Brief Interventions and

Brief Therapies for

Substance Abuse

34

Treatment Improvement Protocol (TIP) Series

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration
Brief Interventions

and Brief 

Therapies

For Substance 

Abuse

Treatment Improvement Protocol (TIP) Series 

34

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

1 Choke Cherry Road 

Rockville, MD 20857 
ii

Acknowledgments

This publication was prepared under contract 

number 270-95-0013 for the Substance Abuse 

and Mental Health Services Administration 

(SAMHSA), U.S. Department of Health and 

Human Services (HHS). Sandra Clunies, M.S., 

I.C.A.D.C., served as the Contracting Officer’s 

Representative. 

Disclaimer

The opinions expressed herein are the views of 

the consensus panel members and do not 

necessarily reflect the official position of 

SAMHSA or HHS. No official support of or 

endorsement by SAMHSA or HHS for these 

opinions or for the instruments or resources 

described are intended or should be inferred. 

The guidelines presented should not be 

considered substitutes for individualized client 

care and treatment decisions.

Public Domain Notice

All materials appearing in this volume except 

those taken directly from copyrighted sources 

are in the public domain and may be 

reproduced or copied without permission from 

SAMHSA or the authors. Citation of the source 

is appreciated. However, this publication may 

not be reproduced or distributed for a fee 

without the specific, written authorization of the 

Office of Communications, SAMHSA, HHS.

Electronic Access and Printed Copies

This publication may be ordered for free from 

SAMHSA’s Publications Ordering Web page at 

http://store.samhsa.gov. Or, please call 

SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) 

(English and Español). The document can be 

downloaded from the KAP Web site at 

http://kap.samhsa.gov. 

Recommended Citation

Center for Substance Abuse Treatment. Brief 

Interventions and Brief Therapies for Substance 

Abuse. Treatment Improvement Protocol (TIP) 

Series, No. 34. HHS Publication No. (SMA) 12-

3952. Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 1999. 

Originating Office

Quality Improvement and Workforce 

Development Branch, Division of Services 

Improvement, Center for Substance Abuse 

Treatment, Substance Abuse and Mental Health 

Services Administration, 1 Choke Cherry Road, 

Rockville, MD 20857.

HHS Publication No. (SMA) 12-3952

First Printed 1999 

Revised 2002, 2003, 2004, 2007, 2009, 2011, and 

2012

 
Contents 

What Is a TIP?..........................................................................................................................................................

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vii 

Editorial Advisory Board ix 

Consensus Panel xi 

Foreword xiii 

Executive Summary and Recommendations xv 

Summary and Recommendations xvi 

Chapter 1—Introduction to Brief Interventions and Therapies 1 

An Overview of Brief Interventions 3 

An Overview of Brief Therapies 7 

The Demand for Brief Interventions and Therapies 8 

Barriers to Increasing the Use of Brief Treatments 10 

Evaluating Brief Interventions and Therapies 11 

Chapter 2—Brief Interventions in Substance Abuse Treatment 13 

Stages-of-Change Model 14 

Goals of Brief Intervention 16 

Components of Brief Interventions 18 

Brief Intervention Workbooks 24 

Essential Knowledge and Skills for Brief Interventions 25 

Brief Interventions in Substance Abuse Treatment Programs 27 

Brief Interventions Outside Substance Abuse Treatment Settings 28

Research Findings 30 

Chapter 3—Brief Therapy in Substance Abuse Treatment 37 

Research Findings 38 

When To Use Brief Therapy 39 

Approaches to Brief Therapy 41 

Components of Effective Brief Therapy 41 

Therapist Characteristics 49 

iii 
Contents 

Chapter 4—Brief Cognitive–Behavioral Therapy..............................................................................................

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51 

Behavioral Theory 51 

Behavioral Therapy Techniques Based on Classical Conditioning Models 53 

Behavioral Therapy Techniques Based on Operant Learning Models 55 

Cognitive Theory 61 

Cognitive Therapy 63 

Cognitive–Behavioral Theory 68 

Cognitive–Behavioral Therapy 77 

Chapter 5—Brief Strategic/Interactional Therapies 87 

Solution-Focused Therapy for Substance Abuse 88 

Compatibility of Strategic/Interactional Therapies and 12-Step Programs 89 

When To Use Strategic/Interactional Therapies 90 

Case Study 92 

Strategic/Interactional Therapies 99 

Chapter 6—Brief Humanistic and Existential Therapies 105 

Using Humanistic and Existential Therapies 106 

The Humanistic Approach to Therapy 109 

The Existential Approach to Therapy 117 

Chapter 7—Brief Psychodynamic Therapy 121 

Background 121 

Introduction to Brief Psychodynamic Therapy 122 

Psychodynamic Psychotherapy for Substance Abuse 123

Psychodynamic Concepts Useful in Substance Abuse Treatment 128 

Transference 131 

Models of Brief Psychodynamic Therapy 135 

Other Research 140 

Chapter 8—Brief Family Therapy 143 

Appropriateness of Brief Family Therapy 144 

Definitions of “Family” 145 

Theoretical Approaches 147 

Using Brief Family Therapies 152 

Followup 154 

Cultural Issues 154 

Chapter 9—Time-Limited Group Therapy 157 

Appropriateness of Group Therapy 157 

Group Therapy Approaches 158 

Theories of Group Therapy 160 

Use of Psychodrama Techniques in a Group Setting 164 

Therapeutic Factors 166 

Using Time-Limited Group Therapy 168 

iv 
Contents 

Appendix A—Bibliography.................................................................................................................................

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173 

Appendix B—Information and Training Resources 209 

General Brief Therapy 209 

Cognitive–Behavioral Therapy 209 

Strategic/Interactional Therapies 210 

Humanistic and Existential Therapies 211 

Psychodynamic Therapy 213 

Family Therapy 213 

Group Therapy 214 

Appendix C—Glossary 215 

Appendix D—Health Promotion Workbook 221 

Part 1: Summary of Health Habits..................................................................................................................221 

Part 2: Types of Drinkers in the U.S. Population..........................................................................................

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222 

Part 3: Consequences of Heavy Drinking 223 

Part 4: Reasons To Quit or Cut Down on Your Drinking 224

Part 5: Drinking Agreement 225 

Part 6: Handling Risky Situations 227 

Appendix E—Resource Panel 229

Appendix F—Field Reviewers 231 

Figures 

1-1 Substance Abuse Severity and Level of Care ...........................................................................................4 

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

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2-1 The Stages of Change 15 

2-2 Sample Objectives 16 

2-3 American Society of Addiction Medicine (ASAM) Patient Placement Criteria 18 

2-4 FRAMES 19 

2-5 Scripts for Brief Intervention 20 

2-6 Screening for Brief Interventions for Alcoholism 22 

2-7 Client Feedback and Plan of Action 23 

2-8 Talking About Change at Different Stages 24 

2-9 Steps in Active Listening 26 

2-10 Professionals Outside of Substance Abuse Treatment Who Can Administer 

 Brief Interventions 28 

3-1 Criteria for Longer Term Treatment 39 

3-2 Selected Criteria for Providing Brief Therapy 40 

3-3 Approaches to Brief Therapy 42 

3-4 Characteristics of All Brief Therapies 44 

3-5 Sample Battery of Brief Assessment Instruments 45 

4-1 Classical Conditioning and Operant Learning 52 

v 
Contents 

4-2 Basic Assumptions of Behavioral Theories of Substance Abuse and Its Treatment .........................

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4-3 Advantages of Behavioral Theories in Treating Substance Abuse Disorders 54 

4-4 Functional Analysis 56 

4-5 Teaching Stress Management 60 

4-6 Programmed Therapy and Writing Therapy 61 

4-7 The Relationship Among Factors Maintaining Behavior in Behavioral and 

 Cognitive Models 62 

4-8 Fifteen Common Cognitive Errors 63 

4-9 Characteristic Thinking of People With Substance Abuse Disorders 64 

4-10 Common Irrational Beliefs About Alcohol and Drugs With More Rational Alternatives 65 

4-11 Thoughts, Feelings, and Behaviors 66 

4-12 Introducing Cognitive Therapy: A Sample Script 67 

4-13 Common Elements of Brief CognitiveBehavioral Therapies 69 

4-14 Attributional Styles 70 

4-15 Relapse Prevention Model Based on Self-Efficacy Theory 73 

4-16 Taxonomy of High-Risk Situations Based on Marlatt’s Original 

 Categorization System 75 

4-17 A CognitiveBehavioral Model of the Relapse Process 76 

4-18 Essential and Unique Elements of CognitiveBehavioral Interventions 78 

4-19 Intrapersonal and Interpersonal Skills Training Elements 80 

4-20 Assertiveness Training 80 

4-21 Types of Clients for Whom Outpatient CBT Is Generally Not Appropriate 85 

5-1 Deliberate and Random Exceptions to Substance Abuse Behaviors 89 

5-2 Strategic/Interactional Therapy in Practice: A Case Study 93 

6-1 A Case Study 111 

7-1 Defense Mechanisms 132 

7-2 Brief Psychodynamic Therapy 136 

vi 
vii

What Is a TIP?

reatment Improvement Protocols (TIPs) 

are developed by the Substance Abuse 

and Mental Health Services 

Administration (SAMHSA) within the U.S. 

Department of Health and Human Services 

(HHS). Each TIP involves the development of 

topic-specific best-practice guidelines for the 

prevention and treatment of substance use and 

mental disorders. TIPs draw on the experience 

and knowledge of clinical, research, and 

administrative experts of various forms of 

treatment and prevention. TIPs are distributed 

to facilities and individuals across the country. 

Published TIPs can be accessed via the Internet 

at http://kap.samhsa.gov.

Although each consensus-based TIP strives 

to include an evidence base for the practices it 

recommends, SAMHSA recognizes that 

behavioral health is continually evolving, and 

research frequently lags behind the innovations 

pioneered in the field. A major goal of each TIP 

is to convey "front-line" information quickly but 

responsibly. If research supports a particular 

approach, citations are provided.

T

Editorial Advisory Board

Karen Allen, Ph.D., R.N., C.A.R.N. 

Professor and Chair 

Department of Nursing 

Andrews University 

Berrien Springs, Michigan 

Richard L. Brown, M.D., M.P.H. 

Associate Professor 

Department of Family Medicine 

University of Wisconsin School of Medicine 

Madison, Wisconsin 

Dorynne Czechowicz, M.D. 

Associate Director 

Medical/Professional Affairs 

Treatment Research Branch 

Division of Clinical and Services Research 

National Institute on Drug Abuse 

Rockville, Maryland 

Linda S. Foley, M.A. 

Former Director 

Project for Addiction Counselor Training 

National Association of State Alcohol and 

Drug Abuse Directors 

Washington, D.C. 

Wayde A. Glover, M.I.S., N.C.A.C. II 

Director 

Commonwealth Addictions Consultants and 

Trainers 

Richmond, Virginia

Pedro J. Greer, M.D. 

Assistant Dean for Homeless Education 

University of Miami School of Medicine 

Miami, Florida 

Thomas W. Hester, M.D. 

Former State Director 

Substance Abuse Services 

Division of Mental Health, Mental 

Retardation and Substance Abuse 

Georgia Department of Human Resources 

Atlanta, Georgia 

James G. (Gil) Hill, Ph.D. 

Director 

Office of Substance Abuse 

American Psychological Association 

Washington, D.C. 

Douglas B. Kamerow, M.D., M.P.H. 

Director 

Office of the Forum for Quality and 

Effectiveness in Health Care 

Agency for Health Care Policy and Research 

Rockville, Maryland 

Stephen W. Long 

Director 

Office of Policy Analysis 

National Institute on Alcohol Abuse and 

Alcoholism 

Rockville, Maryland 

Richard A. Rawson, Ph.D. 

Executive Director 

Matrix Center and Matrix Institute on 

Addiction 

Deputy Director, UCLA Addiction Medicine 

Services 

Los Angeles, California 

ix 
Editorial Advisory Board 

Ellen A. Renz, Ph.D. 

Former Vice President of Clinical Systems 

MEDCO Behavioral Care Corporation 

Kamuela, Hawaii 

Richard K. Ries, M.D. 

Director and Associate Professor 

Outpatient Mental Health Services and Dual 

Disorder Programs 

Harborview Medical Center 

Seattle, Washington 

Sidney H. Schnoll, M.D., Ph.D. 

Chairman 

Division of Substance Abuse Medicine 

Medical College of Virginia 

Richmond, Virginia 

x 
Consensus Panel

Chair 

Kristen Lawton Barry, Ph.D. 

Associate Research Scientist 

Alcohol Research Center 

University of Michigan 

Ann Arbor, Michigan 

Workgroup Leaders 

Christopher W. Dunn, Ph.D., M.A.C., C.D.C. 

Psychiatry and Behavioral Science 

University of Washington 

Seattle, Washington 

Jerry P. Flanzer, D.S.W., L.C.S.W., C.A.C. 

Director 

Recovery and Family Treatment, Inc. 

Alexandria, Virginia 

Stephen Gedo, Ph.D. 

Clinical Psychologist 

Gaffney, South Carolina 

Eugene Herrington, Ph.D. 

Associate Professor 

Department of Counseling and Psychological 

Services

Clark Atlanta University 

Atlanta, Georgia 

Fredrick Rotgers, Psy.D. 

Director 

Program for Addictions Consultation and 

Treatment 

Center of Alcohol Studies 

Rutgers University 

New Brunswick, New Jersey

Terry Soo-Hoo, Ph.D. 

Clinic Director/Assistant Professor 

Counseling Psychology Department 

University of San Francisco 

San Francisco, California 

Panelists 

Janice S. Bennett, M.S., C.S.A.C. 

Owner/Consultant 

Pacific Consulting and Training Services of 

Hawaii 

Honolulu, Hawaii

Robert L. Chapman, M.S.S.W., C.A.D.O.A.C.,

 C.R.P.S.

Cumberland Heights 

Nashville, Tennessee 

John W. Herdman, Ph.D., C.A.D.A.C. 

Psychologist 

The Encouragement Place 

Lincoln, Nebraska 

Fanny G. Nicholson, C.C.S.W., A.C.S.W., 

N.C.A.C.I., C.S.A.E. 

Alcohol and Drug Specialist 

Oconaluftee Job Corps 

Cherokee, North Carolina

Mary Alice Orito, C.S.W., C.A.S.A.C., N.C.A.C.I. 

Evaluation Supervisor 

Stuyvesant Square Outpatient Services for 

Chemical Dependency 

New York, New York 

xi 
Consensus Panel 

Jerome J. Platt, Ph.D. 

Professor of Psychiatry and Public Health 

Director, Institute for Addictive Disorders 

Hahnemann School of Medicine 

Allegheny University of the Health Sciences 

Philadelphia, Pennsylvania 

Marilyn Sawyer Sommers, Ph.D., R.N.

Professor 

College of Nursing 

University of Cincinnati

Cincinnati, Ohio 

José Luis Soria, M.A., L.C.D.C., I.C.A.D.C., 

C.C.G.C., C.A.D.A.C. 

Clinical Deputy Director 

Aliviane NO-AD, Inc. 

El Paso, Texas 

Ava H. Stanley, M.D. 

Somerset, New Jersey 

Robert S. Stephens, Ph.D. 

Associate Professor 

Department of Psychology 

Virginia Polytechnic Institute and State 

University 

Blacksburg, Virginia 

xii 
xiii

Foreword

he Treatment Improvement Protocol (TIP) 

series fulfills the Substance Abuse and 

Mental Health Services Administration’s 

(SAMHSA’s) mission to improve prevention and 

treatment of substance use and mental disorders 

by providing best practices guidance to clinicians, 

program administrators, and payers. TIPs are the 

result of careful consideration of all relevant 

clinical and health services research findings, 

demonstration experience, and implementation 

requirements. A panel of non-Federal clinical 

researchers, clinicians, program administrators, 

and patient advocates debates and discusses their 

particular area of expertise until 

they reach a consensus on best practices. This 

panel’s work is then reviewed and critiqued by 

field reviewers.

The talent, dedication, and hard work that TIPs 

panelists and reviewers bring to this highly 

participatory process have helped bridge the gap 

between the promise of research and the needs of 

practicing clinicians and administrators to serve, 

in the most scientifically sound and effective ways, 

people in need of behavioral health services. We 

are grateful to all who have joined with us to 

contribute to advances in the behavioral health

field.

Pamela S. Hyde, J.D.

Administrator

Substance Abuse and Mental Health Services Administration

Peter J. Delany, Ph.D., LCSW-C RADM, USPHS

Director

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services Administration

T

Executive Summary and

Recommendations 

This Treatment Improvement Protocol 

(TIP) responds to an increasing body of 

research literature that documents the 

effectiveness 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 

developing them. The TIP will also be useful for 

health care workers, social service providers 

who work outside the substance abuse 

treatment field, people in the criminal justice 

system, and anyone else who may be called on 

to intervene with a person who has substance 

abuse problems. 

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 are 

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 efforts and more intensive treatment 

for persons with serious substance abuse 

disorders. However, studies have shown that 

brief interventions are effective for a 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 substance users, and as adjuncts to 

more extensive treatment for substancedependent persons. 

Brief therapies can be used to effect 

significant changes in clients’ behaviors and 

their understanding of them. The term “brief 

therapy” covers several treatment approaches 

derived from a number of 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. 

xv 
Executive Summary and Recommendations 

This TIP presents the historical background, 

outcomes research, rationale for use, and stateof-the-art practical methods and case scenarios 

for implementation of brief interventions and 

therapies for a range of problems related to 

substance abuse. This TIP is based on the body 

of research conducted on brief interventions and 

brief therapies for substance abuse as well as on 

the broad clinical expertise of the Consensus 

Panel. Because many therapists and other 

practitioners are eclectically trained, elements 

from each of the chapters may be of use to a 

range of professionals. 

This discussion of brief therapies is in no 

way intended to detract from the value of longer 

term therapies that clinicians have found to be 

effective in the treatment of substance abuse 

disorders. However, the Consensus Panel 

believes it necessary to discuss innovative 

and/or often-used theories that members have 

encountered and applied in their clinical 

practice. 

The Consensus Panel’s recommendations 

summarized below are based on both research 

and clinical experience. Those supported by 

scientific evidence are followed by (1); clinically 

based recommendations are marked (2). 

Citations for the former are referenced in the 

body of this document, where the guidelines are 

presented in full detail. Many of the 

recommendations made in the latter chapters of 

this TIP are relevant only within a particular 

theoretical framework (e.g., the Panel might 

recommend how a person practicing strategic 

therapy should approach a particular situation); 

because such recommendations are not 

applicable to all readers, they have not been 

included in this Executive Summary. 

Throughout this TIP, the term “substance 

abuse” has been used in a general sense to cover 

both substance abuse disorders and substance 

dependence disorders (as defined by the 

Diagnostic and Statistical Manual of Mental 

Disorders, 4th Edition [DSM-IV] [American 

Psychiatric Association, 1994]). Because the 

term “substance abuse” is commonly used by 

substance abuse treatment professionals to 

describe any excessive use of addictive 

substances, it will be used to denote both 

substance dependence and substance abuse. 

The term includes the use of alcohol as well as 

other substances of abuse. Readers should 

attend to the context in which the term occurs in 

order to determine the meaning; in most cases, 

the term will refer to all varieties of substance 

abuse disorders as described by DSM-IV. 

Summary and 

Recommendations 

Brief Interventions 

Brief interventions are those practices that aim 

to investigate a potential problem and motivate 

an individual to begin to do something about his 

substance abuse, either by natural, clientdirected means or by seeking additional 

substance abuse treatment. 

A brief intervention, however, is only one of 

many tools available to clinicians. It is not a 

substitute for care for clients with a high level of 

dependency. It can, however, be used to engage 

clients who need specialized treatment in specific 

aspects of treatment programs, such as 

attending group therapy or Alcoholics 

Anonymous (AA) meetings. 

 The Consensus Panel believes that brief 

interventions can be an effective addition to 

substance abuse treatment programs. These 

approaches can be particularly useful in 

treatment settings when they are used to 

address specific targeted client behaviors and 

issues in the treatment process that can be 

difficult to change using standard treatment 

approaches. (2) 

 Variations of brief interventions have been 

found to be effective both for motivating 

alcohol-dependent individuals to enter 

xvi 
Executive Summary and Recommendations 

long-term alcohol treatment and for treating 

some alcohol-dependent persons. (1) 

 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) 

 Substance abuse treatment personnel should 

collaborate with other providers (e.g., 

primary care providers, employee assistance 

program, wellness clinic staff, etc.) in 

developing plans that include both brief 

interventions and more intensive care to help 

keep clients focused on treatment and 

recovery. (2) 

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 substances. 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 success in the intervention 

and 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) 

 When conducting a brief intervention, the 

clinician should set aside the final treatment 

goal (e.g., accepting responsibility for one’s 

own recovery) to focus on a single behavioral 

objective. Once this objective is established, 

a brief intervention can be used to help reach 

it. (2) 

Components of brief interventions 

There are six elements that are critical for 

effective brief interventions. (1) The acronym 

FRAMES was coined to summarize these six 

components: 

 Feedback is given to the individual about 

personal risk or impairment. 

 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. 

A brief intervention consists of five basic 

steps that incorporate FRAMES and remain 

consistent regardless of the number of sessions 

or the length of the intervention: 

1. Introducing the issues in the context of the 

client’s health. 

2. Screening, evaluating, and assessing. 

3. Providing feedback. 

4. Talking about change and setting goals. 

5. Summarizing and reaching closure. 

Providers may not have to use all five of 

these components in any given session with a 

client. However, before eliminating steps in the 

brief intervention process there should be a 

well-defined reason for doing so. (2) 

Essential knowledge and skills for 

brief interventions 

Providing effective brief interventions requires 

the clinician to possess certain knowledge, skills, 

and abilities. The following are four essential 

skills (2): 

1. An overall attitude of understanding and 

acceptance 

xvii 
Executive Summary and Recommendations 

2. Counseling skills such as active listening 

and helping clients explore and resolve 

ambivalence

3. A focus on intermediate goals 

4. A working knowledge of the stages-ofchange through which a client moves when 

thinking about, beginning, and trying to 

maintain new behavior 

Brief Therapies 

Brief therapy is a systematic, focused process 

that relies on assessment, client engagement, 

and rapid implementation of change strategies. 

The brief therapies presented in this TIP should 

be seen as separate modalities of treatment, not 

episodic forms of long-term therapy. 

Brief therapies usually feature more (as well 

as longer) sessions than brief interventions. The 

duration of brief therapies is reported to be 

anywhere from 1 to 40 sessions, with the typical 

therapy lasting between 6 and 20 sessions. 

Brief therapies also differ from brief 

interventions in that their goal is to provide 

clients with tools to change basic attitudes and 

handle a variety of underlying problems. Brief 

therapy differs from longer term therapy in that 

it focuses more on the present, downplays 

psychic causality, emphasizes the effective use 

of therapeutic tools in a shorter time, and 

focuses on a specific behavioral change rather 

than large-scale or pervasive change. 

Research concerning relative effectiveness of 

brief versus longer term therapies for a variety 

of presenting complaints is mixed. However, 

there is evidence suggesting that brief therapies 

are often as effective as lengthier treatments for 

certain populations. 

 The best outcomes for brief therapy may 

depend on clinician skills, comprehensive 

assessments, and selective criteria for 

eligibility. Using selective criteria in 

prescribing brief therapy is critical, since 

many clients will not meet its eligibility 

requirements. (2) 

 Brief therapy for substance abuse treatment 

is a valuable approach, but it should not be 

considered a standard of care for all 

populations. (1) The Consensus Panel hopes 

that brief therapy will be adequately 

investigated in each case before managed 

care companies and third-party payors 

decide it is the only modality for which they 

will pay. 

 Brief interventions and brief therapies are 

well suited for clients who may not be 

willing or able to expend the significant 

personal and financial resources necessary to 

complete more intensive, longer term 

treatments. (2) 

 Both research and clinical expertise indicate 

that individuals who are functioning in 

society but have patterns of excessive or 

abusive substance use are unlikely to 

respond positively to some forms of 

traditional treatment, but some of the briefer 

approaches to intervention and therapy can 

be extremely useful clinical tools in their 

treatment. (1) 

When to use brief therapy 

Determining when to use a particular type of 

brief therapy is an important consideration for 

counselors and therapists. The Panel 

recommends that client needs and the suitability 

of brief therapy be evaluated on a case-by-case 

basis. (2) Some criteria for considering the 

appropriateness of brief therapy for clients 

include 

 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 

xviii 
 The clarity of the client’s short- and longterm goals 

 The client’s belief in the value of brief 

therapy 

 The numbers of clients needing treatment 

The following criteria are derived from Panel 

members’ clinical experience: 

 Less severe substance dependence, as 

measured by an instrument like the 

Addiction Severity Index (ASI) 

 Level of past trauma affecting the client’s 

substance abuse 

 Insufficient resources available for more 

prolonged therapy 

 Limited amount of time available for 

treatment 

 Presence of coexisting medical or mental 

health diagnoses 

 Large numbers of clients needing treatment 

leading to waiting lists for specialized 

treatment 

The Consensus Panel also notes that 

 Planned brief therapy can be adapted as part 

of a course of serial or intermittent therapy. 

When doing this, the therapist conceives of 

long-term treatment as a number of shorter 

treatments, which require the client’s 

problems to be addressed serially rather than 

concurrently. (1) 

 Brief therapies will be most effective with 

clients whose problems are of short duration 

and who have strong ties to family, work, 

and community. However, a number of 

other conditions, such as limited client 

resources, may also dictate the use of brief 

therapy. (2) 

 It is essential to learn the client’s perceived 

obstacles to engaging in treatment as well as 

to identify any dysfunctional beliefs that 

could sabotage the engagement process. The 

critical factor in determining an individual’s 

response is the client’s self-perception and 

associated emotions. (1) 

Executive Summary and Recommendations 

Components of effective 

brief therapy 

While there are a variety of different schools of 

brief therapy available to the clinician, all forms 

of brief therapy share some common 

characteristics (2): 

 They are either problem focused or solution 

focused—they target the symptom, not its 

causes. 

 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 can be easily influenced by the 

personality and counseling style of the 

therapist. 

 They rely on rapid establishment of a strong 

working relationship between client and 

therapist. 

 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 enhance his self-efficacy and 

understand that change is possible. 

 Termination is discussed from the beginning. 

 Outcomes are measurable. 

Screening and assessment 

Screening and assessment are critical initial 

steps in brief therapy. Screening is a process in 

which clients are identified according to 

characteristics that indicate they are possibly 

abusing substances. Screening identifies the 

need for more in-depth assessment but is not an 

adequate substitute for complete assessment. 

Assessment is a more extensive process that 

involves a broad analysis of the factors 

contributing to and maintaining a client’s 

substance abuse, the severity of the problem, 

and the variety of consequences associated with 

it. Screening and assessment procedures for 

xix 
Executive Summary and Recommendations 

brief therapy do not differ significantly from 

those used for lengthier treatments. 

