b s ta n c e -a b u s in g b e h a v io r in a

w ith m o tiv a te d fa m ilie s. W e g sc h e id e r-C ru s e 's

co m p le x and u n iq u e re la tio n sh ip . In th e sa m e

w o rk h a s b e e n re p lic a te d in se v e ra l re sid e n tia l

m a n n er, the fa m ily ca n p a rtic ip a te in the

se ttin g s an d tra in in g in s titu te s (e .g ., the O n -S ite

p o sitiv e e x p e rie n c e o f tre a tm e n t an d re co v ery .

a n d th e S ie rra T u c so n T re a tm e n t C e n te rs in

Duration of Therapy and

Frequency of Sessions

T u c so n , A riz o n a ).

Opening Session

T h e m a jo rity of fa m ily th e ra p y is c o n d u c te d o n a

A ty p ica l o p e n in g s e s s io n fo r a fa m ily in w h ich a

sh o rt-te rm b a sis, w ith s o m e e x c e p tio n s (O b je ct

m e m b e r h a s a s u b s ta n c e a b u s e d is o rd e r m ig h t

R e latio n s th e ra p y m a y tak e y e a rs). S e ssio n s

in v o lv e th e fo llo w in g :

m ay be VA to 2 h o u rs in len g th . T h e p re fe rre d

tim e lin e fo r fa m ily th e ra p y is n o t m o re th a n tw o

T h e th e ra p is t se e k s to c la rify th e n a tu re of
th e p ro b le m a n d to id e n tify th e fa m ily 's

sessio n s p e r w e e k (e x c e p t in re s id e n tia l se ttin g s)

g o a ls. T h e th e ra p is t a sk s e a c h fa m ily

to allow tim e to p ra c tic e n e w b e h a v io rs an d

m e m b e r th e sa m e so rt o f o p e n -e n d e d

e x p e rie n ce ch a n g e . D u ra tio n o f th e ra p y co u ld

q u e s tio n s ty p ic a lly u se d in in d iv id u a l

be 6 to 10 sessio n s, d e p e n d in g on the p u rp o se

th e ra p y . F or e x a m p le :

and g o als o f th e in te rv e n tio n .

In a re sid e n tia l tre a tm e n t p ro g ra m , fa m ily

h ere?"

th e rap y ca n ta k e p la c e in a v a rie ty o f w ay s
d ep en d in g on p ro g ra m d e sig n an d le n g th of
stay . S o m e p ro g ra m s h a v e " fa m ily w e e k s " in
co n ju n ctio n w ith in d iv id u a l tre a tm e n t. O th e rs

m ay re q u ire c lie n ts to b rin g in a s ig n ific a n t o th er

"W h a t w o u ld y o u lik e to w o rk o n ? "

"W h a t is y o u r g o a l in co m in g h e re ? "

"H o w d id y o u g e t h e r e ? "

T h e th e ra p is t e d u c a te s th e fa m ily in w h a t is

th e ra p e u tic p ro c e s s a n d to u n d e rsta n d k ey

re co v ery issu es. A d o le s c e n t tre a tm e n t p ro g ra m s

b io s o c ia l issu e s re la te d to s u b s ta n c e ab u se.

th ro u g h o u t tre a tm e n t.

T h e th e ra p is t p ro v id e s fe e d b a c k to th e fa m ily
o n w h a t w a s s a id , d e m o n s tra tin g w h o se

C e rta in fo rm s o f fa m ily th e ra p y h a v e b e e n
d ev elo p e d to a ch ie v e a h ig h im p a c t in a sh o rte r

n e e d e d to p a rtic ip a te e ffe c tiv e ly in the

on e to tw o n ig h ts w e e k ly to w o rk to g e th e r on

so m e tim e s in v o lv e th e fa m ily co n tin u o u sly

"W h a t y o u w o u ld lik e to se e h a p p e n

g o a ls a re s im ila r or d iffe re n t.

p erio d o f tim e. O n e n o ted d e riv a tiv e o f

T h e th e ra p is t c a n th e n m o v e o n to
p rio ritiz in g d ir e c tio n s fo r c h a n g e or, if the

m u ltifa m ily th e ra p y is th e M u ltip le Im p a ct

d ire c tio n is s u ffic ie n tly cle a r, s ta rt w o rk .

M o d el d ev elo p e d by W e g sc h e id e r-C ru s e (1989),

S o m e th e ra p is ts a sk th e fa m ily to e n g a g e in a

w h o b ro u g h t to g e th e r g ro u p s o f fo u r or fiv e

" c o n tr a c t" th a t id e n tifie s th e d ire c tio n of

so b er in d iv id u a ls w h o w e re p re v io u sly

th e ra p y a n d d e lin e a te s e a c h m e m b e r's

su b sta n ce d e p e n d e n t an d th e ir fa m ilie s fo r a

c o m m itm e n t to th e p ro c e s s .

co n c e n tra te d , e x te n d e d w e e k en d o f w o rk . T h e
E a rly on, p ra c titio n e rs o f d iffe re n t th e o retica l

p u rp o se w a s to e n a b le th e fa m ilie s to su p p o rt
the co n tin u ed s o b rie ty o f th e ir fo rm e rly

m o d e ls w ill m a k e c h o ic e s a b o u t w h a t th ey w ill

s u b s ta n ce -d e p e n d e n t m e m b e rs. F a m ily ro les

fo cu s o n an d h o w to p ro c e e d , fo r e x a m p le :

w ere re ca st so th a t e a c h fa m ily m e m b e r co u ld

T h e ra p is ts w h o p ra c tic e s o lu tio n -fo c u se d

take on a d iffe re n t ro le, su ch as w h o w o u ld

th e ra p y w o u ld d e v o te m o re tim e to

m ak e fam ily fin a n c ia l d ecisio n s. N ew

g a th e rin g in fo r m a tio n a n d a ffirm in g fa m ily

a g re em en ts b e tw e e n fa m ily m e m b e rs w e re

m e m b e r s a t th e firs t se s s io n , w h ic h w o u ld
153

C h ap ter 8

p ro b a b ly co n c lu d e w ith th e a s s ig n m e n t of

w h o w a n t to a tte n d o n a v o lu n ta ry , a s-n e e d e d

task s d esig n e d to test the p o ssib ility of

b a sis. S o m e p ra c titio n e rs a sk th e c lie n t and

ch an g e in a rea s w h e re ch a n g e see m s fe a sib le .

fa m ily m e m b e r s to ca ll th e m a fte r 6 m o n th s or 1

T h e ra p is ts a p p ly in g E rik s o n ia n th e ra p y , a fte r

y e a r fo r a fo llo w u p c o n v e rs a tio n . D e p e n d in g on

a sk in g fa m ily m e m b e rs w h a t th e y w an t,

th e fa m ily 's n e e d s , th e th e ra p is t m a y b e a b le to

m ig h t ask, "H o w w ill y o u k n o w w h e n you

p ro v id e re in fo rc e m e n t w ith o u t fu rth e r m e e tin g s,

g e t th e re ? " A fo llo w u p q u e stio n w o u ld be,

or m a y s u g g e s t o n e o r tw o fo llo w u p s e ssio n s to

"Is th ere an y re a so n y ou ca n th in k o f w h y it

a d d re ss e m e rg in g issu es.

w o u ld n o t b e o k a y to g et th e re ? " T h is

A t a m in im u m , c lie n ts s h o u ld b e a ssu re d th at

q u e stio n tests fo r re s is ta n c e an d any

th ey ca n ca ll th e th e ra p is t w h e n n e c e ssa ry .

co n stra in ts, su ch as the p o ssib ility o f fa m ily

v io le n ce, w h ic h co u ld p re v e n t o p e n and

Cultural Issues

h o n e st c o m m u n ic a tio n . T h e th e ra p is t w o u ld
It is im p o rta n t th a t a fa m ily th e ra p is t

th en try to d o so m e th in g a b o u t th a t
co n stra in t in o rd e r to c re a te sa fe ty (an actio n

b a c k g ro u n d . (S e e th e e x a m p le in th e te x t b o x

re fe rre d to as an "e c o lo g ic a l c h e c k ").

b elo w .) F a ilu re to d o so m a y b e p a rtia lly

T h e ra p ists u sin g th e M e n ta l R e se a rch

re s p o n s ib le fo r th e la rg e d ro p o u t ra te b y e th n ic

In stitu te (M R I) s tra te g ic m o d e l w o u ld
e x a m in e s o lu tio n s th a t h a v e a lre a d y b ee n
a tte m p ted b e c a u se m o st fa m ilie s w ith a
m e m b e r stru g g lin g w ith a su b s ta n c e a b u se
d iso rd e r try a v a rie ty o f so lu tio n s th a t h a v e
n o t w o rk e d b e fo re fo rm a l tre a tm e n t.

u n d e rsta n d th e fa m ily 's e th n ic a n d cu ltu ra l

The

fa m ily 's s o lu tio n m a y b e se e n as th e p ro b lem .

m in o ritie s a fte r th e firs t th e ra p y s e ssio n

(S o o -H o o , 19 9 9 ). T o s u c c e s s fu lly p ro m o te
c h a n g e w ith in a fa m ily s y s te m , th e th e ra p is t w ill
n e ed th e fa m ily 's p e rm is s io n to sh a re th eir
c lo se ly h e ld s e c re ts. T h e th e ra p is t's a p p ro a ch ,
h o w e v e r, m u s t v a ry a c c o rd in g to th e cu ltu ra l
b a c k g ro u n d o f th e fa m ily . W o rk in g w ith a

Followup

F ilip in o fa m ily re c e n tly s e ttle d in th e U n ite d

S ta te s, o n e th e ra p is t h a d to re q u e st a le tte r fro m

T h e ra p ists sh o u ld p la n fo r fo llo w u p and

the fa m ily e ld e r in th e P h ilip p in e s in o rd e r to

su p p o rt as p a rt o f th e te rm in a tio n p ro cess.

a llo w m e m b e rs to re v e a l fa m ily m a tte rs to an

R e sid en tia l p ro g ra m s, fo r e x a m p le , ca n hold

o u tsid e r. O n c e th e fa m ily o p e n e d u p , h o w e v e r,

su p p o rt g ro u p s ru n b y a lu m n i or c o u n se lo rs

th e th e ra p is t w a s se e n as a n " e ld e r " an d w as

th at are a v a ila b le w e e k ly fo r fa m ily m e m b e rs

a c c o rd e d th e re s p e c t h e n e e d e d to p ro m o te

N a tiv e A m e r ic a n s in B rief F a m ily T h e r a p y

A 2 6 -y e a r-o ld N a tiv e A m e ric a n m a n s o u g h t tre a tm e n t fo r h is a lc o h o l a b u se . In a re s id e n tia l tre a tm e n t
settin g , the th e ra p is t le a rn e d th a t th e c lie n t's fa th e r w a s a fa n a tic a lly re lig io u s e x -d rin k e r w h o tried to
fo rce h is so n to g o to ch u rch . A s a resu lt, the clie n t b e g a n d rin k in g h e a v ily o n S u n d a y m o rn in g s in
o rd e r to a v o id g o in g to c h u rch . T h e clie n t w a s to rn b e tw e e n a c u ltu ra lly b a se d b e lie f th a t h e sh o u ld
re sp e ct h is e ld e rs an d h is o w n d e sire fo r in d e p e n d e n c e . T h e th e ra p is t e n c o u ra g e d fa th e r an d so n to
e x p re ss b o th th eir re s e n tm e n t an d th e ir a p p re c ia tio n o f e a ch o th e r in le tte rs re a d a lo u d to e a ch oth er.
T h ro u g h th is p ro c e s s , the c lie n t b e g a n to re m e m b e r w h a t h is fa th e r h a d b e e n lik e as a n a lc o h o lic an d
saw th a t h e h im s e lf w a s in d a n g e r o f m a k in g th e sa m e m ista k e . T h is m o tiv a te d th e c lie n t to
a cco m p lish a b stin e n c e an d to m o v e o u t o f h is fa th e r's h o m e in o rd e r to e s ta b lis h h is o w n h o u se h o ld .

154

B r ie f F am ily T herapy

p o sitiv e ch an g e . In a n o th e r e x a m p le , a th e ra p ist

A b lo n (w ith m id d le -c la s s C a th o lic fa m ilie s)

w o rk in g w ith a clie n t w h o b e lo n g e d to the

an d K a u fm a n an d B o rd e rs h a v e d ra w n a tte n tio n

S o u th e rn B a p tist fu n d a m e n ta lis t m o v e m e n t

to th e im p o rta n c e o f e th n ic a n d cu ltu ra l

fo u n d th at th e c lie n t w a s im m o b iliz e d b y th e

d iffe re n c e s to u n d e rs ta n d a n d tre a t fa m ilie s w ith

sh am e th at s u rro u n d e d d rin k in g in h e r fa m ily

su b s ta n c e a b u s e p ro b le m s (A b lo n , 1980;

and the d ifficu lty o f ta lk in g a b o u t it. T h e c lie n t

K a u fm a n a n d B o rd e rs, 1 9 8 8 ). M a n y su b sta n ce

ap p ro a ch e d th e fa m ily 's m in iste r to h e lp fra m e

a b u se tre a tm e n t p ro g ra m s h a v e d ev elo p e d

the s itu a tio n so th a t th e fa m ily co u ld fa ce the

cu ltu ra lly sp e c ific fa m ily th e ra p y

p ro b lem to g e th e r an d fin d a so lu tio n . (F o r m o re

m o d e ls fo r L a tin o fa m ilie s (F lo re s -O rtiz and

in fo rm a tio n on fa m ily th e ra p y fo r th o se fro m

B ern a l, 1 9 8 9 ; L a u re a n o a n d P o lia n d ro , 1991;

u n fa m ilia r cu ltu re s, see M cG o ld ric k et al., 1996;

P a n itz et al., 1 9 8 3 ; S z a p o c z n ik e t al., 1991),

S u e and S u e , 1990.)

A fric a n -A m e ric a n fa m ilie s (A k ta n et al., 1996;

T h e la n g u a g e u sed to d e sc rib e d y n a m ics

w ith in th e fa m ily s y s te m is c h a rg e d w ith
sp e cific cu ltu ra l m e a n in g . F o r e x a m p le , if a

Z ite r, 1 9 8 7 ), an d N a tiv e A m e ric a n fa m ilie s (H ill,

1 9 8 9 ), a m o n g o th ers.
A fa m ily th e ra p y a p p ro a c h th a t h a s b ee n

clie n t b e lo n g s to a c u ltu re th a t v a lu e s life lo n g

su c c e s s fu l w ith s u b s ta n c e -u s in g H isp a n ic

in te rd e p e n d e n ce a m o n g fa m ily m e m b e rs, the

a d o le s c e n ts c o m b in e s e le m e n ts fro m stru ctu ra l,

th e ra p ist w o u ld b e ill a d v ised to e n c o u ra g e

stra te g ic , a n d M ila n th e ra p ie s (S z a p o c z n ik and

g re a te r in d e p e n d e n c e fro m the fa m ily .

K u rtin es, 1 9 8 9 ; S z a p o c z n ik e t al., 1 9 8 8 ,1 9 9 1 ).

H o w ev er, th e th e ra p ist m ig h t e n c o u ra g e th e

T h is a p p ro a c h fo c u s e s c o n s id e ra b le e ffo rt on

clie n t to b e co m e m o re e ffe c tiv e w ith in h is fa m ily

o v e rc o m in g in itia l re s is ta n c e to tre a tm e n t

and e x p la in w a y s th a t w o u ld a llo w so m e

b e c a u se th e p ro c e s s e m b o d ie s th e fa m ily 's issu es

fre e d o m w ith in th e c u ltu ra l p a ra m e te rs o f th e

a ro u n d th e a d o le s c e n t's s u b s ta n c e u se

fam ily.

(S a n tis te b a n a n d S z a p o c z n ik , 1 9 9 4 ; S z a p o c z n ik
a n d K u rtin e s , 1 9 8 9 ).

155

9 Time-Limited Group Therapy

ro u p p s y c h o th e ra p y is o n e o f th e m o st

(Y a lo m , 1 9 9 5 ). F o r m a n y y e a rs, A lc o h o lic s

c o m m o n m o d a litie s fo r tre a tm e n t of

A n o n y m o u s (A A ) a n d N a rc o tic s A n o n y m o u s

s u b sta n ce a b u se d iso rd e rs. G ro u p

(N A ) h a v e re c o g n iz e d th e im p o rta n c e of

th e ra p y is d efin e d as a m e e tin g o f tw o or m o re

b re a k in g th e iso la tio n a s s o c ia te d w ith su b sta n ce

p e o p le fo r a c o m m o n th e ra p e u tic p u rp o s e or to a b u se , w h ile a t th e sa m e tim e c o n n e c tin g

ach iev e a co m m o n g oal. It d iffe rs fro m fa m ily

in d iv id u a ls w ith o th e rs w h o s e c o m m o n p u rp o se

th e rap y in th a t the th e ra p is t c re a te s o p e n - and

is to d ra m a tic a lly c h a n g e th e ir liv e s th ro u g h

clo se d -e n d e d g ro u p s o f p e o p le p re v io u sly

c o n n e c tio n an d c o m m u n ity . F ro m th ese

u n k n o w n to e a ch o th er. T h e lesso n s le a rn e d in

p e rs p e c tiv e s , tim e -lim ite d g ro u p p sy ch o th e ra p y

th erap y are p ra ctice d in th e n o rm a l so cia l

o ffe rs p o te n t o p p o rtu n itie s to m a x im iz e the

n e tw o rk . A lth o u g h e ffic a c y re se a rc h on g ro u p

tre a tm e n t e n e r g ie s o f b o th th e ra p is t an d clien t.
R e se a rc h s u g g e s ts th a t m o st c lie n t

th erap y fo r s u b s ta n c e a b u se d is o rd e r clie n ts h a s
b een lim ite d , th e re is s u b s ta n tia l a n e c d o ta l an d

im p ro v e m e n t as a re s u lt o f g ro u p th e ra p y o ccu rs

clin ical e v id e n c e th a t it ca n h a v e a d ra m a tic

w ith in a b rie f s p a n o f tim e ty p ic a lly , 2 or 3

im p a ct on p a rticip a tin g clie n ts. In T IP 8,

m o n th s (G a rv in et al., 1 9 7 6 ). T h is re sea rch

In ten siv e O u tp a tien t T rea tm en t f o r A lco h o l an d

im p lie s th a t s h o rt-te rm th e ra p y ca n b e as

O th er D ru g A b u se (C S A T , 1 9 9 4 a ), g ro u p th e ra p y

s u c c e s s fu l as lo n g -te rm th e ra p y in p ro m o tin g

is cited as the tre a tm e n t m o d a lity o f c h o ic e fo r a

c h a n g e . S h o r t-te rm g ro u p th e ra p y sh o u ld be

v arie ty o f reaso n s. In clin ica l p ra c tic e , g ro u p

m o re g o a l-o rie n te d , m o re s tru c tu re d , an d m o re

p sy ch o th e ra p y o ffe rs in d iv id u a ls su ffe rin g fro m

d ire c tiv e th a n lo n g -te rm g ro u p th e ra p y . S o m e

su b sta n ce ab u se d iso rd e rs th e o p p o rtu n ity to see

th e ra p is ts a lso b e lie v e th e e x p e rie n c e sh o u ld be

the p ro g re ss io n o f a b u se an d d e p e n d e n c y in

in te n sifie d th r o u g h th e u se o f h ig h -im p a c t

th e m se lv es and in o th e rs; it a lso g iv e s th e m an

te c h n iq u e s s u c h as p s y c h o d ra m a (see d iscu ssio n

o p p o rtu n ity to e x p e rie n c e th e ir s u cc e s s an d the

la te r in th is ch a p te r).

su cce ss o f o th er g ro u p m e m b e rs in an
a tm o sp h e re o f s u p p o rt and h o p e fu ln e s s . T h e
cu rativ e fa cto rs a sso c ia te d w ith g ro u p
p sy ch o th e ra p y , d efin e d b y Y a lo m , s p e c ifica lly

Appropriateness of
Group Therapy

a d d ress su ch issu es as the in s tilla tio n o f h op e,

G ro u p s ca n b e e x tre m e ly b e n e fic ia l to

the u n iv ersa lity e x p e rie n c e d b y g ro u p m e m b e rs

in d iv id u a ls w ith s u b s ta n c e a b u s e p ro b lem s.

as they see th e m s e lv e s in o th e rs, th e o p p o rtu n ity

L e v in e an d G a llo g ly h a v e n o te d th a t g ro u p s for

to d ev elo p in s ig h t th ro u g h re la tio n sh ip s , an d a

a lc o h o l-d e p e n d e n t c lie n ts

v ariety o f o th er c o n c e rn s sp e c ific to the s u p p o rt

o f s u b sta n ce -a b u sin g clie n ts an d th e ir re co v e ry

H e lp re d u c e d e n ia l, p ro c e s s a m b iv a le n ce ,
an d fa c ilita te a c c e p ta n c e o f a lc o h o l a b u se
157

C h ap ter 9

G ro u p E ffects
O n e C o n se n su s P a n e list re c a lls a th e ra p y se ssio n in w h ic h a m e m b e r a rriv e d , fu rio u s an d h o stile ,
sh o u tin g , "H o w m u c h lo n g e r d o I h a v e to d o th is stu p id p ro g ra m ? N o n e o f it w o rk s a n y w a y !"
A n o th e r g ro u p m e m b e r im m e d ia te ly a sk ed , " S o , h o w d o e s th e a n g e r k e e p th in g s g o in g fo r y o u ? " In
the e n su in g co n v e rs a tio n , th e g ro u p le a rn e d th a t th e a n g ry m e m b e r 's e x -w ife h a d ju s t se n t h im a b ottle
o f e x p e n siv e w h isk e y w ith th e fo llo w in g n o te: "D y in g to g e t to g e th e r a g a in ." T h is re v e la tio n , and the
su p p o rtiv e g ro u p liste n in g th a t fo llo w e d , o c cu rre d la rg e ly w ith o u t v e rb a l in v o lv e m e n t fro m th e
th erap ist.

