210 -Brief Interventions and Brief Therapies | SAMHSA TIP 34
Counselor Toolbox

 
 
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8 Useful Brief Interventions and Brief Therapies
Objectives
~ We will review:
~ Stages-of-Change Model
~ Goals of Brief Intervention
~ Components of Brief Interventions and Effective Brief Therapy
~ Essential Knowledge and Skills for Brief Interventions
~ When To Use Brief Therapy
~ Approaches to Brief Therapy
~ Components of Effective Brief Therapy

~ Cognitive Behavioral (CBT)
~ Cognitive Processing
~ Trauma Focused CBT
~ Brief Strategic/Interactional
~ Brief Humanistic/Existential
~ Brief Psychodynamic
~ Brief Family therapy
~ Time Limited Group Therapy

Benefits
~ Reduce no-show
~ Increase treatment engagement
~ Increase compliance
~ Increase self-efficacy
~ Reduce aggression and isolation
~ Provide an interim for clients on waiting lists
Goals of Brief Interventions
~ Goals should be…
~ Specific
~ Measurable
~ Achievable in 8-10 weeks
~ Realistic
~ Time Limited
~ Purpose: Reduce the likelihood of damage/additional problems from the current issue. (i.e. family, work, health, self-esteem, guilt, anger)

Objectives for Brief Interventions
~ It is important to extract at least one measurable change in the client's behavior
~ Time management
~ Expanding a support system
~ Improving social skills
~ Changing unhelpful thoughts
~ Improving health behaviors
~ Vulnerability awareness and prevention
~ Vocational issues
~ Support group attendance
~ Forgiveness and acceptance
~ Staying in the “here and now
~ Identifying triggers for the mood or behavior
~ Coping with high risk or triggering situations

Components of Brief Interventions
~ FRAMES
~ Feedback
~ Responsibility
~ Identification of future goals for health, activities, hobbies, relationships
~ Identification of the pros and cons of current behavior in terms of self or family/community
~ Consequences of staying the same
~ Reasons to change
~ Sensible strategies for change
~ Advice
~ Menu
~ Empathy
~ Self-Efficacy

Stages of Change
~ Precontemplation: “I’m okay”
~ Provide
~ Information linking problems with current behaviors (thoughts, reactions) or issues (health, environment, social etc.)
~ Education
~ Motivational Interviewing: “List 5 ways substances use has impacted….”
~ Family/Peer commentary specifically about the client
~ Types
~ Reluctant
~ Increase knowledge of the problem, and the personal impact
~ Rebellious
~ Shift energy from fear of losing control to improving the next moment
~ Resigned
~ Rekindle hope/optimism by highlighting successes, strengths
Stages of Change
~ Contemplation: “It’s getting a little hot, but I’m okay”
~ Increase awareness of the consequences of the current problem
~ Explore/address ambivalence by tipping the decisional balance scales
~ Address anxiety and grief about change
~ Help clients visualize change

Treatment Needs: Preparation
~ Preparation: “I’ll just stick my toe in and see.”
~ Identify benefits of treatment
~ Identify/address fears/apprehensions about treatment
~ Give the client a list of options for treatment
~ Clarify goals and strategies
~ Identify and address barriers to change
~ Highlight strengths and past successful strategies
~ Garner social support
~ Envision change and find motivating stories from others
~ Identify motivations in each area and create small successes for components of the goal
~ Increase self efficacy and hardiness (C3)
~ Strengthen commitment
~ Begin learning about the issues

Stages of Change
~ Action: “I’m tired of being hot.”
~ Help client implement plan
~ Identify ways to ensure motivation and progress is maintained (Mindfulness)
~ Identify triggers, how they could cause relapse and how to deal with them
~ Provide practical tools in each session and discuss/roleplay application
~ Address obstacles
~ Acknowledge the client's feelings and experiences as a normal part of recovery
~ Maintenance:
~ Enjoy your successes. Step back and look how far you’ve come.
~ Stay mindful of continuing to “work your program.” Remaining vigilant for relapse triggers.
~ Make minor adjustments as needed.