 Clinicians can use a variety of brief 

assessment instruments, many of which are 

free. These instruments should be 

supplemented in the first session by a clinical 

assessment interview that covers current use 

patterns, history of substance use, 

consequences of substance abuse, coexisting 

psychiatric disorders, major medical 

problems and health status, education and 

employment status, support mechanisms, 

client strengths and situational advantages, 

and family history. (2) 

 The screening and assessment process 

should determine whether the client’s 

substance abuse problem is suitable for a 

brief therapy approach. (2) 

 Assessment is critical not only before 

beginning brief therapy but also as an 

ongoing part of the process. (2) 

 Therapists who primarily provide brief 

therapy should be adept at determining early 

in the assessment process which client needs 

or goals are appropriate to address. Related 

to this, and equally important, the therapist 

must establish relationships that facilitate the 

client’s referral when her needs or goals 

cannot be met through brief therapy. (2) 

The first session 

In the first session, the main goals for the 

therapist are to gain a broad understanding of 

the client’s presenting problems, begin to 

establish rapport and an effective working 

relationship, and implement an initial 

intervention, however small. 

 Counselors should gather as much 

information as possible about a client before 

the first counseling session. However, when 

gathering information about a client from 

other sources, counselors must be sensitive to 

confidentiality and client consent issues. (2) 

 Therapists should identify and discuss the 

goals of brief therapy with the client early in 

treatment, preferably in the first session. (2) 

 Although abstinence is an optimal clinical 

goal, it still must be negotiated with the 

client (at least in outpatient treatment 

settings). Abstinence as a goal is not 

necessarily the sole admission requirement 

for treatment, and the therapist may have to 

accept an alternative goal, such as decreased 

substance use, in order to engage the client 

effectively. (2) 

 The provider of brief therapy must 

accomplish certain critical tasks during the 

first session (2), including 

i Producing rapid engagement 

i Identifying, focusing, and prioritizing 

problems 

i Working with the client to develop a 

treatment plan and possible solutions for 

substance abuse problems 

i Negotiating the approach toward change 

with the client (which may involve a 

contract between client and therapist) 

i Eliciting client concerns about problems 

and solutions 

i Understanding client expectations 

i Explaining the structural framework of 

brief therapy, including the process and its 

limits (i.e., those items not within the 

scope of that treatment segment or the 

agency’s work) 

i Making referrals for critical needs that 

have been identified but cannot be met 

within the treatment setting 

Maintenance strategies, 

termination of therapy, and 

followup 

Maintenance strategies must be built into the 

treatment design from the beginning. A 

practitioner of brief therapy must continue to 

provide support, feedback, and assistance in 

setting realistic goals. Also, the therapist should 

xx 
Executive Summary and Recommendations 

 help the client identify relapse triggers and 

situations that could endanger continued 

sobriety. (2) 

Strategies to help clients maintain the 

progress made during brief therapy include the 

following (2): 

 Educating the client about the chronic, 

relapsing nature of substance abuse 

 Considering which circumstances might 

cause a client to return to treatment and 

planning how to address them 

 Reviewing problems that emerged but were 

not addressed in treatment and helping the 

client develop a plan for addressing them in 

the future 

 Developing strategies for identifying and 

coping with high-risk situations or the 

reemergence of substance abuse behaviors 

 Teaching the client how to capitalize on 

personal strengths 

 Emphasizing client self-sufficiency and 

teaching self-reinforcement techniques 

 Developing a plan for future support, 

including mutual help groups, family 

support, and community support 

Termination of therapy should always be 

planned in advance. (2) When the client has 

made the agreed-upon behavior changes and 

has resolved some problems, the therapist 

should prepare to end the brief therapy. If a 

client progresses more quickly than anticipated, 

it is not necessary to complete the full number of 

sessions. 

Therapist characteristics 

Therapists will benefit from a firm grounding in 

theory and a broad technical knowledge of the 

many different approaches to brief therapy that 

are available. (2) When appropriate, elements of 

different brief therapies may be combined to 

provide successful outcomes. However, it is 

important to remember that the effectiveness of 

highly defined interventions (e.g., workbookdriven interventions) used in some behavioral 

therapies depends on administration of the 

entire regimen. 

 The therapist must use caution in combining 

and mingling certain techniques and must be 

sensitive to the cultural context within which 

therapies are integrated. (2) 

 Therapists should be sufficiently trained in 

the therapies they are using and should not 

rely solely on a manual such as this to learn 

those therapies. (2) 

 Training for brief therapies, in contrast to the 

training necessary to conduct brief 

interventions, requires months to years and 

usually results in a specialist degree or 

certification. The Consensus Panel 

recommends that anyone seeking to practice 

the therapies outlined here should receive 

more thorough training appropriate to the 

type of therapy being delivered. (Appendix 

B of the TIP provides contact information for 

some organizations that may be able to 

provide such training.) (2) 

 Providers of brief therapy should be able to 

focus effectively on identifying and adhering 

to specific therapeutic goals in treatment. (2) 

 Providers who practice brief therapy should 

be able to distill approaches from longer 

term therapies and apply them within the 

parameters of brief therapy. (2) 

Cognitive–Behavioral Therapy 

CBT represents the integration of principles 

derived from behavioral theory, cognitive social 

learning theory, and cognitive therapy, and it 

provides the basis for a more inclusive and 

comprehensive approach to treating substance 

abuse disorders. 

CBT can be used by properly licensed and 

trained mental health practitioners even if they 

have limited experience with this type of 

therapy—either as a cost-effective primary 

approach or in conjunction with other therapies 

or a 12-Step program. CBT can be also used 

early in and throughout the treatment process 

xxi
Executive Summary and Recommendations 

whenever the therapist feels it is important to 

examine a client’s inaccurate or unproductive 

thinking that could lead to risky or negative 

behaviors. (2) 

CBT is generally not appropriate for certain 

clients, namely, those 

 Who have psychotic or bipolar disorders and 

are not stabilized on medication 

 Who have no stable living arrangements 

 Who are not medically stable (as assessed by 

a pretreatment physical examination) (2) 

Cognitivebehavioral techniques 

The cognitive–behavioral model assumes that 

substance abusers are deficient in coping skills, 

choose not to use those they have, or are 

inhibited from doing so. It also assumes that 

over the course of time, substance abusers 

develop a particular set of effect expectancies 

based on their observations of peers and 

significant others abusing substances to try to 

cope with difficult situations, as well as through 

their own experiences of the positive effects of 

substances. 

 CBT is generally effective because it helps 

clients recognize the situations in which they 

are likely to use substances, find ways of 

avoiding those situations, and cope more 

effectively with the variety of situations, 

feelings, and behaviors related to their 

substance abuse. (2) To achieve these 

therapeutic goals, CBT incorporates three 

core elements: 

i Functional analysis—This analysis attempts 

to identify the antecedents and 

consequences of substance abuse behavior, 

which serve as triggering and maintaining 

factors. 

i Coping skills training—A major component 

in CBT is the development of appropriate 

coping skills. 

i Relapse prevention—These approaches rely 

heavily on functional analyses, 

identification of high-risk relapse 

situations, and coping skills training, but 

also incorporate additional features. These 

approaches attempt to deal directly with a 

number of the cognitions involved in the 

relapse process and focus on helping the 

individual gain a more positive selfefficacy. 

 Overall, behavioral, cognitive, and cognitive– 

behavioral interventions are effective, can be 

used with a wide range of substance abusers, 

and can be conducted within the timeframe 

of brief therapies. (1) 

 A broad range of cognitions will be 

evaluated in CBT, including attributions, 

appraisals, self-efficacy expectancies, and 

substance-related effect expectancies. (2) 

Strategic/Interactional Therapies 

Strategic/interactional therapies attempt to 

identify the client’s strengths and actively create 

personal and environmental situations in which 

success can be achieved. The primary strength 

of strategic/interactional approaches is that they 

shift the focus from the client’s weaknesses to 

his strengths. 

The strategic/interactional model has been 

widely used and successfully tested on persons 

with serious and persistent mental illnesses. (1) 

Although the research to date on these therapies 

(using nonexperimental designs) has not 

focused on substance abuse disorders, the use of 

these therapies in treating substance abuse 

disorders is growing. 

The Consensus Panel believes that these 

therapeutic approaches are potentially useful for 

clients with substance abuse disorders and 

should be introduced to offer new knowledge 

and techniques for treatment providers to 

consider. (2) 

Using strategic/interactional 

therapies 

No matter which type of strategic/interactional 

therapy is used, this approach can help to 

xxii 
Executive Summary and Recommendations 

 Define the situation that contributes to 

substance abuse in terms meaningful to the 

client (2) 

 Identify steps needed to control or end 

substance abuse (2) 

 Heal the family system so it can better 

support change (2) 

 Maintain behaviors that will help control 

substance abuse (2) 

 Respond to situations in which the client has 

returned to substance use after a period of 

abstinence (2) 

Strategic/interactional approaches are most 

useful in 

 Learning how the client’s relationships deter 

or contribute to substance abuse (2) 

 Shifting power relationships (2) 

 Addressing fears (2) 

Most forms of strategic/interactional 

therapies are brief by the definition used in this 

TIP. Strategic/interactional therapies normally 

require 6 to 10 sessions, with 6 being most 

common. 

Humanistic and 

Existential Therapies 

Humanistic and existential psychotherapies use 

a wide range of approaches to the planning and 

treatment of substance abuse disorders. They 

are, however, united by an emphasis on 

understanding human experience and a focus 

on the client rather than the symptom. 

Humanistic and existential approaches share a 

belief that people have the capacity for selfawareness and choice. However, the two 

schools come to this belief through different 

theories. 

Humanistic and existential therapeutic 

approaches may be particularly appropriate for 

short-term substance abuse treatment because 

they tend to facilitate therapeutic rapport, 

increase self-awareness, focus on potential inner 

resources, and establish the client as the person 

responsible for 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 reach their full 

potential. (2) 

Using humanistic and 

existential therapies 

Many aspects of humanistic and existential 

approaches (including empathy, encouragement 

of affect, reflective listening, and acceptance of 

the client’s subjective experience) can be useful 

in any type of brief therapy. They help establish 

rapport and provide grounds for meaningful 

engagement with all aspects of the treatment 

process. (2) 

Humanistic and existential approaches can 

be used at all stages of recovery in creating a 

foundation of respect for clients and mutual 

acceptance of the significance of their 

experiences. (2) There are, however, some 

therapeutic moments that lend themselves more 

readily to one or more specific approaches. 

 Client-centered therapy can be used 

immediately to establish rapport and to 

clarify issues throughout the session. (2) 

 Existential therapy may be used most 

effectively when a client has access to 

emotional experiences or when obstacles 

must be overcome to facilitate a client’s entry 

into or continuation of recovery (e.g., to get 

someone who insists on remaining helpless 

to accept responsibility for her actions). (2) 

 Narrative therapy can be used to help the 

client conceptualize treatment as an 

opportunity to assume authorship and begin 

a “new chapter” in life. (2) 

 Gestalt approaches can be used throughout 

therapy to facilitate a genuine encounter with 

the therapist and the client’s own 

experience. (2) 

xxiii 
Executive Summary and Recommendations 

 Transpersonal therapy can enhance spiritual 

development by focusing on the intangible 

aspects of human experience and awareness 

of unrealized spiritual capacity. (2) 

Using a humanistic or existential therapy 

framework, the therapist can offer episodic 

treatment, with a treatment plan that focuses on 

the client’s tasks and experiences between 

sessions. (2) 

For many clients, momentary circumstances 

and other problems surrounding substance 

abuse may seem more pressing than notions of 

integration, spirituality, and existential growth, 

which may be too remote from their immediate 

situation to be effective. In such instances, 

humanistic and existential approaches can help 

clients focus on the fact that they do indeed 

make decisions about substance abuse and are 

responsible for their own recovery. (2) 

Psychodynamic Therapies 

Psychodynamic therapy focuses on unconscious 

processes as they are manifested in the client’s 

present behavior. The goals of psychodynamic 

therapy are client self-awareness and 

understanding of the past’s influence on present 

behavior. In its brief form, a psychodynamic 

approach enables the client to examine 

unresolved conflicts and symptoms that arise 

from past dysfunctional relationships and 

manifest themselves in the need and/or desire 

to abuse substances. 

Several of the brief forms of psychodynamic 

therapy are less appropriate for use with 

persons with substance abuse disorders, partly 

because their altered perceptions make it 

difficult to achieve insight and problem 

resolution. However, many psychodynamic 

therapists use forms of brief psychodynamic 

therapy with substance-abusing clients in 

conjunction with traditional substance abuse 

treatment programs or as the sole therapy for 

clients with coexisting disorders. (2) 

Although there is some disagreement in the 

details, psychodynamic brief therapy is 

generally thought more suitable for (2) 

 Those who have coexisting psychopathology 

with their substance abuse disorder 

 Those who do not need or who have 

completed inpatient hospitalization or 

detoxification 

 Those whose recovery is stable 

 Those who do not have organic brain 

damage or other limitations to their mental 

capacity 

Integrating psychodynamic concepts 

into substance abuse treatment 

Most therapists agree that people with substance 

abuse disorders comprise a special population, 

one that often requires more than one approach 

if treatment is to be successful. Therapists 

whose orientations are not necessarily 

psychodynamic may still find these techniques 

and approaches useful, and therapists whose 

approaches are psychodynamic may be more 

effective if they conduct psychotherapy in a way 

that complements the full range of services for 

clients with substance abuse disorders. (2) 

Family Therapy 

For many individuals with substance abuse 

disorders, interactions with their family of 

origin, as well as their current family, set the 

patterns and dynamics for their problems with 

substances. Furthermore, family member 

interactions with the substance abuser can either 

perpetuate and aggravate the problem or 

substantially assist in resolving it. Family 

therapy is particularly appropriate when the 

client exhibits signs that his substance abuse is 

strongly influenced by family members’ 

behaviors or communications with them. (2) 

Family involvement is often critical to 

success in treating many substance abuse 

xxiv 
disorders—most obviously in cases where the 

family is part of the problem. (2) 

Family therapy can be used to 

 Focus on the expectation of change within 

the family (which may involve multiple 

adjustments) 

 Test new patterns of behavior 

 Teach how a family system works—how the 

family supports symptoms and maintains 

needed roles 

 Elicit the strengths of every family member 

 Explore the meaning of the substance abuse 

disorder within the family 

Appropriateness of brief 

family therapy 

Long-term family therapy is not usually 

necessary for the treatment of substance abuse 

disorders. While family therapy may be very 

helpful in the initial stages of treatment, it is 

often easier to continue to help an individual 

work within the family system through 

subsequent individual therapy. (2) 

Short-term family therapy is an option that 

could be used in the following circumstances (2): 

 When resolving a specific problem in the 

family and working toward a solution 

 When the therapeutic goals do not require indepth, multigenerational family history, but 

rather a focus on present interactions 

 When the family as a whole can benefit from 

teaching and communication to better 

understand some aspect of the substance 

abuse disorder 

Definitions of “family” 

Family therapy can involve a network that 

extends beyond the immediate family, involves 

only a few members of the family system, or 

even deals with several families at once. (2) The 

definition of “family” varies in different cultures 

and situations and should be defined by the 

client. 

Executive Summary and Recommendations 

Therapists can “create” a family by drawing 

on the client’s network of significant contacts. 

(2) A more important question than whether the 

client is living with a family is, “Can the client’s 

problem be seen as having a relational 

(involving two or more people) component?” 

Using brief family therapies 

In order to promote change successfully within 

a family system, the therapist will need the 

family’s permission to enter the family space 

and share their closely held confidences. The 

therapy, however, will work best if it varies 

according to the cultural background of the 

family. (1) 

Most family therapy is conducted on a shortterm basis. Sessions are typically 90 minutes to 

2 hours in length. The preferred timeline for 

family therapy is not more than 2 sessions per 

week (except in residential settings), to allow 

time to practice new behaviors and experience 

change. Therapy may consist of as few as 6 or as 

many as 10 sessions, depending on the purpose 

and goals of the intervention. 

Group Therapy 

Group psychotherapy is one of the most 

common modalities for treatment of substance 

abuse disorders. Group therapy is defined as a 

meeting of two or more people for a common 

therapeutic purpose or to achieve a common 

goal. It differs from family therapy in that the 

therapist creates open- and closed-ended groups 

of people previously unknown to each other. 

Appropriateness of group therapy 

Group psychotherapy can be extremely 

beneficial to individuals with substance abuse 

problems. (2) It gives them the opportunity to 

see the progression of abuse and dependency in 

themselves and others; it also provides an 

opportunity to experience personal success and 

the success of other group members in an 

atmosphere of support and hope. 

xxv 
Executive Summary and Recommendations 

Use of psychodrama techniques 

in a group setting 

Psychodrama has long been effectively used 

with substance-abusing clients in a group 

setting. Psychodrama can be used with different 

models of group therapy. It offers persons with 

substance abuse disorders an opportunity to 

better understand past and present 

experiences—and how past experiences 

influence their present lives. (2) 

Using time-limited group therapy 

The focus of time-limited therapeutic groups 

varies a great deal according to the model 

chosen by the therapist. Yet some 

generalizations can be made about several 

dimensions of the manner in which brief group 

therapy is implemented. 

Client preparation is particularly important 

in any time-limited group experience. Clients 

should be thoroughly assessed before their entry 

into a group for therapy. (2) Group participants 

should be given a thorough explanation of 

group expectations. 

The preferred timeline for time-limited 

group therapy is not more than 2 sessions per 

week (except in the residential settings), with as 

few as 6 sessions in all, or as many as 12, 

depending on the purpose and goals of the 

group. 

Sessions are typically 11⁄2 to 2 hours in length. 

Residential programs usually have more 

frequent sessions. 

Group process therapy is most effective if 

participants have had time to find their roles in a 

group, to “act” these roles, and to learn from 

them. The group needs time to define its 

identity, develop cohesion, and become a safe 

environment in which there is enough trust for 

participants to reveal themselves. (2) 

Conclusion 

The brief interventions and therapies described 

in this TIP are intended to introduce a range of 

techniques to clinicians. Clinicians will find 

different portions of this TIP more useful than 

others depending on their theoretical 

orientation, but all clinicians who work with 

substance-abusing clients should find material 

of value here. Brief interventions will be useful 

for a wide variety of service providers; brief 

therapies are intended for properly qualified, 

educated, and licensed professionals. 

xxvi 
1 Introduction to Brief 

Interventions and Therapies 

The use of brief intervention and brief 

therapy techniques has become an 

increasingly important part of the 

continuum of care in the treatment of substance 

abuse problems. With the health care system 

changing to a managed model of care and with 

changes in reimbursement policies for substance 

abuse treatment, these short, problem-specific 

approaches can be valuable in the treatment of 

substance abuse problems. They provide the 

opportunity for clinicians to increase positive 

outcomes by using these modalities 

independently as stand-alone interventions or 

treatments and as additions to other forms of 

substance abuse and mental health treatment. 

They can be used in a variety of settings 

including opportunistic settings (e.g., primary 

care, home health care) and specialized 

substance abuse treatment settings (inpatient 

and outpatient). 

Used for a variety of substance abuse 

problems from at-risk use to dependence, brief 

interventions can help clients reduce or stop 

abuse, act as a first step in the treatment process 

to determine if clients can stop or reduce on 

their own, and act as a method to change 

specific behaviors before or during treatment. 

For example, there are some issues associated 

with treatment compliance that benefit from a 

brief, systematic, well-planned intervention such 

as attending group sessions or doing homework. 

In other instances, brief interventions address 

specific family problems with a client and/or 

family members or deal with specific individual 

problems such as personal finances and work 

attendance. The basic goal for a client regardless 

of setting is to reduce the risk of harm that may 

result from continued use of substances. The 

reduction of harm, in its broadest sense, pertains 

to the clients themselves, their families, and the 

community. 

The brief therapies discussed in this TIP are 

brief cognitive–behavioral therapy, brief 

strategic and interactional therapies, brief 

humanistic and existential therapies, brief 

psychodynamic therapy, short-term family 

therapy, and time-limited group therapy. The 

choice to include these therapeutic modalities 

was based on a combination of relevant research 

and, in some instances where there is a smaller 

research base, the clinical knowledge and 

expertise of the Consensus Panel. All of these 

approaches are currently being used in the 

treatment of substance abuse disorders, and all 

of them can contribute something to the array of 

treatment techniques available to the eclectic 

practitioner. 

Brief interventions and brief therapies may 

be thought of as elements on a continuum of 

care, but they can be distinguished from each 

other according to differences in outcome goals. 

Interventions are generally aimed at motivating 

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

enter treatment, change a behavior, think 

1 
Chapter 1 

differently about a situation), whereas therapies 

are used to address larger concerns (such as 

altering personality, maintaining abstinence, or 

addressing long-standing problems that 

exacerbate substance abuse). This TIP presents 

brief interventions as a way of improving client 

motivation for treatment. The brief therapies 

considered here are ways of changing client 

attitudes and behaviors. Other differences that 

help distinguish brief interventions from brief 

therapies include 

 Length of the sessions (from 5 minutes for an 

intervention to more than six 1-hour therapy 

sessions) 

 Extensiveness of assessment (which will be 

greater for therapies than for interventions) 

 Setting (nontraditional treatment settings 

such as a social service or primary care 

setting, which will use interventions 

exclusively, versus traditional substance 

abuse treatment settings where therapy or 

counseling will be used in addition to 

interventions) 

 Personnel delivering the treatment (brief 

interventions can be administered by a wide 

range of professionals, but therapy requires 

training in specific therapeutic modalities) 

 Materials and media used (certain materials 

such as written booklets or computer 

programs may be used in the delivery of 

interventions but not therapies) 

Although the theoretical bases for brief 

therapy and brief intervention may be different, 

this distinction is less obvious in practice. These 

two approaches to substance abuse problems 

and behavior change reflect a continuum rather 

than a clear dichotomy. The distinction may be 

further blurred as the change process associated 

with the success of brief interventions is better 

understood or refined and as theories are 

developed to explain a brief intervention’s 

mechanism of action. Already, some forms of 

brief intervention overlap with therapy, such as 

motivational enhancement therapy, which has a 

clearly articulated theoretical rationale (for more 

on this topic, see TIP 35, Enhancing Motivation for 

Change in Substance Abuse Treatment, which was 

conceived as a companion volume to this TIP 

[Center for Substance Abuse Treatment (CSAT), 

1999c]). 

For the purposes of this TIP, brief therapy 

involves a series of steps taken to treat a 

substance abuse problem, whereas brief 

interventions are those practices that aim to 

investigate a potential problem and motivate an 

individual to begin to do something about his 

substance abuse. Therapy involves movement 

(or an attempt at movement) toward change. 

Brief therapy concentrates particularly on 

investigating a problem in order to develop a 

solution in consultation with the client; brief 

interventions generally involve a therapist 

giving advice to the client. 

The increasing emphasis on brief approaches 

is partly attributable to recent changes in the 

health care delivery system, in which clinicians 

are urged to reduce costs while maintaining 

treatment efficacy. Essentially, clinicians are 

constrained by time and diminishing resources 

yet are treating an increasing number of 

individuals with substance abuse problems. 

Fortunately, there is a body of literature on 

brief approaches in the treatment of substance 

abuse disorders. Brief interventions and brief 

therapies have the appeal not only of being brief 

but also of having research backing that 

supports their use. Brief interventions have 

been widely tested with both general clinical 

and substance-abusing populations and have 

shown great promise in changing client 

behavior. Brief therapies, however, have been 

unevenly researched. As indicated in the 

discussion of each type, in addition to the 

empirical results reported in scientific journals, 

clinical and anecdotal evidence supports the 

efficacy of brief therapies in the treatment of 

substance abuse. The brevity and lower 

2 
Introduction 

delivery costs of these brief approaches make 

them ideal mechanisms for use in settings from 

primary care to substance abuse treatment 

where cost often plays as much of a role as 

efficacy in determining what treatments clients 

receive. 

Brief interventions and brief therapies are 

also well suited for clients who may not be 

willing or able to expend the significant 

personal and financial resources necessary to 

complete more intensive, longer term 

treatments. Although much research supports 

the theory that longer time in treatment is 

associated with better outcomes, research also 

suggests that for some clients, there is no loss in 

effectiveness when length and intensity of 

treatment are reduced. 

An Overview of Brief 

Interventions 

Definitions of brief interventions vary. In the 

recent literature, they have been referred to as 

“simple advice,” “minimal interventions,” “brief 

counseling,” or “short-term counseling.” They 

can be simple suggestions to reduce drinking 

given by a professional (e.g., social worker, 

nurse, alcohol and drug counselor, physician, 

physician assistant) or a series of interventions 

provided within a treatment program. As one 

researcher notes, 

Brief interventions for excessive drinking 

should not be referred to as an homogenous 

entity, but as a family of interventions varying 

in length, structure, targets of intervention, 

personnel responsible for their delivery, media 

of communication and several other ways, 

including their underpinning theory and 

intervention philosophy (Heather, 1995, p. 

287). 

Brief interventions, therefore, can be viewed as a 

set of principles regarding interventions which 

are different from, but not in conflict with, the 

principles underlying conventional treatment 

(Heather, 1994). 

Brief interventions for alcohol problems, for 

example, have employed various approaches to 

change drinking behaviors. These approaches 

have ranged from relatively unstructured 

counseling and feedback to more formal 

structured therapy and have relied heavily on 

concepts and techniques from the behavioral 

self-control training (BSCT) literature (Miller 

and Hester, 1986b; Miller and Munoz, 1982; 

Miller and Rollnick, 1991; Miller and Taylor, 

1980) (see Chapter 4 for more information on 

BSCT). Usually, brief treatment interventions 

have flexible goals, allowing the individual to 

choose moderation or abstinence. The typical 

counseling goal is to motivate the client to 

change her behavior and not to assign selfblame. While much of the research to date has 

centered on clients with alcohol-related 

problems, similar approaches can be taken with 

users of other substances. 

Brief interventions are a useful component of 

a full spectrum of treatment options; they are 

particularly valuable when more extensive 

treatments are unavailable or a client is resistant 

to such treatment. Too few clinicians, however, 

are educated and skilled in the use of brief 

interventions and therapies to address the very 

large group of midrange substance users who 

have moderate and risky consumption patterns 

(see Figure 1-1). Although this group may not 

need or accept traditional substance abuse 

treatment, these individuals are nonetheless 

responsible for a disproportionate share of 

substance-related morbidity, including lowered 

workforce performance, motor vehicle accidents 

and other injuries, marital discord, family 

dysfunction, and medical illness (Wilk et al., 

1997). These hazardous substance users are 

identified in employment assistance programs 

(EAPs), programs for people cited for driving 

while intoxicated (DWI), and urine testing 

programs, as well as in physicians’ offices and 

other health screening efforts (Miller, 1993). 

Despite appeals from such distinguished bodies 

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as the National Academy of Sciences in the 

United States and the National Academy of 

Physicians and Surgeons in the United 

Kingdom, widespread adoption of brief 

interventions by medical practitioners or 

treatment providers has not yet occurred 

(Drummond, 1997; Institute of Medicine [IOM], 

1990). 