In cre a se m o tiv a tio n fo r s o b rie ty an d o th er

se n sitiv e a p p r o a c h an d th e d ire c tiv e a p p ro a ch .

ch an g e s

T h e p ro c e ss-sen sitiv e g ro u p a p p r o a c h fin d s its

T re a t the e m o tio n a l c o n d itio n s th a t o ften

d ire c tio n in th e tra d itio n s o f a n a ly tic a l th e o ry

a cco m p a n y d rin k in g (e.g ., a n x ie ty ,

an d h a s a s ig n ific a n t ra n g e o f e x p re s s io n .

d ep ressio n , h o stility )

D e p e n d in g o n th e th e o re tic a l b a se an d

In cre a se the c a p a city to re co g n iz e , a n ticip a te,

le a d e rs h ip sty le o f th e fa c ilita to r, a p ro ce ss-

an d co p e w ith s itu a tio n s th a t m a y p re cip ita te

s e n sitiv e g ro u p c a n e x a m in e th e u n c o n scio u s

d rin k in g b e h a v io r

p ro c e s s e s o f th e g ro u p a s a w h o le , u tiliz in g

M e e t the in te n se n e ed s o f a lc o h o l-d e p e n d e n t

th e se e n e rg ie s to h e lp in d iv id u a ls see

clie n ts fo r so cia l a c c e p ta n c e an d s u p p o rt

th e m s e lv e s m o re c le a rly an d th e re fo re o p en up

(L ev in e an d G a llo g ly , 1985)

th e o p p o rtu n ity fo r c h a n g e . T h is "g r o u p -a s -a -

M a n y b e n e fic ia l e ffe c ts h a p p e n m o re e a sily

in g ro u p s th an in o n e -o n -o n e th e ra p y . G ro u p
m e m b ers co n fro n t e a ch o th er, d o "r e a lity
c h e c k s ," p ra ctice re fle c tiv e liste n in g , m irro r e a ch
oth er, and h elp e a ch o th er re fra m e k ey issu es.
In d iv id u als in e a rlie r sta g e s o f d e p e n d e n ce ca n
w itn e ss w h at la te r sta g e e x p e rie n c e s are like
(and by in fe ren ce w h ere th e y co u ld p ro g re ss if
they d o n o t re d u ce th e ir u se). O fte n , g ro u p
m e m b ers can b e m o re e ffe c tiv e th a n the
th e ra p ist in co n fro n tin g a p a rtic ip a n t w h o is n o t
facin g an im p o rta n t issu e (e.g ., th e clie n t w h o
b elie v e s she can q u it d rin k in g an d still sm o k e
m a riju a n a ).

w h o le " a p p r o a c h is b e s t e x e m p lifie d b y the

w o rk o f B io n , w h o see s h e a lin g as an e x te n sio n
o f th e in d iv id u a ls w ith in th e g ro u p a s th e g ro u p
c o m e s to te rm s w ith a c o m m o n ly sh a re d a n x iety
(B io n , 19 6 1 ).
Y a lo m o ffe rs a s ig n ific a n t c o n tra s t to th ese
g ro u p -a s -a -w h o le in te rv e n tio n s th ro u g h h is
in te ra c tio n a l g ro u p p ro c e s s m o d e l (Y a lo m ,
19 9 5 ). B y a tte n d in g to th e re la tio n sh ip s w ith in
th e g ro u p a n d h e lp in g in d iv id u a ls u n d e rsta n d
th e m s e lv e s w ith in th e re la tio n a l fra m e w o rk , an
in te ra c tio n a l g ro u p p ro c e s s p ro v id e s in d iv id u a ls
w ith s ig n ific a n t in fo r m a tio n a b o u t h o w th eir
b e h a v io r a ffe c ts o th e rs an d h o w th e y a re in tu rn
a ffe cte d b y o th e r m e m b e rs. In a d d itio n ,

Group Therapy
Approaches
S e v e ra l k in d s o f g ro u p s fa ll u n d e r th e sp e ctru m
of tim e -lim ite d g ro u p th e ra p y . In th e b ro a d e s t
sen se, tw o fu n d a m e n ta l m o d e ls h e lp d efin e
ca te g o rie s o f g ro u p in te rv e n tio n s: th e p ro ce ss-

fo cu s in g e n e rg y o n th e re la tio n sh ip s w ith in the

c o n te x t o f g ro u p , th e le a d e r is c a re fu l n o t to
a ssu m e a c e n tra l ro le b u t, ra th e r, re co g n iz e s th at
th e g ro u p its e lf b e c o m e s th e a g e n t o f ch a n g e ,
w ith th e le a d e r s u p p o rtin g th e p ro c e s s b u t n o t
in itia tin g it. A tte n tio n is fo c u s e d o n th e n a tu re
and g ro w th o f th e re la tio n s h ip s m a n ife s te d in
the "h e r e an d n o w " as th e g ro u p ta k e s p la ce.

158

T im e-L im ited G rou p T herapy

T h e seco n d a p p ro a c h , an d o n e b e tte r k n o w n

It is im p o r ta n t to n o te th a t in a n y k in d o f

to a lco h o l and d ru g c o u n s e lo rs, is a d ra m a tic a lly

g ro u p th e ra p y , re la tio n s h ip s a re fo rm e d and

d iffe ren t fo rm o f g ro u p th e ra p y , o fte n re fe rre d

p ro c e s s issu e s e x p e rie n c e d . E v e n w ith in the

to as a d irectiv e ap p roach . It o ffe rs stru ctu re d

c o n te x t o f a c o g n itiv e -b e h a v io r a l a p p ro a c h su ch

g o als and th e ra p is t-d ire c te d in te rv e n tio n s to

as R B T , w h ic h is m o re e d u c a tio n a l th an

e n a b le in d iv id u a ls to c h a n g e in d esire d w a y s. A

th e ra p e u tic , issu e s o f p ro c e s s in v a ria b ly arise.

s h o rt-te rm d irecte d g ro u p m a y b e u sed to

T h e e x p e rie n c e d th e ra p is t c a n u se the

ad d ress m a jo r issu e s o f c o n c e rn fo r c lie n ts w ith

re la tio n sh ip s w ith in th e g ro u p e v e n in a

su b sta n ce a b u se d is o rd e rs an d to fa c ilita te self-

p s y c h o e d u c a tio n a l fra m e w o rk to su p p o rt and

d isco v e ry an d g ro w th th ro u g h a p p ro p ria te ly

e n h a n c e th e tre a tm e n t e x p e rie n c e . W h e n e v e r

seq u en tia l a ctiv itie s. B e c a u se th e th e ra p is t is

th e o p p o rtu n ity a rise s, th e g ro u p fa c ilita to r

" c e n tr a l" an d in ch a rg e , th is ty p e o f g ro u p

sh o u ld h e lp c o n n e c t m e m b e r s to m e m b ers.

d ep en d s less fo r su c c e ss on g ro u p m e m b e rs and

W h e n sh a re d h is to rie s a re a c k n o w le d g e d , the

th eir ab ility to cre a te a c o h e s iv e se n se of

se n se o f b e lo n g in g is in c re a se d , a n d g re a te r

b elo n g in g .

c o h e s io n ta k e s p la ce. C o h e s io n m a y se e m less

C o m p a re d w ith th e p ro c e s s -s e n s itiv e g ro u p ,

im p o rta n t in a d ire c tiv e p s y c h o e d u c a tio n a l

w h ich sees th e co h e siv e p o w e r o f th e g ro u p as a

g ro u p . H o w e v e r, b e c a u s e o f th e v e ry n a tu re of

p rim a ry cu ra tiv e fa c to r, th e d ire c tiv e a p p ro a c h

su b s ta n ce a b u s e d is o rd e rs , a fe e lin g o f

a d d resse s sp e cific a g e n d a ite m s in a lo g ica l

b e lo n g in g to a g ro u p c o m m itte d to its ow n

o rd e r w ith g re a te r e m p h a sis on c o n te n t as the

h e a lth ra th e r th a n its o w n d e s tru c tio n is an

p rim a ry so u rce o f e ffe c tiv e ch a n g e . T h e

im p o rta n t m o tiv a to r fo r m a n y clie n ts.

d irectiv e a p p ro a c h , th e re fo re , is p e rh a p s m o re

T h e re h a s b e e n s ig n ific a n t d e b a te w ith in the

lik ely to b e e ffe c tiv e w ith th o se in e a rly

field re g a rd in g th e p ro s an d c o n s o f

re co v ery . A p o te n t e x a m p le o f d ire c tiv e , tim e-

h e te ro g e n e o u s an d h o m o g e n e o u s g ro u p s. T h e

lim ited g ro u p e x p e rie n c e , d e v e lo p e d by

h e te ro g e n e o u s g ro u p , in w h ic h m e m b e rs h a v e a

M a u ltsb y an d E llis, is k n o w n as R a tio n a l

v a rie ty o f d ia g n o s e s , o ffe rs g re a te r co m p le x ity

B e h a v io ra l T ra in in g (R B T ) (M a u ltsb y , 1976).

a n d m o re o p p o rtu n itie s fo r a w id e ra n g e of

T h is c o g n itiv e -b e h a v io ra l th e ra p y ta k e s p la ce

re la tio n sh ip s , w h ic h ca n b e e x tre m e ly h e lp fu l to

o v er 13 w e e k s, o n e se s s io n p er w e e k . It u ses

m a n y c lie n ts. H o w e v e r, th e h o m o g e n e o u s

fu n d a m e n ta l c o g n itiv e -b e h a v io r a l in te rv e n tio n s

g ro u p , p a rtic u la rly w h e n c o m p o s e d o f clie n ts

an d the c lie n ts ' g ro w in g a w a re n e s s o f th eir

w ith s u b s ta n c e a b u s e d is o rd e rs , te n d s to lend

ab ility to co n tro l th e ir o w n b e lie f sy ste m s and

its e lf m o re q u ic k ly to iss u e s o f c o h e s io n and

s elf-ta lk an d th u s c o n tro l th e ir a ffe c tiv e sta tes.

sa fe ty . F o r th is re a s o n , h o m o g e n e ity has

C lien ts are ask ed to sh a re h o m e w o rk

p a rtic u la r u tility in th e tim e -lim ite d g ro u p

a ssig n m en ts an d b rin g re a l-life situ a tio n s in to

in te rv e n tio n .

the g ro u p fo r e x p lo ra tio n an d e x a m in a tio n .

A n im p o rta n t issu e w ith in th e c o n te x t o f the

T h e re is little e ffo rt in th is g ro u p m o d a lity to

h o m o g e n e o u s s u b s ta n c e a b u se d is o rd e r g ro u p ,

a n a ly z e or d ire c t e n e rg y to th e re la tio n sh ip s

w h e th e r tim e lim ite d or n o t, is th e g ro u p 's

w ith in the ro o m . R B T a ffo rd s a sh o rt-te rm

te n d e n c y to b o n d a ro u n d its h is to ry o f su b sta n ce

in te rv e n tio n to d e v e lo p th e c lie n t's sk ill in

a b u s e ra th e r th a n its c o m m itm e n t to re co v ery .

co n tro llin g e m o tio n s. T h e in fe re n c e is th a t

A lth o u g h th e g e n e ra l fo c u s o f s u b s ta n c e a b u se

in d iv id u a ls w h o e x p e rie n c e th e ir e m o tio n a l

tre a tm e n t is o n th e a b u s e itself, th e fo cu s also

w o rld as c o n tro lla b le w ill no lo n g e r n eed to use

m u st in c lu d e issu e s o f liv in g w ith in th e co n tex t

su b sta n ce s to e x e rt " e x te r n a l" co n tro l.

o f the g ro u p . T h ro u g h m o d e lin g an d g en tle

159

C h ap ter 9

p e rsu a sio n , the g ro u p fa c ilita to r ca n b ro a d e n the

Brief Cognitive Group Therapy

sco p e o f a su b sta n c e a b u se tre a tm e n t g ro u p to

C o g n itiv e te c h n iq u e s w o rk w e ll in g ro u p

in clu d e re la tio n sh ip s , c o n c e rn s a b o u t d a ily

th e ra p y . T h e g ro u p is ta u g h t th e b a sic s o f the

liv in g , and n e w ly d isc o v e re d p e rso n a l in te g rity .

c o g n itiv e a p p ro a c h , th e n in d iv id u a l m e m b ers

S u ch are the s tru g g le s o f all p e o p le in all

ta k e tu rn s p re s e n tin g an e v e n t o r situ a tio n that

circu m sta n ce s. T h e m o v e m e n t fro m "w h a t is

te m p te d th e m to a b u s e s u b s ta n c e s. O th e r

w ro n g w ith u s " to "h o w d o w e b u ild b e tte r

m e m b e rs a s s is t th e th e ra p is t in a s k in g fo r m o re

liv e s ? " is an im p o rta n t tra n sitio n in th e tim e-

in fo rm a tio n a b o u t th e c lie n t's th o u g h ts o n the

lim ited g ro u p , w h e th e r p s y c h o e d u c a tio n a l or

e v e n t a n d h o w it d id or d id n o t le a d to

p ro cess sen sitiv e .

s u b s ta n c e a b u se (o r to n e g a tiv e fe e lin g s th at

G ro u p th e ra p y c a n b e co n d u c te d w ith in the

m ig h t h a v e led to u se ). F in a lly , th e g ro u p

co n tex t o f a lm o s t an y th e o re tic a l fra m e w o rk

m e m b e rs p ro v id e th e c lie n t w ith a lte rn a tiv e

fa m ilia r to the th e ra p is t an d a p p ro p ria te to

w a y s o f v ie w in g th e s itu a tio n . C h a p te r 4

g ro u p g o als. O fte n the th e ra p is t w ill w o rk w ith

d is c u ss e s b rie f c o g n itiv e th e ra p y in m o re d ep th .

tw o or m o re m o d e ls a t th e sa m e tim e. T h e

sen sitiv e g ro u p s an d a m o re d ire c tiv e sty le can

C ognitive-Behavioral
Group Therapy

be co m b in ed e ffe ctiv e ly to a d d re s s su b sta n c e -

T h e c o g n itiv e -b e h a v io r a l a p p r o a c h fo cu se s the

a b u sin g clie n ts.

g ro u p 's a tte n tio n o n s e lf-d e fe a tin g b e lie fs,

th e o retica l b a se s su p p o rtin g b o th p ro ce ss-

re ly in g on g ro u p m e m b e rs to id e n tify su ch

Theories of Group
Therapy

g ro u p m e m b e rs to a p p ly b e h a v io ra l te ch n iq u es
su ch as h o m e w o rk a n d v is u a liz a tio n to h elp

T h e fo llo w in g g ro u p th e ra p y m o d e ls are

p a rtic ip a n ts th in k , fe e l, a n d b e h a v e d iffe ren tly .

d iscu sse d in th is sectio n :

C h a p te r 4 d is c u ss e s b rie f c o g n itiv e -b e h a v io r a l

B rief co g n itiv e g ro u p th e ra p y

C o g n itiv e -b e h a v io ra l g ro u p th e ra p y

S tra te g ic/ in te ra c tio n a l th e ra p y

B rief g ro u p h u m a n istic an d e x iste n tia l

th e ra p ie s

G ro u p p s y c h o d y n a m ic th e ra p y

M o d ified d y n a m ic g ro u p th e ra p y (M D G T )

M o d ified in te ra c tio n a l g ro u p p ro ce s s (M IG P )
T h e first fiv e a re s u m m a riz e d b elo w and

th e ra p y in m o re d ep th .

Strategic/Interactional Therapies
T h e stra te g ic th e ra p is t u se s te c h n iq u e s sim ila r to
th o se u sed in fa m ily th e ra p y to c h a lle n g e each
g ro u p m e m b e r to e x a m in e in e ffe c tiv e a tte m p ted
so lu tio n s. T h e th e ra p is t e n c o u ra g e s g ro u p
m e m b e rs to e v a lu a te a n d p ro c e s s th e se
a tte m p te d s o lu tio n s a n d re c o g n iz e w h e n they
a re n o t w o rk in g , th e n e n g a g e s th e g ro u p in

d iscu sse d at g re a te r len g th in C h a p te rs 4 th o u g h

g e n e ra tin g a lte rn a tiv e s o lu tio n s . T h e th e ra p ist

7 o f this T IP . M IG P , c o n sid e re d a h ig h ly

a lso w o rk s, w h e re a p p r o p ria te , to ch a n g e g ro u p

e ffe ctiv e ty p e o f b rie f g ro u p tre a tm e n t fo r

m e m b e r s ' p e rc e p tio n s o f p ro b le m s an d h elp

su b sta n ce a b u sers, is d iscu sse d in d eta il in this

th e m u n d e rs ta n d w h a t is h a p p e n in g to th em .

sectio n . T h e 11 th e ra p e u tic fa cto rs id e n tifie d by

T y p ic a lly , th e th e ra p is t g u id e s th e p ro c e s s , w h ile

Y a lo m as the b a sis o f su c c e s s fu l g ro u p th e ra p y

m e m b e rs o ffe r s u g g e s tio n s an d e n c o u ra g e m e n t

are p re sen ted at th e en d o f th is s e c tio n (Y a lo m ,

to e a c h o th e r as th e y id e n tify a n d im p le m e n t

1995).

160

b e lie fs in e a c h o th e r. T h e th e ra p is t e n c o u ra g e s

T im e-L im ited G rou p T herapy

effe ctiv e s o lu tio n s. T o a d d re ss the p ro b le m of

R o le -p la y in g an d d re a m a n a ly sis in g ro u p s are

su b sta n ce ab u se, th e g ro u p w ill o ften be

p ra c tic a l an d re le v a n t e x e rc ise s th a t ca n help

d irecte d to e x a m in e p ro b le m s th a t m ig h t re su lt

clie n ts c o m e to te rm s w ith th e m se lv e s.

in s u b sta n ce ab u se and re fra m e th eir

p e rce p tio n s of th e se p ro b lem s.
T h e p rin cip le s o f s o lu tio n -fo c u s e d th e ra p y

O n e o f th e m o st in flu e n tia l c o n te m p o ra ry
e x p e rts on g ro u p th e ra p y , Irv in D. Y a lo m ,
co n s id e rs h im s e lf a n e x is te n tia lis t b e c a u se he is

are the sam e fo r g ro u p tre a tm e n t as fo r

n o t c o n c e rn e d w ith p a s t b e h a v io r e x c e p t as it

in d iv id u al th e ra p y . T h e se in c lu d e clie n t g o a l-

in flu e n ce s th e " h e r e a n d n o w ." A su m m a ry of

settin g th ro u g h th e u se o f the "m ir a c le "

h is e x is te n tia l a p p ro a c h is p re s e n te d in T he

q u estio n , use o f sca lin g q u e stio n s to m o n ito r

Y alom R ea d er (Y a lo m , 1 9 9 7 ) an d c o n sists o f th ree

p ro g ress, and id e n tifica tio n o f s u c ce ssfu l

sectio n s: (1) th e ra p e u tic fa c to rs in g ro u p

stra te g ies th a t w o rk fo r ea ch clie n t. (T h ese

th e ra p y , (2) a d e s c rip tio n o f th e "h e r e and n o w "

te ch n iq u es are d efin e d in C h a p te r 5 o f this T IP .)

co re co n c e p t, an d (3) th e ra p y w ith sp e cia liz e d

T h e th e ra p ist w o rk s to cre a te a g ro u p cu ltu re

g ro u p s, in c lu d in g a c h a p te r o n g ro u p th erap y

and d y n am ic th a t e n co u ra g e s and su p p o rts

an d a lc o h o lism . T h is la st c h a p te r d eta ils sp ecific

g ro u p m e m b ers by a ffirm in g th e ir su cce sses. A t

te ch n iq u e s to d im in is h a n x ie ty b u t still p e rm it

the sam e tim e, th e th e ra p ist w o rk s to re stra in

the g ro u p to m a in ta in an in te ra c tio n a l fo cu s

clien t d ig re ssio n s (" w a r s to r ie s ") an d p e rso n a l

fo r e x a m p le , w ritin g a ca n d id su m m a ry o f the

attack s. T h e th e ra p ist tries to c h a lle n g e g ro u p

se ssio n and m a ilin g it to m e m b e rs b efo re the

m e m b e rs all o f w h o m , u n lik e in fa m ily

n e x t m e e tin g . Y a lo m h a s w o rk e d clo sely w ith

th erap y , are seen as "c u s to m e r s " to tak e a ctio n

the N a tio n a l In s titu te on A lc o h o l A b u se and

to create p o sitiv e ch a n g e . C h a p te r 5 d iscu sse s

A lc o h o lis m to a p p ly b a sic p rin c ip le s of g ro u p

b rie f stra te g ic / in te ra c tio n a l th e ra p ie s in m o re

th e ra p y to a lc o h o l a b u se rs, an d h is id ea s are

d ep th.

a p p lica b le to th o se w ith o th e r su b s ta n c e ab u se

Brief Group Humanistic and

Existential Therapies

d iso rd e rs as w e ll. S e e C h a p te r 6 fo r m o re
d is c u ss io n o f h u m a n istic an d e x iste n tia l
th e ra p ie s.

S e v e ral a p p ro a ch e s fa ll w ith in th is ca te g o ry .
T h e tra n sp e rso n a l a p p ro a c h is u sefu l in

Group Psychodynam ic Therapy

m e d ita tio n , stre ss re d u c tio n , and re la x a tio n

G ro u p p s y c h o d y n a m ic th e ra p y e n a b le s the

th erap y g ro u p s and can be a d a p te d fo r clie n ts

g ro u p its e lf to b e c o m e b o th th e c o n te x t and

w h o h av e su b sta n c e a b u se d iso rd e rs. In d ea lin g

m e a n s o f c h a n g e th ro u g h w h ic h its m em b ers

w ith issu es of re lig io n or sp iritu a lity , it is h e lp fu l

s tim u la te e a ch o th e r to s u p p o rt, stre n g th e n , or

to h av e o th er p e o p le talk a b o u t th eir

c h a n g e a ttitu d e s , fe e lin g s , re la tio n sh ip s ,

p e rsp e ctiv es. In th is w a y , p a st d e g ra d in g or

th in k in g , and b e h a v io r w ith th e a ssista n ce of

p u n itiv e e x p e rie n c e s re la ted to o rg a n iz e d

the th e ra p ist.

relig ion can be re d efin e d in a m o re m e a n in g fu l

T he c o n te x t so u g h t is o n e in w h ich the g ro u p

and u sefu l co n tex t.

b e co m e s an in flu en tial re fe re n ce g ro u p for the

G e sta lt th e ra p y in g ro u p s a llo w s fo r m o re
c o m p re h e n siv e in te g ra tio n in th a t ea ch g ro u p

in d iv id u a l. P a rticip a tio n of m e m b e rs
a c c o r d in g to th eir ab ilities lead s to so m e
d e g re e o f in v o lv e m e n t of each in p u rsu in g

m e m b er can p ro v id e a p ie ce o f sh a re d p e rso n a l

in d iv id u a l an d g ro u p g o a ls. T he p ro ce ss of

e x p e rien ce. E a ch g ro u p m e m b e r p la y s a ro le in

g o a l-s e ttin g a n d cla rifica tio n for e x p e cta tio n

creatin g the g ro u p , an d all o f th e ir p e rc e p tio n s

m u st be tak e n in to a c c o u n t in m a k in g a ch a n g e .

p ro v id e s an a g re e d u p o n fra m e w o rk for
m e e tin g o f m u tu a l n e e d s. T h is, in tu rn ,

161

C h ap ter 9

co n trib u te s to the b u ild in g o f co h e siv e fo rces

(R o b erts a n d N o rth e n , 1 9 7 6 , p. 141).

e n c o u ra g e s iss u e s o f u n iv e rs a lity as a m e a n s o f
o v e rc o m in g iso la tio n , w h ile a t th e sa m e tim e

C h a p te r 7 d iscu sse s p s y c h o d y n a m ic th e ra p y in

d e a lin g w ith a c o m m o n s h a m e so o ften

m o re d ep th .

e n c o u n te re d in th e s u b s ta n c e -a b u s in g clien t.

