The Addiction Messenger

Transcription

1 The Addiction Messenger Volume 3: 2000 Edited by: Dixie L. Montague 3414 Cherry Ave NE, #100 Salem, Oregon Phone: (503) Fax: (503) A project of Oregon s Office of Alcohol & Drug Abuse Programs Northwest Frontier Addiction Technology Transfer Center 1

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3 Table of Contents Table of Contents Forward... 5 Issue 1: Addressing the Needs of Cultural Minorities in Drug Treatment... 7 Issue 2: Four Approaches to Cultural Responsiveness: Individualize the Counseling Issue 3: Client Specific Approaches To Cultural Responsiveness Issue 4: Brief Therapy: Issues to Consider Issue 5: Brief Therapy: Using Stages-of-Change Issue 6: Brief Therapy: Components of Effective Brief Therapy Issue 7: Brief Therapy: Goals of Treatment Issue 8: American Indians: Issues in Treatment Issue 9: Lesbian & Gay Issues in Chemical Dependency Treatment: Acceptance Issue 10: Lesbian & Gay Issues in Chemical Dependency Treatment: Dealing With Sexual Identity & Sobriety Issue 11: Comprehensive Treatment for Adult Survivors of Child Abuse & Neglect: Screening...47 Issue 12: Comprehensive Treatment for Adult Survivors of Child Abuse & Neglect: Therapeutic Issues for Counselors Issue 13: Comprehensive Treatment for Adult Survivors of Child Abuse & Neglect: Legal Issues Issue 14: The Transition Group:Linking Clients with Outpatient Care Issue 15: Comprehensive Case Management: Why Case Management Issue 16: Comprehensive Case Management: Functions of Case Management Issue 17: Comprehensive Case Management: Engagement & Assessment Issue 18: Substance Abuse Treatment for Persons With HIV/AIDS: Staff Training, Attitudes, And Issues Issue 19: Substance Abuse Treatment for Persons With HIV/AIDS: Continuum of Care Northwest Frontier Addiction Technology Transfer Center 3

4 Issue 20: Integrated Mental Health & Substance Abuse Treatment: Treatment Models Issue 21: Integrated Mental Health & Substance Abuse Treatment: Stages of Treatment Issue 22: Integrated Mental Health & Substance Abuse Treatment: How Families Can Help Issue 23: Treatment of Opiate Addiction: Buprenorphine/LAAM Issue 24: Treatment of Opiate Addiction: Methadone Index Table of Contents 4 Northwest Frontier Addiction Technology Transfer Center

5 Forward Forward Research based information on effective clinical practices often does not find its way into a counselor s hands because it is either couched in research terminology, is lengthy, or is not written in a way that can be easily used by busy practitioners. One of the objectives at the Northwest Frontier Addiction Technology Transfer Center (NFATTC) is to create channels for the flow of new information to practitioners in the field of addiction treatment. The Addiction Messenger is one of those channels. Our goal is to share tips for treatment improvement that have been validated through research or clinical practice in a format useful to counselors on a daily basis. The idea for a condensed, useable, practical format for communicating with counselors was a challenge presented to us by advisers, faculty, government officials and clinical supervisors. We took the challenge to heart. The Addiction Messenger was published twice each month and mailed to approximately 3,000 counselors, treatment agencies, colleges, and government offices. Each issue of the Addiction Messenger is a condensed four-page synopsis of counseling and treatment methods that can enhance the quality of addiction treatment. Based on clinical protocols supported by research and proven effective in clinical settings, these ideas are practical, efficient and likely to be received positively by clients. Many can be used in individual and group settings. We hope they will prove useful to counselors and students in training as an introduction to new ideas or as a refresher of concepts learned previously. This volume is a compilation of 24 Addiction Messengers published in During the course of the year changes in content evolved. We have attempted to fulfill some of the suggestions made in response to the survey we published as our first issue of the year. We hope the ideas we send you each month are useful to you and that you will share with us your reaction and your ideas for future issues. If you would like to be a subscriber, just let us know where you are! So far, the publication continues to be a free service. We look forward to hearing from you. Northwest Frontier Addiction Technology Transfer Center 5