Brief interventions in traditional settings 

usually involve a more in-depth assessment of 

substance abuse patterns and related problems 

1990). The characterizations of hazardous, 

harmful, or dependent use as they relate to 

alcohol consumption patterns (Edwards et al., 

1981) were used to distinguish the targets of 

4 
Introduction 

brief intervention in a World Health 

Organization (WHO) study (Babor and Grant, 

1991). Hazardous drinking refers to a level of 

alcohol consumption or pattern of drinking that, 

should it persist, is likely to result in harm to the 

drinker. Harmful drinking is defined as alcohol 

use that has already resulted in adverse mental 

or physical effects. Dependent use refers to 

drinking that has resulted in physical, 

psychological, or social consequences and has 

been the focus of major diagnostic tools, such as 

the Diagnostic and Statistical Manual, 4th Edition 

(American Psychiatric Association [APA], 1994) 

or the International Classification of Diseases, 9th 

Revision (ICD-9) (ICD-9-CM, 1995). 

Categorizing drinking patterns in this fashion 

provides both clinicians and researchers with 

flexible guidelines to identify individuals at risk 

for alcohol problems who may not meet criteria 

for alcohol dependence. Similar levels of use for 

other substances are much more difficult to 

define, since most of them are illicit and those 

that are not have often not been widely studied 

in relation to substance abuse. 

Studies of brief interventions have been 

conducted in a wide range of health care 

settings, from hospitals and primary health care 

locations (Babor and Grant, 1991; Chick et al., 

1985; Fleming et al., 1997; Wallace et al., 1988) to 

mental health clinics (Harris and Miller, 1990). 

(Refer to “Research Findings” in Chapter 2 for 

more discussion of research on brief 

interventions.) Individuals recruited from such 

settings are likely to have had some contact with 

a health care professional during the study 

participation and therefore had alcohol-related 

professional assistance available. Nonetheless, 

many of these patients would not be identified 

as having an alcohol problem by their health 

care providers and would not ordinarily receive 

any alcohol-specific intervention. 

In general, brief interventions are conducted 

in a variety of opportunistic and substance 

abuse treatment settings, target different goals; 

may be delivered by treatment staff or other 

professionals, and do not require extensive 

training. Because of the short duration of brief 

intervention strategies, they can be considered 

for use with injured patients in the emergency 

department who have substance abuse 

problems. Useful distinctions between the goals 

of brief interventions as applied in different 

settings are listed in Figure 1-2. 

Brief interventions in traditional settings 

usually involve a more in-depth assessment of 

substance use patterns and related problems 

than interventions administered in 

nontraditional settings and tend to examine 

other aspects of participants’ attitudes, such as 

readiness for or resistance to change. They can 

be useful for addressing specific behavior 

change issues in treatment settings. Because 

they are timely, focused, and client centered, 

brief interventions can quickly enhance the 

overall working relationship with clients. 

However, brief interventions should not be a 

care substitute for clients who have a high level 

of abuse. 

Some of the assessments conducted for 

research studies of brief interventions are very 

extensive and may have been conducted during 

prior treatment (e.g., in detoxification programs, 

during treatment intake procedures). Most brief 

interventions offer the client detailed feedback 

about assessment findings, with an opportunity 

for more input. The assessment typically 

involves obtaining information regarding 

frequency and quantity of substance abuse, 

consequences of substance abuse, and related 

health behaviors and conditions. 

The intervention itself is structured and 

focused on substance abuse. Its primary goals 

are to raise awareness of problems and then to 

recommend a specific change or activity (e.g., 

reduced consumption, accepting a referral, selfmonitoring of substance abuse). The participant 

in a brief intervention is usually offered a menu 

of options or strategies for accomplishing the 

5 
Chapter 1 

Figure 1-2 

Goal of Brief Interventions According to Setting 

Setting Purpose 

Opportunistic setting 



Facilitate referrals for additional specialized treatment 

(e.g., a nurse identifying substance-abusing clients 

through screening and advising them to seek further 

assessment or treatment) 

Affect substance abuse directly by recommending a 

reduction in hazardous or at-risk consumption patterns 

(e.g., a primary care physician advising hazardous or atrisk drinkers to cut down, National Alcohol Screening 

Day) or establishing a plan for abstinence 

Neutral environments (e.g., individuals 

responding to media advertisements) 

 Assess substance abuse behavior and give supportive 

advice about harm reduction (e.g., a public health 

initiative to screen people in shopping malls and provide 

feedback and advice) 

Health care setting  Facilitate referrals for additional specialized treatment 

Substance abuse treatment programs 





Act as a temporary substitute for more extended 

treatment for persons seeking assistance but waiting for 

services to become available (e.g., an outpatient 

treatment center that offers potential clients assessment 

and feedback while they are on a waiting list) 

Act as a motivational prelude to engagement and 

participation in more intensive treatment (e.g., an 

intervention to help a client commit to inpatient 

treatment when the assessment deems it appropriate but 

the client believes outpatient treatment is adequate) 

Facilitate behavior change related to substance abuse or 

associated problems 

Source: Adapted from Bien et al., 1993. 

target goal and encouraged to take 

responsibility for selecting and working on 

behavioral change in a way that is most 

comfortable for him. Any followup visits will 

provide an opportunity to monitor progress and 

to encourage the client’s motivation and ability 

to make positive changes. The person 

delivering the brief intervention is usually 

trained to be empathic, warm, and encouraging 

rather than confrontational. 

Brief interventions are typically conducted in 

face-to-face sessions, with or without the 

addition of written materials such as self-help 

manuals, workbooks, or self-monitoring diaries. 

A few have consisted primarily of mailed 

materials, automated computer screening and 

advice, or telephone contacts. 

Some interventions are aimed at specific 

health problems that are affected by substance 

abuse, rather than substance abuse itself. 

6 
Introduction 

For example, an intervention may be conducted 

to help a client reduce her chances of contracting 

human immunodeficiency syndrome (HIV) by 

using clean needles; as a result, if the client only 

has dirty needles, she might avoid using them in 

order to reduce her risk of HIV and thus reduce 

her use of heroin. By raising an individual’s 

awareness of her substance abuse, a brief 

intervention can act as a powerful catalyst for 

changing a substance abuse pattern. 

The distress clients feel about their substance 

abuse behavior can act as an influence to 

encourage change as they recognize the negative 

consequences of that behavior to themselves or 

others. Positive and negative external forces are 

also influences. Life events, such as a major 

illness or the death of significant others, career 

change, marriage, and divorce, can contribute to 

the desire to change. Brief interventions can 

address these events and feelings that 

accompany them with the underlying goal of 

changing clients’ substance abuse behaviors. 

An Overview of Brief 

Therapies 

In contrast to most simple advice or brief 

interventions, brief therapies are usually 

delivered to persons who are seeking—or 

already in—treatment for a substance abuse 

disorder. That is, the individual usually has 

some recognition or awareness of the problem, 

even if he has yet to accept it. The therapy itself 

is often client driven; the client identifies the 

problems, and the clinician uses the client’s 

strengths to build solutions. The choice of a 

brief therapy for a particular individual should 

be based on a comprehensive assessment rather 

than a cursory screening to identify potentially 

hazardous drinking or substance-abusing 

patterns (IOM, 1990). In some cases, brief 

therapy may also be used if resources for more 

extensive therapy are not available or if 

standard treatment is inaccessible or unavailable 

(e.g., remote communities, rural areas). Brief 

therapies often target a substance-abusing 

population with more severe problems than 

those for whom brief interventions are 

sufficient. Brief therapies can be useful for 

special populations if the therapist understands 

that some client issues may be developmental or 

physiological in nature (see TIP 26, Substance 

Abuse Among Older Adults, and TIP 32, Treatment 

of Adolescents With Substance Use Disorders 

[CSAT, 1998b, 1999b]). 

Although brief therapies are typically shorter 

than traditional versions of therapy, these 

therapies generally require at least six sessions 

and are more intensive and longer than brief 

interventions. Brief therapy, however, is not 

simply a shorter version of some form of 

psychotherapy. Rather, it is the focused 

application of therapeutic techniques specifically 

targeted to a symptom or behavior and oriented 

toward a limited length of treatment. 

In addition to the goals of brief interventions, 

the goals of brief therapy in substance abuse 

treatment is remediation of some specified 

psychological, social, or family dysfunction as it 

pertains to substance abuse; it focuses primarily 

on present concerns and stressors rather than on 

historical antecedents. Brief therapy is 

conducted by therapists who have been 

specifically trained in one or more psychological 

or psychosocial models of treatment. Therapist 

training requires months or years and usually 

results in a specialist degree or certification. In 

practice, many therapists who have been trained 

in specific theoretical models of change borrow 

techniques from other models when working 

with their clients. Although the models remain 

distinct, therapists often become eclectic 

practitioners. 

7 
Chapter 1 

The Demand for Brief 

Interventions and 

Therapies 

The impetus for shorter forms of interventions 

and treatments for a range of substance abuse 

problems comes from several sources: 

 Historical developments in the field that 

encourage a comprehensive, communitybased continuum of care—with treatment 

and prevention components to serve clients 

who have a wide range of substance abuserelated problems 

 A growing body of evidence that consistently 

demonstrates the efficacy of brief 

interventions 

 An increasing demand for the most costeffective types of treatment, especially in this 

era of health care inflation and cost 

containment policies in the private and 

public sectors 

 Client interest in shorter term treatments 

The increasing demand for treatment of 

some sort—arising from the identification of 

more at-risk consumers of substances through 

EAPs, substance-testing programs, health 

screening efforts, and drunk driving arrests— 

coupled with decreased public funding and cost 

containment policies of managed care leave only 

two options: provide diluted treatment in 

traditional models for a few or develop a system 

in which different levels and types of 

interventions are provided to clients based on 

their identified needs and characteristics (Miller, 

1993). 

Expanding Treatment Options 

The development of public substance abuse 

treatment programs subsidized by Federal, 

State, and local monies dates to the late 1960s 

when public drunkenness was decriminalized 

and detoxification centers were substituted for 

drunk tanks in jails. At about the same time, 

similar efforts were made to curtail heroin use in 

major cities by establishing methadone 

maintenance clinics and residential therapeutic 

communities (IOM, 1990). 

By the 1980s, direct Federal financial support 

for treatment had slowed, and although some 

States continued to grant subsidies, the most 

rapid growth in the field switched to the 

insurance-supported private sector and the 

development of treatment programs targeted 

primarily to heavy consumers of alcohol, 

cocaine, and marijuana (Gerstein and Harwood, 

1990). The standardized approach used in most 

of these private, hospital-based programs 

incorporated many aspects of the Minnesota 

model pioneered in the late 1950s, with a strong 

focus on the 12-Step philosophy developed in 

Alcoholics Anonymous (AA), a fixed-length, 28-

day stay, and insistence on abstinence as the 

major treatment goal (CSAT, 1995). 

Initially, treatment programs in both the 

public and private sectors tended to serve the 

most seriously impaired populations; however, 

providers gradually recognized the need for 

treatment options for a wider range of clients 

who had different types of substance abuse 

disorders. Providers realized that not all clients 

benefit from a single standardized treatment 

approach. Rather, treatment should be tailored 

to individual needs determined by in-depth 

assessments of the client’s problems and 

antecedents to her substance abuse disorder. 

Providers were also aware that interventions 

with less dysfunctional clients often had greater 

success rates. In the interest of reducing drunk 

driving, for example, educational efforts were 

targeted at offenders charged with DWI as an 

alternative to revoking their driving licenses. In 

such programs, more attention was given to 

outcomes and factors in the treatment setting 

than to the client’s history; these seemed to 

affect success rates whether or not treatment 

was completed. 

8 
Introduction 

As assessments became more 

comprehensive, treatment also began to address 

the effects of substance abuse patterns on 

multiple systems, including physical and mental 

health, social and personal functioning, legal 

entanglements, and economic stability. In recent 

years, this biopsychosocial approach to the 

treatment of substance abuse disorders has 

stimulated more cross-disciplinary cooperation. 

It has also prompted more attempts to match 

client needs to the most appropriate and 

expeditious intensity of care and treatment 

modality. Consideration is now given to 

differences not only in the severity and types of 

problems identified but also to the cultural or 

environmental context in which the problems 

are encountered, the types of substances abused, 

and differences in gender, age, education, and 

social stability. Determining a client’s 

appropriateness for treatment is one of the 46 

global criteria for competency of certified 

alcohol and drug abuse counselors (Herdman, 

1997). Indeed, client assessment and treatment 

matching and referral has become a specialty 

area in itself that avoids the hazards of random 

treatment entry. 

In order to test the efficacy of current 

treatment-matching knowledge, the National 

Institute on Alcohol Abuse and Alcoholism 

(NIAAA) initiated Project MATCH (Matching 

Alcoholism Treatment to Client Heterogeneity), 

which assessed the benefits of matching alcoholdependent clients (using 10 client 

characteristics) to three types of treatments: 12-

Step facilitation, cognitive–behavioral therapy, 

and motivational enhancement therapy (Project 

MATCH Research Group, 1997). Clients from 

two parallel but independent clinical trials (one 

in which clients were receiving outpatient 

treatment, the other in which clients were 

receiving aftercare therapy following inpatient 

treatment) were assigned to receive one of the 

three treatments. Although the results do not 

indicate a strong need to consider client 

characteristics to match clients to treatment, the 

findings do suggest that the severity of 

coexisting psychiatric disorders should be 

considered. 

Another study, conducted by McLellan and 

colleagues, identified specific problems of 

clients in treatment (e.g., employment, family, 

psychiatric problems), then matched the clients 

to services designed to address the problems 

(McLellan et al., 1993). These clients stayed in 

treatment longer, were more likely to complete 

treatment, and had better posttreatment 

outcomes than unmatched clients in the same 

treatment programs. 

In this context, increasing emphasis has also 

been given to integrating specialized approaches 

to substance abuse treatment with the general 

medical system and the services of other 

community agencies. A 1990 IOM report called 

for more community involvement in health care, 

social services, workplace, educational, and 

criminal justice systems (IOM, 1990). Because 

the vast majority of persons who use substances 

in moderation experience few or minor 

problems, they are not likely to seek help in the 

specialized treatment system. Instead, the 

estimated 20 percent of the adult population 

who drink or use heavily or in inappropriate 

ways (Higgins-Biddle et al., 1997) are those most 

likely to come to the attention of physicians, 

social workers, family therapists, employers, 

teachers, lawyers, and police. Because the 

prevalence of harmful and risky substance use 

far exceeds the capacity of available services to 

treat it, briefer and less intensive interventions 

seem warranted for a broad range of 

individuals, including those who are unwilling 

to accept referral for more formal and extensive 

specialized care (Bien et al., 1993) and those 

whose substance use is risky but not abusive 

(Higgins-Biddle et al., 1997). 

9 
Chapter 1 

Cost and Funding Factors 

Studies of the cost-effectiveness of different 

treatment approaches have been particularly 

appealing to policymakers seeking to reduce 

costs and better allocate scarce resources. In the 

managed care environment, however, cost 

containment has become a byword, and no 

standard type of care or treatment protocol for 

all clients is acceptable. In order to receive 

reimbursement, substance abuse treatment 

facilities must find the least intensive yet safe 

modality of care that can be objectively proven 

to be appropriate and effective for a client’s 

needs. Now that more treatment is delivered in 

ambulatory care facilities, the usual time in 

treatment is being shortened, and the credibility 

of recommended treatment approaches must be 

increasingly documented through carefully 

conducted research studies. In this context, 

some of the most widely used substance abuse 

treatment approaches, such as the Minnesota 

model, halfway houses, and 12-Step programs, 

have only recently been subjected to rigorous 

tests of effectiveness in controlled clinical trials 

(Barry, 1997; Holder et al., 1991; Landry, 1996). 

In addition to the emphasis on cost 

containment and careful client–treatment 

matching, other researchers tout the potentially 

enormous public health impact that could be 

derived from conducting mass screenings in 

existing health care and other community-based 

systems to identify problem drinkers and then 

delivering brief interventions aimed at reducing 

excessive drinking patterns (Kahan et al., 1995). 

If appropriately selected persons with less 

severe substance abuse respond successfully to 

brief interventions with a consequent long-term 

reduction in substance abuse-related morbidity 

and associated health care costs, time and 

energy could be saved for treating those with 

more severe substance abuse disorders in 

specialized treatment facilities. 

Barriers to Increasing the 

Use of Brief Treatments 

Many clinicians and other care providers in 

community agencies retain the long-standing 

notion that clients are generally resistant to 

change, unmotivated, and in denial of problems 

associated with their substance abuse disorders. 

As a result, clinicians are hesitant to work with 

this population. Some of these attitudes also 

persist in the specialist treatment community 

(Miller, 1993). Although this perspective is 

shifting as clinicians better understand the many 

aspects of client motivation, there is still a 

tradition of waiting for a substance user to “hit 

bottom” and ask for help before attempting to 

treat him. 

Other ideological obstacles present barriers 

in earlier stages of substance abuse. The focus of 

brief interventions on harm or risk reduction 

and moderating consumption patterns as a first 

and sometimes only goal is not always 

acceptable to counselors who were trained to 

insist on total and enduring abstinence. 

Assumptions underlying brief interventions 

aimed at harm reduction may seem to challenge 

ideas that substance abuse disorders are a 

chronic and progressive disease requiring 

specialized treatment. However, if substance 

abuse is placed on a continuum from abstinence 

to severe abuse, any move toward moderation 

and lowered risk is a step in the right direction 

and not incongruous with a goal of abstinence 

as the ultimate form of risk reduction (Marlatt et 

al., 1993). Moreover, research indicates that 

substance-abusing individuals who are 

employed and generally functioning well in 

society are unlikely to respond positively to 

some forms of traditional treatment which may, 

for example, tell them that they have a primary 

disease of substance dependency and must 

abstain from all psychoactive substances for life 

(Miller, 1993). 

10 
Introduction 

In addition to resisting a harm reduction 

approach, treatment staffs in programs that 

incorporate pharmacotherapies may be skeptical 

of behavioral approaches to client change if they 

believe addiction primarily stems from 

disordered brain chemistry that should be 

treated medically. There are many models of 

pharmacotherapy that suggest that counseling 

(often in a brief form) coupled with medication 

provides the most well-rounded and 

comprehensive treatment regime (McLellan et 

al., 1993; Volpicelli et al., 1992). 

Moreover, research reveals that a longer time 

in treatment may contribute to a greater 

likelihood of success (Lamb et al., 1998). Brief 

interventions challenge this assumption by 

acknowledging that spontaneous remission and 

self-directed change in substance abuse 

behaviors do occur. A new perspective might 

reconcile these observations by recognizing that 

limited treatment can be beneficial—especially 

considering that at least half of all clients drop 

out of specialized treatment before completion. 

Probably the largest impediment to broader 

application of briefer forms of treatment is the 

already overwhelming responsibilities of 

frontline treatment staff members who are 

overworked and unfamiliar with the latest 

treatment research findings (Schuster and 

Silverman, 1993). Not only are these clinicians 

reluctant to make clinical changes, but their 

programs may also lack the financial and 

personnel resources to adopt innovative 

approaches. Treatment programs limit 

themselves by such inability and unwillingness 

to learn new techniques. 

Evaluating Brief 

Interventions and 

Therapies 

Quality improvement has become an important 

consideration in the contemporary health care 

environment. Because of changes in the nature 

and provision of health care delivery in the 

United States, health care organizations have 

been working to develop systematic quality 

improvement programs to monitor provision of 

care, client satisfaction, and costs. Brief 

interventions can be an important part of a 

treatment program’s quality improvement 

initiative. These approaches can be used to 

improve treatment outcomes in specific areas. 

Not only can brief interventions improve client 

compliance with specific aspects of treatment 

and therapist morale by focusing on attainable 

goals, but they can also demonstrate specific 

clinical outcomes of importance to both 

clinicians and managed care systems. 

Importance of Evaluation 

The Consensus Panel recommends that 

programs use quality assurance improvement 

projects to determine whether the use of a brief 

intervention or therapy in specific treatment 

situations is improving treatment. Examples of 

outcome measures include 

 Aftercare followup rates 

 Aftercare compliance rates 

 Alumni participation rates 

 Discharge against medical advice rates 

 Counselors’ ratings of client involvement in 

substance abuse following treatment 

 The number of complaints related to the brief 

intervention or therapy 

Mechanisms To Use in Evaluation 

The effects of adding brief approaches to 

standard care should be evaluated as part of 

continuous quality improvement program 

testing. Some of these outcomes can be 

measured by 

 Client satisfaction surveys 

 Followup phone calls 

 Counselor-rating questions added to clinical 

chart 

11 
Chapter 1 

Programs should monitor client satisfaction 

over time, and whenever possible counselors 

should be involved in quality improvement 

activities. Identifying trends over time can 

indicate what improvements need to be made. 

Implementation of substance abuse prevention 

and brief intervention strategies in clinical 

practice requires the development of 

systematized protocols that can provide easier 

service delivery. The need to implement 

effective and unified strategies for a variety of 

substance abusers who are at risk for more 

serious health, social, and emotional problems is 

high, both from a public health and a clinical 

perspective. As the health care system 

undergoes changes, programs should take the 

opportunity to develop and advocate a 

comprehensive system of substance abuse 

interventions, combining the skills of clinicians 

with the knowledge gained from the research 

community. 

12 
2 Brief Interventions in Substance 

Abuse Treatment 

Brief interventions for substance abuse 

problems have been used for many years 

by alcohol and drug counselors, social 

workers, psychologists, physicians, and nurses, 

and by social service agencies, hospital 

emergency departments, court-ordered 

educational groups, and vocational 

rehabilitation programs. Primary care providers 

find many brief intervention techniques effective 

in addressing the substance abuse issues of 

clients who are unable or unwilling to access 

specialty care. Examples of brief interventions 

include asking clients to try nonuse to see if they 

can stop on their own, encouraging 

interventions directed toward attending a selfhelp group (e.g., Alcoholics Anonymous [AA] or 

Narcotics Anonymous [NA]), and engaging in 

brief, structured, time-limited efforts to help 

pregnant clients stop using. 

Brief interventions are research-proven 

procedures for working with individuals with 

at-risk use and less severe abuse behaviors and 

can be successful when transported into 

specialist treatment settings and performed by 

alcohol and drug counselors. As presented in 

the literature, brief interventions to change 

substance abuse behaviors can involve a variety 

of approaches, ranging from unstructured 

counseling and feedback to formal structured 

therapy (Chick et al., 1985; Fleming et al., 1997; 

Kristenson et al., 1983; Persson and Magnusson, 

1989). Brief interventions, as defined and 

discussed in this TIP are time limited, 

structured, and directed toward a specific goal. 

They follow a specific plan (and in some cases a 

workbook) and have timelines for the adoption 

of specific behaviors. 

Several studies have attempted to identify 

factors that result in differential responses to 

brief intervention by varying client 

characteristics or by conducting subgroup 

analyses. Most studies of brief interventions to 

date are limited by their lack of sufficient subject 

assessments. Findings from the available 

research suggest that client characteristics are 

not good predictors of a person’s response to a 

brief intervention and that brief interventions 

may be applicable to individuals from a wide 

range of cultures and backgrounds (Babor, 1994; 

Babor and Grant, 1991). 

This chapter provides theoretical and 

practical information on brief interventions, 

both in opportunistic settings and in the 

substance abuse treatment setting. The stagesof-change model is presented first because of its 

usefulness in understanding the process of 

behavioral change. Next, the goals of brief 

intervention are described and applied to 

various levels of substance use. FRAMES 

elements critical to brief intervention are 

detailed, and five essential steps are listed with 

scripts to use in various settings. The brief 

intervention workbook, a practical tool for use 

during a brief intervention, is explained. 

13 
Chapter 2 

Essential clinician knowledge and skills for 

conducting a successful brief intervention are 

then described. Discussions of the use of brief 

intervention in substance abuse programs and 

nonspecialized settings follow. The final section 

presents research findings on brief interventions 

for both at-risk users and dependent users. 

Stages-of-Change Model 

The work of Prochaska and DiClemente and 

their “stages-of-change” model help clinicians 

tailor brief interventions to clients’ needs 

(Prochaska and DiClemente, 1984, 1986). 

Prochaska and DiClemente examined several 

theories concerning how change occurs and 

applied their findings to substance abuse 

behavior modification. They devised a model 

consisting of five stages of change that seemed 

to best represent the process people go through 

when thinking about, beginning, and trying to 

maintain new behavior (see Figure 2-1). The 

stages-of-change model is explained more fully 

in TIP 35, Enhancing Motivation for Change in 

Substance Abuse Treatment (CSAT, 1999c). 

These stages have proven useful, for 

example, in predicting those most likely to quit 

smoking and in targeting specific kinds of 

interventions to smokers in different stages 

(DiClemente et al., 1991; Prochaska, 1999; 

Prochaska and DiClemente, 1986; Velicer et al., 

1992). Stages of change are being examined in 

brief interventions with hazardous and harmful 

substance users as well, as a means of tailoring 

interventions to the individual’s current stage of 

change (Hodgson and Rollnick, 1992; Mudd et 

al., 1995). 

Clients need motivational support 

appropriate to their stage of change. If the 

clinician does not use strategies appropriate to 

the stage the client is in, treatment resistance or 

noncompliance could result. To consider 

change, clients at the precontemplation stage 

must have their awareness raised. 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. 

The clinician can use brief interventions to 

motivate particular behavioral changes at each 

stage of this 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 

personal decisions made at earlier stages. 

Understanding these stages helps the 

clinician to be patient, to accept the client’s 

current position, to avoid “getting too far 

ahead” of the client and thereby provoking 

resistance, and, most important, to apply the 

correct counseling strategy for each stage of 

readiness. Effective brief interventionists 

quickly assess the client’s stage of readiness, 

plan a corresponding strategy to assist her in 

progressing to the next stage, and implement 

that strategy without succumbing to distraction. 

Indeed, clinician distraction can be a greater 

obstacle to change in brief intervention than 

time limitations. 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. 

14 
Brief Interventions 

Figure 2-1 

The Stages of Change 

Stage Example Treatment Needs 

Precontemplation. The A functional yet alcohol-dependent This client needs information linking his 

user is not considering individual who drinks himself into problems and potential problems with his 

change, is aware of few a stupor every night but who goes substance abuse. A brief intervention might 

negative consequences, to work every day, performs his be to educate him about the negative 

and is unlikely to take job, has no substance abuse-related consequences of substance abuse. For 

action soon. legal problems, has no health 

problems, and is still married. 

example, if he is depressed, he might be told 

how his alcohol abuse may cause or 

exacerbate the depression. 

Contemplation. The user An individual who has received a This client should explore feelings of 

is aware of some pros citation for driving while ambivalence and the conflicts between her 

and cons of substance intoxicated and vows that next time substance abuse and personal values. The 

abuse but feels she will not drive when drinking. brief intervention might seek to increase the 

ambivalent about She is aware of the consequences client’s awareness of the consequences of 

change. This user has but makes no commitment to stop continued abuse and the benefits of 

not yet decided to drinking, just to not drive after decreasing or stopping use. 

commit to change. drinking. 