Modified Dynamic Group Therapy

U n lik e in te rp e rs o n a lly fo c u se d p ro c e s s g ro u p s,
w h ic h lo o k m o re a t re la tio n a l co n c e rn s , M D G T

O n th e b asis o f p sy ch o d y n a m ic th e o ry , a

p la ce s g re a te r e m p h a s is o n th e c lie n ts ' g ro w in g

m o d ified d y n a m ic g ro u p th e ra p y a p p ro a c h w as

u n d e rs ta n d in g o f th e ir c h a ra c te ro lo g ic a l

d efin e d fo r su b s ta n c e -a b u s in g c lie n ts (K h a n tz ia n

d iffic u ltie s a n d / o r d e fic its, n o t e n tire ly

et al., 1990). V ie w in g s u b s ta n c e a b u se d iso rd e rs

d is sim ila r to iss u e s id e n tifie d in s e lf-h e lp g ro u p s

as an e x p re s s io n o f e g o d y sfu n ctio n , a ffe c t

s u ch as A A a n d N A .

d y sreg u la tio n , fa ilu re o f s e lf-c a re , and

M D G T falls in the in te rm e d ia te len g th o f tim e-

M odified Interactional
Group Process

lim ited g ro u p p s y ch o th e ra p y , w ith its b asic

T im e -lim ite d M IG P is a sy n th e s is o f th e w o rk of

stru ctu re d efin e d b y tw o m e e tin g s p er w eek

se v e ra l th e o ris ts (F lo re s, 1 9 8 8 ; K h a n tz ia n et al.,

d y sfu n ctio n a l in te rp e rs o n a l re la tio n sh ip s ,

o v er a 2 6 -w e e k fo rm a t. B a sed p rim a rily on

1 9 9 0 ; M a c K e n z ie , 1 9 9 0 ; Y a lo m , 19 9 5 ). M IG P is

in te rv e n tio n s to a d d re ss c o c a in e a d d icts, M D G T

d is tin g u is h e d in a v a r ie ty o f w a y s fro m the

fo cu se s e n e rg y o n th e in d iv id u a ls w ith in the

p s y c h o e d u c a tio n a l g ro u p s so im p o rta n t in

g ro u p and co n c e p tu a liz e s th e b a sic o rig in s of

su b s ta n c e a b u s e tre a tm e n t. A s re fe re n c e d in T IP

su b sta n ce a b u se d iso rd e rs as e x p re s s io n s o f

8, In ten siv e O u tp a tien t T rea tm en t f o r A lc o h o l an d

v u ln era b ilitie s w ith in th e c h a ra cte ro lo g ica l

O th er D ru g A b u se (C S A T , 1 9 9 4 a ), b o th p ro cess-

m ak e u p o f the clie n t (K h a n tz ia n et al., 1990). A s

se n sitiv e a n d p s y c h o e d u c a tio n a l g ro u p lea rn in g

a su p p o rtiv e , e x p re s s iv e g ro u p e x p e rie n c e ,

e x p e rie n c e s a re o fte n n e c e s s a ry fo r the

M D G T p ro v id e s s u b s ta n c e -a b u s in g clie n ts th e

s u b s ta n c e -a b u s in g c lie n t. E v e n in a sh o rt-te rm ,

o p p o rtu n ity to e v a lu a te an d ch a n g e th eir

in te n siv e tre a tm e n t e x p e rie n c e , c o m b in in g a

v u ln era b ilitie s in fo u r p rim a ry areas:

p s y c h o e d u c a tio n a l g ro u p a n d a p ro c e s s g ro u p

(1) acce ssin g , to le ra tin g , an d re g u la tin g fe e lin g s;

h a s s ig n ific a n t c lin ic a l im p a c t. T h e

(2) p ro b lem s w ith re la tio n sh ip s ; (3) s elf-ca re

p s y c h o e d u c a tio n a l g ro u p is m o re d ire c tiv e , w ith

failu re s; an d (4) se lf-e s te e m d eficits. C o n g ru e n t

th e th e ra p is t as th e c e n tra l fig u re. H o w e v e r, as

w ith th is u n d e rsta n d in g o f the o rig in s of

w ill b e e x p la in e d , it is im p o r ta n t to u tiliz e the

su b stan ce a b u se, M D G P e m p h a s iz e s sa fe ty ,

e n e rg y o f g ro u p p ro c e s s its e lf, e v e n in a

co m fo rt, an d co n tro l w ith in th e g ro u p co n tex t.

p s y c h o e d u c a tio n a l fo rm a t, to e n a b le clie n ts to

G ro u p fa cilita tio n is d efin e d p rim a rily b y the

m a k e c o n n e c tio n s an d b u ild re la tio n sh ip s th at

th e ra p is t's ab ility to e n g a g e an d re ta in su b sta n ce

w ill s u p p o rt th e ir re c o v e ry .

a b u sers in tre a tm e n t b y p ro v id in g stru ctu re,

co n tin u ity , and a c tiv ity in an e m p a th ic

m o re tra d itio n a l in te ra c tiv e p ro c e s s are the

atm o sp h e re.

g re a te r a ctiv ity o f th e le a d e r an d th e sen sitiv ity

T h is s u p p o rtiv e a p p ro a c h cre a te s an

262

T h e fe a tu re s th a t d is tin g u is h M IG P fro m a

to th e d e v e lo p m e n t o f a sa fe a tm o s p h e re th a t

a tm o sp h e re o f sa fe ty , a llo w in g the c lie n t to

a llo w s g ro u p m e m b e r s to e x a m in e re la tio n a l

m o v e a w ay fro m the sa fe ty o f th e k n o w n

issu es w ith o u t e x c e s s iv e e m o tio n a l c o n ta g io n .

b e h a v io r a sso cia te d w ith su b sta n c e a b u se and

T h e a tm o s p h e re o f s a fe ty is g re a tly e n h a n c e d by

in to the less k n o w n w o rld o f re c o v e ry . A s in

th e th e ra p is t's a d h e re n c e to g ro u p a g re e m e n ts

o th er g ro u p e x p e rie n c e s , th is g ro u p th e o ry

or g ro u p n o rm s a n d b y th e c o n tin u e d

T im e-L im ited G rou p T herapy

re in fo rce m e n t o f th e se a g re e m e n ts th ro u g h o u t

th e m fro m d o m in a tin g th e g ro u p is a n o th er

the g ro u p p ro cess. T h e im p o rta n c e o f

h a llm a rk o f M IG P .

co n fid e n tia lity , the g ro u p 's a c c e p tin g

re sp o n sib ility fo r itself, an d se lf-d is c lo su re are
all su p p o rte d b y th e fa c ilita to r. P ro ce d u ra l
a g re em en ts, in c lu d in g b e g in n in g an d e n d in g the
g ro u p se ssio n on tim e an d e n su rin g th a t e a ch
m e m b er has a p la ce w ith in th e circle , w ith an y
ab sen ces a d d re s s e d , a re p a rt o f the d e v e lo p m e n t
of the safe e n v iro n m e n t.
In this p ro ce ss, th e th e ra p is t h e lp s th e clie n ts
re co g n iz e th a t th ey a re th e p rim a ry ch a n g e
agen ts. T h e g ro u p b e c o m e s a s a fe p la ce b o th to

General issues in MIGP

F o llo w in g th e in s ig h ts o f F lo re s a n d M a h o n ,
M IG P fo c u s e s s p e c ia l a tte n tio n in fo u r a rea s of
th e c lie n t's life: g ra tific a tio n a n d su p p o rt,
v u ln e ra b ility o f se lf, re g u la tio n o f a ffect, and
s e lf-c a re (F lo re s an d M a h o n , 19 9 3 ). T h e se four
a re a s re c e iv e p a rtic u la r a tte n tio n b e c a u se th ey
re p re s e n t a re a s o f v u ln e ra b ility w ith in the
s u b s ta n c e -a b u s in g clie n t th a t ca n e a sily lead to
re la p se a n d u n d e rm in e re c o v e ry .

giv e and to re ce iv e su p p o rt. A lth o u g h

Gratification and support

tra d itio n a lly s u b s ta n c e a b u se g ro u p s ten d to be

M a n y clie n ts c o m e to tre a tm e n t w ith p ro fo u n d

co n fro n ta tiv e , M IG P is fa r m o re s u p p o rtiv e .

issu es o f g u ilt an d sh a m e . T h e re fo re , th ey lack

T h is ste m s fro m the b e lie f th a t d e n ia l an d oth er

th e ab ility to g iv e th e m s e lv e s g ra tific a tio n and

d efen se m e ch a n is m s b e c o m e m o re rig id w h en a

s u p p o rt in th e fa c e o f ch a n g e . T h e a ctiv e

p e rso n is a tta ck e d . C o n s e q u e n tly , g ro u p

le a d e rs h ip sty le o f M IG P a llo w s g ro u p m e m b ers

m e m b ers a re e n c o u ra g e d to su p p o rt o n e a n o th er

to o p en ly s u p p o rt o n e a n o th e r an d a t the sa m e

an d lo o k fo r a re a s o f co m m o n a lity ra th e r th an

tim e p ro v id e s e a c h g ro u p m e m b e r w ith

use m o re sh a m e -b a se d in te ra ctiv e sty les that

a tte n tio n fro m th e le a d e r th a t le a d s to h ig h er

a tte m p t to "b re a k th ro u g h d e n ia l."

le v e ls o f g ra tific a tio n . A ffirm in g g ro u p

Intellectualization and MIGP

M an y th e ra p ists a re told th a t clie n ts sh o u ld g et
in to u ch w ith th e ir fe e lin g s an d e x p e rie n c e
"w h a t is in th e ir g u t." A lth o u g h a w a re n e ss o f
the a ffe ctiv e life is im p o rta n t to e v e ry o n e , it is
p re cise ly th e re g u la tio n o f e m o tio n s th a t m an y

m e m b e r s ' w illin g n e ss to s h a re an d su p p o rt one

a n o th e r is an e s s e n tia l in g re d ie n t in tim e-lim ite d
g ro u p w o rk . It c re a te s a p o sitiv e a tm o sp h e re
a n d in c re a se s le v e ls o f sa fe ty an d co h e siv e n ess,
w h ic h fu rth e r s u p p o rts th e c h a n g e p ro cess.

Vulnerability o f self

s u b sta n ce -a b u sin g c lie n ts h a v e d ifficu lty

S u b s ta n c e -a b u s in g c lie n ts o fte n e n te r tre a tm e n t

a d d ressin g . C o n s e q u e n tly , a lth o u g h e m o tio n a l

w ith s h a tte re d s e lf-e s te e m . D e fe n d in g a g a in st

e x p lo ra tio n is e n co u ra g e d w ith in th e c o n te x t of

th is in te rn a l v u ln e ra b ility c a n b e c o m e

M IG P , the fa cilita to r is co n s ta n tly m o n ito rin g

d a m a g in g , b e c a u se clie n ts p ro je c t th e ir fea rs

the a ffectiv e e n erg y w ith in the g ro u p , ta k in g

on to o th e rs. T h e y m a y try to h id e in te rn a l

step s to b re a k e m o tio n a l c o n ta g io n sh o u ld it

v u ln e ra b ility b y a p p e a rin g h o s tile and o v erly

b eg in . In a p a rtic u la rly in te n se g ro u p

se lf-c o n fid e n t. A n a tm o s p h e re o f sa fe ty and

e x p e rien ce, th e th e ra p is t m a y a sk th e g ro u p as a

e m p a th y e n a b le s c lie n ts w ith p ro fo u n d

w h ole to tak e a step b a ck an d lo o k at w h a t ju s t

v u ln e ra b ilitie s to e n te r th e p ro c e s s o f s e lf

to ok p lace. In this w ay , th e g ro u p n o t on ly

d is c lo s u re , th ro u g h w h ic h th e y b eco m e

learn s fro m its sh a re d life b u t a lso e x p e rie n ce s

a cc e ssib le n o t o n ly to th e g ro u p b u t a lso to

its a b ility to c o n tro l in te n se e m o tio n a l re sp o n se s.

th e m s e lv e s . T h e g ro u p fa c ilita to r a ctiv e ly

T h is co n s is te n t e ffo rt to re d u ce h ig h le v e ls o f

e n c o u ra g e s su ch s e lf-d is c lo s u re b u t a t th e sam e

an x iety or e m o tio n a l c a th a rsis a n d to p re v e n t

tim e e m p h a s iz e s th a t in d iv id u a l m e m b e rs n eed

163

C hapter 9

s e lf-d isclo su re .

Use of Psychodrama
Techniques in a
Group Setting

Regulation o f affect

P sy ch o d ra m a h a s lo n g b e e n e ffe c tiv e ly used

S u b sta n ce a b u se d iso rd e rs ca n b e p e rc e iv e d as

w ith th e s u b s ta n c e -a b u s in g c lie n t p o p u la tio n in

the co n se q u e n ce s o f try in g to c o n tro l o n e 's

a g ro u p se ttin g . W e g sc h e id e r-C ru s e e ffe ctiv e ly

n o t d isclo se an y issu e th e y a re n o t y e t re a d y to
d iscu ss. C le a r b o u n d a rie s a n d c le a r g ro u p
a g re em en ts fu rth e r su p p o rt th e p o ssib ility fo r

e m o tio n a l life w ith e x te rn a l s u b s ta n c e s. T h is

in te g ra te d p s y c h o d ra m a a s a m e a n s to h ea l

p o in ts to a fa ilu re o f in te rn a l re g u la tio n th a t

fa m ily -o f-o rig in iss u e s w ith in th e c o n te x t of

m a k e s the clie n t u n co m fo rta b le w h e n fe e lin g

a d d ic tiv e b e h a v io rs (W e g s c h e id e r -C r u s e , 1989).

e m o tio n s th a t o th e rs m ig h t c o n sid e r

T h e u tility o f s u ch a n in te rv e n tio n s e e m s to be

co m m o n p la ce . Issu e s o f g rief, lo ss, sa d n e ss, and

c lin ic a lly w e ll e sta b lis h e d . T h e te c h n iq u e s can

jo y can b e so a ffe c tiv e ly c h a rg e d an d lin k e d to

h elp th e g ro u p m o v e m o re q u ic k ly in te rm s of

the clie n t's p a s t a lc o h o l an d d ru g u se th a t th ey

s e lf-u n d e rs ta n d in g an d re la tio n a l a w a ren e ss.

th rea te n the c lie n t's co n tin u e d re co v ery . A s

T h e in sig h ts g a in e d fro m th e e x p e rie n c e of

m e n tio n e d a b o v e , the le a d e r's se n sitiv ity to the

fa m ily s c u lp tin g (illu s tra te d b e lo w ) ca n be

lev els o f a ffe ctiv e e n e rg y in the g ro u p is

w o rth w h ile a n d p o te n t. H o w e v e r, it is

p a rticu la rly im p o rta n t. S u p p o rtin g g ro u p

im p o rta n t to s tre s s th a t p s y c h o d ra m a an d oth er

m e m b ers to b o th fe e l w h a t th e y a re e x p e rie n c in g

sim ila r e x p r e s s iv e th e ra p e u tic in te rv e n tio n s

and at the sa m e tim e m o v e to a s a fe r an d m o re

b rin g w ith th e m a c lin ic a l p o te n c y th a t n e ed s to

o b je ctiv e v ie w p o in t re g a rd in g th o se fe e lin g s is

b e u n d e rsto o d . T h e s e in te rv e n tio n s ca n raise

in h eren t in M IG P .

a n x ie ty a n d sh a m e to th e p o in t w h e re so m e

Self-care

clie n ts m a y b e p u sh e d to w a rd re la p se or ev en

S u b sta n ce -a b u sin g clie n ts o fte n p re s e n t to

tre a tm e n t u n a w a re o f in te rn a l s tre sse s an d p a in ,
h a v in g lo st se n sitiv ity to p h y sic a l cu es th a t lead
oth ers to the n o rm a l s e lf-c a re fu n c tio n s o f d aily
liv in g . T h e se fu n c tio n s m a y b e as s im p le as
b asic h y g ie n e or m o re c o m p le x in te rm s of
b o u n d a ry s ettin g an d re la tio n a l d efin itio n s.
S e ttin g b o u n d a rie s w ith in th e g ro u p and
e n co u ra g in g h e ig h te n e d se n sitiv ity to se lf-c a re
are w a y s in w h ic h M IG P a d d re sse s th is issu e.
C lien ts m u s t h e a r a c o n s is te n t m e ssa g e th a t th ey
are w o rth y o f th e g ro u p 's s u p p o rt an d ,
th e re fo re, w o rth y o f th e ir o w n a tte n tio n in
reg a rd to se lf-ca re . A ll o f th e a b o v e can
co m fo rta b ly b e a d d re sse d w ith in th e c o n te x t of
M IG P , w ith the le a d e r a ctiv e ly c o n n e c tin g
m e m b ers to m e m b e rs, w h o su p p o rt on e a n o th er
on the im p o rta n ce o f se lf-m o n ito rin g an d care.

164

fe e l the n e ed to le a v e tre a tm e n t to e sc a p e the

in te rn a l c o n flic ts e n c o u n te re d . A s w ith an y
th e ra p e u tic te c h n iq u e , th e ra p is ts s h o u ld n o t
u tiliz e s u c h te c h n iq u e s u n le ss th e y are
th o ro u g h ly tra in e d a n d w e ll s u p e rv is e d . A n y
in te rv e n tio n th a t h a s a p o w e rfu l p o te n tia l fo r
g ro w th a lm o s t a lw a y s h a s an e q u a l p o te n tia l fo r
d a m a g e if p o o rly c o n d u c te d . T ra in in g and
a p p ro p ria te s u p e rv is io n a re p a rtic u la rly
im p o rta n t w ith e x p r e s s iv e te c h n iq u e s b e ca u se of
th eir c lin ic a l p o te n cy .
P sy c h o d ra m a ca n b e u se d w ith d iffe re n t
m o d e ls o f g ro u p th e ra p y . It o ffe rs p e rso n s w ith
su b sta n ce a b u s e d is o rd e rs an o p p o rtu n ity to
b e tte r u n d e rs ta n d p a s t an d p re s e n t
e x p e rie n c e s a n d h o w p a s t e x p e rie n c e s
in flu e n ce th e ir p re s e n t liv es. T h is a p p ro a ch
e n c o u ra g e s c lie n ts to re le a rn fo rg o tte n sk ills,

T im e-L im ited G rou p T herapy

im ag in ativ ely c h a n g e a p p a re n t p ro b le m s th a t

th e m s e lv e s as iso la te d sit in th e c o rn e r or u n d er

b lock p ro g re ss, re h e a rse n ew b e h a v io rs , p ra c tic e

a ta b le w ith a " s p o n s o r ." T h e th e ra p is t g ives

e m p a th y , and e x p a n d th e ir e m o tio n a l ra n g e by

th em s e n te n c e s to c o m p le te , s u c h a s, " I lik e this

co n fro n tin g fe e lin g s th a t h a v e n e v e r b e e n

c o rn e r b e c a u s e ...." o r "T h e firs t tim e I re m e m b er

p ro p e rly d e a lt w ith . A s c lie n ts a ct, im p o rta n t

iso la tin g i s . . . . " F in a lly , th e y a re a sk ed to

co n cep ts b e co m e re a l, in te rn a liz e d , and

c o m p le te th e s e n te n c e , " I h a v e to g e t o u t o f this

o p era tio n a l th a t m ig h t o th e rw ise be p u re ly

c o rn e r b e c a u s e .. . . " T h e s p o n s o rs th e n g a th e r in

th eo retical. C h a n g e s e x p e rie n c e d th ro u g h

a circle an d in v ite th e p e rs o n s th e y h a v e b ee n

acting b e co m e a cce ssib le to th e p sy c h e as p a rt of

s u p p o rtin g to jo in th e m , s a y in g , " I w a n t y ou to

the liv ed h isto ry o f the in d iv id u a l.

jo in th is c irc le b e c a u s e ...." T h is e x p e rie n ce of

So m e th e ra p ists u se p s y c h o d ra m a to h elp
tran sfo rm in te rn a l d y n a m ic s th a t m a in ta in old
p a ttern s re le v a n t to s u b s ta n c e a b u se . F or

c o n n e c tio n o fte n e n h a n c e s p a rtic ip a n ts '

m o tiv a tio n an d a b ility to c h a n g e .
A c o m m o n u se o f p s y c h o d ra m a in tre a tm e n t

e x a m p le , o n e th e ra p is t in v ite s g ro u p m e m b e rs

fo r s u b s ta n c e a b u s e d is o r d e rs is " s c u lp tin g "

to list " r u le s " in th e ir fa m ily o f o rig in . T h e se

fa m ily m e m b e r s in ty p ic a l ro le s an d e n a ctin g

ru les m ay be re la ted to su b s ta n c e a b u se (e.g.,

s ig n ific a n t s itu a tio n s re la te d to su b s ta n ce a b u se

" D o n 't e v e r say th a t M o th e r is d ru n k . S h e is

p a tte rn s. In th is p ro c e s s , d e v e lo p e d b y P ap p ,

tak in g a n a p ."). A fte r a c lie n t d e s c rib e s a

fa m ily m e m b e rs e n a c t a sc e n e to g ra p h ica lly

situ a tio n in w h ich th e ru le w o u ld b e in v o k e d , he

d e p ict th e p ro b le m (P a p p , 1 9 7 7 ,1 9 8 3 ). T h e

assig n s fam ily ro le s to o th er p a rtic ip a n ts , g iv in g

p h y s ic a l a rra n g e m e n t o f the fa m ily m e m b ers

th em in stru ctio n s fo r h o w th e y w o u ld b e h a v e in

illu s tra te s e m o tio n a l re la tio n sh ip s an d co n flicts

this situ a tio n . T h e c lie n t is e n c o u ra g e d to b re a k

w ith in th e fa m ily . F o r e x a m p le , a fa m ily m ay

the ru le in the c a s e o f th e " n a p p in g " m o th e r,

n a tu ra lly b re a k up in to a tria d o f th e m o th e r,

by in sistin g on b rin g in g th e tru th in to the

siste r, an d b ro th e r, an d a d y a d o f th e fa th e r and

o p en w ith th e v e rb a l e n c o u ra g e m e n t o f all

a n o th e r sib lin g . In th a t c a s e , th e th e ra p ist m ig h t

re m a in in g g ro u p m e m b e rs w h o a re n o t p la y in g

h ig h lig h t th e fa c t th a t th e m o th e r an d fa th er

assig n e d ro le s. T h e c lie n t's v ic to ry w h ic h ca n

c o m m u n ic a te th ro u g h o n e o f th e ir c h ild re n and

b e a tra n sfo rm a tiv e , p o w e rfu l e x p e rie n c e is

n e v e r ta lk to e a c h o th e r d ire c tly .

ce le b ra te d as the a c h ie v e m e n t it is. In this

In y e t a n o th e r fo rm o f p s y c h o d ra m a , one

e x a m p le , the in d iv id u a l e x p e rie n c e s h im s e lf as a

p e rs o n in th e g ro u p m a y b e a sk ed to g iv e v o ice

p o w e rfu l tru th -s p e a k e r ra th e r th a n the

to d iffe re n t a s p e c ts o f h e r o w n s e lf th a t eith er

p o w e rle ss and v o ic e le ss p a rtic ip a n t he

h e lp m a in ta in d e p e n d e n c y or s p e a k fo r ch a n g e

p e rce iv ed h im s e lf to b e in the p a st. T h is new

(so m e tim e s c a lle d th e " d is e a s e " an d " r e c o v e r y "

e x p e rie n ce can e n h a n ce h is se n se o f se lf-e ffic a cy

se lv e s). T h e c lie n t m ig h t s p e a k fro m a d iffe ren t

and h elp fo ste r ch a n g e in h is o w n p a tte rn o f

c h a ir or p o sitio n fo r e a ch o f th e se v o ice s. T h e

s u b sta n ce ab u se.

in te n sity o f p s y c h o d ra m a o fte n h e lp s

In a n o th er e x a m p le o f p s y c h o d ra m a , g ro u p

c o m p e n sa te fo r th e s h o rte r tim e sp a n n ow

p a rticip a n ts e x p lo re "c h a r a c te r d e fe c ts " su ch as

c o m m o n ly fu n d e d fo r tre a tm e n t. A lth o u g h

g ra n d io sity or iso la tio n a sso cia te d w ith th eir

m a n y p a rtic ip a n ts e x p re s s c o n c e rn a b o u t actin g,

p a ttern o f s u b s ta n c e a b u se. T h e d e fe c ts are

th e b a rrie r o f sh y n e s s o fte n d ro p s c o m p le te ly as

d ra m a tiz e d , w ith h a lf th e g ro u p e n g a g e d in the

th e y e n te r th e p ro c e s s w ith th e a s s is ta n c e o f a

d ra m a tiz a tio n an d h a lf s ittin g as an a u d ien ce.

d y n a m ic a n d c o m m itte d fa c ilita to r.