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7 Issue 1 Addressing the Needs of Cultural Minorities in DrugTreatment The number of minority clients in treatment is increasing but many agencies have difficulty recruiting, retaining, and successfully treating them. While some studies have found that minorities fare about the same as nonminority clients in drug treatment, other research has suggested that ethnic and racial minorities are: less likely than other persons to seek substance abuse treatment, less likely to complete treatment, and less likely to reduce or eliminate substance abuse during or after treatment. Failure to understand a client s cultural values may be responsible for the high failure rate. For example, many blacks are regular churchgoers who feel that religion can help them with their addiction, and that 12-step programs like AA and NA don t meet their needs. Some treatment staff may disagree with this orientation and insist that their clients place church activities at a lower priority than attending 12-step meetings. It is important for counselors to support their African-American clients active church involvement while at the same time encouraging them to supplement their religious activities with frequent attendance at 12-step meetings. Some staff may become upset at what they perceive to be the loud and confrontational manner in which some African-American clients talk. Because of these and other cultural differences, it is important to have staff trained by a specialist in cultural issues; these staff, can then train other staff. Definition of Terms In this case, culture is defined as the way of life of a group of people, including their shared values, beliefs, and behaviors, which is passed from one generation to another and maintained by communication and learning, not by biological inheritance. Cultural sensitivity is: showing awareness of and respect for the cultural differences among ethnic and racial groups, and taking these differences into consideration in providing drug treatment to minority clients. You need to play an active role in integrating the client s cultural background into the treatment process. Why Cultural Responsiveness Is Important Some substance abuse counselors believe it is best to be color blind and ignore the client s culture, contending that Addiction is a democratic illness that strikes every group. All substance abusers have the same types of problems and needs. Addiction Messenger - Ideas for Treatment Improvement Northwest Frontier Addiction Technology Transfer Center 7

8 Substance abusers who bring up cultural issues are just trying to be unique. We re here to talk about disease. Addressing the Needs of Cultural Minorities in Drug Treatment However, to overlook a client s ethnic or racial group membership is to deny an extremely important aspect of his or her identity. Cultural characteristics-such as prohibitions against sharing family problems outside the family-may make it difficult or impossible for the client to participate effectively in the counseling process unless modifications are made to accommodate the person s values and behaviors. Clients may have cultural traits that interfere directly with recovery. Clients whose culture teaches them to be passive may feel it is wrong for them to take positive steps to avoid threats to recovery, such as leaving the home when a parent or spouse comes home drunk. Other clients may believe in their right to take actions that would promote recovery but are concerned about their family s culturally-based hostile reaction. Clients may fear that avoiding or departing early from stressful family events will result in the family withholding resources or ostracizing them. Members of ethnic and racial groups often experience stress unique to their minority status that may contribute to drug abuse. They often feel pressure to accommodate the incompatible values of their culture of origin with the values of mainstream U.S. culture. It is well documented that differences in the effectiveness of individual counselors regardless of treatment technique employed, play an important role in client retention in treatment. A key measure of effective treatment with minority clients is likely to be the counselor s degree of cultural responsiveness. It Is Important To Consider Culture Counselors may assume that all clients from the same culture share the same values, beliefs, and behaviors. The cultural traits attributed to each ethnic and racial group are at best only generalizations that can lead to stereotyping, alienating the client, and compromising treatment effectiveness. Various subcultures within each major ethnic grouping often have different values and behaviors. Hispanics who are Cuban-American, Central American, Puerto Rican, and Mexican American do not think and act alike on every issue. Hispanics in the United States are split into at least 18 different profiles. Members of even the same subculture will exhibit different values and behaviors because of the influence of such factors as gender, age, birth order, recency of immigration, education, residence, income, upbringing, and environmental influences. Members of the same minority group may have become acculturated to U.S. society to different degrees, or may conform to different features of American society. A client may be acculturated in some situations and not in others. This is most noticeable in the differences between first and second generation Americans. All of the characteristics ascribed to a particular minority group may also be found among other minority groups and among non-minorities as well. Some cultures may be much more likely to 8 Northwest Frontier Addiction Technology Transfer Center

9 keep their feelings to themselves or at least within the family. This lack of public display of emotion probably occurs among some members of every culture. Traits that are ascribed to an ethnic or racial group may not reflect cultural influences at all; they may instead be caused by the poverty, lack of education, or poor living conditions that a disproportionate number of minority group members share. Addressing the Needs of Cultural Minorities in Drug Treatment Even when a cultural characteristic has been identified in a minority client, you must be careful not to allow the client to use the trait as an excuse for avoiding treatment or engaging in behaviors that threaten recovery. Some clients may attribute their drug abuse entirely to discrimination. You need to assist clients who may justify a relapse on the basis of cultural discrimination to avoid using the prevalence of discrimination as an excuse for substance abuse. There have always been significant differences in life-style, values, and background between counselors and many of their clients. To be culturally responsive to minorities, follow what has always been good counseling practice in the treatment of any client. Do not jump to conclusions about the meaning of a client s thoughts, feelings, or behavior but instead determine what they signify on a client-by-client basis. General Techniques For Being Culturally Responsive The drug treatment counselor needs to be responsive to only those culturally influenced values and behaviors that are related to the client s decision to use drugs, struggle to remain abstinent, or resistance to treatment. If a client expresses a cultural belief that animals have souls or follows a cultural practice of taking an afternoon nap or dining at 10:00 P.M., and these cultural characteristics have no implications for sobriety or treatment, the counselor can ignore them. The counselor s task is to respond to the influence of culture on the client s drug problem so that treatment will have the best possible chance of promoting the person s recovery. There Are Four General Approaches to cultural responsiveness the counselor can apply to all minority clients, regardless of their cultural background or traits. While these approaches represent principles of sound counseling for use with any client, they assume added importance when treating a client from a different ethnic or racial group. 1. Individualize the counseling approach 2. Avoid assumptions 3. Act to build trust 4. Identify and address cultural issues that affect client recovery Source: Finn, Peter (1994). Addressing the Needs of Cultural Minorities in Drug Treatment: Journal of Substance Abuse Treatment, Vol II, No. 4, pp Northwest Frontier Addiction Technology Transfer Center 9