Preparation. This stage An individual who decides to stop This client needs work on strengthening 

begins once the user has abusing substances and plans to commitment. A brief intervention might 

decided to change and attend counseling, AA, NA, or a give the client a list of options for treatment 

begins to plan steps formal treatment program. (e.g., inpatient treatment, outpatient 

toward recovery. 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. 

Action. The user tries 

new behaviors, but 

these are not yet stable. 

This stage involves the 

first active steps toward 

change. 

An individual who goes to 

counseling and attends meetings 

but often thinks of using again or 

may even relapse at times. 

This client requires help executing an action 

plan and may have to work on skills to 

maintain 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 An individual who attends This client needs help with relapse 

establishes new counseling regularly, is actively prevention. A brief intervention could 

behaviors on a long- involved in AA or NA, has a reassure, evaluate present actions, and 

term basis. sponsor, may be taking disulfiram 

(Antabuse), has made new sober 

friends, and has found new 

substance-free recreational 

activities. 

redefine long-term sobriety maintenance 

plans. 

Source: Adapted from Prochaska and DiClemente, 1984. 

15 
Chapter 2 

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 

are. 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. 

Setting goals for clients is particularly useful 

in centers that specialize in substance abuse 

treatment. Performing brief interventions in this 

setting requires the ability to simplify and 

reduce a client’s treatment plan to smaller, 

measurable outcomes, often expressed as 

“objectives” in the Joint Commission on the 

Accreditation of Healthcare Organizations’ 

(JCAHO) language of treatment planning. The 

clinician must be aware of the 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. 

The clinician should temporarily set aside the 

final goal (e.g., accepting responsibility for one’s 

own recovery) to focus on a single behavioral 

objective. Once this objective is established, a 

brief intervention can be used to reach it. 

Objectives vary according to the client’s stage of 

recovery and readiness to change, but brief 

interventions can be useful at any stage of 

recovery. Figure 2-2 presents several objectives 

that might be addressed with a brief 

intervention. 

The following are suggested goals for brief 

interventions according to the client’s level of 

consumption. 

Abstainer 

Even though abstainers do not require 

intervention, they can be educated about 

substance use with the aim of preventing a 

substance abuse disorder. Such prevention 

education programs are particularly important 

for youth. 

Figure 2-2 

Sample Objectives 

 Learning to schedule and prioritize time 

 Expanding a sober support system 

 Socializing with recovering people or learning to have fun without substance abuse 

 Beginning skills exploration or training if unemployed 

 Attending an AA or NA meeting 

 Giving up resentments or choosing to forgive others and self 

 Staying in the “here and now” 

16 
Brief Interventions 

Light or Moderate User 

The goal of a brief intervention with someone 

who is a light or moderate user is to educate her 

about guidelines for low-risk use and potential 

problems of increased use. Even light or 

moderate use of some substances can result in 

health problems or, in the case of illicit 

substances, legal problems. These users may 

also engage in binge drinking (i.e., five or more 

drinks in a single occasion). Clients who drink 

should be encouraged to stay within empirically 

established guidelines for low-risk drinking (no 

more than 14 drinks per week or 4 per occasion 

for men and no more than 7 drinks per week or 

3 per occasion for women [American Society of 

Addiction Medicine (ASAM), 1994]). 

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, even at this level, 

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. 

At-Risk User 

This group includes those whose use is above 

recommended guidelines for alcohol use (as 

described above) or whose use puts them at risk 

for problems related to their consumption or at 

risk for meeting the criteria for a substance 

abuse disorder (e.g., people who may be able to 

report the requisite number of symptoms of a 

substance abuse disorder may not have three or 

more symptoms within a 12-month period). 

Brief interventions with this group address the 

level of use, encourage moderation or 

abstinence, and educate about the consequences 

of risky behavior and the risks associated with 

increased use. Brief interventions can help users 

understand the biological and social 

consequences of their substance use. 

Abuser 

These are clients with a substance abuse 

disorder as defined by the Diagnostic and 

Statistical Manual of Mental Disorders, 4th Edition 

(DSM-IV) (American Psychiatric Association 

[APA], 1994). The goal of intervention with this 

population, depending on the clinician’s 

theoretical perspective and the substances used, 

is to prevent any increase in the use of 

substances, to facilitate introspection about the 

consequences of risky behavior, to encourage 

the client to consider assessment or treatment, 

and to encourage moderation or abstinence. 

There is mixed evidence on whether persons 

who meet criteria for substance abuse can 

successfully reduce their use to meet lower-risk 

guidelines or if abstinence is the only reasonable 

goal. (See “Research Findings” later in this 

chapter for a discussion of this issue.) Both 

research and clinical experience have produced 

varying results regarding this issue. From a 

clinical standpoint, however, some clients who 

meet abuse criteria may not achieve abstinence 

but might benefit from a positive, 

nonjudgmental approach to change their 

behavior over time. For example, after working 

with a clinician to monitor problems associated 

with the substance abuse, a client might agree 

not to drive after using substances or might 

consider quitting. 

Goals of brief interventions with hazardous 

drinkers who are not alcohol dependent have 

been flexible, allowing the individual to choose 

drinking in moderation or abstinence. In such 

cases, the goal of the intervention is to motivate 

17 
Chapter 2 

the problem drinker to change his behavior, not 

to assign blame. Helping clients to recognize 

the need for change is an essential step in this 

process. 

Substance-Dependent User 

Intervention at this level of use may focus on 

encouraging users to consider treatment, to 

contemplate abstinence, or to return to 

treatment after a relapse. The goal of 

intervention for dependent users is to 

recommend the optimal behavior change and 

level of care. In reality, however, the clinician 

may be able to negotiate a change the client is 

willing to accept and work over time toward 

abstinence. For example, if a client resists 

committing to prolonged abstinence, the 

provider could negotiate a limited period 

ending with a “checkup,” at which time the 

client might consider extending abstinence 

further. 

It should be noted that some substancedependent clients may be in a life-threatening 

stage in their addiction or risk serious 

consequences such as losing their jobs, going to 

jail, or losing their families. For these clients, 

brief interventions should be linked to a referral 

strategy in which the goal is a therapeutic 

alliance between the client and the referral 

treatment team. Brief intervention in this 

context is more like “case management,” in 

which the primary care provider tracks the 

client’s progress with other service providers 

and determines if the client needs any additional 

services. 

ASAM Criteria 

Under ASAM criteria (see Figure 2-3), 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 atrisk 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. 

Components of Brief 

Interventions 

There is tremendous diversity in the process of 

recovery from a substance abuse disorder. 

Clients make changes for different reasons, and 

an intervention that works well for one client 

may not work for another. Brief interventions 

are components of the journey toward recovery 

and can be integral steps in the process. For 

some clients, assistance with the decision to 

Figure 2-3 

American Society of Addiction Medicine (ASAM) Patient Placement Criteria 

ASAM has developed client placement criteria for the treatment of substance-related disorders (1996). 

ASAM delineates the following levels of service: 

 Level 0.5, early intervention 

 Level I, outpatient services 

 Level II, intensive outpatient/partial hospitalization services 

 Level III, residential inpatient services 

 Level IV, medically-managed intensive inpatient services 

18 
Brief Interventions 

make the change will be enough to motivate 

them to start changing the behavior, whereas 

others may need more intensive clinical 

involvement throughout the change process. 

Brief interventions can be tailored to different 

populations, and many options are available to 

augment interventions and treatments, such as 

AA, NA, and medications. It should be noted, 

however, that brief interventions are not a 

substitute for specialized care for clients with a 

high level of dependency. They can be used to 

engage clients in specific aspects of treatment 

programs, such as attending group and AA or 

NA meetings. Brief interventions can also help 

potential clients move toward seeking treatment 

and can serve as a temporary measure for clients 

on waiting lists for treatment programs. Even 

clinicians who advocate abstinence as a goal can 

use brief interventions as tools to help clients 

reach that goal. 

There are six elements critical to a brief 

intervention to change substance abuse behavior 

(Miller and Sanchez, 1994). The acronym 

FRAMES was coined to summarize these active 

ingredients, which are shown in Figure 2-4. The 

FRAMES components have been combined in 

different ways and tested in diverse settings and 

cultural contexts. 

A brief intervention consists of five basic 

steps that incorporate FRAMES and remain 

consistent regardless of the number of sessions 

or the length of the intervention: 

1. Introducing the issue in the context of the 

client’s health 

2. Screening, evaluating, and assessing 

3. Providing feedback 

4. Talking about change and setting goals 

5. Summarizing and reaching closure 

Providers may not have to use all five of 

these components in every session. It is more 

important to use the components that reflect the 

needs of the client and her personal style. 

Before eliminating steps in the brief intervention 

process, however, there should be a welldefined reason for doing so. Moreover, a vital 

part of the intervention process is monitoring to 

determine how the patient is progressing after 

the initial intervention has been completed. 

Monitoring allows the clinician and client to 

determine gains and challenges and to redirect 

the longer term plan when necessary. 

Following are descriptions of the five basic 

steps. Sample scenarios are provided where brief 

interventions might be initiated, with practical 

information about that particular step. For each 

step, Figure 2-5 presents scripts for brief 

interventions that clinicians can use in substance 

abuse treatment units or other settings where 

interventions might occur. (For examples 

focused on at-risk drinkers, see TIP 24, A Guide to 

Substance Abuse Services for Primary Care Clinicians 

[CSAT, 1997]. For detailed descriptions of more 

techniques, see TIP 35, Enhancing Motivation for 

Change in Substance Abuse Treatment [CSAT, 

1999c]). 

Figure 2-4 

FRAMES 

 Feedback is given to the individual about personal risk or impairment. 

 Responsibility for change is placed on the participant. 

 Advice to change is given by the provider. 

 Menu of alternative self-help or treatment options is offered to the participant. 

 Empathic style is used in counseling. 

 Self-efficacy or optimistic empowerment is engendered in the participant. 

Source: Miller and Sanchez, 1993. 

19 
Chapter 2 

Figure 2-5 

Scripts for Brief Intervention 

Component 

Script in the emergency department, 

primary care office, or other setting 

where consultations will be 

performed 

Script in the substance abuse 

treatment unit 

Introducing 

the Issue 

“I’m from the substance abuse 

disorder unit. Your doctor asked me 

to stop by to tell you about what we do 

on that unit. Would you be willing to 

talk to me briefly about it? Whatever 

we talk about will remain 

confidential.” Or, “This must be tough 

for you. Would it be OK with you if 

we take a few minutes to talk about 

your drinking?” 

“Would it be OK with you if we 

discuss some of the difficulties you’ve 

had in getting homework done for the 

group meetings and how we can work 

together to help you take advantage of the 

treatment process?” 

Screening, 

Evaluating, and 

Assessing 

“In reviewing the information 

you’ve given me, using a scale of ‘not 

ready,’ ‘unsure,’ and ‘ready,’ how 

prepared do you feel you are to stop 

drinking?” 

Client says “unsure.” 

“One of the factors that might tie 

together your accident and your 

problems with your wife is your 

drinking.” 

“I think it would be worth talking 

more to some of the people at the 

substance abuse disorder unit so that 

your problems don’t get worse,” or, “I 

think a 2-week trial when you don’t 

drink alcohol at all would be helpful in 

determining whether or not drinking 

makes things worse and if stopping 

use works for you. What do you 

think?” 

“Given what you see as the additional 

stress in your family and your desire to 

make the treatment work for you this 

time, on a scale of 1 to 10, how ready do 

you feel to find a way to put time into 

your homework?” 

Client says, “6.” 

“I am pleased that you are willing to 

consider trying this, even though it won’t 

be easy. Let’s come up with some 

strategies that we can write down to help 

you accomplish this goal.” 

Providing 

Feedback 

“I’d like to get some confidential 

information about your drinking to 

give me a better idea of your drinking 

style. Can you tell me how many days 

a week you drink? How many drinks 

a day?” 

“I’d like to talk about what was going 

on when you decided not to do the 

homework assignment. Can you tell me a 

little about what you were thinking or 

feeling at the time? Why do you think it 

was difficult to get your homework done? 

20 
Brief Interventions 

Figure 2-5 (continued) 

Scripts for Brief Intervention 

Providing “Have you had any problems with “Have there been other parts of 

Feedback your health, family or personal life, or treatment that have been hard to follow?” 

(continued) work in the last 3 months? Were you 

drinking in the 6 hours before your 

accident took place?” 

Talking “It looks as if you have been having “You’ve said that you completely 

About about 30–35 drinks a week and have been forgot to do the homework because of 

Change and doing some binge drinking on weekends. arguments with your wife and daughter 

Setting Goals You’ve said that your accident took place 

after you’d had some alcohol, and you 

said you’ve been under a lot of stress with 

your family and at work. You also 

indicated that you don’t really think 

alcohol is making things worse, but 

you’re willing to think about that. Is that 

an accurate assessment of how you see 

it?” 

and that this surprised you because you 

had really intended to get it done. Is that 

about right?” 

Summarizing “Even though you’re not ready to stop “You just did a good piece of work. I 

and Reaching drinking at this time, I’m glad you agreed think you made some progress. I’m glad 

Closure to write down the pros and cons of not 

drinking. How about if we meet 

tomorrow for a followup?” 

you’re trying something new. How about 

if we meet again in a week to see how 

things went for you?” 

Introducing the Issue 

In this step, the clinician seeks to build rapport 

with the client, define the purpose of the session, 

gain permission from the client to proceed, and 

help the client understand the reason for the 

intervention. 

Counseling tips: Help the client understand 

the focus of the interview. State the target topic 

clearly and stress confidentiality; be 

nonjudgmental and avoid labels. Do not skip 

this opening; without it, the success of the next 

steps could be jeopardized. 

Screening, Evaluating, 

And Assessing 

In general, this is a process of gaining 

information on the targeted problem; it varies in 

length from a single question to several hours of 

assessment on the targeted topic of change. It 

could involve a structured or nonstructured 

interview or a combination of both, coupled 

with questionnaires or standardized 

instruments, with the extent of the process 

determined largely by the setting, time, and 

available resources. A sample screening 

guideline for alcoholism is provided in Figure 2-6. 

Additional information about and examples of 

screening and assessment instruments can be 

found in the following TIPS: TIP 9, Assessment 

and Treatment of Patients With Coexisting Mental 

Illness and Alcohol and Other Drug Abuse; TIP 10, 

Assessment and Treatment of Cocaine-Abusing 

Methadone-Maintained Patients; TIP 11, Simple 

Screening Instruments for Outreach for Alcohol and 

21 
Chapter 2 

Figure 2-6 

Screening for Brief Interventions for Alcoholism 

Screen 

At each visit, ask about alcohol use 

 How many drinks per week? 

 Maximum drinks per occasion in past month? 

Use CAGE questions to probe for alcohol problems 

 Have you ever tried to Cut down on your drinking? 

 Do you get Annoyed when people talk about your drinking? 

 Do you feel Guilty about your drinking? 

 Have you ever had an Eye-opener? (i.e. a drink first thing in the morning) 

Screen is positive if 

 Consumption is greater than 14 drinks per week or greater than 4 drinks per occasion (men) 

 Consumption is greater than 7 drinks per week or greater than 3 drinks per occasion (women) 

 CAGE score is greater than 1 

Then assess for 

 Medical problems: blackouts, depression, hypertension, trauma, abdominal pain, liver dysfunction, 

sexual problems, sleep disorders 

 Laboratory: elevated gamma-glutamyl transpeptidase or other liver function tests; elevated mean 

corpuscular volume; positive blood alcohol concentrations 

 Behavioral problems: work, family, school, accidents 

 Alcohol dependence: a score of 3 or higher on CAGE or one or more of the following: compulsion to 

drink, impaired control, withdrawal symptoms, increased tolerance, relief drinking 

Source: ASAM, 1994; reprinted with permission. 

Other Drug Abuse and Infectious Diseases; TIP 24, 

A Guide to Substance Abuse Services for Primary 

Care Clinicians; and TIP 31, Screening and 

Assessing Adolescents for Substance Use Disorders 

(CSAT, 1994b, 1994c, 1994d, 1997, 1999a). 

Counseling tips: Before you begin the brief 

intervention, decide how much information you 

have time to obtain and whether you want to 

have the client answer any questionnaires. 

Watch for defensiveness or other resistance, and 

avoid pushing too hard. 

Providing Feedback 

This component highlights certain aspects of the 

client’s behavior using information gathered 

during screening. It involves an interactive 

dialog for discussing the assessment findings; it 

is not just clinician driven. Feedback should be 

given in small amounts. First, the clinician gives 

a specific piece of feedback, then asks for a 

response from the client. Sometimes the 

feedback is a brief, single sentence; at other 

times it could last an hour or more. Figure 2-7 

provides an example of giving feedback. 

Counseling tips: Use active listening (see 

“Active listening” later in this chapter). Be 

aware of cultural, language, and literacy issues. 

Be nonjudgmental. 

22 
Brief Interventions 

Figure 2-7 

Client Feedback and Plan of Action 

Give specific feedback to the patient, then advise in a firm but empathic manner 

If diagnosed as at risk: 

 Advise patient of risk 

 Advise abstinence or moderation 

 Set drinking goals 

 Schedule followup to discuss progress 

 PROGRESS 

SUCCEEDS DOES NOT SUCCEED 

 CONTINUE FOLLOWUP 

If diagnosed as alcohol dependent: 

 Advise patient of objective evidence 

 Advise on plan of action 

 Assess acute risk of intoxication or withdrawal 

 Medical and psychiatric comorbidities 

 Agree on plan of action 

Plan of Action 

 Involve family: refer for family treatment and 

self-help (e.g., Al-Anon, etc.) (must have 

patient permission and involvement) 

 Stress abstinence 

 Urge patient to attend self-help meetings (AA, 

NA, Self-Management and Recovery Training 

[SMART], etc.) 

 Consider referral to addiction medicine 

specialist, and/or possible pharmacotherapy 

with disulfiram (Antabuse) or naltrexone 

(ReVia) 

Source: ASAM, 1994; reprinted with permission. 

Talking About Change 

And Setting Goals 

Talking about change involves talking about the 

possibility of changing behavior. It is used with 

clients in all stages of change, but it differs 

profoundly depending on the stage the client 

has reached. For example, in precontemplation, 

clients are helped to recognize and change their 

view of consequences; in contemplation, they 

are helped to resolve ambivalence about change. 

In action, the focus is on planning, removing 

barriers, and avoiding risky situations; in 

maintenance, the emphasis is on establishing 

new long-term behaviors. It is important that 

the clinician assess the client’s readiness to 

change if it is not already known. (See Figure 

2-8 for examples of discussing change with a 

client who is trying to stop using cocaine but 

wants to continue to drink alcohol.) 

In talking about change, the clinician often 

suggests a course of action, then negotiates with 

the client to determine exactly what he is willing 

to do. Sometimes, talking about change is 

premature (i.e., before the assessment and 

feedback have happened). In that case, it should 

be postponed until later in the intervention. 

Counseling tips: Offer change options that 

match client’s readiness for change. Be realistic: 

Recommend the ideal change, but accept less if 

the client is resistant. 

Summarizing and 

Reaching Closure 

This step involves a summary of the discussion 

and a review of the agreed-upon changes. 

23 
Chapter 2 

Figure 2-8 

Talking About Change at Different Stages 

In this example, a client who has come to treatment to stop using cocaine has her alcohol use brought 

to her attention. At each stage of readiness, the counselor might use a different strategy. Following are 

some of the possible scripts that might be used: 

 Precontemplation: “Some people find it helpful to ask others in a group if any of them tried to quit 

cocaine but continued drinking. If you were to try that with your group, you might be surprised at 

what you hear. What do you think?” 

 Contemplation: “One thing you might try is writing a list of the pros and cons of stopping drinking, 

as you see them. Just write down all the ideas that come to you, no matter how silly or offbeat they 

seem. This may help you get a clearer picture of your situation. Is that something you’d be willing 

to try?” 

 Action: “You’ve said you want to try quitting alcohol, as well as cocaine. Can we talk about how 

you might go about making that happen?” 

 Maintenance: “Things have improved in a lot of ways for you. I’d like to meet with you each month 

for a while to talk about what things work for you and what things don’t work as well.” (Because 

relapse can occur at any point in the change process, addressing this issue in a proactive, positive 

manner is useful.) 

If no agreement was reached, review the 

positive action the client took during the session. 

At this point, it is important to schedule a 

followup visit to talk about how the client is 

progressing. The followup could be another 

face-to-face meeting, a telephone call, or even a 

voice mail message. The goals of closing on 

good terms are to arrange another session, to 

leave the client feeling successful, and to instill 

confidence that will enable the client to follow 

through on what was agreed upon 

Counseling tips: Tailor your closure to the 

client and the particular circumstance of this 

brief intervention; interpret any client resistance 

in a positive light leading to progress. Thus, if a 

client has been unwilling to commit to changes, 

thank her for her willingness to consider the 

issues and express the hope that she will 

continue to consider committing to changes. 

Brief Intervention 

Workbooks 

Brief intervention protocols often involve using 

a workbook that is based on the steps listed 

below. A workbook provides the client and 

clinician with opportunities to discuss the 

client’s cues for using substances, reasons for 

using substances, and reasons for cutting down 

or quitting. It also usually provides a substance 

abuse agreement in the form of a prescription 

and substance abuse diary cards for selfreporting. These techniques, which often target 

reduction in substance abuse rather than 

abstinence, are similar to homework techniques 

used in substance abuse treatment programs. A 

sample of a workbook used to address drinking 

problems is provided in Appendix D. The steps 

24 
Brief Interventions 

in the workbook follow a script and may focus 

on the following: 

 Identification of future goals for health, 

activities, hobbies, relationships, and 

financial stability 

 Customized feedback on screening questions 

relating to substance abuse patterns and 

other health habits (also may include 

smoking, nutrition, etc.) 

 Discussion of where the client’s substance 

abuse patterns fit into the population norms 

for his age group 

 Identification of the pros and cons of 

substance abuse—this is particularly 

important because the clinician must 

understand the role of substance abuse in the 

context of the client’s life (given the 

opportunity to discuss the positive aspects of 

her substance abuse, the client may talk 

about her concerns honestly instead of 

feeling she should say what she thinks the 

clinician wants to hear; this builds a better 

working relationship) 

 Consequences of continued substance use to 

encourage the client to decrease or stop 

abusing substances and avoid longer term 

effects of continued substance abuse 

 Reasons to cut down or quit using 

(maintaining family, work, independence, 

and physical health all may be important 

motivators) 

 Sensible use limits and strategies for cutting 

down or quitting—useful strategies include 

developing social opportunities that do not 

involve abusing substances and becoming 

reacquainted with hobbies and interests 

 A substance abuse agreement—agreed-upon 

use limits (or abstinence) signed by the client 

and the clinician—can often be an effective 

way to alter use patterns 

 Coping with risky situations (e.g., socializing 

with substance users, isolation, boredom, 

and negative family interactions) 

 Summary of the session 

Essential Knowledge and 

Skills for Brief 

Interventions 

Providing effective brief interventions requires 

knowledge, skills, and abilities. Studies have 

shown that applying the clinician’s skills listed 

below produces good outcomes, including 

getting clients to enter treatment, work harder in 

treatment, stay longer in treatment, and have 

better outcomes after treatment such as higher 

participation in aftercare and better sobriety 

rates (Brown and Miller, 1993; Miller et al., 

1993). 

 Overall attitude of understanding and 

acceptance 

 Counseling skills such as active listening and 

helping clients explore and resolve 

ambivalence 

 A focus on intermediate goals (see discussion 

earlier in this chapter) 

 Working knowledge of the stages-of-change 

model (see discussion earlier in this chapter) 

Attitude of Understanding 

And Acceptance 

Clinicians must assure their clients that they will 

listen carefully and make every effort to 

understand the client’s point of view during a 

brief intervention. Brief interventions are by 

definition time limited, which increases the 

difficulty of adopting such an attitude. 

However, when clients experience this 

nonjudgmental, respectful interest and 

understanding from the clinician, they feel safe 

to openly discuss their ambivalence about 

change—rather than resist pressure from the 

clinician to change before they are ready to do 

so. The sooner they address their ambivalence, 

the sooner they progress toward lasting change 

(see also TIP 35, Enhancing Motivation for Change 

in Substance Abuse Treatment [CSAT, 1999c]). 

25 
Chapter 2 

When clients feel they are being pushed 

toward change—even if the clinician is not 

pushingthey are likely to resist. Clients must 

summon all of their attention and strength to 

resolve their ambivalence, and resisting the 

clinician may cause them to lose track and argue 

against change. If the client and clinician begin 

arguing or debating, the clinician should 

immediately shift to a new strategy, otherwise 

the brief intervention will fail. In other words, 

resistance is a signal for the clinician to change 

strategies and defuse the resistance. 

Counseling Skills 

Active listening 

One of the most important skills for brief 

interventionists is “active listening” (see Figure 

2-9). Active listening is the ability to accurately 

restate the content, feeling, and meaning of the 

client’s statements. This is also called “reflective 

listening,” “reflecting,” or sometimes 

“paraphrasing.” Active listening is one of the 

most direct ways to rapidly form a therapeutic 

alliance. When done well, it is a powerful 

technique for understanding and facilitating 

change in clients. Active listening goes beyond 

nonverbal listening skills or responses such as, 

“Hmmm,” “Uh-huh,” “I see,” “I hear you,” or “I 

understand where you’re coming from.” None 

of these short statements demonstrates that the 

clinician understands. Counselors should also 

ask open-ended questions to which the client 

must respond with a statement, rather than a 

simple yes or no. Instead of summarizing a 

situation and then asking, “Is this correct?” ask 

the client, “What do you think? How do you 

feel about the situation?” Open-ended 

questions are invitations to share and provide a 

means to probe for important information that 

emerges in the interview. 

Exploring and resolving ambivalence 

Another important skill is the ability to help 

clients explore and resolve ambivalence. 

Ambivalence is the hallmark of a person in the 

contemplation stage of readiness. It is one of the 

most prevalent clinical challenges encountered 

in brief interventions. Whether it takes 1 minute 

or 40 minutes, the goal is to help clients become 

more aware of their position and the discomfort 

that accompanies their ambivalence. Increasing 

awareness of this discomfort within an 

understanding and supporting relationship can 

inspire the client to progress to a stage of 

preparation or action. For example, a client 

might be willing to go to counseling but not an 

AA meeting; in that case, the clinician should 

work with the client’s motivation and focus on 

the positive step the client is willing to make. 

One way to help a client recognize his 

ambivalence is to ask him to identify the benefits 

and costs of the targeted behavior (e.g., using 

alcohol) and the benefits and costs of changing 

Figure 2-9 

Steps in Active Listening 

1. Listen to what the client says. 

2. Form a reflective statement. To reflect your understanding, repeat in your own words what the client 

said. 