For e x a m p le , p e rs o n s w h o e x p e rie n ce

165

C h ap ter 9

Therapeutic Factors

ta k e an a c tiv e ro le in th e c re a tio n o f th e im a g e ,
m o n ito rin g it fo r iss u e s o f s a fe ty w ith all

In h is cla ssic w o rk , T h eory a n d P ra ctice o f G rou p

m e m b e rs o f th e g ro u p as th e e x e rc ise d ev elo p s.

P sy ch oth erap y , Irv in Y a lo m id e n tifie d 11 p rim a ry

"th e r a p e u tic fa c to rs " in g ro u p th e ra p y (Y a lo m ,

Universality

1995). E ach o f th e se fa cto rs h a s p a rtic u la r

S u b s ta n c e a b u s e d is o r d e rs ten d to im p e d e

im p o rta n ce fo r c lie n ts w ith su b s ta n c e a b u se

re la tio n sh ip s an d fo rce c lie n ts in to in c re a se d

d iso rd e rs an d ca n b e used to h e lp e x p la in w h y a

iso la tio n . In a b rie f g ro u p e x p e rie n c e , th e clien ts

g ro u p w o rk s in a p a rtic u la r w a y fo r th is clie n t

e n c o u n te r o th e r in d iv id u a ls w h o h a v e fa ce d

p o p u la tio n . T h e s e cu ra tiv e fa c to rs a re p re s e n t in

sim ila r p ro b le m s . T h e y b e c o m e a w a re th a t they

all g ro u p in te rv e n tio n s an d a re listed b elo w .

are n o t a lo n e in life a n d c a n fe e l tre m e n d o u s

s a tisfa c tio n in th is c o n n e c tio n . T h e se n se th at

Instillation of Hope

th e ir p a in is n o t e x c lu s iv e o r u n iq u e a n d th at

M a n y clie n ts c o m e to a tre a tm e n t se ttin g fe e lin g

o th e rs w ith s im ila r p ro b le m s a re w illin g to

d efea te d b y life an d o v e rw h e lm e d b y th eir

s u p p o rt th e m ca n b e p ro fo u n d ly h e a lin g . It

failu re to co n tro l th e ir u se o f su b sta n ce s. T h ey

h e lp s c lie n ts m o v e b e y o n d th e ir iso la tio n , and it

feel they h a v e n o w h e re to go an d no p o ssib ility

g iv e s fu rth e r e n e rg y to h o p e , w h ic h h e lp s to fu el

fo r a b e tte r o u tco m e in life. W h e n in d iv id u a ls

th e c h a n g e p ro ce s s .

w ith th is life v ie w jo in a g ro u p o f p e o p le
s tru g g lin g w ith sim ila r p ro b le m s , th e y h a v e the

Im parting Inform ation

re m a rk a b le o p p o rtu n ity o f w itn e s s in g ch a n g e in

T h e in e v ita b le e x c h a n g e o f in fo r m a tio n in a

o th ers w h ile at th e sa m e tim e h a v in g th e ir o w n

g ro u p s e ttin g h e lp s m e m b e r s g e t fro m o n e d ay

sm all v icto rie s a ck n o w le d g e d an d c e le b ra te d by

to th e n e x t. P a rtic u la rly in c o n ju n c tio n w ith

g ro u p m e m b ers. T h ro u g h th is p ro c e ss, h o p e

fo rm a l p s y c h o e d u c a tio n a l g ro u p s , M IG P affo rd s

b eg in s to e m e rg e. T h e e n e rg y o f h o p e and the

g ro u p m e m b e rs th e o p p o rtu n ity to re fle c t on

fo cu sed a tte n tio n on th is c u ra tiv e fa c to r re ce iv e

w h a t th e y h a v e le a rn e d an d a t th e sa m e tim e

sp e cific a tte n tio n in the M IG P m o d el.

A v a rie ty o f e x e rc ise s c a n b e u tiliz e d to
fu rth e r in still h o p e w ith in su b s ta n c e -a b u s in g

b e e x p e rie n c e d a s m o tiv a tio n a l. T h e c lie n t

clien ts. C lie n ts ca n b e a sk ed to p a rtic ip a te in a

stru g g lin g w ith iss u e s o f s u b s ta n c e a b u se can

v isu a liz a tio n e x e rcise w h e re th ey se e th e m se lv es

h e a r fro m o th e rs h o w th e y h a v e d e a lt w ith

in a life w ith o u t s u b s ta n ce use, e n v isio n in g

d iffic u lt c o n c e rn s an d h o w th e y h a v e

p a rticu la rly h o w life w o u ld b e d iffe re n t and

e x p e rie n c e d s u cc e ss. T h is m u tu a lly sh a re d

b e tte r u n d e r su ch c irc u m sta n ce s . T h e g ro u p

su c c e s s g iv e s p o sitiv e e n e rg y to th e g ro u p and

en erg y fu els th is e x p e rie n ce an d a d d s the

e n c o u ra g e s ch a n g e .

in ten sity o f o th er c lie n ts ' su p p o rt. A s w ith all

"g u id e d im a g e ry e x e r c is e s ," the g ro u p le a d e r

166

a p p ly th a t le a rn in g w ith in th e g ro u p settin g .
T h e in fo r m a tio n s h a re d is p e rs o n a l an d te n d s to

Altruism

m u st m o v e w ith c a u tio n . M a n y s u b sta n c e -

F u n d a m e n ta l to th e h u m a n c o n d itio n is the

ab u sin g c lie n ts m a y n o t h a v e a p ic tu re o f life

d esire to h e lp o th e rs w h e n th e y a re in tro u b le.

w ith o u t s u b s ta n c e s, and c o n s e q u e n tly su ch an

C lie n ts s tru g g lin g w ith s u b s ta n c e a b u se

e x e rcise can b e h u m ilia tin g if n o t h a n d led

d is o rd e rs ten d to b e fo cu s e d o n th e ir ow n

sen sitiv e ly . If th e c lie n t is u n a b le to v isu a liz e , he

d iffic u ltie s an d h a v e a h a rd tim e re a c h in g o u t to

o n ce ag a in p e rc e iv e s fa ilu re . T o g u a rd a g a in st

h e lp th o se in n e e d . G ro u p th e ra p y o ffe rs th e

su ch p o te n tia l sh a m in g , th e g ro u p fa c ilita to r can

m e m b e rs o p p o rtu n itie s to p ro v id e a ssista n c e

T im e-L im ited G rou p T herapy

and in sig h t to o n e a n o th er. P a rticu la rly w ith in

an d u se th e e n e rg y o f th e re la tio n sh ip s to

the m o d e l o f M IG P , th e fa c ilita to r p a y s g re a t

fa c ilita te ch a n g e . A s p a rtic ip a n ts e n g a g e in

a tte n tio n to a ltru istic m o v e s o n the p a rt of

r e la tio n sh ip s , th e y le a rn n e w s o c ia l sk ills that

m e m b ers. T h e y a re ce le b ra te d and

ca n h e lp th e m b re a k th ro u g h th e ir iso la tio n and

a ck n o w le d g e d . A s in d iv id u a ls re c o g n iz e th a t

c o n n e c t w ith o th e rs in m o re m e a n in g fu l w ays.

they h a v e s o m e th in g o f v a lu e to g iv e th e ir

T h e y a lso le a rn h o w to d is c o n n e c t, w h ic h is

fellow g ro u p m e m b e rs, th eir s e lf-e s te e m rise s as

e q u a lly im p o r ta n t g iv e n th e a n x ie tie s o ften

ch an g e and se lf-e ffic a c y a re s u p p o rte d .

a s s o c ia te d w ith re la tio n a l lo ss a n d g rief. T h e

Corrective Recapitulation of the

Primary Family Group

g ro u p fa c ilita to r m a y a t tim e s d e lib e ra te ly fo cu s

on th e se s o c ia l s k ills th ro u g h ro le -p la y in g or
m o d e lin g e x e rc ise s w ith in th e c o n te x t o f the

T h is th e ra p e u tic fa c to r p e rta in s to the

g ro u p itself. T h e h e a lin g ta k e s p la c e as the

im p o rta n ce o f re la tio n sh ip s w ith in th e c lie n t's

c lie n ts ta k e w h a t th e y h a v e le a rn e d and

fam ily o f o rig in , w h ich in v a ria b ly fin d s

e x p e rie n c e d in g ro u p an d a c tiv e ly g e n e ra liz e it

e x p ressio n w ith in th e g ro u p e x p e rie n ce .

in th e ir liv es o u ts id e o f th e g ro u p .

"R e c a p itu la tio n o f the fa m ily g r o u p " h a p p e n s

w h en a clie n t b o th c o n s c io u s ly and

Imitative Behaviors

u n co n scio u sly re la te s to a n o th e r g ro u p

Im ita tiv e b e h a v io rs a re an im p o r ta n t so u rce of

m e m b er as if th a t p e rs o n is a m e m b e r o f his

le a rn in g in g ro u p th e ra p y . T h e p ro c e s s of

fam ily o f o rig in w ith w h o m h e h a s s tru g g le d in

m o d e lin g c a n b e p a rtic u la rly im p o rta n t as

the p ast. T h is o c c u rre n c e is c le a rly a p ro je c tio n ,

clie n ts le a rn n e w w a y s to h a n d le d iffic u lt

b u t it ca n b e id e n tifie d b y th e le a d e r, an d b o th

e m o tio n s w ith o u t re s o rtin g to v io le n c e or d ru g

g ro u p m e m b e rs in v o lv e d ca n b e n e fit as th ey

u se. T h e ra p is ts m u s t b e a c u te ly se n sitiv e to the

in v e stig a te n ew w a y s o f re la tin g th a t b re a k the

im p o rta n t ro le th e y p la y w ith in th is c o n te x t;

old d y sfu n ctio n a l p a tte rn s o f th e fa m ily of

c lie n ts o fte n lo o k to th e th e ra p is t to m o d e l new

o rig in . In a w ay , th e g ro u p b e g in s to serv e as a

b e h a v io rs a s th e y e n c o u n te r n e w situ a tio n s

s u b stitu te fa m ily . T h e g ro u p m e m b e rs a re th e

w ith in th e g ro u p co n te x t. G ro u p m e m b e rs can

sib lin g s, and th e g ro u p fa c ilita to r is in a p a re n ta l

a lso le a rn b y im ita tin g o th e r m e m b e r s w h o are

role. E v e n in a tim e -lim ite d g ro u p , issu es of

s u c c e s s fu lly d e a lin g w ith d iffic u lt re la tio n a l

tra n sfe re n ce an d c o u n te rtra n sfe re n c e m a y

issu es. It is h e lp fu l fo r a n e w g ro u p m e m b e r to

re q u ire a tte n tio n . H o w e v e r, M IG P te n d s to

w itn e ss an o n g o in g g ro u p w h e re p e o p le are

d ilu te the tra n sfe re n c e b y "s p r e a d in g it

c o n fro n tin g th e ir p ro b le m s a p p ro p ria te ly ,

th ro u g h o u t the g ro u p " ra th e r th a n

m o v in g b e y o n d old d y s fu n c tio n a l p a tte rn s, and

co n c e n tra tin g it w ith in the d y a d ic co u n se lin g

fo rm in g n e w re la tio n sh ip s th a t s u p p o rt ch a n g e.

re latio n sh ip .

T h e g ro u p b e c o m e s a liv in g d e m o n s tra tio n of

th e se n e w b e h a v io rs , w h ic h fa c ilita te s and

Development of Socializing
Techniques

s u p p o rts in s ig h t a n d c h a n g e .

M a n y su b sta n c e a b u se rs a re "fie ld -s e n s itiv e " or

Interpersonal Learning

"fie ld -d e p e n d e n t" in d iv id u a ls w h o a re k e en ly

G ro u p s p ro v id e a n o p p o rtu n ity fo r m e m b e rs to

co n scio u s o f the n e tw o rk o f sp e cific

le a rn a b o u t re la tio n sh ip s a n d in tim a c y . T h e

re la tio n sh ip s as o p p o se d to p rin c ip le s or

g ro u p its e lf is a la b o r a to ry w h e re g ro u p

g e n e ra liz a tio n s th a t a p p ly re g a rd le s s o f co n tex t.

m e m b e rs ca n , p e rh a p s fo r th e first tim e,

G ro u p th e ra p y ca n tak e a d v a n ta g e o f th is trait

h o n e s tly c o m m u n ic a te w ith in d iv id u a ls w h o
167

C h ap ter 9

w ill s u p p o rt th e m and p ro v id e th e m w ith

Existential Factors

re sp ectfu l fe e d b a ck . T h is in te rp e rs o n a l lea rn in g

E x is te n tia l fa c to rs o f lo ss a n d d e a th are o ften

is fa cilita te d by the M IG P m o d e l, in th a t sp e cia l

issu es o f g re a t d is c o m fo r t in th e su b sta n c e -

a tte n tio n is g iv e n to re la tio n a l issu es w ith in th e

a b u sin g p o p u la tio n . T h e b re v ity o f a tim e-

co n te x t o f gro u p .

lim ite d g ro u p e x p e rie n c e fo rc e s th e se issu es to

Group Cohesiveness
O ften m is u n d e rs to o d , g ro u p co h e s io n is a sen se
of b e lo n g in g th a t d e fin e s the in d iv id u a l n o t on ly
in re la tio n to h e rs e lf b u t a lso to th e g ro u p . It is a
p o w e rfu l fe e lin g th a t o n e h a s m e a n in g in
re la tio n sh ip s and th a t o n e is v a lu e d .
D e v e lo p m e n t o f g ro u p c o h e s io n is p a rtic u la rly
im p o rta n t in th e M IG P m o d e l, so th a t g ro u p
m e m b ers feel sa fe e n o u g h to ta k e th e risk s of

th e s u rfa c e a n d a llo w s m e m b e r s to d iscu ss th em

o p en ly in a s a fe e n v iro n m e n t. T im e itse lf
re p re s e n ts lo ss a n d a lso s e rv e s as a m o tiv a to r, as
the m e m b e r s fa ce th e e n d in g o f e a c h g ro u p
se ssio n a n d o f th e g ro u p tre a tm e n t e x p e rie n c e .
A s th ey b e c o m e m o re a w a re o f th e fru stra tio n s
o f re a lity a n d th e lim its th e y fa ce , c lie n ts ca n
re c e iv e s u p p o rt fro m th e g ro u p in a c c e p tin g
" life on life 's te r m s " in s te a d o f th e ir p a st
p a tte rn s o f e sca p e .

se lf-d isclo su re an d ch a n g e . T h e e x p e rie n ce of

b e lo n g in g is b o th n u rtu rin g an d e m p o w e rin g .

Catharsis
S o m etim e s g ro u p p a rtic ip a n ts w ill g a in a
su d d en in s ig h t th ro u g h in te ra c tio n w ith o th ers,
w h ich can ca u se a sig n ific a n t in te rn a l sh ift in the
w ay th ey re sp o n d to life. S u c h in sig h ts m a y be
acco m p a n ie d by b u rs ts o f e m o tio n th a t relea se
p ain or a n g e r a sso c ia te d w ith old p s y ch o lo g ic a l
w o u n d s. T h is p ro c e s s h a p p e n s m o re e a sily in a
g ro u p w h e re co h e s io n h a s b e e n d e v e lo p e d and
w h ere the th e ra p is t ca n fa c ilita te a safe
e n v iro n m e n t in w h ic h e m o tio n s ca n b e freely
sh ared . It is im p o rta n t to re co g n iz e , h o w e v e r,
th at a lth o u g h ca th a rsis is a g e n u in e e x p ressio n ,
it is n o t see n as cu ra tiv e in an d o f itself. H ig h
lev els of e m o tio n a l e x c h a n g e n o t a d d re sse d in
the g ro u p can b e c o m e p o te n tia l re la p se trig g e rs,
w h ich e n d a n g e r th e su c c e ss o f in d iv id u a l
m e m b ers. T h e th e ra p is t a c k n o w le d g e s the
p o w e rfu l e m o tio n s a fte r th e m e m b e r h a s sh a re d
th em b u t asks th e g ro u p as w e ll as the m e m b e r
to g iv e th o se e m o tio n s m e a n in g and co n te x t
w ith in th e g ro u p . T h u s, b o th th e e x p e rie n c e of
the e m o tio n an d the u n d e rs ta n d in g o f h o w th at
e m o tio n e ith e r in te rfe re s or su p p o rts
re la tio n sh ip s are h e a lin g .

168

Using Time-Limited
Group Therapy
T h e fo cu s o f tim e -lim ite d th e ra p e u tic g ro u p s
v a rie s a g re a t d e a l a c c o rd in g to th e m o d e l
c h o se n b y th e th e ra p ist. Y e t s o m e
g e n e ra liz a tio n s c a n b e m a d e a b o u t sev era l
d im e n s io n s o f th e m a n n e r in w h ic h b rie f g ro u p
th e ra p y is im p le m e n te d .

Assessm ent and Preparation

C lie n t p re p a ra tio n is p a rtic u la rly im p o rta n t in
an y tim e -lim ite d g ro u p e x p e rie n c e . C lien ts
s h o u ld b e th o ro u g h ly a s s e s s e d b e fo re th e ir en try
in to a g ro u p fo r th e ra p y . In te rm s of
e x c lu s io n a ry iss u e s , p e rs o n s w ith sev ere
d iso rd e rs or th o se w h o c a n n o t a c c e p t s u p p o rt
m a y n e e d to b e g iv e n m o re in d iv id u a l tim e
b e fo re a g ro u p e x p e rie n c e . A lso , p e rs o n s w ith
s ig n ific a n t d e fic its in c o g n itio n m a y n o t b e n e fit
as m u c h fro m a tim e -lim ite d g ro u p .
G ro u p p a rtic ip a n ts s h o u ld b e g iv e n a
th o ro u g h e x p la n a tio n o f g ro u p e x p e c ta tio n s .
F o r an M IG P g ro u p , fo r e x a m p le , th e y n eed to
u n d e rsta n d th e ir re s p o n s ib ility fo r sp e a k in g
w ith in th e g ro u p an d th a t th e p rim a ry fo cu s of

T im e-L im ited G rou p T herapy

the g ro u p is re la tio n sh ip s . A b rie f e x p la n a tio n

an d the p e rs o n a l sty le o f th e th e ra p ist. In

of a "h e r e and n o w " e n c o u n te r is h e lp fu l the

h o m o g e n e o u s , p ro b le m -fo c u s e d g ro u p s, fo r

g ro u p can b e co m e a p la ce w h ere fe e d b a c k tak es

e x a m p le , less tim e is n e e d e d to d e fin e w h a t

p lace in the "h e r e an d n o w ," as m e m b e rs learn

g ro u p m e m b e rs h a v e in c o m m o n . O p e n in g

h o w th ey are a ffe c te d b y th e o th ers an d h ow

s e ssio n s ty p ic a lly in c lu d e th e fo llo w in g :

they in tu rn a ffe c t o th er m e m b e rs. T h is "h e r e

and n o w " fo cu s b rin g s clie n ts in to the p re s e n t

at th e o p e n in g s e s s io n , re s p o n d in g to a

and allo w s th e m to d ea l w ith re a l issu es w ith in

s im p le re q u e st s u ch a s, " T e ll us w h a t led you

the g ro u p th at th ey ca n th en a p p ly in th eir d aily

h e r e ." R e se a rc h s u g g e s ts th a t if g ro u p s do

liv es. It also d is tin g u is h e s M IG P fro m self-h elp

n o t e x p lic itly a d d re s s th e re a s o n fo r ea ch

su p p o rt g ro u p s, w h ic h tra d itio n a lly d isc o u ra g e

m e m b e r 's p a rtic ip a tio n , m o re m e m b e rs w ill

re la tio n a l "h e r e and n o w " in te ra c tio n s.

d ro p o u t (L e v in e , 1 9 6 7 ). In th e co n te x t of

If tim e p e rm its, it is p a rtic u la rly e ffe ctiv e fo r

s u b s ta n c e a b u se tre a tm e n t, th e th e ra p ist

g ro u p m e m b ers as th e y a re b e in g a s se sse d an d

sh o u ld th e re fo re in itia lly d is c u ss w ith g ro u p

p re p a re d fo r g ro u p to e ith e r w a tch or p a rtic ip a te

m e m b e rs h o w s u b s ta n c e a b u se issu es w ill be

in a p ra ctice g ro u p as a tria l e x p e rie n c e . A

a d d re s s e d so as to e n s u re th a t fo cu s is

v arie ty o f g ro u p ta p es are a v a ila b le ; h o w e v e r,

any p ro g ra m c a n v id e o ta p e o n e o f its ow n

m a in ta in e d .

g ro u p s, w ith a p p ro p ria te re le a se s fo r c lie n t

b e lie v e th ey h a v e th e a b ility to c h o o se

T h is e n a b le s n ew c lie n ts to see w h a t w ill h a p p e n

e ffe c tiv e a c tio n s or if th ey th in k of

in the g ro u p se s s io n an d lo w e rs a n x ie ty . T h is

th e m s e lv e s as h e lp le s s v ic tim s o f

in te n tio n a l e ffo rt to m a k e th e g ro u p s a fe and

c irc u m sta n c e . F o r d ir e c tiv e g ro u p s, in w h ich

re d u ce its in h e re n t a n x ie ty d is tin g u is h e s M IG P

the th e ra p is t e x e rc ise s g re a te r co n tro l, this

fro m a m o re tra d itio n a lly in te ra c tiv e p ro cess

p ro c e ss w ill b e s h o rte r th a n fo r g ro u p

g ro u p . In tro d u ctio n s to g ro u p ca n a lso be

p ro c e s s g ro u p s, in w h ic h g ro u p m e m b ers

p ro v id e d in a p s y c h o e d u c a tio n a l fo rm a t.

ta k e tu rn s as lea d e rs.