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11 Issue 2 Four Approaches to Cultural Responsiveness: Individualize the Counseling Approach A variety of clinical techniques and approaches are used in drug counseling. Some approaches work better with some clients for reasons unrelated to ethnic or racial background, such as the client s stage of recovery, degree of emotional development, cognitive skills, or verbal ability. Directive approaches may be most effective with clients who have a poor ability expressing themselves, while supportive approaches may be most appropriate when a client is extremely distraught. If a client suspects you are prejudiced, or if a client refuses to discuss personal feelings until you have opened up, disclosing some of your own background and experiences to the client may help build trust. Individualizing treatment is particularly important because clients who are culturally different adopt to the dominant culture in a wide variety of ways. While one minority client may be extremely reluctant to discuss personal issues, another client from the same background may be very open. Avoiding automatic use of the same counseling approach with each client is essential to your success in building an effective relationship with the client. Counselors have often assumed that minority clients prefer a directive style. Research tells us otherwise. Actually, counselors need to study each client s reactions during treatment and modify their communication approach as needed. With time and effort, counselors can often develop the skills and comfort level to employ a range of approaches aimed at meeting the needs of individual clients.. Avoid Assumptions You should avoid jumping to conclusions regarding the meanings of statements, body language, and expressions of feeling presented by any client, but especially by a client from another cultural background. Among some ethnic groups it is a sign of respect for young people or women not to speak until spoken to. Counselors can misinterpret such behavior as reflecting dishonesty, feelings of guilt, lack of verbal ability, or depression. You should form hypotheses about what potentially culturally based behavior or statements may mean and then verify your hypotheses. Allow the client to explain the behavior or statements, consult with family members, and review the case with informed colleagues. Cultural responsiveness involves constantly testing alternative hypotheses in this manner. Act To Build Trust Proving that you are a competent and trustworthy clinician may be difficult with some minority clients. Some people of color may assume that any white person harbors racist attitudes. They may begin treatment with the belief that a culturally different counselor cannot be qualified to treat them. White counselors need to learn whether an African- American or Asian-American client harbors this belief in order to make a conscious effort Addiction Messenger - Ideas for Treatment Improvement Northwest Frontier Addiction Technology Transfer Center 11

12 to establish trust in their objectivity and competence. Learning about the client s perceptions of you involves inquiring about the person s experiences with racism and bigotry, and developing an understanding of how the larger socio-political system has historically and may currently discriminate against the ethnic or racial group to which the person belongs. There are several ways in which you may need to modify your clinical approach in order to develop client trust: Four Approaches to Cultural Responsiveness disclose information about your personal experiences with minorities; openly express feelings (anger, frustration, joy); and explain during the first counseling session how confidentiality will be maintained. Make clear that no mention of the client s involvement in counseling or certain admissions by the client (extramarital affairs, homosexuality, strong feelings of resentment toward a close relative) will be shared with other family members. Some clients may test your objectivity for several sessions until they are convinced you are not bigoted or that you recognize your prejudices and are able to prevent them from interfering with treatment. Identify and Address Cultural Issues That Affect Client Recovery Counselors sometimes avoid addressing cultural issues because they: do not believe that cultural beliefs and behaviors influence recovery. feel they must treat every client the same. are concerned about exposing their own ignorance or prejudices about the client s culture. are concerned that the client will use ethnic differences as an excuse for his or her addiction/inappropriate behavior. believe that exploring these issues will heighten awareness of the differences between them and the client. There is some validity to all of these concerns: Many cultural values and behaviors do not have any effect on recovery, people are more similar to each other than they are different, some clients will use their cultural background to try to manipulate the counselor, clients will always know more about their culture than the counselor knows, and addressing cultural issues will focus attention on the different ethnic backgrounds of counselor and client. The reality is that counselors are most likely to succeed with a client from another ethnic or racial group when the cultural issues that are affecting the client s recovery are openly and objectively talked about. If you fail to address relevant cultural issues, clients may infer that they have to shed their cultural identity in order to stop taking drugs and maintain abstinence. Addressing pertinent cultural issues involves collaborating with the client to: ~ identify the cultural issues that are affecting his or her recovery. ~ assisting the client to acknowledge them. 12 Northwest Frontier Addiction Technology Transfer Center