3. Test the accuracy of your reflective statement. Watch, listen, and/or ask the client to verify the accuracy 

of the content, feeling, and/or meaning of the statement. 

Skilled active listeners perform these three steps automatically, naturally, smoothly, and quickly. Active 

listening saves time by reducing or preventing resistance, focusing the client, focusing the clinician, 

encouraging self-disclosure, and helping the client remember what was said during the intervention. 

26 
Brief Interventions 

the behavior. The clinician listens and 

summarizes these benefits and costs, then asks 

the client if any of them is more important than 

the others. This helps identify values that are 

important to the client and can therefore 

increase or decrease the chance of changing. 

Clinicians might also ask if any of the pros and 

cons is more or less accurate than others. This 

provides an opportunity for irrational thoughts 

to be refuted, which can help remove barriers to 

change (see example in the text box below). 

Another approach to raising awareness of 

ambivalence is to explore the client’s experience 

of feeling caught between opposing desires. For 

more specific techniques for resolving 

ambivalence, see TIP 35, Enhancing Motivation for 

Change in Substance Abuse Treatment (CSAT, 

1999c). 

Brief Interventions in 

Substance Abuse 

Treatment Programs 

Substance abuse treatment programs frequently 

use brief interventions, although they might not 

be called by that name. Brief interventions can 

be effectively integrated into more 

comprehensive treatment plans for clients with 

substance abuse disorders. These approaches 

can be particularly useful in treatment settings 

when they are used to address specific targeted 

client behaviors and issues in the treatment 

process that can be difficult to change using 

standard treatment approaches. Brief 

interventions can be used with clients before, 

during, and after substance abuse treatment. 

To integrate the use of brief interventions 

into specialized treatment, counselors and 

providers should be trained to provide this 

service. The Consensus Panel recommends that 

agencies consider allocating counselor training 

time and resources to these modalities. The 

Panel 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. It is also extremely 

important for substance abuse treatment 

personnel to collaborate with primary care 

providers, employee assistance program (EAP) 

personnel, wellness clinic staff, and other 

community-based service providers in 

developing plans that include both brief 

interventions and more intensive care to help 

keep the client focused on treatment and 

recovery. The following is a list of the potential 

benefits of using brief interventions in substance 

abuse treatment settings: 

 Reduce no-show rates for the start of 

treatment 

 Reduce dropout rates after the first session of 

treatment 

 Increase treatment engagement after intake 

assessment 

 Increase compliance for doing homework 

 Increase group participation 

 Address noncompliance with treatment rules 

(e.g., smoking in undesignated places, 

unauthorized visits, or phone calls) 

Removing a Barrier to Change 

Your client, Mary, is hospitalized because of an alcohol-related injury. You conduct a brief intervention 

in the hospital. During the session, she says that one of the good things about her drinking is that she 

“always had fun when she was drinking.” In that case, you can ask her what her perspective is on the 

situation and whether she sees a connection between her drinking and her current behavior. This could 

lead to her challenging one of her reasons for drinking. By systematically exploring the reasons for and 

against drinking, you can help her tip the scale in favor of change. 

27 
Chapter 2 

 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 

 Obtain a sponsor, if involved with a 12-Step 

program 

 Increase compliance with psychotropic 

medication therapies 

 Increase compliance with outpatient mental 

health referrals 

 Serve as interim intervention for clients on 

treatment program waiting lists 

Brief Interventions 

Outside Substance Abuse 

Treatment Settings 

Brief interventions are commonly administered 

in nonsubstance abuse treatment settings, often 

referred to as opportunistic settings, where 

clients are not seeking help for a substance 

abuse disorder but have come to receive medical 

treatment, to meet with an EAP counselor, or to 

respond to a court summons (see Figure 2-10 for 

a list of health care and other professionals who 

often conduct brief substance use interventions). 

These settings and many others provide a 

multitude of opportunities to help people 

change their substance abuse patterns. It is 

unrealistic and unnecessary for providers in 

opportunistic settings to avoid working with 

people with a range of substance abuse 

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 specialized, mainstream 

substance abuse treatment programs. Moreover, 

some individuals may attach a stigma to 

attending treatment versus general health care 

services. Older adults and women often do not 

seek or engage in treatment because of stigma. 

An individual’s level of substance use is 

detected through screening instruments, 

medical tests (e.g., 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 

requires more than several sessions, each lasting 

only 5 minutes to 1 hour (average = 15 minutes). 

The goal of a brief intervention is to raise the 

recipient’s awareness of the association between 

the expressed problem and substance abuse and 

to recommend change, either by natural, clientdirected means or by seeking additional 

substance abuse treatment. Because the 

recipient usually does not expect to have a 

substance abuse problem identified, he may or 

may not be motivated to apply any 

recommendations. The brief intervention is 

highly structured and focuses on delivering a 

message about the individual’s substance abuse 

Figure 2-10 

Professionals Outside of Substance Abuse Treatment Who Can 

Administer Brief Interventions 

 Primary care physicians 

 Substance abuse treatment providers 

 Emergency department staff members 

 Nurses 

 Social workers 

 Health educators 

 Lawyers 

 Mental health workers 

 Teachers 

 EAP counselors 

 Crisis hotline workers, student counselors 

 Clergy 

28 
Brief Interventions 

and advice to reduce or stop it. If the initial 

intervention does not result in substantial 

improvement, the professional may refer the 

individual for additional specialized substance 

abuse treatment. 

Treatment providers who work in settings 

other than substance abuse treatment must be 

flexible when assessing, planning, and carrying 

out brief interventions. For example, they will 

likely encounter more risky drinkers than 

alcohol-dependent individuals (in the United 

States there are four times as many risky 

drinkers as dependent drinkers [Mangione et al., 

1999]). Some research indicates that the 

potential for brief interventions to reduce the 

harm, problems, and costs associated with 

moderate to heavy alcohol use by risky drinkers 

significantly surpasses the effectiveness from 

applications of brief interventions on substancedependent individuals (Higgins-Biddle et al., 

1997). Other research on brief interventions, as 

presented below, highlights some of the more 

rigorous studies with positive outcomes. The 

costs of alcohol abuse to society, as interpreted 

by health care costs, lost productivity, and 

criminal activity, are enormous, and brief 

interventions are a cost-effective technique to 

address such abuse. Typically these brief 

interventions act as an early intervention before 

or close to the development of alcohol-related 

problems and primarily entail instructional and 

motivational components addressing drinking 

behavior. In substance abuse treatment, brief 

interventions are used to assist in the treatment 

engagement process and to deal with specific 

individual, family, or treatment-related issues. 

When delivering a brief intervention in any 

treatment setting, the provider should be 

mindful of room conditions and interruptions 

because client confidentiality is of utmost 

importance. Federal law requires that chart 

notes or other records on substance abuse be 

kept apart from the rest of the client’s main 

chart. For example, if a medical client in a 

primary care clinic is also seen by an alcohol and 

drug counselor for treatment of a substance 

abuse disorder, those medical records are 

strictly protected by Federal law and may not be 

put in the client’s chart. (For more information 

on these Federal laws, see TIP 24, A Guide to 

Substance Abuse Services for Primary Care 

Clinicians [CSAT, 1997].) 

Heather makes an important distinction 

between brief interventions that are delivered in 

opportunistic settings where patients are not 

directly seeking help for a substance abuse 

disorder and those conducted in treatment 

environments where patients are seeking the 

help of specialists (Heather, 1995). Brief 

interventions conducted in opportunistic 

settings tend to be shorter, rely less on theory 

and more on an existing clinician–client 

relationship, and are less expensive because they 

are offered as part of an existing service. 

Conducting Brief Interventions 

With Older Adults 

Older adults present unique challenges in 

applying brief intervention strategies for 

reducing alcohol consumption. The level of 

drinking necessary to be considered risky 

behavior is lower than for younger individuals 

(Chermack et al., 1996). Intervention strategies 

should be nonconfrontational and supportive 

due to increased shame and guilt experienced 

by many older problem drinkers. As a result, 

older adult problem drinkers find it particularly 

difficult to identify their own risky drinking. In 

addition, chronic medical conditions may make 

it more difficult for clinicians to recognize the 

role of alcohol in decreased functioning and 

quality of life. These issues present barriers to 

conducting effective brief interventions for this 

vulnerable population. For more on this topic, 

refer to TIP 26, Substance Abuse Among Older 

Adults (CSAT, 1998b). 

29 
Chapter 2 

Research Findings 

Brief interventions for substance abuse have 

been implemented since the 1960s. The 

literature in this area includes theoretical 

articles, clinical case studies and 

recommendations, quasi-experimental studies, 

and randomized controlled experimental 

research trials. Many of the brief intervention 

clinical trials have been conducted in the United 

States and Europe since the early 1980s, and 

most have focused on alcohol use. There is 

some experimental research on brief 

interventions for drug use but very little has 

been published to date. This is an area of 

ongoing and future work. 

Reviews of Brief 

Intervention Studies 

A 1995 review article (Kahan et al., 1995) sorted 

through 43 relevant articles found in MEDLINE 

published from 1966 to 1985 and 112 in 

EMBASE published from 1972 to 1994. Another, 

more recent review (Wilk et al., 1997) culled 

nearly 6,000 articles from MEDLINE and 

PsychLIT searches from 1966 to 1995 to find 99 

that met criteria for closer inspection. A total of 

11 of the articles found by Kahan and colleagues 

and 12 of those reviewed by Wilk and associates 

had control groups, adequate sample sizes, and 

specified criteria for brief interventions. 

The most recent reviews of brief intervention 

studies concluded that brief interventions have 

merit, especially for carefully selected clients 

and can be applied successfully in several 

settings for different purposes (Bien et al., 1993; 

Kahan et al., 1995; Mattick and Jarvis, 1994; Wilk 

et al., 1997). The review by Bien and colleagues 

was one of the first to categorize brief 

interventions and evaluate their effectiveness 

according to the stated goals and settings in 

which they were conducted. After examining 12 

controlled studies of strategies to improve 

clients’ acceptance of referrals for additional 

specialist treatment or return to the clinic for 

additional treatment following an initial visit, 

Bien and colleagues concluded that relatively 

simple strategies and specific aspects of 

counselors’ styles can increase rates of 

followthrough on referrals as well as improve 

initial engagement and participation in 

treatment (Bien et al., 1993). Only one 

unsuccessful trial of referral procedures is 

described, and the failure is attributed to the fact 

that all subjects had previously failed to respond 

to brief advice about getting into treatment for 

alcoholism. 

Bien and colleagues also examined 11 wellconducted trials of brief interventions for 

excessive drinkers identified in health care 

settings (including the large-scale, 10-nation 

World Health Organization [WHO] study) (Bien 

et al., 1993). They found that eight of the studies 

showed significant reductions in alcohol 

consumption levels and/or associated problems 

for the subjects receiving brief, drinking-focused 

interventions in comparison with those 

receiving no counseling. Three other studies 

found no significant differences between 

experimental and control groups at followup, 

although drinking levels and other problem 

measures were reduced in both groups. Bien 

and colleagues concluded that it is better for 

health care providers in opportunistic settings 

such as primary care to intervene in a 

nonjudgmental motivational format than it is to 

provide no intervention to patients who did not 

expect to have their drinking patterns evaluated. 

In addition, these authors also reviewed 13 

randomized clinical trials comparing brief 

interventions to a range of more extensive 

therapies in specialized alcohol treatment 

settings and found that shorter counseling was, 

with remarkable consistency, comparable in 

impact to more traditional approaches in 

yielding specified outcomes (Bien et al., 1993). 

Only two studies reported an advantage of more 

extensive treatment over brief interventions on 

30 
Brief Interventions 

some outcome measures. They concluded that 

no evidence supports the inferiority of brief 

interventions in comparison with more 

extensive treatment offered by treatment 

specialists to patients who are seeking help for 

their alcohol-related problems. Heather argues, 

however, that the findings do not support the 

statement that the effectiveness of brief 

interventions is equal to that of other studied 

treatments for alcohol abuse (Heather, 1995). 

Finally, Bien and colleagues concluded from 

an analysis of three other studies that brief 

interventions enhanced the motivation of 

treatment-seeking problem drinkers to enter and 

remain in outpatient or residential alcohol 

treatment compared with clients not receiving 

such attention (Bien et al., 1993). 

Although other reviewers of brief 

interventions have reported more qualified 

reactions, all seem to agree that strong research 

evidence supports the use of brief interventions 

for heavy or excessive, nondependent drinkers, 

particularly those identified in general medical 

practice settings (Heather, 1995; Kahan et al., 

1995; Mattick and Jarvis, 1994; Wilk et al., 1997). 

Wilk and colleagues examined evidence from 12 

controlled clinical trials that randomized nearly 

4,000 heavy drinkers to brief intervention or no 

intervention (Wilk et al., 1997). They concluded 

that heavy drinkers who received interventions 

in a primary care setting were almost twice as 

likely to moderate drinking than those who did 

not receive an intervention. The National 

Institute on Alcohol Abuse and Alcoholism 

(NIAAA) has also presented data on the efficacy 

and uses of brief interventions for dependent 

drinkers (NIAAA, 1999). 

This TIP reviews the most methodologically 

sound brief intervention studies and discusses 

methodological limitations of previous and 

current research in this area. The research is 

presented in two sections: (1) brief interventions 

for at-risk and problem use and (2) brief 

interventions for substance abuse. 

Brief Interventions for At-Risk 

And Problem Use 

A study conducted in 1983 focused on males in 

Malmo, Sweden, in the late 1970s (Kristenson et 

al., 1983). The subjects, advised to reduce their 

alcohol use in a series of health education visits, 

subsequently demonstrated significant 

reductions in gamma-glutamyl transferase 

levels and health care utilization up to 5 years 

after the brief interventions. The Medical 

Research Council (MRC) trial, conducted in 47 

general practitioners’ offices in Great Britain 

(Wallace et al., 1988), found significant 

reductions in alcohol use by the intervention 

group compared to the control group 12 months 

following the intervention. 

Anderson and Scott identified men and 

women from eight general practices in England 

who consumed more than 15 standard drinks 

(for men) or 9 standard drinks (for women) of 

alcohol per week (Anderson and Scott, 1992). 

These individuals were randomly assigned to 

receive either no intervention or feedback about 

the findings from the screening and 10 minutes 

of advice from the physician to reduce their 

consumption levels, accompanied by a 

pamphlet of self-help information. After 1 year, 

the males in the advice group had significantly 

reduced their mean weekly alcohol 

consumption by 2.8 ounces more than those 

who received no intervention. The females in 

both groups, however, showed significant 

reductions in alcohol consumption at the same 

followup point, with no between-group 

differences. 

In a widely publicized evaluation of brief 

interventions conducted in health care settings 

in 10 nations sponsored by WHO, the 

investigators identified 1,490 nonalcoholic heavy 

drinkers from eight core sites through a 20-

minute health interview (Babor and Grant, 1991; 

Babor et al., 1994). These participants were 

randomly assigned to one of four groups: (1) no 

further intervention, (2) 5 minutes of simple 

31 
Chapter 2 

advice about the importance of sensible 

drinking or abstinence, (3) simple advice plus 15 

minutes of brief counseling and a self-help 

manual that encouraged the development of a 

habit-breaking-plan, or (4) at five of the sites, 

extended supportive counseling delivered in 

three extra sessions following the initial advice 

and 15-minute session. After 9 months, males 

who received any intervention, including the 5 

minutes of advice, reported approximately 25 

percent less daily alcohol consumption—a 

greater change than was observed in the nointervention control group. Significantly, the 

men who showed the greatest response to 

simple advice had more severe alcohol problems 

and higher consumption patterns. 

Another interesting finding from the WHO 

study was that female participants in all groups 

had reduced their drinking at 9 months, 

regardless of whether they received any 

intervention. One explanation may be that the 

female participants were only recruited from 

two relatively affluent countries—Australia and 

the United States—thus, the results cannot be 

generalized to all women (Sanchez-Craig, 1994). 

Furthermore, the 20-minute comprehensive 

assessment was sufficiently intensive that some 

women may have responded to implicit 

messages of cutting down on consumption 

without further overt advice, especially 

considering that only 10 minutes of simple 

advice or 15 minutes of counseling were 

additionally provided (Kristenson and 

Osterling, 1994). 

One successful study demonstrated the 

efficacy of a brief alcohol intervention in a 

community-based primary care setting (Fleming 

et al., 1997). Project TrEAT (Trial for Early 

Alcohol Treatment) identified 723 men and 

women as problem drinkers from 17,695 

patients who were screened in 17 communitybased primary care practices. The outcomes 

studied were reductions in alcohol consumption 

and health resource utilization. In comparison 

with a no-intervention control group, the 

patients who received two 10- to 15-minute 

sessions of scripted advice (using a workbook 

that focused on advice, education, and 

contracting information) showed significantly 

greater reductions in alcohol consumption at a 

12-month followup based on drinking levels 

during the previous week, episodes of binge 

drinking over the past month, and frequency of 

excessive drinking in the previous 7 days. 

Males in the study also had significantly fewer 

days of hospitalization than counterparts in the 

control group. Females in the experimental 

groups reduced their consumption significantly 

more than males in the experimental group. 

This research group (Fleming et al., 1999) also 

conducted a similar trial with primary care 

patients over 65 and found significant 

differences in drinking after 12 months for the 

experimental group compared to the control 

group. 

Miller and colleagues have developed a 

special form of a brief intervention known as the 

Drinker’s Check-Up (Miller and Sovereign, 

1989), designed to evaluate whether alcohol is 

harming an individual in any way. In the 1989 

study, participants were recruited through 

media advertisements and were asked to come 

into a neutral setting for the assessment. As 

reported by Bien and colleagues, several trials of 

this approach have demonstrated encouraging 

results from providing systematic feedback 

about assessment results and some self-help 

options (Bien et al., 1993). Compared with a nointervention group of respondents who had to 

wait 6 weeks for assessment, the recipients of 

immediate feedback and brief, empathic 

assistance showed prompt and persistent 

reductions (of 29 to 57 percent) in consumption 

patterns. More empathic counseling, an 

important component of brief interventions (see 

discussion on FRAMES earlier in this chapter), is 

also associated with larger reductions than the 

32 
Brief Interventions 

use of the more traditional confrontational styles 

(Miller et al., 1993). 

While the types of brief interventions vary, 

the basic design of most studies is a randomized 

controlled trial that assigns clients with 

hazardous drinking patterns either to a brief 

intervention (ranging from one to ten sessions) 

or to one or more control conditions (Anderson 

and Scott, 1992; Babor, 1992; Babor and Grant, 

1991; Chick et al., 1985; Fleming et al., 1997; 

Harris and Miller, 1990; Heather et al., 1987; 

Kristenson et al., 1983; Persson and Magnusson, 

1989; Wallace et al., 1988). Overall, the majority 

of brief alcohol intervention studies have found 

significantly greater improvements in drinking 

outcomes for the experimental group compared 

to the control group; however, most also found 

significant changes in drinking over time for 

both the control and brief intervention 

conditions. Meta-analyses found an effect size 

of 20 to 30 percent in studies conducted in 

health care settings (Bien et al., 1993; Kahan, 

1985). Trials conducted since 1995 have 

garnered similar effect sizes with one trial 

finding a greater effect size for women (35 

percent) (Fleming et al., 1997). Women were not 

always included in earlier trials, but later trials 

that did include women found that they were 

more likely than men to decrease their drinking 

based on brief targeted advice. 

Because of the success of brief alcohol 

interventions with adults in opportunistic 

settings, new trials with special populations 

(e.g., older adults, injured patients in emergency 

departments, pregnant women) are now being 

proposed and conducted. In addition, new 

technologies are being studied, including 

computerized real-time tailored booklets for atrisk drinkers, and the use of Interactive Voice 

Recognition (IVR) for interventions and 

followup. These and other technologies, if 

efficacious and effective, will provide clinicians 

with new tools to assist them in working with a 

difficult and important clinical and public health 

issue. 

Brief Interventions for 

Dependent Use 

Most studies of brief interventions for alcohol 

use that had the goal of changing drinking 

behavior have included only subjects who did 

not meet criteria for alcohol dependence and 

explicitly excluded dependent drinkers with 

significant withdrawal symptoms. The rationale 

for this practice was that alcohol-dependent 

individuals or those affected most severely by 

alcohol should be referred to formal specialized 

alcoholism treatment programs because their 

conditions are not likely to be affected by low 

intensity interventions (Babor et al, 1986; 

Institute of Medicine [IOM], 1990). However, 

there have been positive trials that address this 

issue specifically. 

NIAAA reviewed the studies focused on 

alcohol-dependent drinkers (NIAAA, 1999). 

Some of these studies focused on the 

effectiveness of motivating alcohol-dependent 

patients to enter specialized alcohol treatment. 

As long ago as 1962, a nonrandomized study 

was conducted of alcohol-dependent patients, 

identified in the emergency department 

(Chafetz et al., 1962). Of those receiving brief 

counseling, 65 percent followed through in 

keeping a subsequent appointment in a 

specialized alcohol treatment setting. Only 5 

percent in the control group followed through 

with an appointment. 

Brief interventions have also been compared 

to more intensive and extensive treatment 

approaches used in traditional treatment 

settings with positive results (Edwards et al., 

1977; Project MATCH Research Group, 1997, 

1998). In a small study, the effectiveness of a 

one-session brief advice protocol plus monthly 

followup telephone calls, focused on the 

patient’s personal responsibility to stop 

33 
Chapter 2 

drinking, was compared to standard alcohol 

treatment for 100 men who were alcohol 

dependent (Edwards and Orford, 1977). At 1-

year followup both groups reported a 40 percent 

decrease in alcohol-related problems. The study 

found, at 2-year followup, that the patients with 

the less severe alcohol problems did best in the 

brief intervention group. The patients with 

more serious alcohol-related problems did best 

in intensive alcohol treatment (Orford et al., 

1976). 

Several similar studies conducted in New 

Zealand (Chapman and Huygens, 1988), 

London (Drummond et al., 1990), the United 

States (Miller et al., 1980, 1981; Miller and 

Munoz, 1982), and Norway (Skutle and Berg, 

1987) essentially replicated the results of 

previous positive trials, comparing brief 

interventions favorably with a variety of 

extended treatments for problem drinking 

(including cognitive–behavior therapies, marital 

therapy, confrontational counseling, and 

standard inpatient and outpatient treatment). 

Sanchez-Craig and colleagues found that 

when comparing the 12-month treatment 

outcomes of severely dependent and 

nonseverely dependent men receiving brief 

treatment in Toronto and Brazil, there were no 

significant differences in “successful” outcomes 

as measured by rates of abstinence or moderate 

drinking (Sanchez-Craig et al., 1991). The IOM 

also noted that rates of spontaneous remission of 

alcoholism suggest that some portion of the 

most severe alcoholic population will reduce or 

discontinue their drinking without formal 

intervention (IOM, 1990). 

The largest multisite NIAAA-sponsored 

study of treatment matching and outcomes, 

Project MATCH (Matching Alcoholism 

Treatment to Client Heterogeneity), compared 

the effects of treatment type on outcomes for 

more than 1,500 alcohol-dependent patients 

(Project MATCH Research Group, 1997, 1998). 

Treatment types included (1) four 1-hour 

sessions of motivational enhancement therapy, 

which is often considered a brief intervention 

even though it is more intensive than most brief 

interventions (NIAAA, 1995), (2) 12 sessions of 

12-Step facilitation, and (3) 12 sessions of 

cognitive–behavioral coping skills therapy. At 

1- and 3-years postintervention, all three groups 

reported improvements including drinking less 

often and drinking fewer drinks per day. 

A small successful application of a brief 

motivational intervention within a substance 

abuse treatment setting administered 

approximately 1 hour of motivational 

interviewing for problem drinkers (adapted 

from Miller and Sovereign, 1989) to seriously 

opiate-dependent clients recently admitted to a 

methadone maintenance clinic (Saunders et al., 

1995). Fifty-seven clients were randomized to 

the experimental group and were asked to 

identify positive and negative aspects of their 

opiate use and to project the consequences into 

the future. These clients were then asked to 

think about their use and discuss it at the 1-

week followup session. The 65 subjects in the 

control group received a 1-hour educational 

intervention covering six substance-related 

issues such as overdose responses, legal aspects, 

and referral sources. Followup sessions were 

held with both groups at 1 week, 3 months, and 

6 months. Significantly fewer clients receiving 

the motivational intervention dropped out of the 

study at each of the followup points compared 

with those receiving the educational component. 

By the 6-month point, the motivational subjects 

had significantly fewer opiate-related problems 

than the others. In comparison with the 

educational group, the clients receiving the 

motivational intervention were also more likely 

to make a positive initial shift on a stage-ofchange measure (see the discussion of stages-ofchange earlier in this chapter), express a 

stronger commitment to abstinence, remain in 

treatment longer, and relapse less quickly if they 

did drop out. The study concluded that brief 

34 
Brief Interventions 

motivational interventions strengthened 

recipients’ resolution to abstain from opiate use 

and participate fully in treatment, and were 

therefore useful in improving performance and 

program compliance among clients attending a 

methadone clinic (Saunders, 1995). This and 

other studies have found that compliance with a 

treatment plan, rather than simply length of 

treatment, is one of the important factors 

influencing positive outcomes for clients 

receiving treatment. 

In a study looking at the costs of brief 

interventions, Holder and colleagues evaluated 

the evidence of clinical effectiveness and the 

typical costs of various alcoholism treatment 

modalities and found brief motivational 

counseling among the most effective in terms of 

a combination of clinical and cost effectiveness 

(Holder et al., 1991). It ranked third among the 

six highest ranking approaches in terms of 

weighted effectiveness (based on a total of nine 

studies conducted between 1983 and 1990). 

Brief motivational counseling was also rated the 

least costly of the six most effective modalities— 

or most cost-effective of 33 evaluated modalities. 

The authors of this study specifically stated that 

treatment planning and funding decisions 

should not be based on this initial effort to make 

“first level approximations” of costeffectiveness. 

Critics have raised concerns that brief 

interventions could be construed as a treatment 

panacea for all patients with varying levels of 

alcohol-related problems and different 

consumption patterns (Drummond, 1997; 

Heather, 1995; Mattick and Jarvis, 1994). 

Although most researchers acknowledge that 

many clients do not need a protracted and 

expensive course of individual or group 

treatment, the literature advocating brief 

interventions as a treatment for all substance 

abuse is overstated (Heather, 1995; Mattick and 

Jarvis, 1994). Caution always needs to be 

employed in evaluating study 

recommendations. The clinical trials in this TIP 

on the use of brief interventions have been 

specific regarding the targeted population tested 

and the level of generalizability possible. 

Methodological Issues 

Issues are frequently raised regarding specific 

methodological concerns of studies on brief 

interventions. First, many of the brief 

intervention studies, particularly those focused 

on alcohol, rely on self-report data to determine 

outcomes. The validity of measuring alcohol 

and other use by self-report is routinely 

questioned; however, reviewers of relevant 

literature have concluded that these data are 

generally valid and reliable (Midanik, 1982; 

Sobell and Sobell, 1990). Reports from 

collaterals, such as family members, are not as 

reliable except for highly visible events, such as 

drinking-related arrests (Midanik, 1982). 