G o a ls fo r th e g ro u p (a n d o fte n fo r

T h e th e ra p is t se e k s to e sta b lis h a sa fe , w arm ,

in the g ro u p b u t a lso w h y an d h o w th e g ro u p
p ro cess b rin g s a b o u t h e a lin g . T h e im p o rta n c e of

in d iv id u a ls ) a re c la rifie d .

re la tio n sh ip s an d o p e n c o m m u n ic a tio n s th ro u g h

s u p p o rtiv e e n v iro n m e n t. T h e re m a y b e a

s e lf-d is clo su re an d su p p o rt c a n b e e x p la in ed .

n e ed to e sta b lis h ru le s to in c re a se s a fe ty for

It is im p o rta n t to re co g n iz e th a t a lth o u g h a

e x a m p le , th a t m e m b e r s w ill n o t e n g a g e in

s ig n ifica n t a m o u n t o f c lie n t p re p a ra tio n tak es

p h y s ic a l c o n ta c t, w ill n o t d is c u ss w h a t w as

p la ce b e fo re th e clie n t e v e r e n te rs a g ro u p , clie n t

sa id o u tsid e th e ro o m , a n d w ill g iv e fe e d b ack

p re p a ra tio n its e lf is a lso a p ro c e ss an d n o t an

ev en t. T h ro u g h c o n tin u a l re fe re n ce s to the
g ro u p a g re e m e n ts and g ro u p c o n tra c ts , the
th e ra p ist c o n tin u e s to p re p a re c lie n ts as th e y

T h e "lo c u s o f c o n tr o l" fo r the g ro u p is

c la rifie d . C lie n ts e x p lo r e w h e th e r they

p e rm issio n , to u se fo r in s tru c tio n a l p u rp o se s.

C lie n ts le a rn n o t o n ly w h a t is g o in g to tak e p la ce

N e w g ro u p m e m b e r s in tro d u c e th e m se lv es

to e a c h o th e r in an a g re e d -u p o n m a n n er.

T h e th e ra p is t h e lp s g ro u p m e m b e rs e sta b lish
co n n e c tio n s w ith e a c h o th er, p o in tin g ou t
co m m o n c o n c e rn s an d p ro b le m s.

m o v e in to th e e x p e rie n ce .
S o m e th e ra p is ts a sk th e g ro u p to e v a lu a te the

Initial Session

o p e n in g se s s io n . T h is m a y b e d o n e o ra lly or in

O p e n in g s e ssio n s fo r g ro u p th e ra p y d iffe r

w ritin g . T h e g ro u p 's s u c c e s s ca n b e m e a su re d

acco rd in g to the ty p e o f g ro u p , its sp e cific g o a ls,

th ro u g h th e fo llo w in g q u e stio n s:
169

C h ap ter 9

W as s u b sta n ce a b u se d isc u sse d ?

g ro u p . S e ss io n s a re ty p ic a lly IV2 to 2 h o u rs in

D id g ro u p m e m b e rs liste n to e a ch o th er?

len g th . R e sid e n tia l p ro g ra m s u su a lly h a v e m o re

D id m e m b e rs c o o p e ra te and s u p p o rt each

fre q u e n t se ssio n s.

o th er?

D id they g iv e fe e d b a c k ?

Later Sessions
O ften , to e n h a n c e c o n tin u ity , th e th e ra p is t w ill

and re s id e n tia l sta y s a v a ila b le u n d e r m a n a g e d

h e a lth c a re , s o m e h a v e q u e s tio n e d the u tility o f
a p ro c e s s -s e n s itiv e tre a tm e n t g ro u p and are
fo c u sin g o n d ir e c tiv e e d u c a tio n a l g ro u p s. E ven

b eg in the n e x t se s s io n b y re c a llin g th e p re v io u s

th o u g h c lie n ts o fte n d o n o t sta y m o re th a n 3 to 5

on e and e n su rin g th a t " le fto v e r " item s are

d a y s on an in p a tie n t u n it, m u ch ca n be

a d d resse d . T h e th e ra p ist m a y a sk g ro u p

a cc o m p lis h e d in th is b rie f tim e fra m e . A s

m e m b ers h o w le sso n s lea rn ed in th e g ro u p h a v e

m e n tio n e d b e fo re , d ire c tiv e e d u c a tio n a l g ro u p s

affecte d th eir d a ily liv es. M e m b e rs m a y h a v e

are n e c e s s a ry b u t n o t a lw a y s su ffic ie n t. G ro u p s

tried to im p le m e n t s u g g e s tio n s an d fo u n d th ey

w ith a c tiv e fa c ilita tio n , b u t a d h e rin g to p ro c e ss

d id or d id n o t w o rk , or th e y m a y n o t h a v e tried

s e n sitiv ity , c a n b u ild c o h e s io n q u ic k ly an d a ct as

to d o so at all, w h ich is a lso an im p o rta n t to p ic

p o w e rfu l m o tiv a to rs fo r c lie n ts to fo llo w

of d iscu ssio n .

th ro u g h w ith th e n e x t le v e l o f care.

O n an in p a tie n t u n it w ith clie n ts g o in g

170

G iv e n th e d ra m a tic a lly s h o rte n e d in p a tien t

G ro u p p ro c e s s th e ra p y is m o st e ffe c tiv e if

th ro u g h w ith d ra w a l or stru g g lin g w ith

p a rtic ip a n ts h a v e h a d tim e to fin d th e ir ro le s in a

co e x istin g p s y ch ia tric d iso rd e rs, in stillin g h o p e

g ro u p , to " a c t " th e se ro le s, an d to le a rn fro m

is p a rticu la rly im p o rta n t. F o r th e n e w e s t clie n ts

th em . T h e g ro u p n e e d s tim e to d e fin e its

on th e un it, c o n n e c tin g w ith o th e rs w h o h a v e

id e n tity , d e v e lo p c o h e s io n , a n d b e c o m e a safe

ju s t b ee n th ro u g h a s im ila r d iffic u lt e x p e rie n c e

e n v iro n m e n t in w h ic h th e re is e n o u g h tru st fo r

can b e in sp ira tio n a l. S u ch a th e ra p e u tic

p a rtic ip a n ts to re v e a l th e m s e lv e s . (T h e

e n co u n te r ca n a lso re d u c e issu es o f sh a m e , as

e x c e p tio n is an e d u c a tio n a l g ro u p , w h ic h relies

clien ts c o n n e c t w ith o th ers w h o b o th sh a re an d

less o n g ro u p p ro c e s s fa c to rs .) C o n se q u e n tly ,

u n d e rstan d th eir jo u rn e y . In a d d itio n , the

p re m a tu re ly te rm in a te d g ro u p s re ly in g on

in p a tien t g ro u p ca n serv e as an e x a m p le o f w h a t

g ro u p p ro c e s s m a y b e le ss e ffe c tiv e th a n th ey

tre a tm e n t w ill b e lik e a fte r d isch a rg e an d allow

co u ld b e in p ro m o tin g lo n g -te rm ch a n g e .

the clie n t to " p r a c tic e " b e in g in a g ro u p . C lien ts

F u rth e rm o re , p a rtic ip a n ts m a y h a v e to clea r

can e x p e rie n ce th e s u p p o rtiv e n a tu re o f the

th e ir s y s te m s o f th e m o s t s e rio u s e ffe c ts o f

g ro u p , w h ich w ill re d u ce th eir a n x ie ty a b o u t

su b s ta n c e s b e fo re th e y ca n fu lly p a rtic ip a te .

fu tu re g ro u p in v o lv e m e n t. U n d e rs c o rin g the

B e ca u se o f su ch fa c to rs , a rb itr a ry tim e lim its fo r

im p a ct o f b rie f g ro u p in te rv e n tio n s, the

g ro u p s, as o p p o s e d to tim e lin e s se t a c c o rd in g to

in p a tie n t p ro ce ss tre a tm e n t g ro u p re m a in s on e

th e th e ra p e u tic g o a ls o f th e p a rtic u la r g ro u p , can

of the co rn e rsto n e s o f co n tin u e d ch a n g e .

b e ill a d v ised .

Duration of Therapy and

Frequency of Sessions

G ender and Cultural Issues

W ithin Groups

T h e p re fe rre d tim e lin e fo r tim e -lim ite d g ro u p

R e se a rc h e rs a t C o rn e ll U n iv e rs ity fo u n d th a t

th e rap y is n o t m o re th a n tw o s e ssio n s p e r w eek

so cia l c o n ta c t w ith p e rs o n s w h o h a v e g o n e

(e x cep t in the re s id e n tia l se ttin g s), w ith as few

th ro u g h th e sa m e cris is is h ig h ly b e n e ficia l

as six se ssio n s in all, or as m a n y as 12,

(M a n isse s C o m m u n ic a tio n s G ro u p , 19 9 7 a ).

d ep en d in g on th e p u rp o s e an d g o a ls o f the

T h e re fo re , a c o m m o n g e n d e r, c u ltu re a n d / o r

T u n e-L im ited G rou p T herap y

sexu al p re fe re n c e w ill h elp c lie n ts in g ro u p

m a y p o se lo g is tic a l d iffic u ltie s . H o w e v e r, there

th erap y sh a re d iffic u ltie s th ey m a y h a v e

is g ro w in g c o n s e n s u s a m o n g th e ra p ists that,

e n co u n te red b e c a u se o f th a t c o m m o n

w h e n e v e r p o ss ib le , w o m e n n e ed to h a v e their

b a ck g ro u n d .

o w n g ro u p s, p a rtic u la rly d u rin g e a rly re co v ery

P a rticip a tio n in g ro u p th e ra p y m ay be less

e ffe ctiv e fo r w o m e n th an m e n , p e rh a p s b e c a u se

(B y in g to n , 1 9 9 7 ). T h is d o e s n o t s u g g e s t th a t
w o m e n s h o u ld b e fu lly s e g r e g a te d fro m m en.

g ro u p s a re o fte n d o m in a te d b y m e n an d re fle c t

P a rtic ip a tio n in m u tu a lly sh a re d

th eir issu es an d sty le o f in te ra c tio n (Ja rv is, 1992).

p s y c h o e d u c a tio n a l e x p e rie n c e s a n d m u ltifa m ily

A t th is tim e, h o w e v e r, little re s e a rc h is a v a ila b le

g ro u p s is a th e ra p e u tic w a y o f a d d re ssin g

on th e re la tiv e e ffica cy o f w o m e n -o n ly ra th er

g e n d e r issu e s (B y in g to n , 19 9 7 ).

than m ix e d -g e n d e r g ro u p s. W e itz a rg u es th a t

C o n c e rn s o f e th n ic ity a n d ra c e sh o u ld be

w o m en m ay h a v e to b e e m p o w e re d in o rd e r to

h a n d le d w ith s e n sitiv ity . T h is is n o t to su g g e st

rem ain a b stin e n t (W e itz , 1982). G ro u p

th a t in a tim e -lim ite d g ro u p , th e p o te n c y of

c o g n itiv e -b e h a v io ra l th e ra p y h a s b e e n fo u n d to

h o m o g e n e ity is s u c h th a t e a c h an d e v e ry e th n ic

b e an e ffe ctiv e tre a tm e n t fo r w o m e n w ith

or ra c ia l s u b g ro u p s h o u ld b e s e g re g a te d in o rd er

p o sttra u m a tic s tre ss d iso rd e r an d a su b sta n ce

to re a p th e b e n e fits o f th is in te rv e n tio n .

ab u se d iso rd e r (N a ja v its et al., 19 9 6 ) as w ell as

H o w e v e r, c u ltu ra l iss u e s n e e d to b e ad d resse d

fo r w o m e n w ith b o th a su b s ta n ce a b u se d iso rd e r

o p e n ly an d w ith s e n sitiv ity .

and a h isto ry o f p h y sica l or se x u a l a b u se

(M an isse s C o m m u n ic a tio n G ro u p , 19 9 7 ).
C o v in g to n h as w ritten e x te n s iv e ly a b o u t the

Cost-Effectiveness
T h e c lin ic a l u tility o f tim e -lim ite d g ro u p s has

im p o rta n ce o f w o m e n -s p e c ific g ro u p s,

c le a rly b e e n d e m o n s tra te d , b u t th e c o st fa c to r is

p a rticu la rly in e a rly re c o v e ry . S h e a cc u ra te ly

n o t irre le v a n t to a c o n s id e ra tio n o f the v a lu e of

p o in te d o u t th a t th e p o w e rfu l ro le d e fin itio n s

th e se g ro u p s. A lth o u g h in d iv id u a l w o rk and

w ith in ou r c u ltu re ten d to b e p la y e d o u t in

fa m ily w o rk w ill lik e ly a lw a y s re m a in a p a rt of

g ro u p and are o ften o p p re ss iv e to w o m e n

e v e n th e b rie fe s t tim e -lim ite d tre a tm e n t

(C o v in g to n , 19 9 7 ). In a m ix e d g ro u p , the

e x p e rie n c e , a c c e p ta n c e an d u se o f g ro u p

w o m e n q u ick ly b e c o m e th e "e m o tio n a l

in te rv e n tio n s a re slo w ly g ro w in g . F ro m a cost-

c o n ta in e rs " fo r the g ro u p an d ta k e ca re o f the

m a n a g e m e n t p e rs p e c tiv e , th e b e n e fits are

m en. A lth o u g h su ch a c tiv ity is n o t d efin e d as

o b v io u s. N o t o n ly c a n th e th e ra p is t u se the

p a th o lo g ica l, it e x p re s s e s cu ltu ra l n o rm s

p o w e r o f th e g ro u p to s u p p o rt c h a n g e w ith in all

w h e re in w o m e n 's n e e d s b e c o m e s e c o n d a ry to

g ro u p m e m b e r s, b u t o n e w e ll-tra in e d g ro u p

th o se o f m e n , w ith th e w o m e n p rim a rily d efin e d

th e ra p is t c a n m e e t th e c lin ic a l n e e d s o f 8 to 12

as ca re ta k e rs. T h e y a re u n c o m fo rta b le a b o u t

c lie n ts in ro u g h ly th e sa m e a m o u n t o f tim e as an

b rin g in g up issu es o f se x u a lity , p a rtic u la rly

in d iv id u a l se s s io n . W h e n th e se n u m b e rs are

sex u al a b u se, g iv e n th a t m e n h a v e g e n e ra lly

e n la rg e d to in c lu d e m o re d ire c tiv e a p p ro a ch e s

b een the ab u sers (C o v in g to n , 1997).

su ch as c o g n itiv e -b e h a v io r a l or

T h e cre a tio n o f g e n d e r-sp e c ific g ro u p s,

p a rticu la rly in sm a ll a g e n cie s or p riv a te p ra ctice ,

p s y c h o e d u c a tio n a l g ro u p s , th e c o s t-b e n e fit ratio

in c re a se s.

172

Appendix A
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Appendix B
Information and Training
Resources

General Brief Therapy

American Psychological Association
(APA) Division 29: Psychotherapy
D iv isio n o f P sy c h o th e ra p y
P .O . B ox 638
N iw ot, C O 8 0 5 4 4 -0 6 3 8
P h on e: (303) 6 5 2 -9 1 5 4
Fax: (303) 6 5 2 -2 7 2 3
W eb site: h ttp :/ / w w w .c w ru .e d u / a ffil/ d iv 2 9 /
d iv 2 9 .h tm
E -m ail: lp e te @ in d ra .c o m

C ognitive-Behavioral
Therapy
Aaron T. Beck Institute for
Cognitive Studies
E d m u n d F. O 'R e illy , P h .D .
F o u n d e rs H a ll, R o o m 3 1 9
A s s u m p tio n C o lle g e
5 0 0 S a lis b u ry S tre e t
P .O . B o x 15 00 5
W o rce s te r, M A 0 1 6 1 5 -0 0 0 5
P h o n e: (5 0 8 ) 7 6 7 -7 0 0 0 , x 7 5 5 4

A P A , h e a d q u a rte d in W a s h in g to n , D C , is the

W e b site: h ttp :/ / w w w .a ssu m p tio n .e d u /

w o rld 's la rg e st a s s o c ia tio n o f p sy c h o lo g ists.

E -m a il: e o re ill@ e v e .a s s u m p tio n .e d u

A P A 's m e m b e rsh ip in clu d e s m o re th an 1 5 9 ,0 0 0

re sea rch ers, e d u c a to rs, clin ic ia n s, co n s u lta n ts ,
and stu d e n ts. T h ro u g h its d iv is io n s in 50
su b field s o f p s y c h o lo g y an d a ffilia tio n s w ith 59
S tate, te rrito ria l, an d C a n a d ia n p ro v in cia l
a sso cia tio n s, A P A w o rk s to a d v a n c e p s y ch o lo g y
as a scie n ce , as a p ro fe ssio n , an d as a m e a n s of
p ro m o tin g h u m a n w e lfa re .
D iv isio n 29 p ro m o te s e d u c a tio n , re sea rch ,
h ig h sta n d a rd s o f p ra c tic e , an d th e e x c h a n g e of

T h e A a ro n T . B e c k In s titu te fo r C o g n itiv e
S tu d ie s p ro v id e s in fo r m a tio n th a t h ig h lig h ts the
c o n trib u tio n s o f c o g n itiv e fa c to rs to the
r e s o lu tio n o f p ro b le m s in liv in g . T h e In stitu te
h o sts a n n u a l s p e a k e rs an d c o n fe re n c e s th at
a d d re ss re s e a rc h a n d th e ra p e u tic d e v e lo p m e n t
in c o g n itiv e th e ra p y as w e ll as e th ic a l and m o ral
issu es. It a lso s p o n s o rs e d u c a tio n an d tra in in g
p ro je c ts in c o g n itiv e th e ra p e u tic sk ills to
s tu d e n ts a n d to p o s tg ra d u a te p ro fe ssio n a ls.

in fo rm a tio n a m o n g p s y c h o lo g is ts in te re s te d in
p sy ch o th era p y .

209

A p p en d ix B

The Albert Ellis Institute

p a y o rs, an d g o v e r n m e n ta l an d
n o n g o v e rn m e n ta l a g e n c ie s.

45 E ast 65th S tre e t

P hone: (800) 3 2 3 -4 7 3 8

National Association of C ognitiveBehavioral Therapists (NACBT)

W eb site: h ttp :/ / w w w .re b t.o rg /

P .O . B o x 2 1 9 5

E -m ail: in fo @ R E B T .o rg

W e irto n , W V 2 6 0 6 2

N ew Y o rk , N Y 10021

T h e A lb e rt E llis In stitu te , fo rm e rly k n o w n as the

In stitu te fo r R a tio n a l-E m o tiv e T h e ra p y , is a n o tfo r-p ro fit e d u c a tio n a l o rg a n iz a tio n fo u n d e d in
1968. R atio n al E m o tiv e B e h a v io r T h e ra p y

P h o n e: (8 0 0 ) 8 5 3 -1 1 3 5
F ax: (3 04) 7 2 3 -3 9 8 2
W e b site: h ttp : / /w w w .n a c b t.o rg /
E -m a il: n a c b t@ n a c b t.o rg

(R E B T ) is a h u m a n istic , a c tio n -o rie n te d

N A C B T p ro v id e s in fo r m a tio n o n R a tio n a l

a p p ro a ch to e m o tio n a l g ro w th , first a rticu la te d

E m o tiv e B e h a v io r T h e ra p y (A lb e rt E llis),

by D r. A lb e rt E llis in 1 9 5 5 , w h ich e m p h a siz e s

R a tio n a l B e h a v io r T h e ra p y (M a x ie M a u ltsb y ),

in d iv id u a ls ' c a p a c ity fo r c re a tin g th e ir e m o tio n s ;

C o g n itiv e T h e ra p y (A a ro n T . B eck ), R a tio n a l

the ab ility to c h a n g e an d o v e rc o m e th e p a st by

L iv in g T h e ra p y (A ld o P u c c i), a n d o th er

fo cu sin g on the p re s e n t; an d the p o w e r to

c o g n itiv e -b e h a v io r a l a p p ro a c h e s. N A C B T is

ch o o se and im p le m e n t sa tisfy in g a lte rn a tiv e s to

d e d ic a te d to p ro m o tin g th e te a c h in g and

cu rre n t b e h a v io r p a tte rn s. A n e stim a te d 8 ,0 0 0

p ra c tic e o f c o g n itiv e -b e h a v io r a l th e ra p y an d to

m en tal h e a lth p ro fe ss io n a ls p a rtic ip a te in

s u p p o rtin g c o g n itiv e -b e h a v io r a l th e ra p ists.

In stitu te tra in in g p ro g ra m s an d w o rk s h o p s each

N A C B T o ffe rs c o g n itiv e -b e h a v io r a l w o rk sh o p s,

year.

s e m in a rs, c o n fe r e n c e s , a n d h o m e stu d y

The Association for Advancement

Of Behavior Therapy (AABT)
305 S e v e n th A v e n u e - 1 6th F lo o r
N ew Y o rk , N Y 1 0 0 0 1 -6 0 0 8

c e rtific a tio n p ro g ra m s .