13 ~ preventing the client from misusing them to excuse inappropriate behavior. ~ resolving them in a manner that eliminates their harmful effect on recovery but at same time respects their importance to the client. Suggestions: Try to break the ice with a client by sharing information about yourself. Explain how you will make mistakes with regard to his/her culture and not even realize it. Ask the client to please point these mistakes out, even if it looks like you don t want to know about it, or he/ she fears it will be impolite. Encourage your client to deal with racial identity issues. Encourage discussion about the client and the counselor s interactions along racial lines. Four Approaches to Cultural Responsiveness 1. Identify the expectations your minority clients have for counseling, what they believe counseling is, and what their feelings about counseling are. Address any differences in perceptions between the client and yourself. 2. Find out how the client feels about working with a counselor from a different cultural background. 3. Attempt to identify whether the client will have difficulty talking about personal matters and, if so, why. 4. Gather information on the client s family, including its strengths for supporting and weaknesses that may hamper the client s recovery. 5. Examine issues revolving around racial identity and associated personal conflicts. 6. Examine the possible role of environmental factors that may be associated with the client s substance abuse or that represent threats to recovery, such as racism and discrimination, language barriers, and dealing with social service agencies. Because of their sensitive nature, it is best not to explore ethnic and racial issues in group counseling sessions with clients from very different cultural backgrounds. It is less likely with culturally mixed groups that the cohesiveness and peer learning that help make this treatment modality effective will occur. However, ethnically and racially sensitive issues can be addressed in groups composed of clients from a single cultural background. Source: Finn, Peter (1994). Addressing the Needs of Cultural Minorities in Drug Treatment: Journal of Substance Abuse Treatment, Vol II, No. 4, pp Northwest Frontier Addiction Technology Transfer Center 13

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15 Issue 3 Client Specific Approaches To Cultural Responsiveness While general counseling strategies can be used with any minority client, there are a number of specific counseling approaches for responding effectively to particular cultural characteristics. Respond to what you have already learned about each individual client s culturally based values and behaviors. Accommodate Family Values - Some of the most commonly observed cultural characteristics of minority groups involve the nature of the family: Strong feelings of family loyalty may stop clients from discussing family problems with strangers. The opinions of family members may be deferred to Many relatives and even nonrelatives may play a vital role making decisions for individual family members. There may be very distinct and rigid roles for husbands and wives, sons and daughters. Family members may place family concerns above the needs of the individual. Determine the Appropriate Response. You may need to consider involving the family in actively supporting the client s recovery and/or family counseling. Before making this decision you and your client, need to decide: Who constitutes the client s family? How does the client view his or her relationship to the family? (does the client feel it is an act of betrayal to discuss family matters outside the family) Should the family be involved in treatment because the client will have difficulty recovering if his or her relatives are not involved? Should the family be considered the client? Should the client be counseled in one-on-one sessions but counseled with full consideration of the impact of the client s behavior on the family and the family s likely response? Consider One-Person Family Counseling - It can be difficult to bring family members into the counseling process. One person family therapy attempts to achieve the goals of family therapy (the reduction of problem behaviors in the client and the development of more adaptive family functioning) while working with only one family member. The one person modality applies the principle that change in the behavior of the client will require corresponding adjustments in the behavior of other family members toward each other and toward the client. In one person family therapy, you work to change the client s behavior. Then, the client goes home to bring about changes in the family. Among the techniques you may use are Task setting - assigning tasks as homework after careful rehearsal during counseling and starting with very easy assignments. Reversals - suggesting that the client act in the opposite manner to his or her usual behavior with a family member to allow for new interactional patterns to emerge. Detriangulation having the client leave the scene of a conflict between two other family members who are trying to form an alliance with the client as a third party. Addiction Messenger - Ideas for Treatment Improvement Northwest Frontier Addiction Technology Transfer Center 15