Persons with hazardous drinking patterns will 

provide accurate information about their use, 

particularly under the following conditions: (1) 

the setting is a research or clinical one, (2) 

confidentiality is assured, and (3) the interview 

is administered when the respondent is sober 

(Sobell and Sobell, 1990). Techniques to increase 

the accuracy of self-reports have been employed 

in recent studies (Fleming et al., 1997, 1999). 

These studies use interviewers who fully 

understand drinking-related questions and can 

explain confusion about common terms (e.g., 

“blackouts,” “high”). 

Concerns about the methodological 

limitations of some trials have included sample 

sizes that were too small and a statistical power 

insufficient to reliably detect differences 

between effects in the groups compared (Bien et 

al., 1993; Mattick and Jarvis, 1994). There may 

be differential attrition in groups at followup, 

and these dropouts can be ignored or excluded 

from analyses (Bien et al., 1993; Drummond, 

1997; Kahan et al., 1995), or there could be 

contamination because the comparison group 

35 
Chapter 2 

could be seeking additional treatment during 

the course of the research (Bien et al., 1993; 

Kahan et al., 1995; Mattick and Jarvis, 1994). 

Also, randomization of samples has not always 

been conducted (Wilk et al., 1997), and some 

early studies did not have control groups or did 

not have an adequate comparison group (Bien et 

al., 1993). Some of the newer brief intervention 

studies have addressed many of these concerns 

(Fleming et al., 1997, 1999). These, however, 

remain issues that must be addressed by new 

studies of brief intervention techniques with 

special populations and with new technology. 

Future Issues in Research and 

Practice 

The background research in this TIP is based on 

the most rigorous trials from the 1960s through 

the 1990s. As study designs have become more 

sophisticated, many of the earlier 

methodological issues are being addressed. 

Questions remain regarding specific levels of 

abuse and dependence after which brief 

intervention approaches are less effective and 

more intensive treatment is required. It is 

possible that factors such as social stability and 

support (as indicated in Edwards and Orford, 

1977) play a role in improved responses to 

briefer treatments and that these factors may be 

more important than the level of substance 

abuse or dependence. 

As secondary analyses are conducted from 

more recent clinical trials, some of the strongest 

covariates will emerge. Further research 

focused specifically on the myriad of issues that 

could affect outcomes is needed to determine 

whether brief interventions can be useful for 

clients with dual diagnoses or whether they 

always require more intensive treatments 

because of the complexity of their illnesses. 

Although there is ongoing research testing the 

effectiveness of brief interventions with patients 

who have serious psychiatric illnesses and 

coexisting substance abuse disorders, there are 

no published studies that definitively address 

this issue. 

There is strong evidence supporting the 

efficacy of alcohol screening and brief 

interventions, in particular (Fleming et al., 1997). 

However, few studies to date have tested the 

implementation of brief intervention strategies 

in community-based medical and treatment 

settings. Several new initiatives address this 

critical next step in the process. Higgins-Biddle 

and colleagues identified the research base and 

current applications of screening and brief 

interventions (Higgins-Biddle et al., 1997). The 

findings on the effectiveness from clinical trials 

on screening and brief interventions were found 

to be encouraging, with risky drinkers reducing 

their alcohol consumption by 20 percent, on 

average. Individual study results varied from 

15 to 40 percent depending on the population 

and methodology used. In the next few years, 

focused work in these areas will inform 

clinicians regarding optimal brief intervention 

implementation strategies and provide a bridge 

from research efficacy to practical application in 

real world clinical settings. 

There is evidence that a variety of brief 

interventions are effective with at-risk and 

hazardous substance users, and emerging 

evidence suggests that brief interventions can be 

used to motivate patients to seek specialized 

substance abuse treatment and to treat some 

alcohol-dependent persons. Clinical evidence 

also suggests that brief interventions can be 

used in specialized treatment programs to 

address specific targeted issues. 

In sum, the Consensus Panel believes it is 

critical for policymakers and providers of 

managed care to understand that brief 

interventions should never be thought of as the 

only treatment option for persons with 

substance abuse problems but as one of a 

continuum of techniques for use with a 

population of clients with substance abuse 

problems ranging from at-risk to dependent use. 

36 
3 Brief Therapy in Substance

Abuse Treatment 

Brief therapy is a systematic, focused 

process that relies on assessment, client 

engagement, and rapid implementation 

of change strategies. Brief therapy providers 

can effect important changes in client behavior 

within a relatively short period. The brief 

therapies presented in this TIP should be seen as 

contained modalities of treatment, not episodic 

forms of long-term therapy. 

However, in the literature and in practice, the 

term “brief therapy” covers a wide range of 

approaches to treatment of varying lengths and 

with a variety of goals. Brief therapies usually 

consist of more (as well as longer) sessions than 

brief interventions. The duration of brief 

therapies is reported to be anywhere from 1 

session (Bloom, 1997) to 40 sessions (Sifneos, 

1987), with the typical therapy lasting between 6 

and 20 sessions. Twenty sessions usually is the 

maximum because of limitations placed by 

many managed care organizations. Any therapy 

may be brief by accident or circumstance, but 

the focus of this TIP is on planned brief therapy. 

The therapies described here may involve a set 

number of sessions or a set range (e.g., from 6 to 

10 sessions), but they always work within a time 

limitation that is clear to both therapist and 

client. In the following pages, all therapies 

described should be understood as planned or 

time limited. 

Brief therapies differ from brief interventions 

in that their goal is to provide clients with tools 

to change basic attitudes and handle a variety of 

underlying problems. Compared with brief 

therapies, brief interventions are more 

motivational, seeking to motivate the client to 

make a specific change (in thought or action). 

(See Chapter 1 for more on how this TIP 

distinguishes brief therapies from brief 

interventions.) 

Brief therapy differs from longer term 

therapy in that it focuses more on the present, 

downplays psychic causality, emphasizes using 

effective therapeutic tools in a shorter time, and 

focuses on a specific behavioral change rather 

than large-scale or pervasive change. A number 

of specific types of therapy are designed to be 

carried out in a brief period (e.g., cognitive– 

behavioral approaches are often designed to 

require fewer than 20 sessions). Many longer 

approaches have been or can be adapted; even 

lengthy psychodynamic approaches have been 

adapted for brief therapy with clear guidelines 

for their use (Davanloo, 1980; Luborsky, 1984; 

Mann, 1973; Sifneos, 1972; Strupp and Binder, 

1984). 

This chapter provides an overview of brief 

therapy in substance abuse treatment. First, the 

evidence for the efficacy of this approach is 

presented. The appropriateness of brief therapy 

is discussed next, and criteria are provided for 

determining duration of therapy. The 

components of all brief therapies are then 

discussed, including common characteristics 

37 
Chapter 3 

and steps in treatment. Finally, essential 

therapist knowledge and skills for conducting 

successful brief therapies are described. 

The chapters following this present a crosssection of the approaches that are and have been 

used in brief therapy. No one approach is 

endorsed as the best or only approach for use 

with the range of persons with substance abuse 

disorders, nor are all of them considered by the 

Consensus Panel to be equally valid. Rather, the 

therapies in Chapters 4 through 9 were chosen 

because they either represent the most widely 

used brief therapies or they represent models 

that have good potential, are recommended by 

national experts, and will be of interest and 

assistance to providers who treat persons across 

the range of substance abuse disorders. Some of 

these approaches can be used with the whole 

range of people with substance abuse disorders; 

others are useful only for a smaller subset of that 

population. Each of the chapters that follows 

discusses a particular type of the individual 

therapies. However, each of the approaches 

described in Chapters 4 to 9 will provide useful 

techniques for the eclectic practitioner. 

Research Findings 

Research concerning the relative effectiveness of 

brief versus longer term therapies for a variety 

of presenting complaints is mixed. Some studies 

have found that planned, short-term therapies 

are as effective as lengthier (or unlimited) 

therapy (Koss and Shiang, 1993; Smyrnios and 

Kirkby, 1993). Other studies, such as the 

Consumer Reports mental health study (Seligman, 

1995) and the National Institute of Mental 

Health (NIMH) Treatment of Depression 

Research Program (Blatt et al., 1995; Elkin, 1994), 

have found that longer term treatments 

generally lead to better outcomes as perceived 

by clients. Much depends on the modality being 

evaluated and the goals of the treatment. (More 

specific research evaluating different types of 

brief therapy is given in Chapters 4 to 9.) 

There is, however, promising evidence that 

brief therapies as a treatment for substance 

abuse disorders are often as effective as 

lengthier treatments (Bien et al., 1993; Gottheil et 

al., 1998; McLellan et al., 1993; Miller and 

Hester, 1986a; Miller and Rollnick, 1991). These 

studies are positive but are primarily limited to 

program effectiveness studies with smaller 

sample sizes. Future research should both 

replicate previous work and use more rigorous 

designs that include experimental designs with 

randomization. Many of the fundamental 

questions about brief therapies—the optimum 

conditions under which they should be used, the 

economic cost-benefits, and level and type of 

provider, the most suitable types of clients— 

have yet to be studied. 

The majority of clients in therapy (regardless 

of the modality) remain in treatment for 

between 6 and 22 sessions; 90 percent end 

treatment before completing 20 visits (Friedberg, 

1999). The fact that many clients stay in therapy 

for relatively short periods of time suggests that 

brief therapy techniques should be much more 

common than they are in current clinical 

practice (Pekarik and Wierzbicki, 1986; Phillips, 

1987). Many therapists trained in long-term 

treatment modalities choose not to use planned 

short-term therapies (Bloom, 1997). Alcohol and 

drug counselors often have to work with clients 

in a limited period of time, however, and could 

apply brief therapy techniques even when they 

are designed for treatment of different types of 

disorders and problems. 

Because brief therapy is more effective than 

being on a waiting list, it could benefit many 

clients. Wolberg suggested that all clients 

seeking treatment be given brief therapy 

initially, before moving on to long-term 

treatments (Wolberg, 1980). Such an approach 

would help to reserve longer treatments for 

38 
Brief Therapy in Substance Abuse Treatment 

39 

 clients with a greater need for them. However, 

there are clearly exceptions to this rule, such as 

clients who have a history of severe and 

persistent mental illness. Other criteria for 

assigning a client to longer term rather than 

brief therapy are presented in Figure 3-1. 

Planned brief therapy can be adapted as part 

of a course of serial or intermittent therapy 

(Budman and Gurman, 1988; Cummings, 1990). 

When doing this, the therapist conceives a longterm treatment as a number of shorter 

treatments, which requires that the client’s 

problems be addressed serially rather than 

concurrently. Because of insurance constraints, 

many therapists are now billing by episode and 

treating one problem at a time. 

Brief therapy may prove to be a useful tool 

for reconceiving how therapy is delivered. For 

the treatment provider working with clients 

with substance abuse disorders, this means that 

a particular type of therapy could be applied to 

a specific problem associated with a client’s 

substance abuse. By treating these allied 

problems, long-term goals, such as continued 

abstinence, may be more likely to be reached 

(Iguchi et al., 1997; McLellan et al., 1993). 

When To Use Brief 

Therapy 

Insufficient data are available to determine 

which populations would benefit most from 

brief therapy. Therefore, client needs and the 

suitability of brief therapy must be evaluated on 

a case-by-case basis. Some criteria for 

considering the appropriateness of brief therapy 

are presented in Figure 3-2. The American 

Society of Addiction Medicine (ASAM) client 

placement criteria for substance abuse treatment 

(ASAM, 1996) may also be useful for 

determining who could benefit from brief 

therapy (see discussion in Chapter 2). 

Brief therapy may be appropriate for a 

moderate to heavy drinker such as a college 

student but inappropriate as the sole treatment 

for a commercial airline pilot who is alcohol 

dependent, no matter what the motivation is for 

treatment. Therapists must consider 

extenuating circumstances when recommending 

a particular course of treatment. In some 

programs, duration of therapy is determined 

mutually by the client and therapist; brief 

therapy may be the best option if the client 

objects to longer term treatment or if expense is 

an issue. 

Research is needed to identify specific 

populations for which brief therapy would serve 

as the catalyst for resolution of substance abuserelated problems. The impact of brief therapy 

on chronically relapsing, substance-abusing 

persons has not been investigated. Because of 

these large gaps in research, therapists must rely 

on their clinical judgment to determine whether 

brief therapy is appropriate for a particular 

Figure 3-1 

Criteria for Longer Term Treatment

The following criteria can help identify clients who could benefit from longer term treatment: 

 Failure of previous shorter treatment  Cognitive inability to focus 

 Multiple concurrent problems  Long-term history of relapse 

 Severe substance abuse (i.e., dependence)  Many unsuccessful treatment episodes 

 Acute psychoses  Low level of social support 

 Acute intoxication  Serious consequences related to relapse 

 Acute withdrawal 
Chapter 3 

40 

client and what kind of modality would be most 

effective. 

The best outcomes for brief therapy may 

depend on the therapist’s skills, comprehensive 

assessments, and selective criteria for eligibility. 

Using selection criteria in prescribing brief 

therapy is critical, since many clients will not 

meet eligibility. The Consensus Panel hopes 

that brief therapy will be adequately 

investigated before managed care and thirdparty payors decide it is the only modality for 

which they will pay. 

Brief therapy for substance abuse treatment 

is a valuable but limited approach, and it should 

not be considered a standard of care for all 

populations. In fact, time in treatment has been 

found to be directly related to better outcomes 

within a range of modalities, including 

therapeutic communities, psychotherapy, 

methadone maintenance therapy, and extended 

detoxification (Hubbard et al., 1997). Therefore, 

although brief therapy is a useful tool in a 

portfolio of interventions, its use should be 

targeted to those clients who are most likely to 

benefit. 

Determining when to use a particular type of 

brief therapy is also an important consideration 

for counselors and therapists. Counselors 

recognize that not all clients are at the same 

stage in their readiness for treatment. Currently, 

the most widely used model for understanding 

clients’ readiness for change is Prochaska and 

DiClemente’s stages-of-change model, which is 

discussed in Chapter 2. (For more information 

about this model, see also TIP 35, Enhancing 

Motivation for Change in Substance Abuse 

Figure 3-2 

Selected Criteria for Providing Brief Therapy

 Dual diagnosis issues such as a coexisting psychiatric disorder or developmental disability 

 The range and severity of presenting problems 

 The duration of abuse 

 Availability of familial and community supports 

 The level and type of influence from peers, family, and community 

 Previous treatment or attempts at recovery 

 The level of client motivation (brief therapy may require more work on the part of the client but a 

less extensive time commitment) 

 The clarity of the client’s short- and long-term goals (brief therapy will require more clearly defined 

goals) 

 The client’s belief in the value of brief therapy (“buy in”) 

 Large numbers of clients needing treatment 

The following criteria are derived from clinical experience: 

 Less severe substance abuse, as measured by an instrument like the Addiction Severity 

Index (ASI) 

 Level of past trauma affecting the client’s substance abuse 

 Insufficient resources available for more prolonged therapy 

 Limited amount of time available for treatment (e.g., 7-day average length of stay in county–jaillevel correctional facilities; 30- to 45-day limitation in Job Corps program) 

 Presence of coexisting medical or mental health diagnoses 

 Large numbers of clients needing treatment leading to waiting lists for specialized treatment 
Brief Therapy in Substance Abuse Treatment 

Treatment [CSAT, 1999c].) Counselors who use 

this model will have to determine which therapy 

is compatible with the client’s stage of readiness 

for change and the tasks needed to move 

forward in the change process and develop an 

overall understanding of the course of change 

(DiClemente and Scott, 1997). 

Clinical interventions should be targeted to 

the client’s stage of readiness for change to 

increase his motivation to change behaviors and 

to augment a sense of empowerment in 

recovery. Therapies that work with experiential 

processes (such as consciousness raising, selfreevaluation, and a cognitive restructuring) are 

more important for understanding and 

predicting transition from preparation to action 

and from action to maintenance (Prochaska et 

al., 1994). Seeking and processing information, 

observing others, and gathering useful 

information in light of the client’s situation are 

the primary activities reported most frequently 

during the contemplation stage (Prochaska et al., 

1992). Especially during this early stage the 

client should be provided with information 

regarding addiction as well as confronted with 

the short- and long-term consequences of 

continued use. Asking the client to perform a 

risk appraisal of continued use as well as a 

benefit/risk-reduction appraisal of achieving 

abstinence can facilitate sound decisionmaking 

that involves a comparison of all potential gains 

and losses (Janis and Mann, 1977). 

Finally, it will be essential to learn the client’s 

perceived obstacles to engaging in treatment as 

well as to identify any dysfunctional beliefs that 

could sabotage the engagement process. The 

basic assumption behind this approach is that 

the way individuals evaluate a situation and 

cope with it determines their emotional reaction 

to it (Ellis and Grieger, 1977). The critical factor 

in determining an individual’s response is the 

client’s self-perception and associated emotions. 

The therapist should help the client recognize 

the messages she gives herself and help her 

correct problematic thinking patterns and 

dysfunctional beliefs (Kendall and Turk, 1984). 

Often, dysfunctional beliefs lead to low levels of 

perceived self-efficacy and subsequent inability 

to adopt or maintain the desired behavior 

(Bandura, 1986). It is important to note that selfefficacy shifts in a predictable way across the 

stages of behavior change, with clients 

progressively becoming more efficacious as they 

move through the stages (Marcus et al., 1992; 

Prochaska et al., 1994). 

Approaches to 

Brief Therapy 

Brief therapy uses a selected process to change a 

specific problem based on an underlying theory 

about the cause of the problem or the best way 

to encourage positive change. Figure 3-3 lists 

several therapeutic approaches that are 

applicable to brief therapy. These approaches 

can be used with clients with different types of 

problems and varying degrees of substance 

abuse severity. 

Components of Effective 

Brief Therapy 

Although different models of brief therapy may 

stress certain goals and activities more than 

others, all brief therapies have common 

characteristics (see Figure 3-4). In addition, brief 

therapies should incorporate several stages, 

including screening and assessment, an opening 

session that includes the establishment of 

treatment goals, subsequent sessions, 

maintenance strategies, ending treatment, and 

followup. These stages are discussed below. 

Screening and Assessment 

Screening and assessment are critical initial 

steps in brief therapy. Screening is a process in 

41 
Figure 3-3 

Approaches to Brief Therapy 

Approaches Description 

Cognitive 

therapy 

This therapy posits that substance abuse disorders reflect 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. This 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 

Chapter 4 for more information.) 

Behavioral 

therapy 

Using this approach, which is based on learning theories, the therapist teaches the 

client specific skills to improve identified deficiencies in social functioning, selfcontrol, or other behaviors that contribute to substance use disorder. Some of the 

techniques that are used 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 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. This 

approach focuses on learning and practicing a variety of coping skills. The 

emphasis is placed on developing coping strategies, especially early in the 

therapy. Cognitivebehavioral therapy is thought to work by changing what the 

client does and thinks rather than just focusing on changing how the client thinks. 

(See Chapter 4.) 

Strategic/ 

interactional 

therapies 

These approaches seek 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 applied. By shifting the focus to competencies, 

not weaknesses and pathology, the therapist helps clients change their perception 

of the problem and apply existing personal strengths to finding and applying a 

more effective solution. (See Chapter 5.) 

Solutionfocused therapy Using this approach, the therapist helps a client with a substance abuse disorder 

recognize the exceptions to use as a means to reinforce and change behavior. 

Future behavior is based on finding solutions to problem behaviors. Little or no 

time is spent talking about the problem; rather, therapy is focused on solutions 

that have already worked for the client in the past. (See Chapter 5.) 

42 

Chapter 3 
Figure 3-3 (continued) 

Approaches to Brief Therapy 

Approaches Description

Humanistic and 

existential 

therapies 

These therapies assume that the underlying cause of substance abuse disorders is a 

lack of meaning in one’s life, a fear of death, disconnectedness from people, 

spiritual emptiness, or other overwhelming anxieties. Through unconditional 

acceptance, clients are encouraged to improve their self-respect, self-motivation, 

and growth. The approach can be a catalyst for seeking alternatives to substances 

in order to fill the emptiness experienced and expressed as substance abuse. (See 

Chapter 6.) 

Psychodynamic 

therapy 

The psychodynamic therapist works with the assumption that a person’s problems 

with substances are rooted in unconscious and unresolved past conflicts, especially 

in early family relationships. The goal is to help the client gain insight into 

underlying causes of manifest problems, understand what function substance abuse 

is serving, and strengthen present defenses to work through the problem. A strong 

therapeutic alliance with the therapist assists the client to make positive changes. 

(See Chapter 7.) 

Interpersonal 

therapy 

This therapy, which combines elements of cognitive and psychodynamic therapies, 

was originally developed to work with clients with depression but has been used 

successfully with substance-abusing clients. It focuses on reducing the client’s 

dysfunctional symptoms and improving social functioning by concentrating on a 

client’s maladaptive patterns of behavior. It is supportive in nature, providing 

encouragement, reassurance, reduction of guilt, and help in modifying the client’s 

environment. (See Chapter 7 for more information.) 

Family therapy While not a distinct “school” of therapy, family therapy is a modality that either 

treats the client as part of a family system or considers the entire family as “the 

client.” It examines the family system and its hierarchy to determine dysfunctional 

uses of power that lead to negative or inappropriate alignments or poor 

communication patterns and that contribute to substance use disorder by one or 

more family members. The therapist helps family members discover how their 

own system operates, improve communication and problem-solving skills, and 

increase the exchange of positive reinforcement. (See Chapter 8.) 

Group therapy This modality (also not a distinct theoretical school) uses many of the techniques 

and theories described to accomplish specified goals. In some group therapy, the 

group itself and the processes that emerge are central to helping clients see 

themselves in the reactions of others, although the content and focus of the groups 

vary widely. (See Chapter 9.) 

Brief Therapy in Substance Abuse Treatment 

43 
Figure 3-4 

Characteristics of All Brief Therapies 

 They are either problem focused or solution focused; they target the symptom and not what is 

behind it. 

 They clearly define goals related to a specific change or behavior. 

 They should be understandable to both client and clinician. 

 They should produce immediate results. 

 They can be easily influenced by the personality and counseling style of the therapist. 

 They rely on rapid establishment of a strong working relationship between client and therapist. 

 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. 

Chapter 3 

which clients are identified according to 

characteristics that indicate that they are 

possibly abusing substances. Screening does not 

inform the therapist of the severity of the 

individual client’s substance abuse, only its 

presence and, in some cases, broad indications 

of risk. Screening identifies the need for more 

in-depth assessment and is not a substitute for 

an assessment. 

Assessment is a thorough, extensive process 

that involves a broad analysis of the factors 

contributing to and maintaining a client’s 

substance abuse, the severity of the problem, 

and the variety of consequences associated with 

it. Screening and assessment procedures for 

brief therapy do not differ significantly from 

those used for lengthier treatments. 

The assessment should determine whether 

the client’s substance abuse problem is suitable 

for a brief therapy approach. The criteria for 

determining the appropriateness of brief 

therapy, presented in Figures 3-1 and 3-2, are 

first applied during the assessment stage. 

It is reasonable to assume that brief therapies 

are most effective with clients whose problems 

are of short duration and who have strong ties 

to family, work, and community. However, 

limited client resources may also dictate the use 

of brief therapy. For example, if a client lacks 

the financial means to participate in a longer 

treatment process, a brief therapy approach is 

imperative. Some treatment is almost always 

better than no treatment. In addition, brief 

therapy may be indicated for clients who resist 

longer treatment, rather than risk the loss of an 

otherwise motivated client. (Technical 

Assistance Publication [TAP] 21, Addiction 

Counseling Competencies: The Knowledge, Skills, 

and Attitudes of Professional Practice [CSAT, 

1998a] contains further guidance on screening 

and assessment for brief therapy.) 

Therapists should gather as much 

information as possible about a client before the 

first counseling session. One way to do this is to 

obtain copies of any notes taken by an intake 

worker or the referral source. However, when 

gathering information about a client from other 

sources, therapists should be sensitive to 

confidentiality and client consent issues (for 

more information see the section entitled 

“Confidentiality of Information About Clients” 

in Chapter 9 of the forthcoming TIP, Substance 

Abuse Treatment for Persons With HIV/AIDS 

[CSAT, in press]). Other options include asking 

intake workers to administer questionnaires, 

using computerized assessments, or asking the 

44 
Brief Therapy in Substance Abuse Treatment 

client to complete an assessment form before the 

first session. The assessment instrument can be 

brief and informal, generating critical 

information in a short time. Although initial 

screening and assessment ideally should be 

conducted before the first therapy session, the 

process of assessment should continue 

throughout treatment. 

A variety of brief assessment instruments, 

many of which are free, are available to 

clinicians. Assessing Alcohol Problems (National 

Institute on Alcohol Abuse and Alcoholism, 

1995) is a useful source of research-validated 

instruments. Figure 3-5 provides a sample 

battery of brief assessment instruments that 

might be used in a brief therapy setting, ideally 

before the first counseling session. These 

instruments can provide the therapist with a 

quick assessment of the most critical domains 

about which clinical decisions should be made. 

In general, most clients can complete these 

instruments in less than 1 hour. These 

instruments should be supplemented in the first 

counseling session by a clinical assessment 

interview that covers the core areas outlined in 

the following section. For sample screening 

instruments and additional information on 

screening procedures see also TIP 24, A Guide to 

Substance Abuse Services for Primary Care 

Clinicians; TIP 26, Substance Abuse Among Older 

Adults; TIP 31, Screening and Assessing 

Adolescents for Substance Use Disorders; and TIP 

35, Enhancing Motivation for Change in Substance 

Abuse Treatment (CSAT, 1997, 1998b, 1999a, 

1999c). 

For brief therapy, the setting in which 

treatment will occur frequently dictates the kind 

of assessment that can be conducted. Clients 

seek treatment in the type of agency they feel 

will best meet their needs (e.g., those who need 

to continue working while seeking treatment 

will likely enter an outpatient program). 

Constraints may be placed by insurance 

companies or other outside forces. For example, 

managed care environments generate their own 

assessment criteria. Assessment often must be 

conducted outside the treatment facility and 

may not qualify as a reimbursable visit. In 

addition, private practitioners often do not have 

easy access to background information 

Figure 3-5 

Sample Battery of Brief Assessment Instruments 

Assessment Domain Example Instrument(s) 

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 

Sources: Allen and Columbus, 1995; Miller, 1991. 

45 
Chapter 3 

regarding a potential client. In a primary care 

office, screening and assessment consist only of 

taking a client’s history and conducting a 

physical examination. 