Strategic/Interactional
Therapies

P h on e: (212) 6 4 7 -1 8 9 0
Fax: (212) 6 4 7 -1 8 6 5

Brief Family Therapy Center (BFTC)

W eb site: h ttp :/ / se rv e r.p sy c .v t.e d u / a a b t/

P. O . B ox 1 3 7 3 6

E -m ail: m e b ro w n @ a a b t.o rg

M ilw a u k e e , W I 5 3 2 1 3 -0 7 3 6

A A B T is a n o t-fo r-p ro fit m e m b e rsh ip

o rg a n iz a tio n o f o v er 4 ,5 0 0 m e n ta l h e a lth
p ro fe ssio n a ls an d stu d e n ts. F o u n d e d in 1966,
A A B T serv e s as a c e n tra liz e d re so u rce and

P h o n e: (4 1 4 ) 3 0 2 -0 6 5 0
F ax: (4 14) 3 0 2 -0 7 5 3
W e b site: h ttp :/ / w w w .b r ie f-th e r a p y .o rg
E -m a il: b rie fftc @ a o l.c o m

n e tw o rk fo r all fa ce ts o f b e h a v io r th e ra p y and

A n o t-fo r-p ro fit re s e a rc h a n d tra in in g ce n te r

c o g n itiv e -b e h a v io r th e ra p y . It p ro m o te s th ese

fo u n d e d in 1 9 7 8 , B F T C h a s p io n e e re d e ffe ctiv e

th e rap ie s th ro u g h its jo u rn a ls , n e w sle tte rs,

b rie f th e ra p y m e th o d s . T h e m o d e l d e v e lo p e d at

a n n u al co n v e n tio n s , W e b site, an d oth er

the c e n te r h a s c o m e to b e k n o w n as S o lu tio n -

e d u ca tio n a l p u b lica tio n s an d p ro g ra m s. It also

F o cu se d B rie f T h e ra p y . T h is m o d e l h a s b ee n

p ro v id e s o p p o rtu n itie s fo r p ro fe ss io n a l g ro w th

u sed s u c c e s s fu lly fo r m o re th a n a d ec a d e in a

and o ffers in fo rm a tio n an d re fe rra l s erv ices to

v a rie ty o f se ttin g s in c lu d in g ch ild p ro te c tio n

the g e n era l p u b lic, th e m e d ia , th ird -p a rty

a g e n c ie s, c o m m u n ity m e n ta l h e a lth clin ics,

p riv a te p ra c tic e s , s e x u a l a b u s e p ro g ra m s,

210

In fo rm a tio n a n d T ra in in g R esou rces

su b stan ce ab u se tre a tm e n t, fa m ily -b a s e d

Mental Research Institute

services, an d sch o o ls.

5 5 5 M id d le fie ld R o a d

The M ilton H. Erickson

Foundation, Inc.
3606 N o rth 24th S tre e t
P h o en ix , A Z 85 0 1 6

P a lo A lto , C A 94301
P h o n e : (6 5 0 ) 3 2 1 -3 0 5 5
F ax: (650) 3 2 1 -3 7 8 5
W e b site: h ttp :/ / w w w .m ri.o rg
E -m a il: m ri@ m ri.o rg

P h o n e: (602) 9 5 6 -6 1 9 6
Fax: (602) 9 5 6 -0 5 1 9
W eb site: h ttp :/ / e ric k s o n -fo u n d a tio n .o rg
E -m ail: o ffic e @ e ric k s o n -fo u n d a tio n .o rg

S in ce 19 59 , th e M e n ta l R e se a rc h In stitu te o f P alo
A lto , C a lifo rn ia , h a s b e e n a so u rc e o f n ew id eas
in th e a rea o f in te ra c tio n a l/ s y s te m ic stu d ies,
p s y c h o th e ra p y , a n d fa m ily th e ra p y . It o ffers a

T h e M ilto n H. E ric k so n F o u n d a tio n , In c., is

d ed icate d to p ro m o tin g an d a d v a n c in g the
co n trib u tio n s m a d e to th e h e a lth s c ie n c e s b y th e

v a rie ty o f w o rk s h o p s an d tra in in g s re la ted to

b rie f th e ra p y , n a rr a tiv e th e ra p y , an d
stra te g ic / in te ra c tio n a l th e ra p ie s.

late M ilto n H . E ric k so n , M .D ., th ro u g h tra in in g

m e n tal h e a lth p ro fe ss io n a ls w o rld w id e . M o re
th an 60 M ilto n H . E ric k so n In stitu te s and
S o cie tie s in the U n ite d S ta te s a n d a b ro a d h a v e

H um anistic and
Existential Therapies

ap p lied to the F o u n d a tio n fo r p e rm is sio n to use

D r. E rick so n 's n a m e in th e titles o f th e ir

State University of W est Georgia

o rg a n iz a tio n s. T h e se in s titu te s p ro v id e c lin ica l

D e p a rtm e n t o f P sy c h o lo g y

serv ices an d p ro fe ss io n a l tra in in g in m a jo r cities

1 6 0 0 M a p le S tre e t

aro u n d th e w o rld .

C a rro llto n , G A 3 0 1 1 8

Institute for the Study of

Therapeutic Change (ISTC)

P h o n e : (7 7 0 ) 8 3 6 -6 5 1 0

P .O .B . 57 8 2 6 4
C h ica g o , IL 6 0 6 5 7 -8 2 6 4

F ax: (77 0) 8 3 6 -6 7 1 7
W eb site: h ttp :/ / w w w .w e s tg a .e d u /
-p s y d e p t/ in d e x .h tm l
E -m a il: m e a s t@ w e s tg a .e d u

P hone: (773) 4 0 4 -5 1 3 0
Fax: (773) 4 0 4 -1 8 4 0

T h e S ta te U n iv e rs ity o f W e st G e o rg ia

W eb site: h ttp :/ / w w w .ta lk in g c u re .c o m /

P sy c h o lo g y D e p a rtm e n t is o n e o f th e o n ly

E -m ail: s c o ttd m ille r@ ta lk in g c u re .c o m

d e p a rtm e n ts in th e c o u n try w h o s e th e o re tic a l

ro o ts a re in th e h u m a n is tic p s y c h o lo g y and

IST C is a re se a rch , tra in in g , an d c o n s u lta tio n

g ro u p d ed ica te d to u n d e rs ta n d in g and
p ro m o tin g h u m a n c h a n g e , g ro w th , and
p o ten tia l. IST C stu d ies h o w c h a n g e o c cu rs

tra n sp e rs o n a l p s y c h o lo g y tra d itio n s . T h e y offer

c o u rse s th a t e x p lo re h u m a n is tic an d
tra n sp e rs o n a l c o n c e rn s in p s y c h o lo g ic a l th eory
a n d th e ra p y .

n a tu ra lly , s p o n ta n e o u s ly , an d on an e v e ry d a y
b asis an d th e n h e lp s p e o p le an d o rg a n iz a tio n s
ap p ly th a t k n o w le d g e in s o lv in g p ro b le m s.

211

A p p en d ix B

American Psychological Association

(APA) Division 32: Humanistic
Psychology

7 4 4 S a n A n to n io R o a d

Institute of Transpersonal
Psychology (ITP)

W ill W a d lin g to n , P h .D .

P alo A lto , C A 9 4 3 0 3

C e n te r fo r C o u n se lin g & P sy c h o lo g ic a l S e rv ices

P h o n e: (6 5 0 ) 4 9 3 -4 4 3 0

221 R iten o u r

F ax: (6 50) 4 9 3 -6 8 3 5

U n iv e rsity P a rk , P A 16802

W e b site: h ttp :/ / w w w .itp .e d u /

P h on e: (814) 8 6 3 -0 3 9 5

E -m a il: itp in fo @ itp .e d u

Fax: (814) 8 6 3 -9 6 1 0
W eb site: h ttp :/ / w w w .a p a .o rg / a b o u t/ d iv is io n /
d iv 3 2 .h tm l
E -m ail: w lw 3 @ p su .e d u

IT P is a p riv a te , n o n s e c ta ria n g ra d u a te sch o o l

a c c re d ite d b y th e W e ste rn A s s o c ia tio n o f
S ch o o ls an d C o lle g e s . F o r m o re th a n 2 0 y ears,
the In stitu te h a s re m a in e d a t th e fo re fro n t of

D iv isio n 32 o f the A P A (see a b o v e ), w h o se

p s y c h o lo g ic a l re s e a rc h an d e d u c a tio n , p ro b in g

fo u n d a tio n s in c lu d e p h ilo s o p h ic a l h u m a n ism ,

the m in d -b o d y -s p ir it c o n n e c tio n . T h e In stitu te

e x iste n tia lism , an d p h e n o m e n o lo g y , see k s to

p ro v id e s d y n a m ic o n lin e / d ista n c e -le a rn in g

co n trib u te to p s y c h o th e ra p y , e d u c a tio n ,

o p p o rtu n itie s u sin g th e p e rs o n a l m e n to r sy stem ,

th e o ry / p h ilo so p h y , re se a rch , o rg a n iz a tio n and

as w e ll as an e v e n in g m a s te r's p ro g ra m fo r

m a n a g e m e n t, an d so c ia l re s p o n s ib ility and

w o rk in g a d u lts.

ch an ge.

Association for Humanistic

Psychology (AHP)

Saybrook G raduate School and

Research Center
4 5 0 P a c ific, 3 rd F lo o r

45 F ra n k lin S tre e t #315

S a n F ra n c isc o , C A 9 4 1 3 3 -4 6 4 0

S a n F ra n cisco , C A 9 4 1 0 2

P h o n e : (8 0 0 ) 8 2 5 -4 4 8 0

P h on e: (415) 8 6 4 -8 8 5 0

F ax: (4 15) 4 3 3 -9 2 7 1

Fax: (415) 8 6 4 -8 8 5 3

W e b site: h ttp :/ / w w w .s a y b ro o k .e d u

W eb site: h ttp :/ / w w w .a h p w e b .o rg /

E -m a il: s a y b r o o k @ s a y b r o o k .e d u .

E -m ail: a h p o ffic e @ a o l.c o m

T h e S a y b r o o k G ra d u a te S c h o o l an d R e se a rch
A H P w as fo rm e d in 1 9 6 2 b y A b ra h a m M a slo w ,

C e n te r p ro v id e s m a s te r's an d d o c to ra l

C arl R o g e rs, C h a rlo tte B u h le r, R o llo M ay ,

p ro g ra m s , re s e a rc h , a n d c o m m u n ic a tio n in

V irg in ia S atir, an d o th er fo u n d e rs o f the

h u m a n istic p s y c h o lo g y an d h u m a n scie n ce ,

p e rso n a l g ro w th m o v e m e n t. A H P is a fo ru m fo r

fo cu se d on u n d e rs ta n d in g an d e n h a n c in g the

sh a rin g id e a s an d in sp irin g c o m m u n ity th ro u g h

h u m a n e x p e rie n c e .

a fu ll ca le n d a r o f co n fe re n c e s an d e v en ts.
M e m b ers also c o n n e c t an d p u rsu e c o m m o n
in te rests th ro u g h se lf-g e n e ra te d co m m u n itie s
and p ro je cts ca lle d "E n e rg y C e n te r s ," w h ich
o ffe r p e rso n a l an d p ro fe ss io n a l su p p o rt and
carry ou t a ctiv itie s an d p ro je c ts o n sp e cific
issu es.

212

In fo rm a tion a n d T rain in g R esou rces

Psychodynamic Therapy

The C.G. Jung Institutes

T h e In te r-R e g io n a l S o c ie ty o f Ju n g ia n A n a ly sts

American Psychoanalytic
Association (APSA)

W ilm a H . S p ice , P h .D .
4 1 3 5 B ro w n s v ille R o a d
P ittsb u rg h , P A 1 5 2 2 7

309 E ast 4 9 th S tre e t

N ew Y o rk , N Y 1 0 0 1 7
P h on e: (212) 7 5 2 -0 4 5 0

P h o n e: (4 1 2 ) 8 8 2 -7 0 1 0
W e b site: h ttp :/ / w w w .c g ju n g .c o m / irs ja .h tm l
E -m a il: w s p ic e @ c c a c .e d u

Fax: (212) 593-0571

W eb site: h ttp :/ / a p sa .o rg

T h e re a re a n u m b e r o f in d e p e n d e n t C .G . Ju n g

E -m ail: c e n tra l.o ffic e @ a p sa .o rg

In stitu te s in the U n ite d S ta te s , all o f w h o m are

m e m b e rs o f th e In te rn a tio n a l A s s o c ia tio n for

A P SA is a p ro fe ss io n a l o rg a n iz a tio n o f
p sy ch o a n a ly sts th ro u g h o u t the U n ite d S ta te s.
T h e a s so cia tio n c o m p rise s A ffilia te S o c ie tie s and
T ra in in g In stitu te s in m a n y c itie s (liste d on th eir
W eb site at h ttp :/ / a p s a .o rg / o rg a n iz /
so ciety .h tm ) an d h a s a b o u t 3 ,0 0 0 in d iv id u a l
m e m b ers. A P S A is a R e g io n a l A s s o c ia tio n o f the
In te rn a tio n a l P sy c h o a n a ly tic a l A sso cia tio n .

Alfred Adler Institute of

San Francisco
7 C a m eo W ay
San F ra n cisco , C A 94131
P h on e: (415) 282-1661
W eb site: h ttp :/ / o u rw o rld .c o m p u s e rv e .c o m /
h o m e p a g e s / h s te in / h o m e p a g e .h tm
E -m ail: H T S te in @ w o rld n e t.a tt.n e t

A n a ly tic a l P sy c h o lo g y . In a d d itio n to the one

listed a b o v e , o th e r in s titu te s e x is t in
W a s h in g to n , D .C ., P h ila d e lp h ia , S a n F ra n cisco ,
L o s A n g e le s , C h ic a g o , D a lla s, B o sto n , S a n ta Fe,
N e w Y o rk , S e a ttle , a n d E u g e n e , O re g o n . A ll of
th e se in s titu te s o ffe r tra in in g p ro g ra m s , lectu re s,
an d w o rk s h o p s . (C o n ta c t in fo r m a tio n fo r the
o th er In s titu te s c a n b e fo u n d at:
h ttp :/ / b o u ld e r.e a rth n e t.n e t/ c g ju n g / )

Fam ily Therapy

American Association for Marriage
And Family Therapy (AAMFT)
1133 1 5th S tre e t, N W , S u ite 3 0 0
W a s h in g to n , D C 2 0 0 0 5 -2 7 1 0
P h o n e: (2 0 2 ) 4 5 2 -0 1 0 9

T h e A lfred A d le r In stitu te p ro v id e s d ista n ce

tra in in g , stu d y -a n a ly s is, an d c a s e c o n s u lta tio n to
m e n ta l h e a lth p ro fe ss io n a ls an d stu d e n ts

Fax: (2 02) 2 2 3 -2 3 2 9
W e b site: h ttp :/ / w w w .a a m ft.o rg /
E -m a il: C e n tr a l@ a a m ft.o rg

th ro u g h o u t the w o rld via te le p h o n e , E -m a il, and

the In s titu te 's W e b site d o c u m e n ts. A u n iq u e
m e n to r-b a se d s e rv ic e o ffe rs s e lf-p a c e d p ro g ra m s

A A M F T is th e p ro fe s s io n a l a s s o c ia tio n fo r the
field o f m a rr ia g e a n d fa m ily th e ra p y ,

th ro u g h c u sto m iz e d tra in in g , h o m e stu d y of

re p re s e n tin g th e p ro fe s s io n a l in te re sts o f m o re

a u d io -ta p ed se m in a rs, w e e k ly d is c u ss io n s , and

th a n 2 3 ,0 0 0 m a rria g e an d fa m ily th e ra p ists

case c o n s u lta tio n s b y te le p h o n e .

th ro u g h o u t th e U n ite d S ta te s , C a n a d a , and

213

A p p en d ix B

ab ro ad . T h e a sso c ia tio n fa c ilita te s re sea rch ,

g ro u p p s y c h o th e ra p y . C u rre n t p ro je c ts in c lu d e

theory d e v e lo p m e n t, an d e d u ca tio n . A A M F T

d e v e lo p in g n a tio n a l g u id e lin e s fo r d o cto ra l and

h o sts an a n n u a l n a tio n a l tra in in g c o n fe re n c e

p o std o c to ra l tra in in g in g ro u p p sy ch o th e ra p y .

ea ch fall as w ell as a w e e k -lo n g serie s of

co n tin u in g e d u c a tio n w o rk s h o p s in th e su m m er.

Association for Specialists in Group

W ork (ASGW)

Group Therapy

Je re m ia h D o n ig ia n , P re s id e n t
D e p a rtm e n t o f C o u n s e lo r E d u c a tio n

American Psychological Association

(APA) Division 49: Group
Psychology and Group
Psychotherapy

S U N Y C o lle g e a t B ro c k p o rt
B ro c k p o rt, N Y 1 4 4 2 0
P h o n e : (8 0 0 ) 3 4 7 -6 6 4 7
W e b site: h ttp :/ / w w w .c o ls ta te .e d u / c o e / a s g w /
E -m a il: jd o n ig ia @ p o .b r o c k p o r t.e d u

A lan M . O re n ste in , P h .D .
9 7 1 2 D eP a u l D riv e
B eth esd a , M D 2 0 8 1 7
P h on e: (202) 3 7 3 -7 0 8 3
W eb site: h ttp :/ / w w w .p itt.e d u / ~ c s le w is / G P 2 /
H e llo .h tm l
E -m ail: a la n o @ e ro ls .c o m

A S G W w a s fo u n d e d to p ro m o te q u a lity in
g ro u p w o rk tra in in g , p ra c tic e , an d re sea rch ,
b o th n a tio n a lly a n d in te rn a tio n a lly . A d iv isio n
o f th e A m e r ic a n C o u n s e lin g A s s o c ia tio n (A C A ),
A S G W n u m b e rs a m o n g its m e m b e rs m o re th an
5 ,8 0 0 g ro u p w o rk e rs an d g ro u p w o rk ed u ca to rs.
T h e A S G W W e b site p ro v id e s a re s o u rc e b a se

214

D iv isio n 49 o f th e A P A (see a b o v e ) p ro v id e s a

fo r te a c h e rs , s tu d e n ts , a n d p ra c titio n e rs o f g ro u p

fo ru m fo r p s y c h o lo g is ts in te re s te d in re sea rch ,

w o rk an d in c lu d e s b o th o r g a n iz a tio n a l

te ach in g , an d p ra c tice in g ro u p p s y c h o lo g y an d

in fo rm a tio n a n d p ro fe s s io n a l re so u rce s.

Appendix C
Glossary

A ttribution(s): A n in d iv id u a l's e x p la n a tio n o f

th a t e lic its a re s p o n s e w ith o u t an y p rio r

w h y an e v e n t o ccu rre d . S o m e re se a rc h e rs

le a rn in g h isto ry ) o r w ith a c o n d itio n e d

b elie v e th a t in d iv id u a ls d e v e lo p a ttrib u tio n a l

stim u lu s. T h is is a lso re fe rre d to as stim u lu s

sty les (i.e., p a rtic u la r w a y s o f e x p la in in g

su b stitu tio n . A s a p p lie d to s u b s ta n c e ab u se,

e v e n ts in th eir liv es th a t ca n p la y a ro le in the

re p e a te d p a irin g s b e tw e e n the e m o tio n a l,

d e v e lo p m e n t o f e m o tio n a l p ro b le m s and

e n v iro n m e n ta l, a n d s u b je c tiv e cu es

d y sfu n ctio n a l b e h a v io rs). T h e b asic

a s s o c ia te d w ith u se o f s u b s ta n c e s an d the

a ttrib u tio n a l d im e n s io n s a re in te rn a l/

a c tu a l p h y s io lo g ic a l e ffe c ts p ro d u c e d by

e x te rn a l, s ta b le / u n s ta b le , an d

ce rta in s u b s ta n c e s lea d to th e d e v e lo p m e n t of

g lo b a l/ sp e cific . F or in sta n c e , c lin ic a lly

a c la ss ic a lly c o n d itio n e d re sp o n se .

d e p re sse d p e rso n s ten d to b la m e th e m se lv e s

S u b s e q u e n tly , w h e n th e s u b s ta n c e a b u se r is

fo r ad v e rse life e v e n ts (in te rn a l), b e lie v e th a t

in th e p re s e n c e o f s u ch c u e s, a cla ssica lly

the ca u se s o f n e g a tiv e s itu a tio n s w ill last

c o n d itio n e d w ith d ra w a l sta te or cra v in g is

in d e fin ite ly (sta b le ), an d o v e rg e n e ra liz e the

e licited .

cau ses o f d isc re te o cc u rre n c e s (g lo b a l).

C ognitive restru ctu rin g: T h e g e n e ra l term

H e a lth ie r in d iv id u a ls, on th e o th e r h a n d ,

a p p lie d to th e p ro c e s s o f c h a n g in g the

view n e g a tiv e e v e n ts as d u e to e x te rn a l

c lie n t's th o u g h t p a tte rn s. U sin g th is p ro cess,

fo rces (fate, lu ck , e n v iro n m e n t), as h a v in g

th e th e ra p is t id e n tifie s d is to rte d "a d d ic tiv e "

iso la te d m e a n in g (lim ite d o n ly to sp e c ific

th o u g h ts in th e c lie n t an d e n c o u ra g e s h e r to

e v e n ts), an d as b e in g tra n sie n t or c h a n g e a b le

s e a rc h fo r m o re ra tio n a l w a y s o f see in g the

(lastin g on ly a s h o rt tim e).

s a m e e v e n t. T h e c lie n t d e v e lo p s and

A uthenticity: In e x is te n tia l th e ra p y , th is c o n c e p t
re fe rs to the c o n s c io u s fe e lin g s , p e rce p tio n s ,
and th o u g h ts th a t o n e e x p re s s e s and

p ra c tic e s th e se a lte r n a tiv e w a y s o f th in k in g

o v e r th e c o u rs e o f c o g n itiv e re stru ctu rin g .

C ontact: A te rm u se d in G e s ta lt th e ra p y th at

c o m m u n ica te s h o n e stly . A n in d iv id u a l

re fe rs to m e e tin g o n e s e lf an d w h a t is o th er

a ch iev es a u th e n tic ity th ro u g h c o u ra g e an d is

th a n o n e se lf. W ith o u t a p p ro p ria te co n ta ct

thu s a b le to d e fin e an d d is c o v e r h is o w n

a n d c o n ta c t b o u n d a rie s , th e re is n o real

m ean in g .

m e e tin g o f th e w o rld . In s te a d , o n e re m a in s

C lassical conditioning: A c c o rd in g to th is

e ith e r e n g u lfe d b y th e w o rld or d is ta n t from

th eory , an o rig in a lly n e u tra l stim u lu s

the w o rld an d p e o p le . T h e G e s ta lt th e ra p ist

b eco m es a co n d itio n e d s tim u lu s w h e n p a ire d

trie s to h e lp th e c lie n t m a k e c o n ta c t w ith the

w ith an u n co n d itio n e d s tim u lu s (an e v e n t

215

A p p en d ix C

p re se n t m o m e n t ra th e r th an s e e k in g d etailed

a ffe cts, a ctio n s, c o g n itiv e sty le, s e lf-e s te e m ,

in te llectu a l a n a ly sis.

an d s e lf-re p re s e n ta tio n s .