16 Key features of this modality are: 1. Keep it brief 12 to15 counseling sessions, one session per week. 2. Don t spend time on matters that do not directly affect the problem. 3. Plan strategies (with client) to change the way in which family members interact. 4. Use any counseling approaches that work, from gestalt techniques to behavior therapy. Client Specific Approaches To Cultural Responsiveness Clinicians tested one person family therapy. The results indicated that one person family counseling was as effective as the family modality both in reducing substance abuse among clients and in bringing about and maintaining significant improvement in family functioning. Consider Bicultural Counseling Family intergenerational conflict is a common cultural problem for many minorities. Besides the frequent tension between adolescents and their parents, there may be conflict based on cultural disagreements between the younger generation, who have become acculturated and their parents who may wish to retain some or all of the old ways. This conflict can appear in drug counseling in many guises: Intergenerational cultural conflict itself can be a source of stress that may contribute to drug use. Wanting to fit into what they think is the approved drinking and drug use patterns of the dominant society. Anguish at feeling they will betray the family by disclosing to you any family problems that may be interfering with recovery. Treating substance abusers who are experiencing these tensions may be facilitated if the counselor tries to help the client function effectively in both the old culture and the new one. Treatment may be further enhanced if all family members are brought into counseling and assisted to become bicultural. Bicultural Effectiveness Training (BET) BET encourages more harmonious family relations by fostering appreciation of both the original culture and the new culture. BET Training usually consists of twelve minute sessions divided into three phases: Phase I: an introduction to culture, biculturalism, culture conflict, and family development in order to create a shared world view. Phase 2: targets four specific areas in which culture conflicts intersect family interactions: family composition, family relational styles, family stress, and family conflict. Place emphasis on establishing alliances between generations for each content area. Phase 3: establish a transcultural world view that solidifies the gains made in establishing culture conflict as a common foe and fostering intergenerational alliances. Respond to the Client s Style of Communication Some cultures do not believe gaining insight through talk therapy helps find a solution. To be effective with such clients, you may need to adopt a directive approach, providing information, interpretations of the client s problems, and practical suggestions for solving them. At the beginning of family counseling, you could ask the relatives present to introduce themselves one by one and say in one word how they feel about being there (in order to establish the counselor s leadership position and place family members in a peer learning role). 16 Northwest Frontier Addiction Technology Transfer Center

17 Confrontational counseling approaches don t work well with some members of some cultural groups. You may need to provide prompt help with problem solving for clients whose culture is oriented toward the immediate present. Delay in providing a practical advice may result in their dropping out of treatment. Different cultures express feelings in different ways. Among the differences in intensity and style are: emotional expressing feelings openly, animatedly, even heatedly. demonstrative showing what one means and feels through body language, such as gesturing, laughter, and raising one s voice. elliptical conveying in euphemisms and subtleties one s true feelings and intentions. nonexpressive not communicating feelings at all, even by indirection. Client Specific Approaches To Cultural Responsiveness Some common culturally based physical forms of expression: Lack of eye contact. In some cultures, it is a sign of respect not to look a person of authority in the eye. A woman talking with a man, or an adolescent with an adult. Gesturing. In some cultures, gesturing is a normal part of conversation. Moaning, groaning, and crying to express emotion may also be culturally approved. Physical proximity. In some cultures people stand or sit closer together, or farther apart, than you may find comfortable. Remaining too far away may be interpreted by the client as lack of interest or fear on the counselor s part; staying too close may be perceived as intimidating or insulting. Physical contact. Any physical contact between strangers-or among family members in public-may be considered inappropriate. Other cultures may encourage long and firm handshakes, hugging, arm holding, and other means of physical expression even between strangers. You should never initiate any physical contact with a client. Know Thyself You need to be aware of your own cultural values if you hope to be successful in treating clients from a different culture. You need to try to discover the preconceptions, prejudices, and stereotypes you may have. Sometimes, simple misjudgments rather than bias or cultural values get in the way of a counselor s treatment efforts with a client from a different ethnic group. Source: Finn, Peter (1994). Addressing the Needs of Cultural Minorities in Drug Treatment: Journal of Substance Abuse Treatment, Vol II, No. 4, pp Northwest Frontier Addiction Technology Transfer Center 17

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19 Issue 4 Brief Therapy: Issues to Consider Brief therapy for substance abuse treatment is a valuable but limited approach, and it should not be considered a standard of care for all populations. In fact, time in treatment has been found to be directly related to better outcomes within a range of modalities, including therapeutic communities, psychotherapy, methadone maintenance therapy, and extended detoxification. There is promising evidence that brief therapies as a treatment for substance abuse disorders can be as effective as lengthier treatments for some clients. Clients seeking treatment could be given brief therapy initially, before moving on to long-term treatments. But remember, brief therapy should be considered a useful tool in a portfolio of interventions and its use should be targeted to those clients who are most likely to benefit. Planned brief therapy can be adapted as part of a course of serial or intermittent therapy. When doing this, the counselor divides long-term treatment into a number of shorter treatments, which requires that the client s problems be addressed serially rather than concurrently. Because of insurance constraints, many counselors are now billing by episode and treating one problem at a time. For the treatment provider this means that a particular type of therapy could be applied to a specific problem associated with a client s substance abuse. By treating these allied problems, long-term goals, such as continued abstinence, may be more likely to be reached. Issues to Consider Prior to Using Brief Therapy Research has not demonstrated which clients benefit most from brief therapy. Here are some issues to consider carefully: Presence of a coexisting psychiatric disorder or developmental disability Severity of presenting problems Long history of abuse/dependence Familial and community supports The level of influence from peers, family, and community Previous treatment or attempts at recovery Client motivation (brief therapy may require more work on the part of the client but a less extensive time commitment) Clarity of the client s goals (brief therapy will require more clearly defined goals) Client s belief in the value of brief therapy The following criteria are derived from clinical experience: Less severe substance abuse, as measured by an instrument like the Addiction Severity Index (ASI) Insufficient resources available for longer therapy approach Limited amount of time available for treatment Lack of coexisting medical or mental health diagnoses Large numbers of clients needing treatment Addiction Messenger - Ideas for Treatment Improvement Client needs and the suitability of brief therapy must be evaluated on a case-by-case basis. Northwest Frontier Addiction Technology Transfer Center 19