Core assessment areas 

Before proceeding with brief therapy for 

substance abuse disorders, a number of areas 

should be assessed, including the following: 

 Current use patterns 

 History of substance abuse 

 Consequences of substance abuse (especially 

external pressures that are bringing the client 

into treatment at this time, such as family or 

legal pressures) 

 Coexisting psychiatric disorders 

 Information about major medical problems 

and health status 

 Information about education and 

employment 

 Support mechanisms 

 Client strengths and situational advantages 

 Previous treatment 

 Family history of substance abuse disorders 

and psychological disorders 

As mentioned earlier, assessment is critical 

not only before beginning brief therapy but also 

as an ongoing part of the process. Only by 

continually assessing the client’s progress and 

problems can the therapist accomplish the goals 

of brief therapy in the limited timeframe. In 

addition, ongoing assessment can function as a 

therapeutic tool because it helps clients identify 

when they are at risk of using substances as well 

as other negative behaviors. 

The Opening Session 

In the first session, the main goals for the 

therapist are to gain a broad understanding of 

the client’s presenting problems, begin to 

establish rapport and an effective working 

relationship, and implement an initial 

intervention, however small. The therapist must 

accomplish certain critical tasks during the first 

session, including 

 Producing rapid engagement 

 Identifying, focusing, and prioritizing 

problems 

 Working with the client to develop possible 

solutions to substance abuse problems and a 

treatment plan that requires the client’s 

active participation 

 Negotiating the route toward change with 

the client (which may involve a contract 

between client and therapist) 

 Eliciting client concerns about problems and 

solutions 

 Understanding client expectations 

 Explaining the structural framework of brief 

therapy, including the process and its limits 

(i.e., those items not within the scope of that 

treatment segment or the agency’s work) 

 Making referrals for critical needs that have 

been identified but can not be met within the 

treatment setting 

Goals of treatment 

Therapists should identify and discuss the goals 

of brief therapy with the client early in 

treatment, preferably in the first session. The 

client has a critical role in determining the goals 

of therapy, and the therapist might have to be 

flexible. The therapist can recommend 

treatment goals, but ultimately they are 

established through interaction and negotiation 

with the client. If a client has certain 

expectations of therapy that make it difficult for 

her to commit to the goals and procedures of 

brief therapy or to a particular therapeutic 

approach, other approaches should be 

considered or a referral made. 

Treatment goals should focus on the central 

problem of substance abuse and may include the 

following: 

46 
 Making a measurable change in specific 

target behaviors associated with substance 

abuse 

 Helping the client demonstrate a new 

understanding and knowledge of problems 

and issues related to substance abuse 

 Improving the client’s personal relationships 

 Resolving other identified problems (e.g., 

work problems, support group attendance) 

The goals of brief therapy may be more client 

driven than those developed in long-term 

therapies because, by design, the therapist does 

not have as long to shape these goals. A variety 

of goals besides those related to substance abuse 

disorders can be addressed effectively in a brief 

therapy modality, but given time constraints, 

therapists will have to limit the number of issues 

addressed. The key is to identify the goals most 

important to the client and to work with him to 

achieve those goals, keeping in mind the 

ultimate goal of sobriety or decreased use. 

Although abstinence is an optimal clinical 

goal, it still must be negotiated with the client (at 

least in outpatient treatment settings). 

Abstinence as a goal is not necessarily the sole 

admission requirement for treatment, and the 

therapist may have to accept an alternative goal, 

such as decreased use, in order to engage the 

client effectively. 

Subsequent Sessions 

In subsequent sessions of brief therapy, 

therapists should 

 Work with the client to help maintain 

motivation and address identified problems, 

monitoring whether any accomplishments 

are consistent with the treatment plan and 

the client’s expectations 

 Reinforce—through an ongoing review of the 

treatment plan and the client’s 

expectations—the need to do the work of 

brief therapy (e.g., maintain problem focus, 

stay on track) 

Brief Therapy in Substance Abuse Treatment 

 Remain prepared to rapidly identify and 

troubleshoot problems 

 Maintain an emphasis on the skills, 

strengths, and resources currently available 

to the client 

 Maintain a focus on what can be done 

immediately to address the client’s problem 

 Consider, as part of an ongoing assessment 

of progress, whether the client needs further 

therapy or other services and how these 

services might best be provided 

 Review with the client any reasons for 

dropping out of treatment (e.g., medical 

problems, incarceration, the emergence of 

severe psychopathology, treatment 

noncompliance) 

Maintenance Strategies 

Maintenance strategies must be built into the 

treatment design from the beginning. A 

practitioner of brief therapy must continue to 

provide support, feedback, and assistance in 

setting realistic goals. Also, the therapist should 

help the client identify relapse triggers and 

situations that could endanger continued 

sobriety. 

Strategies to help maintain the progress 

made during brief therapy include the 

following: 

 Educating the client about the chronic, 

relapsing nature of substance abuse 

disorders 

 Developing a list of circumstances that might 

provide reasons for the client to return to 

treatment and plans to address them 

 Reviewing problems that emerged but were 

not addressed in treatment and helping the 

client develop a plan for addressing them in 

the future (or identifying specific problems 

that might have emerged but were not dealt 

with in treatment) 

 Developing strategies for identifying and 

coping with high-risk situations or the 

reemergence of substance abuse behaviors 

47 
Chapter 3 

 Teaching the client how to capitalize on 

personal strengths 

 Emphasizing client self-sufficiency 

(encouraging the client to work through his 

own problems and stay focused on the goals 

that have been set in therapy) and teaching 

self-reinforcement techniques 

 Developing a plan for future support, 

including mutual help groups, family 

support, and community support (e.g., 

religious or social service organizations), 

which can be done much earlier than in longterm therapy 

In addition to routine progress assessments 

that are conducted throughout the therapy, 

midway through the agreed-upon number of 

sessions the therapist should formally review 

the client’s progress. Particularly because of the 

time limitations of brief therapy, continuing 

assessments are essential to ensure that 

problems are addressed and that the client can 

recognize when she is most at risk of slipping 

into substance abuse or other negative 

behaviors. Assessments will also take into 

account the level of the client’s progress. When 

the client has made agreed-upon behavior 

changes and has resolved some problems, the 

therapist should prepare to end the brief 

therapy. If a client progresses more quickly than 

anticipated, it is not necessary to complete the 

full number of sessions. 

Ending Treatment 

Termination of therapy should always be 

planned in advance. In many types of brief 

therapy, the end of therapy will be an explicit 

focus of discussion in which the therapist should 

 Leave the client on good terms, with an 

enhanced sense of hope for continued change 

and maintenance of changes already 

accomplished 

 Leave the door open for possible future 

sessions dealing with the client’s other 

problems 

 Elicit commitment from the client to try to 

follow through on what has been learned or 

achieved 

 Review what positive outcomes the client can 

expect 

 Review possible pitfalls the client may 

encounter (e.g., social situations, old friends, 

relationship issues) and talk about the 

likelihood of a good outcome and indicators 

of a poor outcome 

 Review the early indicators of relapse (e.g., 

depression, stress, anger) 

In brief therapy, issues regarding referral and 

followup are often different from those of longer 

term therapy because clients will not necessarily 

remain in contact with the therapist. If the goals 

of therapy have not been met, more intensive 

therapy may be suggested. 

During continual assessment of the progress 

of the therapy, the therapist may decide that 

referral is appropriate before treatment ends. It 

is important to remember that referrals can be 

made at any time during treatment, not just at 

the end of the treatment process. Reasons for 

initiating referrals during or at the end of 

treatment include the following: 

 The client needs ancillary services for other 

problems that have been recognized during 

therapy (e.g., medical or psychiatric 

problems). 

 The client requires more intensive therapy. 

 The client may benefit from involvement 

with a support group, such as Alcoholics 

Anonymous, Self-Management and Recovery 

Training (SMART), or Moderation 

Management (which may also be a part of 

the brief therapy process). 

48 
Brief Therapy in Substance Abuse Treatment 

Followup 

It is always advisable for the therapist to follow 

up with clients who have completed brief 

therapy. Followup reassures the client that the 

therapist is concerned about her progress. In 

addition, it is an effective way to gather muchneeded data regarding treatment effectiveness. 

The therapist might obtain such data by 

conducting a client satisfaction survey via 

telephone or mail. Aftercare, when additional 

treatment is provided, is not part of the brief 

therapy process. However, followup activities 

such as offering reassurance and tracking client 

status are customary. 

Therapist Characteristics 

To successfully integrate different short-term 

therapies into practice, therapists benefit from a 

firm grounding in theory and a broad technical 

knowledge of the many different approaches 

available. When appropriate, elements of 

different brief therapies may be combined to 

provide successful outcomes. However, it is 

important to remember that the effectiveness of 

highly defined interventions (e.g., workbookdriven interventions) used in some behavioral 

therapies depends on administration of the 

entire regimen. The therapist must use caution 

in combining and mingling certain techniques 

and must be sensitive to the cultural context 

within which therapies are integrated. 

Therapists should also be sufficiently trained in 

the therapies they are using and should not rely 

solely on a manual such as this to learn those 

therapies. Appendix B provides some resources 

for further education. 

Although therapists with many levels of 

training and experience can conduct brief 

interventions, certain skills and training are 

particularly important for conducting effective 

brief therapy. Those who specialize in 

providing brief therapy are likely to be more 

successful when grounded in a specific model of 

psychotherapy but possess a general 

understanding of other models from which 

appropriate techniques may be drawn. They 

should be adept at determining early in the 

assessment process the client needs or goals that 

are appropriate to address. Related to this, and 

equally important, therapists must establish 

relationships that facilitate referral when the 

client’s needs or goals cannot be met through 

brief therapy. A comprehensive description of 

the professional and personal attributes that 

practitioners need to be effective providers of 

substance abuse treatment is provided in TAP 

21, Addiction Counseling Competencies: The 

Knowledge, Skills, and Attitudes of Professional 

Practice (CSAT, 1998a). TAP 21 emphasizes that 

practitioners should 

 Be empathic 

 Be able to integrate their training—whether 

in substance abuse treatment or other 

disciplines such as social work, medicine, 

nursing, or psychology—with experience, 

both professional and personal, to create the 

best therapeutic environment for the client 

 Have a mature sense of personal and 

professional boundaries 

 Be sensitive to the cultural and spiritual 

needs of the client 

 Follow appropriate Federal, State, and 

agency regulations in the provision of 

substance abuse treatment services 

Providers of brief therapy must focus 

effectively on identifying and adhering to 

specific therapeutic goals in treatment. They 

should be able to extract techniques from longer 

term therapies and adapt them within the 

parameters of brief therapy. The provider of 

brief therapy will have to focus on short-term 

change that can have long-term benefits and 

avoid issues that are more global. The therapist 

must be able to shift approaches depending on 

what is learned about the client during 

treatment. 

49 
Chapter 3 

Brief therapy is amenable to the use of a wide 

range of techniques from which the therapist 

can choose. It is therefore helpful for therapists 

to be aware of the broad range of therapeutic 

techniques available. Exposure to several 

psychotherapeutic approaches (many described 

in the following chapters) allows therapists to 

understand how other clinicians might approach 

the situation, what a client might have 

experienced in previous treatments, and how to 

build on these experiences. 

Brief therapy for substance abuse disorders is 

often helpful, but should not be considered a 

standard of care for all persons or populations. 

Brief therapy, as presented in this TIP, can be a 

contained modality of treatment and not an 

episodic form of long-term therapy. In fact, 

successful brief therapy may be the only 

treatment some clients will require. 

50 
4 Brief Cognitive–Behavioral 

Therapy 

An approach that has gained widespread 

application in the treatment of 

substance abuse is cognitive–behavioral 

therapy (CBT). Its origins are in behavioral 

theory, focusing on both classical conditioning 

and operant learning; cognitive social learning 

theory, from which are taken ideas concerning 

observational learning, the influence of 

modeling, and the role of cognitive expectancies 

in determining behavior; and cognitive theory 

and therapy, which focus on the thoughts, 

cognitive schema, beliefs, attitudes, and 

attributions that influence one’s feelings and 

mediate the relationship between antecedents 

and behavior. Although there are a number of 

similarities across these three seminal 

perspectives (see Carroll, 1998), each has 

contributed unique ideas consistent with its 

theoretical underpinnings. However, in most 

substance abuse treatment settings, the 

prominent features of these three theoretical 

approaches are merged into a cognitive– 

behavioral model. 

Before focusing more specifically on the 

cognitive–behavioral model, this chapter 

examines the behavioral and cognitive theories 

and therapies that serve as the foundations of 

and have contributed significantly to the 

cognitive–behavioral approach to substance 

abuse treatment. Both behavioral and cognitive 

theories have led to interventions that 

individually have been proven effective in 

treating substance abuse. Several of these are 

reviewed, as they have been successfully 

incorporated into an integrated cognitive– 

behavioral model of addictive behaviors and 

their treatment. 

Behavioral Theory 

In contrast to many other methods, behavioral 

approaches to the treatment of substance abuse 

have substantial research evidence in support of 

their effectiveness. Two recent comprehensive 

reviews of the treatment research literature offer 

strong evidence for their effectiveness (Holder et 

al., 1991; Miller et al., 1995). However, some 

critics argue that this is because behavioral 

approaches have been developed under 

controlled conditions and that in “real” therapy 

there are many more variables at work than can 

be measured in controlled experiments. 

Providers should take advantage of the wide 

range of behavioral therapy techniques that are 

available. These techniques can be conducted 

successfully in individual, group, and family 

settings, among others, to help clients change 

their substance abuse behaviors. 

51 
Chapter 4 

Behavioral approaches assume that substance 

abuse disorders are developed and maintained 

through the general principles of learning and 

reinforcement. The early behavioral models of 

substance abuse were influenced primarily by 

the principles of both Pavlovian classical 

conditioning and Skinnerian operant learning 

(O’Brien and Childress, 1992; Stasiewicz and 

Maisto, 1993). (See Figure 4-1 for definitions of 

classical conditioning and operant learning.) 

Today, behavioral therapy for the treatment 

of substance abuse disorders is based primarily, 

though not exclusively, on methods derived 

from both operant and classical theories of 

learning. A major tenet of behavioral therapy is 

that because substance abuse is a learned 

behavior pattern, changing the reinforcement 

contingencies that govern this behavior can 

modify it. This goal can be achieved by focusing 

on either the classically conditioned craving 

responses or on the operant reinforcement 

patterns that are assessed as maintaining the 

substance abuse. More specifically, the 

classically conditioned response can be 

addressed either through extinction or 

counterconditioning procedures; the operant 

responses can be targeted through contingency 

management or coping skills training. (More 

Figure 4-1 

Classical Conditioning and Operant Learning 

According to the theory of classical conditioning, an originally neutral stimulus comes to elicit a 

response as a result of being paired with an unconditioned stimulus (an event that elicits a response 

without any prior learning history) or with a conditioned stimulus. As applied to substance abuse, 

repeated pairings between the emotional, environmental, and subjective cues associated with the use of 

substances and the actual physiological and phenomenological effects produced by specific substances 

lead to the development of a classically conditioned response. Subsequently, when the substance abuser 

is in the presence of such cues, a classically conditioned withdrawal state or craving is elicited. Cocaineand opiate-dependent individuals, for example, experience marked physiological arousal and report 

strong craving when they see their drug works and other drug paraphernalia or when they experience 

negative emotions such as depression—even after prolonged drug-free periods (Childress et al., 1994, 

1988; Ehrman et al., 1992). Alcohol-dependent clients experience similar physiological reactivity to 

alcohol-related cues such as being in a bar or watching others drink (Rohsenow et al., 1991). These cues 

can become “triggers” or high-risk situations that can lead to substance use and relapse. 

Operant learning refers to those behaviors that are increased in frequency by reinforcement. Behaviors 

that result either in rewarding or positive outcomes or that allow the individual either to avoid or escape 

from negative consequences are likely to increase in frequency. Substance abuse in the presence of 

classically conditioned cues is instrumental in reducing or eliminating the arousal associated with a state 

of craving, thus serving to reinforce the substance abuse behavior. That is, the behavior serves a basic 

rewarding function for the individual. This represents the second form of learning, operant conditioning. 

An alcohol-dependent person who drinks to feel more social and less anxious or a cocaine abuser who 

gets high to overcome depression is using substances in an instrumental way. To the extent that they 

experience the effects they seek, the greater the likelihood they will use substances under similar 

circumstances in the future. Presumably, people continue to abuse substances even in the face of 

negative consequences (e.g., legal, marital, or health problems) because these consequences are quite 

removed in time from the point of use; also, the more immediate positively reinforcing effects of the 

substance typically override consideration of such consequences. 

52 
information about the basic assumptions of 

behavioral theories concerning substance abuse 

disorders is contained in Figure 4-2.) 

According to behavioral theory, changes in 

behavior come about through learning new 

behaviors. Because substance abuse behavior is 

learned, it can be changed by teaching the client 

more adaptive, alternative behaviors aimed at 

achieving the same rewards. Figure 4-3 provides 

an overview of some of the advantages of 

behavioral theories of substance abuse and 

dependence and their treatment. 

By its very design, most behavioral therapy is 

brief. The aim is not to remake personality, but 

rather to help the client address specific, 

identifiable problems in such a way that the 

client is able to apply the basic techniques and 

skills learned in therapy to the real world, 

without the assistance of the therapist. 

Behavioral therapy focuses more on identifying 

and changing observable, measurable behaviors 

than other therapeutic approaches and hence 

lends itself to brief work. Treatment is linked to 

altering the behavior, and success is the change, 

elimination, or enhancement of particular 

behaviors. 

Regular assessment and measurement of 

progress are integral to effective behavioral 

therapy. Decisions about the length of treatment 

are made on the basis of these assessments, 

rather than according to a formula or theoretical 

assumption about how long therapy should take. 

Each individual is approached as a unique case, 

albeit one to which broad principles can be 

applied. 

Behavioral Therapy 

Techniques Based on 

Classical Conditioning 

Models 

Extinction and Cue Exposure 

Procedures 

A principal of classical conditioning is that if a 

behavior occurs repeatedly across time but is not 

reinforced, the strength of both the cue for the 

behavior and the behavior itself will diminish and 

the behavior will extinguish. This principal has 

been the foundation of behavioral treatments 

known as “cue exposure” (O’Brien et al., 1990; 

Rohsenow et al., 1991; Rohsenow and Monti, 1995). 

Even after relatively long periods of abstinence 

from substances, being placed in situations that 

have physical–environmental, social, or emotional 

cues associated with past 

Figure 4-2 

Basic Assumptions of Behavioral Theories of 

Substance Abuse and Its Treatment 

 Human behavior is largely learned, rather than determined by genetic factors. 

 The same learning processes that create problem behaviors can be used to change them. 

 Behavior is largely determined by contextual and environmental factors. 

 Covert behavior such as thoughts and feelings is subject to change through the application of learning 

principals. 

 Actually engaging in new behavior in the contexts in which they are to be performed is a critical part 

of behavior change. 

 Each client is unique and must be assessed as an individual in a particular context. 

 The cornerstone of adequate treatment is a thorough behavioral assessment. 

Source: Rotgers, 1996. 

53 

Brief Cognitive–Behavioral Therapy 
Chapter 4 

Figure 4-3 

Advantages of Behavioral Theories in Treating 

Substance Abuse Disorders 

 Flexible in meeting specific client needs 

 Readily accepted by clients due to high level of client involvement in treatment planning and goal 

selection 

 Soundly grounded in established psychological theory 

 Derived from scientific knowledge and applied to treatment practice 

 Structured in its guidelines for assessing treatment progress 

 Empowering clients to make their own behavior change 

 Effective, according to strong empirical and scientific evidence 

Source: Rotgers, 1996. 

substance abuse will elicit strong physiological 

arousal reactions and reports of strong 

sensations of craving. In cue exposure, a client is 

purposefully presented with such cues 

physically (e.g., by showing his personal drug 

paraphernalia or by accompanying him into a 

well-frequented bar), or visually through video 

depiction of a drug-using scenario or through 

visualization of such a scenario. However, the 

client is prevented from drinking or taking 

drugs. This extinction process, over time, leads 

to a decreased reactivity to such cues. 

O’Brien and colleagues found that cocainedependent clients showed the prototypical 

arousal and craving responses when first 

presented drug-related cues that reminded them 

of their drug use (O’Brien et al., 1990). Clients 

then began the cue-extinction protocol. By the 

sixth 1-hour treatment session, they no longer 

reported either subjective highs or physiological 

withdrawal. By the 15th session, all clients 

reported that they no longer experienced craving 

when presented with the drug-related cues. 

Clients who received the cue exposure as part of 

their standard outpatient treatment for cocaine 

use were also less likely to drop out of treatment 

and had more cocaine-free weeks than did 

clients attending the same outpatient program 

but who did not receive cue exposure. 

Counterconditioning and 

Aversion Procedures 

Another method used to modify behavior 

according to classical conditioning principles is 

to make behaviors that had been associated with 

positive outcomes less appealing by more closely 

associating them with negative consequences. 

By repeatedly pairing those cues that previously 

elicited a particular behavior with negative 

rather than positive outcomes, the cues lose their 

ability to elicit the original classically 

conditioned response; instead, they elicit a 

negative outcome. This has led to the 

development of what have been described as 

aversive conditioning or counterconditioning 

treatment approaches (Howard et al., 1991; 

Rimmele et al., 1995). These procedures 

repeatedly pair negative outcomes with the 

substance-related cues previously associated 

with the positive consequences of substance use. 

For example, the Shick-Shadel Hospital in 

Seattle uses aversive conditioning techniques with 

alcohol-dependent clients (Lemere, 1987). Before 

a treatment session, the client is asked to drink a 

warm saline solution and is given an emetic 

medication that will ultimately lead the client to 

become nauseated and to vomit. The client is 

then brought into “Duffy’s Bar,” a room filled 

with vivid alcohol- and drinking-related 

54 
posters, a bar with bottles of a large number and 

wide range of alcoholic beverages, and other 

drinking-related cues. The room is meant to 

highlight and make more salient the cues 

associated with drinking. The client is asked to 

identify her favorite type and brand of alcohol. 

After pouring a drink, she is asked to swirl the 

alcohol around in the glass, to smell the alcohol, 

to place the glass to her lips and taste, and then to 

begin to take a sip of the drink. At that point, as 

she is about to take a drink, the effects of the 

emetic drug “kick in” and the client becomes 

nauseated and vomits. Over repeated sessions, 

which occur every other day for a 10-day period, 

the alcohol-related sight, smell, and taste cues not 

only do not elicit craving and positive feelings 

about drinking, but rather they now elicit 

conditioned nausea. 

Therapies based on counterconditioning 

theory typically use chemically induced aversion 

or electric shock as negative consequences to be 

paired with the substance-related cues. Visual 

imagery can also be used in a technique called 

covert sensitization. In this procedure, the client is 

asked to imagine as vividly as possible a 

sequence of events that begin by seeing his 

favorite bar; this is typically accompanied by 

increased craving. As the person proceeds 

further in imagining entering the bar, sitting 

down, ordering a drink, and so on, the initial 

sense of craving shifts to mild discomfort. As he 

visualizes beginning to take a drink and tastes 

the alcohol, he is then asked to imagine 

becoming violently sick and vomiting (Rimmele 

et al., 1995). 

While aversive conditioning procedures have 

most often been used in the treatment of alcohol 

dependence, they have also been applied to the 

treatment of marijuana and cocaine use (Frawley 

and Smith, 1990; Smith et al., 1988). It should be 

noted that these aversive conditioning 

techniques, as well as cue exposure approaches, 

are best viewed as components of a more 

comprehensive treatment program rather than as 

Brief Cognitive–Behavioral Therapy 

independent, free-standing treatments (O’Brien, 

et al., 1990; Smith and Frawley, 1993). In this 

context, Smith and colleagues reported positive 

outcomes for dependent users of both alcohol 

and cocaine who received chemical aversion 

procedures as part of their treatment in 

comparison to those who did not receive similar 

treatment (Frawley and Smith, 1990; Smith et al., 

1997). Rimmele and colleagues also 

recommended covert sensitization as a highly 

effective and portable treatment component 

which, unlike chemical or electric aversion 

therapies, can be used at any time and in any 

setting as a self-control strategy (Rimmele et al., 

1995). 

Behavioral Therapy 

Techniques Based on 

Operant Learning Models 

A number of substance abuse treatment 

strategies have derived from operant learning 

principles. While they are often incorporated 

into broad-spectrum cognitive–behavioral 

approaches, they have also been used as 

independent forms of treatment. Common 

elements of behavioral treatments based on 

theories of operant learning include contingency 

management, behavior contracting, community 

reinforcement, and behavioral self-control 

training. The following sections describe some 

of the elements used in brief behavioral therapies 

based on the operant learning model. 

Contingency Management and 

Behavior Contracting 

In contingency management approaches, an 

active attempt is made to change those 

environmental contingencies that can influence 

substance abuse behavior (Higgins et al., 1998). 

The goal is to decrease or stop substance use and 

to increase behaviors that are incompatible with 

use. In particular, those contingencies that are 

found through a functional analysis (see Figure 

55 
Chapter 4 

4-4) to prompt as well as reinforce substance 

abuse are weakened by associating evidence of 

substance use (e.g., a drug-positive urine screen) 

with some form of negative consequence or 

punishment. Contingencies that prompt and 

reinforce behaviors that are incompatible with 

substance abuse and that promote abstinence are 

strengthened by associating them with positive 

reinforcers. 

One recent study evaluated the effects of a 

voucher program in the treatment of methadonemaintained opiate addicts with a history of 

cocaine use (Silverman et al., 1998). Clients who 

provided cocaine-free urine samples received 

vouchers that had monetary value. The value of 

the vouchers increased as the number of 

consecutive cocaine-free urine samples 

increased. Clients in the contingent voucher 

condition, compared to those who received 

vouchers on a noncontingent basis, reported 

decreased craving for cocaine and significantly 

increased cocaine abstinence. A more general 

positive treatment effect was also noted, with 

clients in the contingent voucher condition also 

demonstrating an increased abstinence from 

opiates. 

Chutuape and colleagues have also shown 

that providing methadone take-home privileges 

contingent on drug-free urine samples among 

methadone clients with persistent multiple drug 

abuse resulted in marked reductions in drug use 

(Chutuape et al., 1999). Nearly 25 percent of 

clients in the take-home incentive program met 

the criterion for marked reduction in drug use 

and also were significantly more likely to 

achieve the criterion of having 4 consecutive 

weeks of drug-free urine samples. None of the 

clients in a control condition (no take-home 

privileges) met these criteria. Whereas only 2 

percent of the control group evidenced a 

decrease in the frequency of drug-positive 

urines, clients in the incentive program 

decreased use between 14 and 18 percent. 

In addition to increasing drug abstinence, 

similar voucher systems have been effective in 

maintaining attendance of methadone clients at a 

job-skills training program (Silverman et al., 

1996). However, in contrast to drug treatment, 

less evidence is available concerning the 

effectiveness of such contingency management 

approaches in the treatment of alcohol problems 

(Higgins et al., 1998). 

Attempts to incorporate real-world 

contingencies into treatment programs are 

increasing (Higgins, 1999). Clearly, programs 

can build contingencies such as take-home 

medication privileges into the structure of their 

programs. Milby and colleagues provide an 

example of a contingency management system 

incorporated into treatment that is more relevant 

to real-life situations of users (Milby et al., 1996). 