C ontingency m anagem ent: A co n tin g e n c y

m a n a g e m e n t a p p ro a ch a tte m p ts to ch a n g e

c la ss ic a l c o n d itio n in g p rin c ip le s to m a k e

th o se e n v iro n m e n ta l c o n tin g e n c ie s th a t m ay

b e h a v io rs p re v io u s ly a s s o c ia te d w ith

in flu e n ce s u b s ta n c e a b u se b e h a v io r. T h e

p o sitiv e o u tc o m e s less a p p e a lin g b y m ore

g o al is to in c re a se b e h a v io rs th a t are

c lo se ly a s s o c ia tin g th e m w ith n e g a tiv e

in co m p a tib le w ith u se. In p a rtic u la r,

c o n s e q u e n c e s . B y re p e a te d ly p a irin g those

co n tin g e n cie s th a t a re fo u n d th ro u g h a

cu es th a t fo rm e rly e lic ite d a p a rtic u la r

fu n ctio n a l a n a ly sis to p ro m p t as w ell as

b e h a v io r w ith n e g a tiv e ra th e r th a n p o sitiv e

re in fo rce su b sta n c e u se a re w e a k e n e d by

o u tc o m e s , th e cu es lo se th e ir a b ility to e licit

a sso cia tin g e v id e n c e o f su b s ta n c e a b u se (e.g.,

th e o r ig in a l c la s s ic a lly c o n d itio n e d re sp o n se ;

a d ru g -p o sitiv e u rin e s c re e n ) w ith s o m e fo rm

in s te a d , th e y e lic it a n e g a tiv e o u tco m e. T h is

o f n e g a tiv e c o n s e q u e n c e or p u n ish m e n t.

is a lso c a lle d a n a v er siv e o r co u n terco n d itio n in g

C o n tin g e n cie s th a t p ro m p t a n d re in fo rce

b e h a v io rs th a t are in c o m p a tib le w ith

tre a tm e n t a p p ro a c h .

C ou n tertransferen ce: T h e p h e n o m e n o n in

s u b sta n ce a b u se an d th a t p ro m o te a b stin e n ce

w h ic h th e th e ra p is t tra n sfe rs h is e m o tio n a l

are s tre n g th e n e d b y a s s o c ia tin g th e m w ith

n e e d s a n d fe e lin g s o n to h is c lie n t. T h is can

p o sitiv e re in fo rce rs.

o c c u r to a d e g re e o f p e rs o n a l in v o lv e m e n t

Core conflictual relationship them e (CCRT):

U se d in S u p p o rtiv e -E x p re s siv e (SE ) T h e ra p y ,
this c o n c e p t re fe rs to th e w a y in w h ic h the

th a t s e rio u s ly h a rm s th e th e ra p e u tic
re la tio n sh ip .

C overt sen sitization : A te ch n iq u e u sed in

c lie n t in te ra c ts w ith o th ers an d w ith h e rself.

c o u n te rc o n d itio n in g th e ra p y th a t p a irs

T h e C C R T is c o n s id e re d to b e th e c e n te r o f a

n e g a tiv e c o n s e q u e n c e s w ith s u b sta n c e -

clie n t's p ro b le m s. It d e v e lo p s fro m early

ch ild h o o d e x p e rie n c e s , b u t th e clie n t is

re la te d c u e s th ro u g h v is u a l im a g e ry .

Cue exposure: T h is p rin c ip le o f c la ss ic a l

u n aw are o f it an d o f h o w it d e v e lo p e d . SE

c o n d itio n in g h o ld s th a t if a b e h a v io r o ccu rs

th e rap y p o sits th a t th e c lie n t w ill h a v e b e tte r

re p e a te d ly a cro ss tim e b u t is n o t re in fo rce d ,

co n tro l o v er b e h a v io r if sh e k n o w s m o re

th e s tre n g th o f b o th th e c u e fo r th e b e h a v io r

a b o u t w h a t sh e is d o in g o n a n u n c o n sc io u s

a n d th e b e h a v io r its e lf w ill d im in ish , an d the

lev el.

b e h a v io r w ill e v e n tu a lly v a n is h . U sin g cu e

C ore response from others (RO ): A te rm u sed

e x p o s u re , a c lie n t is p re s e n te d w ith p h y sica l,

in SE th e rap y to e x p la in o n e w ay in w h ich

e n v iro n m e n ta l, s o c ia l, or e m o tio n a l cu es

the co re co n flic tu a l re la tio n sh ip th e m e is

a s s o c ia te d w ith p a s t s u b s ta n c e a b u se (e.g., by

u n co n scio u sly d e v e lo p e d . T h e R O

a c c o m p a n y in g h e r in to an o fte n -fre q u e n te d

re p re se n ts an in d iv id u a l's p re d o m in a n t

b a r). T h e c lie n t th e n is p re v e n te d fro m

e x p e cta tio n s or e x p e rie n ce s o f o th e rs'

d rin k in g or ta k in g d ru g s. T h is p ro c e s s , ov er

in te rn a l an d e x te rn a l re a c tio n s to h im self.

tim e , le a d s to d e c re a s e d re a c tiv ity to su ch

Core response of the self (RS): A te rm u sed in

SE th e ra p y th a t h e lp s to d e v e lo p an

216

C ou n tercon dition in g: A m e th o d th a t uses

cu es.

D efense m echan ism s: T h e m e a s u re s ta k e n by

in d iv id u a l's co re c o n flic tu a l re la tio n sh ip

an in d iv id u a l's e g o to re lie v e e x c e ssiv e

th em e. T h e R S re fe rs to a m o re or less

a n x ie ty . W h e n th e e n v iro n m e n t ca u se s

c o h e re n t c o m b in a tio n o f s o m a tic e x p e rie n ce s,

e x c e s s iv e s tre s s, th e c lie n t's e g o w ill o p era te

G lossary

u n co n scio u sly to d en y , d isto rt, or fa lsify

u p in to a tria d o f th e m o th e r, siste r, and

reality . D efen se m e c h a n is m s in clu d e d en ia l,

b ro th e r, a n d a d y a d o f th e fa th e r an d a n o th er

d isp la ce m e n t, g ra n d io sity , in tro je c tio n ,

sib lin g . In th a t c a s e , th e th e ra p is t m ig h t

iso la tio n , p ro je c tio n , re p re s sio n , re g re ssio n ,

h ig h lig h t th e fa c t th a t th e m o th e r an d fa th er

u n d o in g , and id e n tific a tio n w ith th e

c o m m u n ic a te th ro u g h o n e o f th e ir ch ild re n

ag g resso r.

a n d n e v e r ta lk to e a c h o th e r d irectly .

D eliberate exception: A situ a tio n in w h ich a

Fun ction al analysis: A p ro c e s s u se d in

clie n t h as in te n tio n a lly m a in ta in e d a p e rio d

b e h a v io ra l a n d c o g n itiv e - b e h a v io ra l th erap y

o f so b rie ty or re d u c e d u se fo r a n y re a so n .

th a t p ro b e s th e s itu a tio n s s u rro u n d in g the

F or e x a m p le , a clie n t w h o d id n o t use

c lie n t's s u b s ta n c e a b u s e . A fu n ctio n a l

su b sta n ce s fo r a m o n th in o rd e r to p a ss a

a n a ly sis e x a m in e s th e re la tio n s h ip s a m o n g

d ru g test fo r a n e w jo b h a s m a d e a d e lib e ra te

s tim u li th a t trig g e r u se an d th e c o n se q u e n ce s

e x ce p tio n to h is ty p ic a l p a tte rn o f d a ily

th a t fo llo w . T h is c a n p ro v id e im p o rta n t

su b sta n ce u se. If h e is re m in d e d th a t h e d id

clu e s re g a rd in g th e m e a n in g o f th e su b sta n ce

this in the p a st, it w ill d e m o n s tra te th a t he

u se b e h a v io r to th e c lie n t, as w e ll as p o ssib le

can d o so in th e fu tu re.

m o tiv a to rs a n d b a rrie rs to c h a n g e . In th ese

D irective approach: T h is fo rm o f g ro u p th e ra p y

fo rm s o f th e ra p y , th is is a firs t step in

o ffers stru ctu re d g o a ls a n d th e ra p is t-d ire cte d

p ro v id in g th e c lie n t w ith to o ls to m a n a g e or

in te rv e n tio n s to e n a b le in d iv id u a ls to ch a n g e

a v o id s itu a tio n s th a t trig g e r su b s ta n c e use.

in d esire d w a y s. It is a c o n tra s t to the

F u n c tio n a l a n a ly sis y ie ld s a ro a d m a p o f a

p ro c e s s -s e n s itiv e a p p ro a c h . T h e d ire c tiv e

c lie n t's in te rp e rs o n a l, in tra p e rs o n a l, and

a p p ro a ch a d d re sse s sp e cific a g e n d a ite m s in

e n v iro n m e n ta l c a ta ly s ts a n d re a c tio n s to

a lo g ica l o rd e r w ith g re a te r e m p h a s is on

s u b s ta n c e u se , th e re b y id e n tify in g lik e ly

co n te n t as th e p rim a ry so u rc e o f e ffe c tiv e

ch an g e.

Effect expectancies: A se t o f c o g n itiv e

p re c u rs o rs to s u b s ta n c e u se.

Insight: A p a rtic u la r k in d o f s e lf-re a liz a tio n or

s e lf-k n o w le d g e , u s u a lly re g a rd in g th e

e x p e cta n cie s th a t th e c lie n t d e v e lo p s

c o n n e c tio n s o f e x p e rie n c e s a n d c o n flic ts in

co n c e rn in g a n tic ip a te d e ffe c ts on h e r fe e lin g s

th e p a s t w ith p re s e n t p e rc e p tio n s and

and b e h a v io r as d rin k in g an d d ru g u se are

b e h a v io r, a n d th e re c o g n itio n o f fe e lin g s or

re in fo rce d b y th e p o sitiv e e ffe c ts o f the

m o tiv a tio n s th a t h a v e b e e n re p re sse d .

su b sta n ce b e in g ta k e n . T h e s e re p re s e n t th e

M iracle question: A s o lu tio n -fo c u s e d

e x p e cta tio n sh e h o ld s th a t ce rta in e ffe c ts w ill

in te rv ie w in g s tra te g y in w h ic h th e th e ra p ist

p re d icta b ly re su lt fro m d rin k in g or u sin g

ask s th e c lie n t th e q u e s tio n , " I f a m ira cle

sp e cific d ru g s.

h a p p e n e d a n d y o u r c o n d itio n w e re su d d en ly

Fam ily sculpting: A te c h n iq u e u sed in fa m ily

n o t a p ro b le m fo r y o u , h o w w o u ld y o u r life

th e rap y . T h e th e ra p is t " s c u lp t s " fa m ily

b e d iffe r e n t? " T h is fo rc e s th e c lie n t to

m e m b ers in ty p ic a l ro le s an d p re s e n ts

c o n s id e r a life w ith o u t s u b s ta n c e u se an d to

s ig n ifica n t situ a tio n s re la te d to su b sta n ce

ab u se p a tte rn s. In th is p ro c e s s , fa m ily

im a g in e h im s e lf e n jo y in g th a t life.

O perant learn in g: O p e ra n t le a rn in g re fe rs to the

m e m b e rs e n a c t a sce n e to g ra p h ic a lly d e p ict

p ro c e s s b y w h ic h b e h a v io rs th a t are

the p ro b lem . T h e p h y sic a l a rra n g e m e n t o f

re in fo rc e d in c re a se in fre q u e n cy . B eh a v io rs

the fam ily m e m b e rs ca n illu s tra te e m o tio n a l

th a t re s u lt in p o sitiv e o u tc o m e s or th a t allow

re la tio n sh ip s an d co n flic ts w ith in th e fa m ily .

th e c lie n t to a v o id n e g a tiv e c o n s e q u e n c e s are

F or e x a m p le , a fa m ily m a y n a tu ra lly b re a k

lik e ly to in c re a se in fre q u e n c y . S u b sta n ce

217

A p p en d ix C

use in the p re se n c e o f cla ss ic a lly co n d itio n e d

b e c a u se o f c irc u m sta n c e s th a t a re a p p a re n tly

cu es is in stru m e n ta l in re d u c in g or

b ey o n d h is c o n tro l. T h e c lie n t m a y say , fo r

e lim in a tin g the a ro u sa l a sso c ia te d w ith a

e x a m p le , th a t h e w a s ju s t "fe e lin g g o o d " and

sta te o f cra v in g , th u s se rv in g to re in fo rce the

d id n o t fe e l th e u rg e to u se at a p a rtic u la r

su b sta n ce a b u se b e h a v io r. T h a t is, the

tim e b u t c a n n o t p o in t to a n y in te n tio n a l

b e h a v io r s e rv e s a b a sic re w a rd in g fu n ctio n

b e h a v io rs o n h is p a rt th a t e n a b le d h im to

fo r the in d iv id u a l. F o r e x a m p le , a n a lco h o l

sta y so b e r. In s u ch in s ta n c e s , th e th e ra p ist

a b u ser w h o d rin k s to feel m o re s o cia l and

c a n a sk th e c lie n t to try to p re d ic t w h en such

less a n x io u s is u sin g su b s ta n c e s in an

a p e rio d o f "fe e lin g g o o d " m ig h t o c c u r ag ain ,

in stru m e n ta l w ay . T o th e e x te n t th a t she

w h ic h w ill fo rc e h im to b e g in th in k in g a b o u t

e x p e rie n ce s th e e ffe cts sh e se e k s, th e g re a te r

the b e h a v io rs th a t m a y h a v e h a d a n e ffe c t on

the lik e lih o o d sh e w ill u se a lc o h o l u n d e r

c re a tin g th e ra n d o m e x c e p tio n .

sim ila r c ircu m sta n c e s in the fu tu re.

Process-sensitive approach: T h is term co n sists

re fe rs to s o m e th in g or so m e o n e else th a t is

o f tw o, s o m e w h a t d iffe re n t, c o n tra s tin g ty p e s

e x p e rie n c e d an d u se d as if it w e re p a rt o f

o f g ro u p p s y ch o th e ra p y . T h e p ro c e ss-

o n e 's o w n self. F o r e x a m p le , a ch ild is

sen sitiv e g ro u p a p p ro a c h e x a m in e s the

d e p e n d e n t o n h e r p a re n t's lo v e an d p ra ise in

u n co n scio u s p ro ce s s e s o f th e g ro u p as a

o rd e r to d e v e lo p a s e n se o f s e lf-w o rth and

w h o le, u sin g th e se e n e rg ie s to h elp

se lf-e s te e m . In th a t w a y , th e ch ild

in d iv id u a ls see th e m se lv e s m o re cle a rly an d

in te rn a liz e s a p a rt o f th e p a re n t as the

th e re fo re o p en up the o p p o rtu n ity fo r

s e lfo b je c t.

ch an g e . T h e first ty p e o f p ro c e s s -s e n s itiv e

T h erap eu tic alliance: T h e re la tio n sh ip b e tw e e n

a p p ro a ch m a y b e te rm e d th e "g r o u p -a s -a -

the th e ra p is t a n d clie n t. In all

w h o le " a p p ro a c h and sees h e a lin g as an

p s y c h o d y n a m ic th e ra p ie s, th e first g o a l is to

e x te n sio n o f th e in d iv id u a ls w ith in th e g ro u p

e sta b lis h a "th e r a p e u tic a llia n c e " b e tw e e n

as the g ro u p c o m e s to term s w ith a

th e ra p is t a n d c lie n t, b e c a u se th is a sso c ia tio n

co m m o n ly sh a re d a n x ie ty . T h e seco n d ty p e

fu n ctio n s as th e v e h ic le th ro u g h w h ich

o f p ro c e s s -s e n s itiv e a p p ro a ch u se s an

c h a n g e o c c u rs. A th e ra p e u tic a llia n ce

in te ra ctio n a l g ro u p p ro c e s s m o d e l. By

re q u ire s in tim a te s e lf-d is c lo s u re o n th e p a rt

a tte n d in g to th e re la tio n sh ip s w ith in the

o f th e c lie n t a n d an e m p a th ic and

g ro u p and h e lp in g in d iv id u a ls u n d e rsta n d

a p p r o p ria te re s p o n s e o n th e p a rt o f the

th e m se lv es w ith in the re la tio n a l fra m e w o rk ,

th e ra p ist. In b rie f p s y c h o d y n a m ic th e ra p y ,

an in te ra ctio n a l g ro u p p ro c e s s p ro v id e s

th is a llia n c e m u s t b e e s ta b lis h e d as so o n as

in d iv id u a ls w ith sig n ific a n t in fo rm a tio n

p o ss ib le , a n d th e th e ra p is t m u s t b e a b le to

a b o u t how th e ir b e h a v io r a ffe c ts o th ers and

e sta b lis h a tru s tin g re la tio n sh ip w ith h is

how th ey are in tu rn a ffe c te d b y oth er

c lie n t in a s h o rt tim e.

m e m b ers.

Psychodram a: A m e th o d o f p s y c h o th e ra p y in

Transferen ce: T h e p ro c e s s , b a sic to all

p s y c h o d y n a m ic th e ra p ie s, o f th e c lie n t's

w h ich c lie n ts a ct o u t th e ir p e rso n a l p ro b le m s

tra n sfe re n c e o f s a lie n t c h a ra c te ris tic s of

by s p o n ta n e o u s ly e n a c tin g sp e c ific ro le s in

u n re s o lv e d c o n flic te d re la tio n s h ip s w ith

d ra m a tic p e rfo rm a n ce s p e rfo rm e d b e fo re

s ig n ific a n t o th e rs o n to th e th e ra p is t. For

fellow clien ts.

e x a m p le , a c lie n t w h o s e re la tio n sh ip w ith h er

Random exception: A n o c c a sio n u p o n w h ich a

clie n t re d u ce s su b s ta n ce u se or a b sta in s
218

Selfobject: A te rm u se d in s e lf p s y c h o lo g y th at

fa th e r is d e e p ly c o n flic te d m a y fin d h e rs e lf
re a c tin g to th e th e ra p is t a s if h e w e re h er

G lossary

fath er. A n in itia l g o a l o f b rie f

T ransp erson al aw aken in g: T h e p ro ce ss o f

p s y ch o d y n a m ic th e ra p y is to fo ster

a w a k e n in g fro m a le s s e r to a g re a te r id e n tity

tra n sfe re n ce b y b u ild in g th e th e ra p e u tic

in tra n sp e rs o n a l p s y c h o th e r a p y . T h is fo rm

re la tio n sh ip . O n ly th e n c a n th e th e ra p ist

o f th e ra p y u se s th e h e a lin g n a tu re o f

h e lp th e clie n t b e g in to u n d e rsta n d h er

s u b je c tiv e a w a re n e s s a n d in tu itio n in th e

re a so n s fo r u sin g su b s ta n c e s an d to c o n sid e r

p ro c e s s o f a w a k e n in g a n d e m p lo y s the

a ltern a tiv e , m o re p o sitiv e b e h a v io r.

th e ra p e u tic r e la tio n s h ip as a v e h icle fo r this

a w a k e n in g in b o th c lie n t a n d th e ra p ist.

219

Appendix D
Health Promotion Workbook

R ep rin ted w ith p e rm is sio n fro m B a rry , K .L ., and B lo w , F .C ., 1998.

Part 1: Summary of Health Habits

L et's re v iew s o m e o f th e in fo rm a tio n a b o u t y o u r h e a lth , b e h a v io r, a n d h e a lth h a b its th a t w e d iscu sse d in
the clin ic.

Exercise
D ay s p e r w e e k y o u p a rtic ip a te d in v ig o ro u s activ ity

M in u tes o f e x e rcise p e r d ay

none

seld o m

1 -2 days p er w eek

3 -5 days p er w eek

6 -7 days p er w eek

n o t a p p lic a b le

fe w e r th a n 15 m in u te s

1 5 - 3 0 m in u te s

m o re th a n 3 0 m in u te s

n o c h a n g e in w e ig h t

g a in e d m o re th a n 10 p o u n d s

Nutrition
W e ig h t ch a n g e in la st 6 m o n th s

lo st m o re th a n 10 p o u n d s

d o n 't k n o w

221

A p p en d ix D

Tobacco Use
T o b a cco u sed in la st 6 m o n th s

no

y es

If yes, w h ich ones?

A v e ra g e c ig a re tte s sm o k e d p e r d a y in la st 6 m o n th s

cigarettes

ch e w in g to b a cc o

p ip e

n o t a p p lica b le

1 -9

1 0 -1 9

2 0 -2 9

30+

1 -2 days p er w eek

3 -4 d ays p er w eek

5 -6 d ays p er w eek

7 d ays p er w eek

1 - 2 d rin k s

Alcohol Use
D rin k in g d ay s p er w eek

D rin k s p er d ay

3 - 4 d rin k s

5 - 6 d rin k s

7 or m o re

B in g e d rin k in g w ith in la st m o n th (5 or m o re d rin k s p er

none

occa sio n fo r w o m e n ; 6 or m o re d rin k s p e r o cca sio n fo r

1 - 2 b in g e s

m en)

3 - 5 b in g e s

6 -7 binges

8 or m o re

A re th ere an y o f th e se h e a lth b e h a v io rs (e x ercise,

no

n u tritio n , to b a cco u se, a lc o h o l u se) w ith w h ich you

yes

w o u ld lik e s o m e h elp ?

i f ; yes, w h ic h o n e s?

e x e rc ise

n u tritio n

to b a c c o u se

a lc o h o l u se

Part 2: Types of Drinkers in the U.S. Population

It is h e lp fu l to th in k a b o u t the a m o u n t o f a lco h o l c o n su m e d by a d u lts in th e U n ite d S ta te s a n d b y y ou .
T h e re are d iffe re n t ty p e s o f d rin k e rs a m o n g th e a d u lt p o p u la tio n , a n d th e se ty p e s c a n b e e x p la in e d by
d iffe ren t p a tte rn s o f a lco h o l c o n s u m p tio n . T h e s e in clu d e :

222

H ea lth P rom otion W orkbook

Patterns of A lcohol C onsum ption

Types

A b sta in e rs an d lig h t

D rin k n o a lc o h o l or fe w e r th a n 3 d rin k s p e r m o n th

d rin k ers

A lco h o l u se d o e s n o t a ffe c t h e a lth or re s u lt in n e g a tiv e co n s e q u e n c e s

P re g n a n t an d b re a s tfe e d in g w o m e n a re a d v is e d to d rin k NO a lco h o l

M o d e ra te d rin k ers

D rin k 3 or fe w e r tim es p e r w e e k
D rin k 1 -3 sta n d a rd d rin k s p e r o c c a sio n
A lc o h o l u se d o e s n o t a ffe c t h e a lth or re s u lt in n e g a tiv e c o n s e q u e n c e s
A t tim e s m o d e ra te d rin k e rs c o n s u m e NO a lc o h o l, s u c h as b e fo re
d riv in g , w h ile o p e ra tin g m a c h in e ry , w h ile p r e g n a n t, etc.

A t-risk d rin k ers

D rin k o v e r 12 (w o m e n ) an d 15 (m en ) s ta n d a rd d rin k s p e r w e e k
A t risk fo r n e g a tiv e h e a lth an d s o c ia l c o n s e q u e n c e s

H e a v y d rin k in g h a s led to p h y s ic a l n e e d fo r a lc o h o l a n d to o th er

A lco h o lics

p ro b le m s
A t-R isk D rin k e rs (1 0 % )

A lco h o lic s (1 0 % )
M o d e ra te D rin k e rs (4 0 % )

A b sta in ers an d L ie h t D rin k e rs (4 0 % )

Part 3: Consequences of Heavy Drinking

D rin k in g a lco h o l ca n affect y o u r physical health , em otional and social w ell-b ein g, a n d you r

relationships w ith others. T h e fo llo w in g a re s o m e o f th e p o sitiv e e ffe c ts th a t p e o p le s o m e tim e s d escrib e

as a resu lt o f d rin k in g a lco h o l.