20 The American Society of Addiction Medicine (ASAM) client placement criteria for substance abuse treatment (ASAM, 1996) may also be useful for determining who could benefit from brief therapy. Brief therapy may be appropriate for a moderate to heavy drinker such as a college student but inappropriate as the sole treatment for a commercial airline pilot who is alcohol dependent, no matter what the motivation is for treatment. Counselors must consider extenuating circumstances when recommending a particular course of treatment. In some programs, duration of therapy is determined mutually by the client and counselor; brief therapy may be the best option if the client objects to longer term treatment or if expense is an issue. Brief Therapy: Issues to Consider Criteria for considering longer episodes of treatment are: History of severe and persistent mental illness. Failure of previous shorter treatment Multiple concurrent problems Severe substance abuse (i.e., dependence) Acute psychoses Acute intoxication Acute withdrawal Cognitive inability to focus Long-term history of relapse Many unsuccessful treatment episodes Low level of social support Serious consequences related to relapse Determining when to use a particular type of brief therapy is also an important consideration for counselors and counselors. Counselors recognize that not all clients are at the same stage in their readiness for treatment. Currently, the most widely used model for understanding clients readiness for change is Prochaska and DiClemente s stages-of-change model. Counselors who use this model need to develop an overall understanding of the course of change. They have to determine which therapy is compatible with the client s stage of readiness for change and the tasks needed to move forward in the change process. Clinical interventions should be targeted to the client s stage of readiness for change. The goal is always to increase motivation to change behaviors and to augment a sense of empowerment in recovery. Therapies that use experiential processes (such as consciousness raising, self-evaluation, and cognitive restructuring) are more important for facilitating one s transition from preparation to action and from action to maintenance. Seeking and processing information, observing others, and gathering useful information in light of the client s situation are the activities reported most frequently during the contemplation stage. During the early stages of change the client should be provided with information regarding addiction as well as confronted with the short-and long-term consequences of continued use. Asking the client to perform a risk appraisal of potential gains and losses from continued use as well as a benefit/risk-reduction appraisal of achieving abstinence can facilitate sound decision making. Finally, it will be essential to learn the client s perceived obstacles to engaging in treat- 20 Northwest Frontier Addiction Technology Transfer Center

21 ment as well as to identify any dysfunctional beliefs that could sabotage the engagement process. The basic assumption behind this approach is that the way individuals evaluate a situation and cope with it determines their emotional reaction to it. The critical factor in determining an individual s response is the client s self-perception and associated emotions. The counselor should help the client recognize the messages he/she gives himself/herself and help him/her correct problematic thinking patterns and dysfunctional beliefs. Often, dysfunctional beliefs lead to low levels of perceived self-efficacy and subsequent inability to adopt or maintain the desired behavior. It is important to note that self-efficacy shifts in a predictable way across the stages of behavior change, with clients progressively becoming more effective as they move through the stages. Brief Assessment Instruments to Assist Decision Making Include: Quantity/frequency of use: Timeline Follow Back Technique Severity of dependence: Short Alcohol Dependence Data (SADD), Severity of Dependence Scales (SDS) CAGE Consequences of use: Michigan Alcoholism Screening Test (MAST), Drug Abuse Screening Test (DAST), Substance Abuse Subtle Screening Inventory (SASSI), DRINK Readiness to change: Commitment to Change Algorithm, SOCRATES Problem areas: Problem Checklist from Comprehensive Drinker Profile, Problem Oriented Screening Instrument for Teenagers (POSIT), Adolescent Assessment/Referral System (AARS) Treatment placement: Addiction Severity Index (ASI) Goal choice and commitment: Intentions Questionnaire Characteristics of All Brief Therapies They are either problem focused or solution focused, behind it. They clearly define goals related to a specific change or behavior. They should be understandable to both client and clinician. They should produce immediate results. They target the symptom and not what is They can be easily influenced by the personality and counseling style of the counselor. They rely on rapid establishment of a strong working relationship between client and counselor. The therapeutic style is highly active, empathic, and sometimes directive. Responsibility for change is placed clearly on the client. Early in the process, the focus is to help the client have experiences that enhance self-efficacy and confidence that change is possible. Termination is discussed from the beginning. Outcomes are measurable Brief Therapy: Issues to Consider Northwest Frontier Addiction Technology Transfer Center 21

22 Source: SAMHSA s Center for Substance Abuse Treatment. Brief Interventions & Brief Therapies for Substance Abuse. Treatment Improvement Protocol (TIP) Series Number 34. DHHS Pub. No. (SMA) Washington, DC: US Government Printing Office, 1999 Brief Therapy: Issues to Consider 22 Northwest Frontier Addiction Technology Transfer Center