Stages of Change
~ Relapse: Cold pool uncomfortable  Jump out
~ Relapse means falling back into old ways of thinking and acting
~ Relapse is not a requirement for recovery
~ The earlier you catch a relapse the better
~ Relapse is an opportunity for learning about:
~ What triggered the relapse
~ What things need to be addressed to keep recovery the most rewarding choice
~ A good relapse prevention plan will have strategies for identifying early relapse warning signs, triggers and solutions

Treatment Needs: Maintenance
~ Maintenance
~ Relapse prevention
~ Reassure
~ Evaluate present actions
~ Redefine long-term recovery plans
~ Educate about the relapsing nature of mental health/addictive disorders
~ Develop a list of circumstances that require a return to treatment
~ Review problems that emerged but were not addressed and help the client develop a plan for addressing them in the future
~ Develop strategies for identifying and coping with high-risk situations
Treatment Needs: Maintenance
~ Maintenance cont…
~ Teach the client how to capitalize on personal strengths
~ Emphasize client self-sufficiency
~ Develop a plan for support, including family/community support
~ Prepare the client to maintain positive change through difficult times
~ Identify potential stressors and challenges
~ Prepare the client for changes to the environment
~ At the end of treatment, ask the client to look into the future and describe where he intends to be at a certain time

Essential Knowledge and Skills
~ An overall attitude of understanding and acceptance
~ Counseling skills such as active listening to help clients explore and resolve ambivalence
~ A focus on intermediate goals
~ A working knowledge of the stages-of-change
~ For more detailed information, see TIP 34, pp. xvi–xvii, pp. 15–29.
Characteristics of Brief Therapies
~ Problem focused or solution focused
~ Target the symptom and not what is behind it
~ Clearly define goals related to a specific behavior
~ Understandable to both client and clinician
~ Produce immediate results
~ Rapid establishment of a working relationship
~ Highly active, empathic, and sometimes directive
~ Responsibility for change is placed clearly on the client
~ Experiences enhance self-efficacy/confidence that change is possible
~ Termination is discussed from the beginning
~ Outcomes are measurable

Appropriateness of Brief
~ Dual diagnosis issues
~ The range and severity of presenting problems
~ The duration of substance dependence
~ Availability of familial and community supports
~ The level and type of influence from peers, family and community
~ Previous treatment or attempts at recovery
~ The level of client motivation
~ The clarity of the client's short- and long-term goals
~ The client's belief in the value of brief therapy
~ The numbers of clients needing treatment

Criteria for Longer Term Treatment
~ Failure of previous shorter treatment
~ Multiple concurrent problems
~ Severe substance abuse
~ Acute psychoses, intoxication or withdrawal
~ Cognitive inability to focus
~ Long-term history of relapse
~ Many unsuccessful treatment episodes
~ Low level of social support
~ Serious consequences related to relapse
Assessment Areas
~ Current presenting issues and perception of cause
~ Consequences of current problems
~ History of substance abuse, patterns and consequences
~ Major medical problems and health status
~ Education and employment
~ Support mechanisms
~ Client strengths and situational advantages (mitigating factors)
~ Current exacerbating factors
~ Previous treatment (What has and has not worked)
~ Family history of substance abuse and psychological disorders
The Opening Session
~ Produce rapid engagement
~ Identify, focus on and prioritize problems
~ Work with the client to develop possible solutions
~ Negotiate the plan with client
~ Elicit client concerns and solutions
~ Understand client’s expectations
~ Explain the structural framework and rationale of brief therapy
~ Website video can be helpful
~ Make referrals
Cognitive Behavioral (CBT)
~ Assumes that problems are caused by
~ Deficient coping skills
~ Choosing not to use those they have
~ Are inhibited from doing so
~ Helps clients:
~ Recognize situations which are likely to trigger or worsen the problem
~ Identify unhelpful thoughts maintaining their problem
~ Find ways of avoiding those situations
~ Cope more effectively
CBT Core Elements
~ Functional analysis
~ Identify the antecedents and consequences of behaviors/condition which serve as triggering and maintaining factors
~ Coping skills training
~ Relapse Prevention
~ Identification of high risk situations
~ Coping skills training
~ CBT is generally not appropriate
~ psychotic or bipolar disorders and are not stabilized on medication
~ no stable living arrangements
~ not medically stable

CBT cont….
~ The initial session in brief CBT therapy explores:
~ Reasons the client is seeking treatment
~ Extent to which this motivation for treatment is intrinsic, rather than influenced by external sources
~ Areas of concern that the client and significant others may have about the problem
~ Situations in which the problem is worse
~ Consequences she experiences
~ Three Major Steps
• Establish rapport: Understand how the client thinks about his life circumstances and how those thoughts relate to the current problem
• Educate client about the CBT
• Ask client to describe a recent event that has triggered some negative feelings, as a way of illustrating the CBT process