T e m p o ra ry h ig h

S o c ia l ease

T e m p o r a rily re d u c e d stress

F o rg e t o n e 's p ro b le m s

R e la x a tio n

lev els

E n jo y the ta ste

S e n se o f co n fid e n ce an d d a rin g

A v o id u n c o m fo rta b le fe e lin g s
E a se in s p e a k in g o n e 's m in d
223

A p p en d ix D

T h e fo llo w in g a re s o m e o f th e negative co n seq u en ces th a t m a y re s u lt fro m d rin k in g .

D ifficu lty c o p in g w ith

S lee p p ro b le m s

A c c id e n ts / in ju rie s

stre ssfu l situ a tio n s

A rre sts fo r d riv in g u n d e r

R e la tio n s h ip p ro b le m s

D ep ressio n

th e in flu e n c e o f a lco h o l

In c re a s e d risk o f se x u a l a ssau lt

B la ck o u ts

S e x u a lly tra n sm itte d

F in a n c ia l p ro b le m s

P ro b le m s at w o rk or sch o o l

d ise a ses

S to m a c h p a in

L iv er p ro b le m s

C a r cra sh e s

S e x u a l p e rfo rm a n ce p ro b le m s

H ig h b lo o d p re s s u re

Part 4: Reasons To Quit or Cut Down on Your Drinking

T h e p u rp o se o f th is step is to th in k a b o u t th e b e s t re a so n fo r y ou to q u it or cu t d o w n o n y o u r d rin k in g .
T h e re a so n s w ill b e d iffe re n t fo r d iffe re n t p e o p le.

T h e fo llo w in g list id e n tifie s s o m e o f th e re a so n s w h y p e o p le d e c id e to cu t d o w n or q u it d rin k in g . C h eck

each b ox by the th ree m o st im p o rta n t re a so n s w h y Y O U w a n t to q u it or c u t d o w n o n y o u r d rin k in g .
P erh ap s y o u can th in k o f o th e r re a so n s th a t a re n o t o n th is list.

T o c o n su m e fe w e r e m p ty c a lo rie s (a lco h o lic d rin k s c o n ta in m a n y ca lo rie s )

T o sleep b etter

T o liv e lo n g e r p ro b a b ly b e tw e e n 5 and 10 y e a rs lo n g e r

T o lo o k y o u n g e r

T o be less lik e ly to d ie o f h e a rt d ise a se or c a n ce r

T o sa v e lots o f m o n e y

T o be h a p p ie r

T o re d u ce the p o ssib ility th a t I w ill d ie o f liv e r d ise a se

T o re d u ce the p o ssib ility th a t I w ill d ie in a ca r cra sh

T o a ch iev e m o re in m y life

T o d o b e tte r a t m y jo b

T o be a b e tte r fa th e r/ m o th e r to m y ch ild re n

O th er:

W rite d o w n the th ree m o st im p o rta n t re a so n s y ou c h o se to c u t d o w n or q u it d rin k in g .

1.

2.
3.

224

_________________________________________________________________________________

H ealth P rom otion W orkbook

T h in k a b o u t th e c o n s e q u e n c e s o f c o n tin u in g to d rin k h e a v ily . N o w th in k a b o u t h o w y o u r life m ig h t

im p ro v e if y o u ch a n g e y o u r d rin k in g h a b its b y cu ttin g d o w n or q u ittin g . W h a t im p ro v e m e n ts d o you
an ticip a te?
P h y sica l h ealth :

M en tal h ealth :

Fam ily:

O th e r re la tio n sh ip s:

W o rk / sch o o l:

Fin an cial:

L egal:

Part 5: Drinking Agreem ent_____________________________

T h e p u rp o se o f th is step is to d e cid e on a d rin k in g lim it fo r y o u rs e lf fo r a p a rtic u la r p e rio d o f tim e.
N e g o tia te w ith y o u r h e a lth c a re p ro v id e r so y o u ca n b o th a g re e on a re a s o n a b le g o a l. A re a so n a b le goal
for som e p e o p le is a b stin e n c e n o t d rin k in g an y a lco h o l.
A s you d e v e lo p th is a g re e m e n t, a n sw e r th e fo llo w in g q u e stio n s:

H ow m a n y sta n d a rd d rin k s (see b e lo w )?

H ow fre q u e n tly ?

For w h a t p e rio d o f tim e ?

DRINKING AGREEMENT
D a t e :_____________________________

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
P a tie n t sig n a tu re :

P h y sician sig n a tu re :

225

A p p en d ix D

T h e d rin k s sh o w n b elo w in n o rm a l m e a su re c o n ta in ro u g h ly th e sa m e a m o u n t o f p u re a lco h o l. Y o u can

th in k o f e a ch o n e as a standard drink.

W hats a standard drink?

1 standard drink =
1 can of
ordinary
beer or ale
12 oz

a single shot

a small glass
of liqueur or
aperitif
4 oz

Drinking Diary Card

O n e w ay to k eep tra ck o f h o w m u ch y o u d rin k is th e u se o f d rin k in g d ia ry c a rd s. O n e ca rd is u se d fo r
e ach w eek . E v e ry d a y re co rd the n u m b e r o f d rin k s y o u h a v e. A t th e e n d o f th e w e e k a d d up the to ta l
n u m b e r o f d rin k s y o u h a d d u rin g th e w eek .

Diary Card
K E E P T R A C K O F W H A T Y O U D R IN K O V E R T H E N E X T 7 D A Y S

S T A R T IN G D A T E __________________

Day

B eer

W ine

Liq u or

Sunday
M onday
T u esd a y
W e d n esd a y
T h u rsd a y
F rid a y
S a tu rd a y
W E E K 'S T O T A L :

226

N um ber

H ea lth P rom otion W orkbook

Part 6: H andling Risky Situations________________________

Y ou r d e sire to d rin k m a y c h a n g e a c c o rd in g to y o u r m o o d , th e p e o p le y o u a re w ith , an d th e a v a ila b ility of
a lco h o l. T h in k a b o u t y o u r la st p e rio d s o f d rin k in g .

H ere are e x a m p le s o f risk y situ a tio n s. T h e fo llo w in g list m a y h e lp y o u re m e m b e r s itu a tio n s th a t can
resu lt in a t-risk d rin k in g .

P arties

S le e p le s s n e ss

A n ger

B o re d o m

F a m ily

W a tc h in g te le v is io n

T e n sio n

F rien d s

O th e r p e o p le d rin k in g

F e elin g lo n e ly

C ritic ism

C e rta in p la c e s

F e e lin g s o f fa ilu re

D in n e r p a rtie s

A fte r w o rk

F ru stra tio n

C h ild re n

W eekend s

U se o f to b a cco

T V or m a g a z in e A d s

A rg u m e n ts

W h a t are so m e situ a tio n s th a t m a k e y o u w a n t to d rin k a t a risk y le v e l? P le a s e w rite th e m d o w n .

1.

2.

Ways To Cope With Risky Situations

It is im p o rta n t to fig u re o u t h o w y o u ca n m a k e su re y o u w ill n o t g o o v e r d rin k in g lim its w h e n y o u are
tem p ted . H e re are e x a m p le s:

T e le p h o n e a

C a ll on a n e ig h b o r

R ead a book

W a tc h a m o v ie

P a rtic ip a te in a sp o rt

frie n d

G o fo r a w a lk

So m e o f th e se id e a s m a y n o t w o rk fo r y o u , b u t o th e r m e th o d s o f d e a lin g w ith ris k y s itu a tio n s m a y w o rk.

Id en tify w a y s in w h ich y o u co u ld co p e w ith th e sp e c ific risk y s itu a tio n s y o u lis te d a b o v e .

1.

For the firs t risk y s itu a tio n o r fe e lin g , w rite d o w n d iffe re n t w a y s o f c o p in g .

227

A p p en d ix D

2.

For th e seco n d risk y s itu a tio n or fe e lin g , w rite d o w n d iffe re n t w a y s o f co p in g .

T h in k a b o u t o th er situ a tio n s an d w a y s in w h ich y o u co u ld co p e w ith o u t u sin g a lco h o l.

Visit Summary
W e h av e co v e re d a g re a t d ea l o f in fo rm a tio n to d a y . C h a n g in g o n e 's b e h a v io r, e sp e c ia lly d rin k in g
p attern s, ca n b e a d ifficu lt c h a lle n g e . T h e fo llo w in g p o in te rs m a y h e lp y o u stic k w ith y o u r n e w b e h a v io r
and m a in ta in the d rin k in g lim it a g re e m e n t, e sp e c ia lly d u rin g the first fe w w e e k s w h e n it is m o st d ifficu lt.

R e m e m b e r th a t y o u a re c h a n g in g a h a b it and th a t it ca n b e h a rd w o rk . It b e c o m e s e a sie r w ith tim e.

R e m e m b e r y o u r d rin k in g lim it g o a l :______________________ ___________________

R ead this w o rk b o o k fre q u e n tly .

E v ery tim e y o u are te m p te d to d rin k a b o v e lim its an d a re a b le to re s is t, c o n g r a tu la te y o u rs e lf b e c a u se

you are b re a k in g an old hab it.

W h e n e v e r y o u feel v e ry u n co m fo rta b le , tell y o u rs e lf th a t th e fe e lin g w ill p a ss.

A t the en d o f e a c h w e e k , th in k a b o u t h o w m a n y d a y s y o u h a v e b e e n a b stin e n t (h a v e c o n su m e d n o
alco h o l) or h a v e b e e n a lig h t or m o d e ra te d rin k er.

S o m e p e o p le h a v e d a y s d u rin g w h ich th ey d rin k to o m u ch . If th a t h a p p e n s to y o u , D O N 'T G IV E U P.

Ju st sta rt ag a in th e n e x t d ay.

2 28

Appendix E
Resource Panel

G re g o ry B a rra n co

C o l. K e n n e th J. H o ffm a n , M .D ., M .P .H ., M .C .F .S

A ssista n t V ice P re sid e n t

D ru g an d A lc o h o l C o n s u lta n t

G o v e rn m e n t R e la tio n s

H e a d q u a rte rs , 1 8 lh M e d ic a l C o m m a n d

N a tio n a l C o u n c il fo r C o m m u n ity B e h a v io ra l
H e a lth ca re
R o ck v ille , M a ry la n d
P eg g y C la rk , M .S .W ., M .P .A .
B eh a v io ra l H e a lth / M e d ic a id M a n a g e d C a re
H ealth C a re F in a n cin g A d m in is tra tio n
B a ltim o re, M a ry la n d
P eter J. C o h e n , M .D ., J.D .
A sso cia te P ro fe sso r o f Law
G e o rg e to w n U n iv e rsity L aw C e n te r
W a sh in g to n , D .C .
N. R oss D eck
D ep u ty D irecto r
O ffice o f P ro g ra m s, B u d g e t, R e se a rch , and
E v a lu a tio n
O ffice o f N a tio n a l D ru g C o n tro l P o licy

O ffice o f A rm y S u r g e o n G e n e ra l
Y o n g S a n , S e o u l, K o rea
R ic h a rd T . S u c h in s k y , M .D .
A s s o c ia te C h ie f fo r A d d ic tiv e D iso rd e rs and
P sy c h ia tric R e h a b ilita tio n
M e n ta l H e a lth a n d B e h a v io ra l S cien ce s
S e rv ic e s
D e p a rtm e n t o f V e te ra n s A ffa irs
W a s h in g to n , D .C .
M ic h a e l F. W e a v e r, M .D .
A s s ista n t P ro fe s s o r o f In te rn a l M e d ic in e and
P sy ch ia try
D iv isio n o f S u b s ta n c e A b u s e M e d ic in e
M e d ic a l C o lle g e o f V irg in ia
V irg in ia C o m m o n w e a lth U n iv e rsity
R ic h m o n d , V irg in ia

W a sh in g to n , D G .

229

Appendix F
Field Reviewers

H e n rietta R o b in B a rn e s, M .D .

P a tricia B ra d fo rd , L .I.S .W ., L .M .F .T ., C .T .S .

A ssista n t P ro fe sso r o f M e d ic in e

C lin ic a l S o c ia l W o rk e r/ C o o r d in a to r

C a m b rid g e H e a lth A llia n ce

W JB D u n n M e d ic a l C e n te r

C a m b rid g e F a m ily H e a lth

D e p a rtm e n t o f V e te ra n s A ffa irs

H a rv a rd M e d ica l S ch o o l

C o lu m b ia , S o u th C a ro lin a

C a m b rid g e , M a s s a c h u se tts
Je ro m e R. B arry , M .S ., L .M .H .D ., C .P .C .,
C .A .D .A .C .
D irecto r
St. F ra n cis M e d ic a l C e n te r

M ilto n E a rl B u rg la ss, M .D .
P ro fe s s o r a n d T h e o lo g ia n
A d d ic tio n M e d ic in e
N e u ro p s y c h ia tric , F a m ily , an d L eg a l
M e d ic in e

G ran d Islan d , N e b ra sk a

H o m e s te a d , F lo rid a

In so o K im B erg , P h .D ., M .S .W .

A n th o n y J. C e llu c ci, P h .D .

D irecto r

A s s o c ia te P ro fe s s o r o f P sy c h o lo g y

T h e B rie f F a m ily T h e ra p y C e n te r

D ire c to r, Id a h o S ta te U n iv e rs ity C lin ic

B ro o k fie ld , W isc o n sin

Id a h o S ta te U n iv e rs ity

Ju d y A n n B ig b y , M .D .
M e d ica l D irecto r
C o m m u n ity H e a lth S e rv ic e s
B rig h a m an d W o m e n 's H o sp ita l
B o sto n , M a s s a c h u se tts
S u sa n B. B la ck sh e r, M .S .W .
E x e cu tiv e D ire cto r
C a lifo rn ia A s s o c ia tio n o f A d d ic tio n R e c o v e ry
R e so u rce s
S a cra m e n to , C a lifo rn ia

P o c a te llo , Id a h o
L a rry H a lv e rs o n , M .D .
S p rin g fie ld , M is s o u ri
T h o m a s J. H a rv e y , M .S .W .
S e n io r V ic e P re s id e n t fo r M e m b e r S e rv ices
T h e A llia n c e fo r C h ild r e n an d F a m lie s
M ilw a u k e e , W isc o n s in
Ja m e s N . H e ck le r, M .S ., M .B .A ., C .A .S .A .C .
M a n a g e d C a re L ia iso n
N e w Y o rk S ta te O ffic e o f A lc o h o lis m and
S u b s ta n c e A b u s e S e rv ic e s
A lb a n y , N e w Y o rk

231

A p p en d ix F

P ab lo H e rn a n d e z , M .D .
A d m in istra to r
D iv isio n o f B e h a v io ra l H e a lth
D e p a rtm e n t o f H e a lth , S ta te o f W y o m in g
C h ey e n n e , W y o m in g
Jo h n H ig g in s-B id d le , P h .D .
A ssista n t P ro fe s s o r/ P ro je c t D irecto r
C u ttin g B ack
D e p a rtm e n t o f C o m m u n ity M e d icin e and
H e alth C a re
U n iv e rsity o f C o n n e c tic u t H e a lth C e n te r
F a rm in g to n , C o n n e c tic u t
Je ff A . H o ffm a n , P h.D .

L in d a L a n trip , D .O .
M e d ic a l D ire c to r/ D u a l D ia g n o sis
P sy c h ia tris t
L ittle R o c k C o m m u n ity M e n ta l H e a lth
C e n te r
M id -A R K S u b s ta n c e A b u s e S e rie s
L ittle R o ck , A rk a n s a s
B ru c e R. L o re n z , B .S ., C .A .D .C ., N .C .A .C . II
D ire c to r
T h re s h o ld s, Inc.
G e o rg e to w n , D e la w a re
R u sse ll P. M a c P h e rs o n , P h .D ., C .A .P ., C .A .P .P .,
C .C .P ., D .A .C ., D .V .C .

P resid en t

P re s id e n t

D an y a In te rn a tio n a l, Inc.

R P M A d d ic tio n P re v e n tio n T ra in in g

S ilv er S p rin g , M a ry la n d

D e la n d , F lo rid a

R o b ert H o ld e n , M .A .

D o u g la s B. M a rlo w e , P h .D ., J.D .

P ro g ra m D irecto r

S e n io r S c ie n tis t

P artn e rs in D ru g A b u se R e h a b ilita tio n

T re a tm e n t R e se a rc h In s titu te a t the

C o u n se lin g (P ID A R C )
W a sh in g to n , D .C .
V a u g h n J. H o w la n d , M .S .W ., M .A .C .

U n iv e rs ity o f P e n n sy lv a n ia
P h ila d e lp h ia , P e n n sy lv a n ia
R u b y H . M a rtin e z , R .N ., P h .D ., C .S.

D irecto r

A s s ista n t P ro fe s s o r

T h e In te rv e n tio n C e n te r

A c u te a n d L o n g T e rm C a re S c h o o l o f

K e n sin g to n , M a ry la n d
D arin K a w a z o e , M .A ., C .S .A .C .
D irecto r
H a w a ii D ru g C o u rt P ro g ra m
H o n o lu lu , H a w a ii
C aro l L. K u p re v ich , M .A .
T ra in in g A d m in is tra to r
D iv isio n o f A lc o h o lism , D ru g A b u se , and
M e n ta l H e a lth
D e la w a re H e a lth an d S o c ia l S e rv ices
N ew C a stle , D ela w a re

N u rsin g
U n iv e rs ity o f C o lo ra d o H e a lth S cie n ce s
C e n te r
D en v e r, C o lo ra d o
S u sa n M c C ra n e , P h .D .
A s s o c ia te P ro fe s s o r
S c h o o l o f N u rsin g
U n iv e rs ity o f M a ry la n d
B a ltim o re , M a ry la n d
L isa A . M e lc h io r, P h .D .
V ic e P re s id e n t
T h e M e a s u re m e n t G ro u p
C u lv e r C ity , C a lifo rn ia

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Sco tt D. M iller, P h .D .

R o b e rt J. S c h n e id e r, E d .D .

C o -F o u n d er

P sy c h o lo g is t

B rief T h e ra p y T ra in in g C o n s o rtiu m

H a rv a rd V a n g u a rd M e d ic a l A sso cia te s

In stitu te fo r the S tu d y o f T h e ra p e u tic C h a n g e

B ra in tre e , M a s s a c h u se tts

C h ica g o , Illin o is
T h o m a s N ich o lso n , P h .D , M .P .H ., M .A .E d .
P ro fe sso r
D e p a rtm e n t o f P u b lic H e a lth

A n n e H . S k in sta d , P sy .D .
A s s ista n t P ro fe s s o r
D iv is io n o f C o u n s e lin g , R e h a b ilita tio n , and
S tu d e n t D e v e lo p m e n t

W e stern K e n tu c k y U n iv e rsity

Io w a A d d ic tio n T e c h n o lo g y T ra in in g C e n te r

B o w lin g G re e n , K e n tu ck y

U n iv e rs ity o f Io w a

M ich ele A. P a ck a rd , Ph .D .
E x e cu tiv e D irecto r

Io w a C ity , Io w a
R ich a rd E. S te in b e rg , M .S .

T ra in in g an d C o n su ltin g

P re s id e n t/ C E O

S A G E In stitu te

W e stC a re F o u n d a tio n

B o u ld e r, C o lo ra d o

L as V e g a s , N e v a d a

M ich ae l P a n ta lo n , P h .D .
A ssista n t P ro fe sso r o f P sy ch o lo g y
S u b sta n ce A b u se C e n te r
D e p a rtm e n t o f P sy ch ia try
Y ale U n iv e rsity S c h o o l o f M e d ic in e
N ew H a v en , C o n n e c tic u t
G ilb e rt R. P a rk s, M .D .
B o ard o f D irecto rs
N a tio n a l M e d ic a l A s s o c ia tio n
T o p e k a , K a n sa s
Jo e R. P ere ira , L .I.C .S .W ., C .A .S .
C lin icia n / T ra in e r
R e co v e ry S tra te g ie s
B elm o n t, M a ss a c h u se tts

R ich a rd T . S u c h in s k y , M .D .
A s s o c ia te C h ie f fo r A d d ic tiv e D iso rd e rs and
P sy c h ia tric R e h a b ilita tio n
M e n ta l H e a lth an d B e h a v io ra l S cien ce s
S e rv ice s
D e p a rtm e n t o f V e te ra n s A ffa irs
W a s h in g to n , D .C .
M ic h a e l J. T a le ff, P h .D ., C .A .C ., M .A .C .,
N .C .A .C . II
A s s ista n t P ro fe s s o r a n d C o o rd in a to r
G ra d u a te P ro g ra m s in C h e m ic a l D ep en d e n cy
C o u n s e lo r E d u c a tio n
D e p a rtm e n t o f C o u n s e lo r E d u ca tio n ,
C o u n s e lin g P sy c h o lo g y , a n d R e h a b ilita tio n
S e rv ic e s

A n th o n y M . R iz z o , P h .D .
C lin ica l P s y c h o lo g is t/ C o o rd in a to r

P e n n sy lv a n ia S ta te U n iv e rs ity
U n iv e rs ity P a rk , P e n n sy lv a n ia

C h e m ica l D e p e n d e n c y P ro g ra m s
D iv isio n o f M e n ta l H e a lth
S C R IP P S C lin ic
S a n D ieg o , C a lifo rn ia

A n th o n y T u sle r
C o o rd in a to r
H ig h T e c h C e n te r
S a n ta R o sa Ju n io r C o lle g e

M au rilia R o d riq u e z , P h .D ., R .N ., C .D .E .

S a n ta R o sa , C a lifo rn ia

H e alth and M e d ic a l S e rv ic e s
H o u sto n In d e p e n d e n t S c h o o l D istrict
H o u sto n , T e x a s

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N o la C. V e a z ie , P h .D ., L .P .C ., C .A .D .A .C .
S u p e rin te n d e n t

A s s o cia te P ro fe s s o r

M e d ica l S e rv ic e s D e p a rtm e n t

D e p a rtm e n t o f P sy c h ia try

U n ite d S ta te s A ir F o rce

U n iv e rs ity o f M in n e s o ta

San ta M a ria , C a lifo rn ia

M in n e a p o lis , M in n e s o ta

R o b ert W a lk e r, M .S .W ., L .C .S .W ., B .C .D .

D a v id K. Y a m a k a w a , Jr.

A s s ista n t P ro fe sso r

A tto rn e y a t L aw

C e n te r on D ru g a n d A lco h o l R e se a rc h

S a n F ra n c is c o , C a lifo rn ia

U n iv e rsity o f K e n tu ck y
L ex in g to n , K e n tu ck y
M ich a e l F. W e a v e r, M .D .
A ssista n t P ro fe sso r o f In te rn a l M e d icin e and
P sy ch ia try
D iv isio n o f S u b s ta n c e A b u s e M e d ic in e
M e d ica l C o lle g e o f V irg in ia
V irg in ia C o m m o n w e a lth U n iv e rsity
R ich m o n d , V irg in ia

234

K e n C . W in te rs , P h .D .