23 Issue 5 Brief Therapy: Using Stages-of-Change The work of Prochaska, DiClemente and Norcross in defining stages-of-change helps clinicians tailor brief interventions to client needs. Their model consists of five sequential stages that describe what people experience when considering, beginning, and maintaining a change in substance use behavior. The model can be utilized to design brief interventions for substance use disorders which are targeted specifically to the client s stage of change. Substance abuse clients need motivational support appropriate to their stage of change. If you do not use strategies appropriate to the client s change stage, treatment resistance or noncompliance can result. Clients at the pre-contemplation stage, for example, must have their awareness raised before they will even consider making a change in their drug using behavior. To resolve their ambivalence. Clients in the contemplation stage must be helped to choose positive change over their current circumstances. Clients in the preparation stage need help in identifying potential change strategies and choosing the most appropriate ones. Clients in the action stage need help to carry out and comply with the change strategies. Interventions for each stage are different and designed to move the client to the next stage in the change process. You can use brief interventions to motivate behavior change at each stage of the process. For example, in the contemplation stage, a brief intervention could help the client weigh the costs and benefits of change. In the preparation stage, a similar brief intervention could address the costs and benefits of various change strategies (e.g., self-change, brief treatment, intensive treatment, self-help group attendance). In the action stage, brief interventions can help maintain motivation to continue on the course of change by reinforcing healthy decisions. Understanding these stages helps the clinician to be patient, to accept the client s current level of motivation, and to avoid getting too far ahead of the client. Equally important, that understanding helps you, the counselor employ effective counseling strategies. Effective interventionists quickly assess the client s stage of readiness, plan a corresponding strategy to assist him/her in progressing to the next stage, and implement that strategy without succumbing to distraction. Regardless of the stage of readiness, brief interventions can help initiate change, continue it, accelerate it, and prevent the client from regressing to previous behaviors. Precontemplation.. In this stage, the drug user is not considering change, is aware of few negative consequences, and is unlikely to take action soon. Example: A functional yet alcohol-dependent individual who drinks himself into a stupor every night but who goes to work every day, performs his job, has no substance abuse-related legal problems, has no health problems, and is still married. Treatment Needs: This client needs information linking his problems and potential problems with his substance use. A brief intervention might be to educate the client about the negative consequences of substance use. For example, if he is depressed, he might be told how his alcohol use may cause or exacerbate the depression. Addiction Messenger - Ideas for Treatment Improvement Northwest Frontier Addiction Technology Transfer Center 23

24 Contemplation.. The user is aware of some pros and cons of substance abuse but feels ambivalent about change. This user has not yet committed to change. Example: An individual who has received a citation for driving while intoxicated and vows that next time he/she will not drive when drinking. He/she is aware of the consequences but makes no commitment to stop drinking, just to not drive after drinking. Treatment Needs: This client should explore feelings of ambivalence and the conflicts between her substance use and personal values. The brief intervention might seek to increase the client s awareness of the consequences of continued heavy use and the benefits of decreasing or stopping use. Brief Therapy: Using Stages-of-Change Preparation.. This stage begins once the user has decided to change and begins to plan steps toward recovery. Example:. An individual who decides to stop using substances and plans to attend counseling, AA, NA, or enter formal treatment. Treatment Needs: This client typically needs work on strengthening commitment. A brief intervention might give the client a list of options for treatment (e.g., inpatient treatment, outpatient treatment, 12-Step meetings) from which to choose, then help the client plan how to go about seeking the treatment that is best for him/her. Action.. The user tries new behaviors, but is not yet stable. This stage involves the first active steps toward change. Example: An individual who goes to counseling and attends meetings but often thinks of using again or may even relapse at times. Treatment Needs: This client requires help executing an action plan and may have to work on skills for maintaining sobriety. The clinician should acknowledge the client s feelings and experiences as a normal part of recovery. Brief interventions could be applied throughout this stage to prevent relapse. Maintenance. The user establishes new behaviors on a long-term basis. Example:. An individual who attends counseling regularly, is actively involved in AA or NA, has a sponsor, may be taking Disulfiram (Antabuse), has made new sober friends, and has found new substance-free recreational activities. Treatment Needs: This client needs help with relapse prevention. A brief intervention could reassure, evaluate present actions, and redefine long-term sobriety maintenance plans. Goals of Brief Intervention The basic goal for a client in any substance abuse treatment setting is to reduce the risk of harm from continued use of substances. The greatest degree of harm reduction would obviously result from abstinence. However, the specific goal for each individual client is determined by his consumption pattern, the consequences of his use, and the setting in which the brief intervention is delivered. Focusing on intermediate goals allows for more immediate successes in the intervention and treatment process, whatever the long-term goals might be. In specialized treatment, intermediate goals might include quitting one substance, decreasing frequency of use, attending the next meeting, or doing the next homework assignment. Immediate successes are important to keep the client motivated. Performing brief interventions requires the ability to simplify and reduce a client s treatment plan to smaller, measurable outcomes. You, as the counselor, must be aware of the 24 Northwest Frontier Addiction Technology Transfer Center