Cognitive Processing therapy
~ Cognitive processing therapy (CPT) is a manualized therapy used by clinicians to help people recover from posttraumatic stress disorder
~ It includes elements of cognitive behavioral therapy (CBT) treatments.
~ CPT conceptualizes PTSD as a disorder of non-recovery, in which a sufferer's beliefs about the causes and consequences of traumatic events produce strong negative emotions, which prevent accurate processing of the traumatic memory and the emotions resulting from the event
Cognitive Processing therapy
~ Four essential parts
~ Educating the patient about the specific post-traumatic stress disorder (PTSD) symptoms and the way the treatment will help
~ Exploring the connection between thoughts and feelings.
~ Imparting lessons to the patient to help him/her develop skills to challenge or question his/her own thoughts.
~ Helping the patient to recognize changes in his/her beliefs that happened after going through the traumatic event.
~ Structure of CPT individual sessions
~ Twelve 50-minute structured sessions
~ Sessions typically conducted once or twice weekly
~ Patients complete out-of-session practice assignments
Trauma Focused CBT
~ Trauma focused cognitive behavioral therapy (TF-CBT) aims to address the needs of children and adults with post traumatic stress disorder (PTSD), depression, anxiety, behavioral difficulties & shame related to traumatic life events.
~ The goal of TF-CBT is to provide psychoeducation to both the child and the caregivers and help them to identify and cope with emotions, thoughts and behaviors

Trauma Focused CBT
~ Major components of TF-CBT are denoted by the “PRACTICE” acronym.
~ Psychoeducation and Parenting skills
~ Relaxation
~ Affective Expression and Regulation
~ Cognitive Coping
~ Trauma Narrative Development and Processing
~ In Vivo Gradual Exposure
~ Conjoint Parent-Child sessions
~ Enhancing Safety and Future Development
~ https://tfcbt.musc.edu/

Brief Strategic/Interactional Therapies
~ Overview
~ Focus is on the individual’s strengths
~ The relationship to the therapist is essential
~ Interventions are based on client self-determination with the community serving as a resource rather than an obstacle
~ Goals
~ Define situations that contribute to the problem in terms meaningful to the client
~ Identify steps needed to address the problem
~ Heal the family system so it can support change
~ Maintain behaviors that will help support recovery
~ Respond to situations in which the client has relapsed

Brief Humanistic & Existential Therapy
~ Humanistic and existential therapies emphasize
~ Understanding the human experience
~ Focusing on the client rather than the symptom
~ Psychological problems are the result of inhibited ability to make authentic, meaningful, and self-directed choices about how to live
~ Initial Session
~ Build an alliance, developing therapeutic rapport, and creating a climate of mutual respect
~ Emphasize the client's freedom of choice and potential for meaningful change
~ Articulate expectations and goals of therapy (how goals are to be reached)

Brief Psychodynamic Therapy
~ A psychodynamic approach enables the client to examine “stuff” from their past which led to a desire to abuse substances.
~ Techniques
~ Work with the client's perceptions of reality
~ Ask questions
~ Sidestep, rather than confronting defenses

Brief Family Therapy
~ Interactions with family sets the patterns and dynamics for their problems
~ Family member interactions can either perpetuate or help resolve the problem
~ Family therapy offers an opportunity to:
~ Focus on the expectation of change within the family
~ Test new patterns of behavior
~ Teach how a family system supports symptoms and maintains needed roles
~ Elicit the strengths of every family member
~ Explore the meaning of the problem within the family
Brief Family Therapy cont…
~ Initial session
~ Clarify the nature of the problem and identify the family's goals with open-ended questions such as, “What is your goal in coming here?“
~ Educate the family about what is needed to participate effectively in the therapeutic process.
~ Understand key biosocial issues related to the problem
~ Provide feedback to the family on what was said, demonstrating whose goals are similar or different.
~ Prioritize directions for change; or, if the direction is sufficiently clear, start work.
~ Appropriate for families who are able to benefit from teaching and communication to better understand some aspect of the problem

Time-Limited Group Therapy
~ Groups can:
~ Help reduce denial; process ambivalence
~ Facilitate acceptance of the problem
~ Assist in identifying exacerbating and mitigating factors
~ Provide a wealth of coping strategies and resources
~ Increase motivation for change
~ Treat co-occurring conditions
~ Increase the capacity to recognize, anticipate and cope with situations
~ Provide a warm environment that provides social acceptance and support
~ Help explore whether they believe they have the ability to choose effective actions
Summary
~ Brief therapy is a cost effective technique that can:
~ Enhance treatment compliance
~ Improve outcomes
~ Increases success and client self-efficacy
~ Reduce cost-per-patient expenses
~ Be used for a variety of issues to help clients accomplish SMART goals