25 many everyday circumstances in which clients with substance abuse disorders face ambivalence during the course of treatment. The key to a successful brief intervention is to extract a single, measurable behavioral change from the broad process of recovery that will allow the client to experience a small, incremental success. Clients who succeed at making small changes generally return for more successes. Sample outcomes addressed with Brief Therapy: Learning to Schedule and Prioritize time. Establishing/expanding a sober support system. Learning to have fun while clean and sober. Attending AA/NA meetings. Choosing to forgive others. Training if unemployed. Staying in the here and now Brief interventions can enhance users insight into existing or possible consequences or draw attention to the dangers associated with the establishment of an abusive pattern of substance use. For example, a woman who drinks moderately and is pregnant or who is contemplating a pregnancy can be advised to abstain from alcohol in order to prevent fetal alcohol syndrome. Brief interventions can also educate clients about the nature and dangers of substance abuse and possible warning signs of dependency. Older adults who take certain medications and use alcohol may be at risk for problems due to the interaction of medications and alcohol. See TIP 26, Substance Abuse Among Older Adults (CSAT, 1998b), for guidelines on alcohol use in older adulthood. Under ASAM criteria brief interventions are aimed at the nondependent user, at level 0.5 or possibly level I. Individuals at level II may be appropriate for a brief intervention if relapse potential and recovery environment are major problems for those with relatively minor physiological and psychological substance problems and high motivation to change. ASAM criteria have been extremely useful for clinical management of persons with substance abuse disorders who require more care than is needed for at-risk drinkers. Brief interventions, whether directed at reducing at-risk use (often used in primary care settings) or assisting in specific aspects of the treatment process, can be helpful for clients at every ASAM level and in many treatment settings. Brief Therapy: Using Stages-of-Change Source: SAMHSA s Center for Substance Abuse Treatment. Brief Interventions & Brief Therapies for Substance Abuse. Treatment Improvement Protocol (TIP) Series Number 34. DHHS Pub. No. (SMA) Washington, DC: US Government Printing Office, 1999 Northwest Frontier Addiction Technology Transfer Center 25

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27 Issue 6 Brief Therapy: Components of Effective Brief Therapy Brief therapy uses a selected process to change a specific problem. Below is a list of several therapeutic approaches that are applicable to brief therapy. These approaches can be used with clients with different types of problems and varying degrees of substance abuse severity. Components of Effective Brief Therapy It is reasonable to assume that brief therapies are most effective with clients whose problems are of short duration and who have strong ties to family, work, and community. However, limited client resources may also dictate the use of brief therapy. For example, if a client lacks the financial means to participate in a longer treatment process, a brief therapy approach is imperative. Some treatment is almost always better than no treatment. In addition, brief therapy may be indicated for clients who resist longer treatment, rather than risk the loss of an otherwise motivated client. Cognitive Therapy Substance use disorders often include habitual, automatic, negative thoughts and beliefs that must be identified and modified to change erroneous ways of thinking and associated behaviors. The desire to use substances is typically activated in specific, often predictable high-risk situations, such as upon seeing drug paraphernalia or experiencing boredom, depression, or anxiety. A cognitive approach helps clients examine their negative thoughts and replace them with more positive beliefs and actions. Many relapse prevention strategies use cognitive processes to identify triggering events or emotional states that reactivate substance use and replace these with more healthful responses. (See TIP 34, Chapter 4 for more information.) Behavioral Therapy Based on learning theories, the counselor, using a behavioral approach, teaches the client specific skills to improve deficiencies in social functioning, self control, or other behaviors that contribute to a substance use disorder. Techniques include assertiveness training, social skills training, contingency management, behavior contracting, Community Reinforcement and Family Training (CRAFT), behavioral self-control training, coping skills, and stress management. (See TIP 34, Chapter 4 for more general information on behavioral therapy and Chapter 8 for more information on CRAFT and other behavioral family therapies.) Cognitive-Behavioral Therapy This approach combines elements of cognitive and behavioral therapies, but in most substance abuse treatment settings it is considered a separate therapy. The focus is on learning and practicing a variety of coping skills. The emphasis is placed on developing coping strategies, especially early in treatment. Cognitive-Behavioral Therapy is thought to work by changing what the client does and thinks rather than just focusing on changing how the client thinks. (See TIP 34, Chapter 4.) Strategic/ Interactional Therapies The counselor seeks to understand a client s viewpoint on a problem, what meaning is attributed to events, and what ineffective interpersonal interactions and coping strategies are being Addiction Messenger - Ideas for Treatment Improvement Northwest Frontier Addiction Technology Transfer Center 27