In this study, homeless substance abusers were 

enrolled in an intensive day treatment program. 

A subgroup of these clients was also involved in 

a contingent work therapy and housing 

program. As long as the clients remained 

Figure 4-4 

Functional Analysis 

A functional analysis probes the situations surrounding the client’s substance abuse. Specifically, it 

examines the relationships among stimuli that trigger use and the consequences that follow. This type 

of analysis provides important clues regarding the meaning of the behavior to the client, as well as 

possible motivators and barriers to change. In behavioral therapy, this is the first step in providing the 

client with tools to manage or avoid situations that trigger substance use. Functional analysis yields a 

roadmap of a client’s interpersonal, intrapersonal, and environmental catalysts and reactions to 

substance use, thereby identifying likely precursors to substance use. (For more information on this 

topic, see the section below under the heading “Cognitive–Behavioral Therapy.”) 

56 
Brief Cognitive–Behavioral Therapy 

substance free, they were able to remain in the 

work program and remain in the therapeutic 

housing; if they were found to be drinking or 

using drugs, they became ineligible for both the 

job training/work program and housing. Clients 

involved in the abstinence-contingent program 

had fewer cocaine-positive urine samples, fewer 

days of drinking, fewer days of homelessness, 

and more days of employment during the 

followup period than those in the standard 

treatment. 

Naturalistic contingencies may also be useful 

in treatment. These contingencies include 

threatened loss of job, spouse, or driver’s license 

and were positively related to treatment 

outcome among alcohol users (Krampen, 1989). 

However, the prognosis was less favorable in 

those patients who had already experienced a 

loss in one of those areas because the 

contingency no longer existed for them. 

Higgins and colleagues noted that written 

contracts may be used to help implement a 

contingency management program (Higgins et 

al., 1998). The contract should specify clearly, 

using the client’s own words, the target behavior 

to be changed, the contingencies surrounding 

either changing behavior or not, and the 

timeframe in which the desired behavior change 

is to occur. The act of composing and signing a 

contract is a small but potentially important 

ritual signifying the client’s commitment to the 

proposed change. In the contract, the client may 

include contingencies, especially rewards or 

positive incentives that will reinforce target 

behaviors (e.g., attending treatment sessions, 

getting to 12-Step meetings, avoiding stimuli 

associated with substance use). Goals should be 

clearly defined, broken into small steps that 

occur frequently, and revised as treatment 

progresses; contingencies should occur quickly 

after success or failure. 

Most often, behavioral contracts and 

contingency management procedures are 

embedded in a more comprehensive treatment 

program. Contracts targeting goals supportive 

of recovery (e.g., improving vocational behavior, 

saving money, being prompt for counseling, 

regularly taking medication) are generally more 

likely to be achieved and lead to better outcomes 

than those more directly related to substance use 

(e.g., clean urine samples) (Anker and Crowley, 

1982; Iguchi et al., 1997; Magura et al., 1987, 

1988). For instance, research found that 

receiving vouchers contingent on completing 

objective, individually tailored goals related to 

one’s overall treatment plan was more effective 

in reducing substance abuse than either a 

voucher system specifically targeting drug-free 

urine samples or a standard treatment without 

either of these contingency contracts added 

(Iguchi et al., 1997). The effectiveness of such 

contracts also appears to be linked to the severity 

of the consequences that might result from a 

broken contract (Magura et al., 1987). 

Behavioral contracting and contingency 

management are often found as elements in a 

number of more comprehensive approaches such 

as community reinforcement and behavioral selfcontrol training. 

Community Reinforcement 

Approach 

The community reinforcement approach (CRA) 

was developed as a treatment for alcohol abuse 

disorders (Azrin, 1976; Hunt and Azrin, 1973). 

After a period during which it appears to have 

been little used, it has received increased 

interest as a behavioral approach to substance 

abuse (Higgins et al., 1998; Meyers and Smith, 

1995; Smith and Meyers, 1995). CRA is a 

broad-spectrum approach based on the 

principles of operant learning, the goal of 

which is to increase the likelihood of continued 

abstinence from alcohol or drugs by 

reorganizing the client’s environment. In 

particular, CRA attempts to weaken the 

influence of reinforcement received by 

substance abuse and its related activities by 

57 
Chapter 4 

increasing the availability and frequency of 

reinforcement derived from alternative 

activities, particularly those vocational, family, 

social, and recreational activities that are 

incompatible with substance abuse (Higgins et 

al., 1998). 

A goal of CRA is to make these alternative 

interpersonal and social sources of reinforcement 

available when the person is sober or drug-free, 

but to make them unavailable if the person 

drinks or uses. The program consists of a 

number of components, and it can be tailored to 

the specific circumstances of a client. Vocational 

counseling and job clubs can improve clients’ 

basic skills as well as job-seeking skills (e.g., 

résumé development, application completion, 

job interview skills). Social and recreational 

counseling is provided to help clients learn about 

and sample a number of substance-free 

recreational pursuits and social activities. In 

some cases, social clubs have been established to 

provide clients with a substance-free 

environment where they can gather and have 

fun. 

For those clients who are married or in a 

relationship, marital counseling and 

communication skills training are provided to 

enhance the quality of the relationship and 

reduce the stress of substance-related 

arguments. Couples are trained to give each 

other positive attention through compliments, 

appreciation, affection, and offers to help. A 

focus is placed on clarifying expectations that 

each partner has about the behavior of the 

other. For those with a problem with alcohol, 

medication (e.g., disulfiram [Antabuse]) 

monitored by the spouse may be used. The 

client also receives training in problemsolving 

and in ways to refuse requests to drink or use 

drugs. 

CRA has been described as a promising but 

underutilized treatment for alcohol abuse 

(McCrady, 1991). A review of the alcohol 

treatment outcome literature identifies CRA 

among those interventions having the greatest 

empirical support (Miller et al., 1995). CRA’s 

application to substances other than alcohol also 

appears to have been successful (Higgins et al., 

1998). This extension is exemplified by the 

recent publication of a detailed CRA therapy 

manual for the treatment of cocaine dependence 

by the National Institute on Drug Abuse 

(Budney and Higgins, 1998). This manual relies 

heavily on the early work of Higgins and 

colleagues in evaluating the effectiveness of 

combining CRA with contingency management 

approaches (e.g., use of vouchers for drug-free 

urine samples) in the treatment of cocaine 

dependence (Higgins et al., 1991, 1993). In 

comparison to standard outpatient treatment, 

clients in the CRA-plus-vouchers condition 

remained in treatment longer, had more 

continuous weeks of drug-free urine samples, 

and had greater amounts of cocaine abstinence 

even at a 12-month followup. A similar pattern 

of findings has been obtained with methadonemaintained opiate addicts (Abbott et al., 1998). 

The CRA model has been modified into the 

Community Reinforcement and Family Training 

procedure (CRAFT) (Meyers et al., 1996). The 

client’s significant others and family members, 

who are an integral part of this approach, receive 

training in behavior modification and enhancing 

motivation. CRAFT seeks to reduce or stop 

substance abuse by working through nonusing 

family and friends. While CRA involves family 

or significant others in treatment, CRAFT is more 

of a form of family therapy (rather than 

individual therapy) and therefore is discussed in 

Chapter 8 of this TIP. 

Behavioral Self-Control Training 

In contrast to CRA, which incorporates a wide 

array of individuals in the treatment process, the 

behavioral self-control training approach 

focuses on the substance abuser and his 

attempts to reduce or stop substance abuse 

either on his own or with the aid of a therapist 

58 
Brief Cognitive–Behavioral Therapy 

(Hester, 1995; Hester and Miller, 1989). The goal 

of this approach is either moderation and harm 

reduction or abstinence. As applied to alcohol 

problems, the approach consists of the eight 

sequential steps listed below (Hester, 1995): 

1. The client establishes an upper limit on the 

number of drinks per day and the peak 

blood alcohol level on any one drinking 

occasion. 

2. The client begins to self-monitor both the 

number of drinks taken and the drinking 

setting (e.g., when, where, with whom, how 

he is feeling). This provides the basis of a 

functional analysis. 

3. The client begins to modify the rate at which 

alcohol is consumed. This might be done by 

switching from the individual’s standard 

alcoholic beverage to one containing less 

alcohol, by sipping a drink over a longer 

period of time, or by spacing the number of 

drinks consumed across time. 

4. The client must develop and practice being 

able to refuse drinks assertively when 

offered them.

5. The client establishes a reinforcement system 

to reward the achievement of these drinkingrelated goals. 

6. Through the process of self-monitoring, the 

client is able to determine those social, 

emotional, and environmental antecedents 

that prompt overdrinking. 

7. The client learns new coping skills to use 

rather than relying on drinking as a means of 

coping. 

8. The client attempts to learn ways to avoid 

relapsing back to heavy drinking. 

Although a therapist may guide the 

individual in a behavioral self-control model, the 

substance abuser maintains primary 

responsibility for changing his behavior. During 

the course of therapy, the client and therapist 

meet in brief sessions to go over homework and 

ensure that the client is following through. 

Rather than involvement with a therapist, the 

person may be guided instead by self-help 

manuals (Miller and Munoz, 1982; SanchezCraig, 1995), intervention via correspondence 

(Sitharthan et al., 1996), or even a computer 

program (Hester and Delaney, 1997). 

McCrady also included behavioral selfcontrol training as another promising but 

underutilized treatment approach (McCrady, 

1991). Hester indicated that there is good 

empirical support for behavioral self-control 

training in achieving the goal of moderate, 

nonproblematic drinking (Hester, 1995). In 

randomized clinical trials, problem drinkers 

assigned to behavioral self-control with a goal of 

either moderation or abstinence typically have 

comparable long-term outcomes. Although 

behavioral self-control approaches have been 

used primarily with alcohol problems, they have 

also been used with other substances such as 

opiates (van Bilsen and Whitehead, 1994). 

Application of Behavioral 

Techniques 

Behavioral therapies are often delivered using a 

specific manual, but they are also adaptable to 

the individual client. A number of the 

behavioral techniques described here are also 

used by therapists using cognitive–behavioral 

therapy. The following sections describe how 

brief behavioral therapy might be applied at 

different stages of treatment. Some of the 

techniques developed for brief behavioral 

therapy are also presented. 

Initial session 

The initial session in brief behavioral therapy 

involves an exploration of the reasons the client 

is seeking treatment at this particular time; the 

extent to which this motivation for treatment is 

intrinsic, rather than influenced by external 

sources; the areas of concern that the client and 

significant others may have about his substance 

abuse; the situations in which she drinks or uses 

59 
excessively; and the consequences she 

experiences (both positive and negative, as well 

as proximal and removed from the actual 

substance abuse). This involves an abbreviated 

functional analysis. (See the section with that 

name later in this chapter.) 

The information gained in the session will 

assist the counselor in determining the 

antecedents that prompt substance abuse and 

the reinforcers that appear to maintain it. Based 

on the information obtained, the counselor can 

begin to formulate a treatment plan with respect 

to the specific target behaviors to address, the 

behavioral interventions that address these 

target behaviors most effectively, and behaviors 

incompatible with heavy drinking that should 

be reinforced and targeted for an increase in 

frequency. 

During the initial session, the therapist 

should note the most salient problems identified 

by the client and intervene with them first. The 

therapist also should assess the client’s 

readiness to change and then develop initial 

behavioral goals in collaboration with the client. 

For substance abuse disorders, these goals will, 

of course, involve a reduction in or cessation of 

substance use. In addition to targeting 

substance abuse as the primary focus, other 

goals will be developed to assist the client in 

improving daily functioning (e.g., by reducing 

stress, as described in Figure 4-5). The focus of 

the therapy might be to negotiate with the client 

to accomplish these other goals by reducing use. 

The therapist will continue to engage the client 

in a collaborative process in which they 

determine those problems to target, their 

relative priority, and ways to resolve them. 

Near the end of the initial session the 

therapist reviews with the client the procedure 

for filling out the self-monitoring records. In 

addition, the therapist might provide the client 

with self-help manuals that outline the specific 

steps in the behavioral self-control process. Selfmonitoring of substance abuse behavior is one 

form of written homework common in 

behavioral approaches; other types of homework 

might also be used. Homework assignments can 

include such things as keeping a journal of 

behaviors, activities, and feelings when using 

substances or at risk of doing so. In the brief 

behavioral model designed by Phillips and 

Weiner, techniques such as programmed therapy 

and writing therapy (see Figure 4-6) make what 

is typically thought of as “homework” the 

central concern of the therapy session (Phillips 

and Weiner, 1966). 

Chapter 4 

60

Later sessions 

Based on a review of the information collected 

through self-monitoring, subsequent sessions 

involve negotiation about treatment goals. 

While many problem drinkers, for example, 

choose a moderation goal, across time those with 

more severe problems shift to a goal of 

abstinence (Hodgins et al., 1997). Later sessions 

might also consider the introduction of cue 

exposure training or relapse prevention targeted 

at substance abuse above a particular level. 

These behavioral techniques have been 

incorporated into more comprehensive 

Figure 4-5 

Teaching Stress Management 

The client learns methods that will help her reduce stress, including relaxation techniques, systematic 

desensitization, planning in advance for a potentially stressful event, and cognitive strategies. These 

techniques can help in resisting the temptation to abuse substances in otherwise stressful situations. 

While it does not seem that all clients with substance abuse disorders face increased stress (Cappell, 

1987), for those who do, stress management techniques (such as those described by Stockwell, 1995) can 

prove useful. 
Brief Cognitive–Behavioral Therapy 

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 abstinence goal (Larimer and Marlatt, 

1990; Sitharthan et al., 1997). The decision to 

implement such interventions will be guided by 

the client’s continued self-monitoring, which the 

client and counselor review at each session. 

Brief behavioral therapy might also involve 

the client’s spouse or significant others, who may 

attend several of the therapy sessions. In 

addition to serving as a corroborator of the 

client’s self-reported substance use, a significant 

other may be involved in behavioral contracting 

and community reinforcement interventions. 

The significant other could be taught to 

positively reinforce a client’s reduced drinking 

or abstinence and not to argue with her drinking 

when she is intoxicated, but rather to approach 

her when she is sober and provide positive 

feedback. The client and the significant other 

may develop a contingency contract that will 

encourage reinforcement of her positive 

behaviors. 

Cognitive Theory 

Cognitive theory assumes that most 

psychological problems derive from faulty 

thinking processes (Beck and Wright, 1992; Beck 

et al., 1993; Beck and Liese, 1998; Ellis, 1982; Ellis 

et al., 1988). The diagram in Figure 4-7 illustrates 

the three bidirectional components of this theory: 

(1) cognitions or thoughts, (2) affect or feelings, 

and (3) behavior. While cognitive theory owes a 

debt to the behavioral model, the differences are 

apparent. Unlike behavioral models that focus 

primarily on observable behaviors, cognitive 

theory views antecedent events, cognitions, and 

behavior as interactive and dynamic, as 

indicated by the double-headed arrows 

(depicted in Figure 4-7). Each of these 

components is capable of affecting the others, 

but the primary emphasis is placed on cognition. 

The way we act and feel is most often affected by 

our beliefs, attitudes, perceptions, cognitive 

schema, and attributions. These cognitive factors 

serve as a template through which events are 

filtered and appraised. To the extent that our 

thinking processes are faulty and biased, our 

emotional and behavioral responses to what goes 

on in our life will be problematic. According to 

this theory, changing the way a client thinks can 

change the way he feels and behaves. 

Cognitive theory was developed by A.T. Beck 

as a way of understanding and treating 

depression but has since been applied to 

numerous other mental health issues including 

substance abuse disorders. Beck believed that 

61 
Chapter 4 

Figure 4-7 

The Relationship Among Factors Maintaining Behavior in Behavioral and 

Cognitive Models 

Antecedents are activating situations or life events (something happens or is about to happen— 

situations about which the individual has strong feelings). Cognitions represent the individual’s 

opinions, thoughts, or attitudes that serve to filter and distort the perception of the antecedents. 

Behavior is the individual’s observable actions and emotional reactions that result from his beliefs and 

emotions (how someone thinks or feels and the behavior resulting from those thoughts). 

depressed clients held negative views of 

themselves, the world, and their future, and that 

these negative views were the real causes of 

their depression. He found that their 

psychological difficulties were due to automatic 

thoughts, dysfunctional assumptions, and 

negative self-statements. Automatic thoughts 

often precede emotions but occur quite rapidly 

with little awareness; consequently, individuals 

do not value them highly. For example, 

depressed people address themselves in highly 

critical tones, blaming themselves for everything 

that happens. Figure 4-8 is a list of 15 common 

cognitive errors found in the thinking processes 

of individuals with emotional and behavioral 

problems, including substance abuse disorders. 

An overview of the nature and content of 

distorted thinking more specifically associated 

with substance abuse is provided in Figure 4-9 

(Ellis et al., 1988). These thoughts are 

presumably automatic, overlearned, rigid and 

inflexible, overgeneralized and illogical, 

dichotomous, and not based on fact. They also 

tend to reflect reliance on substances as a means 

of coping with boredom and negative emotions, 

a negative view of the self as a person with a 

substance abuse problem, and a tendency to 

facilitate continued substance use. 

62 
Brief Cognitive–Behavioral Therapy 

Figure 4-8 

Fifteen Common Cognitive Errors 

1. Filtering—taking negative details and magnifying them, while filtering out all positive aspects of a

situation 

2. Polarized thinking—thinking of things as black or white, good or bad, perfect or failures, with no 

middle ground

3. Overgeneralization—jumping to a general conclusion based on a single incident or piece of evidence; 

expecting something bad to happen over and over again if one bad thing occurs 

4. Mind reading—thinking that you know, without any external proof, what people are feeling and why 

they act the way they do; believing yourself able to discern how people are feeling about you 

5. Catastrophizing—expecting disaster; hearing about a problem and then automatically considering the 

possible negative consequences (e.g., “What if tragedy strikes?” “What if it happens to me?”) 

6. Personalization—thinking that everything people do or say is some kind of reaction to you; comparing 

yourself to others, trying to determine who’s smarter or better looking 

7. Control fallacies—feeling externally controlled as helpless or a victim of fate or feeling internally

controlled, responsible for the pain and happiness of everyone around 

8. Fallacy of fairness—feeling resentful because you think you know what is fair, even though other 

people do not agree 

9. Blaming—holding other people responsible for your pain or blaming yourself for every problem 

10. Shoulds—having a list of ironclad rules about how you and other people “should” act; becoming 

angry at people who break the rules and feeling guilty if you violate the rules 

11. Emotional reasoning—believing that what you feel must be true, automatically (e.g., if you feel stupid 

and boring, then you must be stupid and boring) 

12. Fallacy of change—expecting that other people will change to suit you if you pressure them enough; 

having to change people because your hopes for happiness seem to depend on them 

13. Global labeling—generalizing one or two qualities into a negative global judgment 

14. Being right—proving that your opinions and actions are correct on a continual basis; thinking that 

being wrong is unthinkable; going to any lengths to prove that you are correct 

15. Heaven’s reward fallacy—expecting all sacrifice and self-denial to pay off, as if there were someone 

keeping score, and feeling disappointed and even bitter when the reward does not come 

Source: Beck, 1976. 

Such negative thoughts and irrational beliefs 

have been found to be associated with substance 

abuse disorders. Problem avoidance, dwelling 

on negative events, holding a negative outlook 

on the world and on one’s future, and avoidance 

of responsibility have been associated with the 

development of patterns of substance abuse and 

urges to drink among individuals with alcohol 

problems (Butterfield and Leclair, 1988; Denoff, 

1988; Rohsenow et al., 1989). Rohsenow and 

associates found that irrational beliefs— 

particularly feeling doomed about the past— 

were predictive of both the frequency of 

drinking and the average quantity of alcohol 

consumed following substance abuse treatment 

(Rohsenow et al., 1989). 

Cognitive Therapy 

Given the view that dysfunctional behavior, 

including substance abuse, is determined in 

large part by faulty cognitions, the role of 

63 
Chapter 4 

Figure 4-9 

Characteristic Thinking of People With Substance Abuse Disorders 

Qualitative Descriptors 

 Automatic, nonconscious 

 Rigid, inflexible 

 Overlearned and often practiced 

 Dichotomous, all-or-none 

 Overgeneralized and illogical 

 Nonempirical and absolute 

Common Content or Themes 

 Denial: alcohol or drugs are not a problem 

 Alcohol or drugs are the best and only way to solve emotional problems 

 Low frustration tolerance and/or self-defined needs for high levels of stimulation, gratification, and 

excitement 

 Discomfort anxiety: all negative emotions are to be avoided at all costs 

 Change is too difficult, therefore one is hopeless, helpless, worthless 

 Self-blame, guilt, and shame for being an addict 

Source: Adapted from Ellis et al., 1988. 

therapy is to modify the negative or selfdefeating automatic thought processes or 

perceptions that seem to perpetuate the 

symptoms of emotional disorders. Clients can 

be taught to notice these thoughts and to change 

them, but this is difficult at first. Cognitive 

therapy techniques challenge the clients’ 

understanding of themselves and their situation. 

The therapist helps clients become more 

objective about their thinking and distance 

themselves from it when recognizing cognitive 

errors or faulty logic brought about by 

automatic thinking. 

Treatment, therefore, is directed primarily at 

changing distorted or maladaptive thoughts and 

related behavioral dysfunction. Cognitive 

restructuring is the general term given to the 

process of changing the client’s thought 

patterns. Figure 4-10 shows a number of 

distorted addictive thoughts and more rational 

alternatives that the therapist might help 

develop and practice over the course of 

cognitive restructuring. 

Once a specific faulty thought is identified, 

the therapist will challenge a client to look at 

alternative ways of seeing the same event. 

Whenever a client has difficulty changing a 

perception, the therapist can give him 

homework to test the truth of his cognitions. If, 

for example, a client insists that his boss hates 

him, the therapist can ask him to verify this with 

an assignment: “Ask your coworkers if your 

boss treats them the same way he treats you.” 

Figure 4-11 gives an example of how a thought 

leads to a feeling and then to a behavior. 

Once the maladaptive thoughts are 

discovered in a person’s habitual, automatic 

thinking, it becomes possible to modify them by 

substituting rational, realistic ideas for the 

distorted ones to create a happier and healthier 

life without substance abuse. 

The approach developed by Beck and 

colleagues to achieve the goal of a substance-free 

life is referred to as cognitive therapy (Beck et 

al., 1993; Beck and Liese, 1998), while Ellis’ 

approach is known as rational-emotive therapy 

64 
Irrational Belief Rational Alternative or Dispute 

Drinking is never a problem for me, even if I 

do lose control once in a while. ’s other 

people who have a problem with the way I 

drink. 

Losing control can be the first sign of a problem, and if 

my drinking is a significant problem for others, sooner 

or later it will be for me. 

I need to use drugs to relax. I want to use drugs but don’t have to use them just 

because I want to. 

I can’t stand not having what I want; it is just 

too hard to tolerate. 

I may not like it, but I have stood it in the past and can 

do so now. 

The only time I feel comfortable is when I’m 

high. 

It’s hard to learn to be comfortable socially without 

drugs but people do so all the time. 

It would be too hard to stop drinking. I’d lose 

all my friends, be bored, and never be 

comfortable without it. 

While stopping drinking and doing drugs might cost 

me some things and take time and effort, if I don’t, the 

consequences will be far worse. 

People who can’t or don’t drink are doomed to 

frustration and unhappiness. 

Where’s the evidence of that? going to an 

Alcoholics Anonymous meeting and do some research 

on how frustrated and miserable these nondrinkers 

actually are. 

Once you’ve stopped using and you see it’s all 

over, you’re right back to where you started, 

and all your efforts only lead you to total 

failure. Once an addict, always an addict. 

A slip is only a new learning experience toward 

recovery. It is not a failure, only a setback that can tell 

me what direction I need to go in now. It’s my choice. 

Source: Adapted from Rotgers, 1996. 

Figure 4-10 

Common Irrational Beliefs About Alcohol and Drugs 

With More Rational Alternatives 

It

I’ll try 

Brief Cognitive–Behavioral Therapy 

(Ellis et al., 1988). Generally, the therapist takes 

a more active role in cognitive therapy than in 

other types of therapy, depending on the stage 

of treatment, severity of the substance abuse, 

and degree of the client’s cognitive capability. 

While Ellis and Beck have similar views 

about the prominent role that cognitions play in 

the development and maintenance of substance 

abuse disorders, their theories differ in 

considering how the therapist should treat 

irrational or maladaptive cognitions. Rationalemotive therapy is often more challenging and 

confrontative, with the therapist informing the 

client of the irrationality of certain types of 

beliefs that all people are prone to. Beck, on the 

other hand, believes that the cognitive therapist, 

using a supportive Socratic method, should 

enlist the client in carefully examining the 

accuracy of her beliefs. Thus, Beck places more 

importance on the client’s own discovery of 

faulty and unproductive thinking, while Ellis 

believes that the client should simply be told 

that these exist and what they are. Nevertheless, 

there is substantial overlap in both the theory 

and practice of these two therapies. Clearly, 

different clients will have different responses to 

these qualitatively different approaches to 

modifying their thoughts and beliefs. 

65 
Chapter 4 

Figure 4-11 

Thoughts, Feelings, and Behaviors 

Thought Feeling Behavior 

“There’s only one way to feel 

really good” 

Desire to feel good Drink alcohol, snort cocaine 

The maladaptive thought in this triad should be replaced in order to avoid the consequent behavior. 

“I can feel good by jogging or 

taking a walk, or...” 

Desire to feel good Walking, running 

Source: Adapted from Rotgers, 1996. 

Therapeutic work in cognitive therapy is 

devoted primarily, although not exclusively, to 

addressing specific problems or issues in the 

client’s present life, rather than global themes or 

long-standing issues. At times, however, it is 

important to understand the connection 

between the origins of a set of cognitions and 

the client’s current behavior. Such an 

understanding of how the individual got to the 

present emotional and behavioral state is often 

essential to understanding the mechanism of 

change. The client’s attention to current 

problems is intended to promote her 

development of a plan of action that can reverse 

dysfunctional thought processes, emotions, and 

behavior—such as avoidance of problems or 

feelings of helplessness. Clients are enlisted as 

coinvestigators or scientists who study their 

own thought patterns and associated 

consequences. 

Cognitive therapy can be useful in the 

treatment of substance abuse disorders in 

several ways. When distorted or unproductive 

ways of thinking about daily life events lead to 

negative emotional states that then promote 

substance use, cognitive therapy can be used to 

alter the sequence by targeting and modifying 

the client’s thoughts. When clients limit their 

options for coping with stress by rigid or all-ornothing thinking (e.g., “nothing will help me 

deal with this problem but a drink”), cognitive 

therapy can help them explore alternative 

behaviors and attitudes that do not involve the 

use of substances. In addition, cognitive therapy 

can help the client develop healthier ways of 

viewing both his history of substance abuse and 

the meaning of a recent “slip” or relapse so that 

it does not inevitably lead to more substance 

abuse. 

Initial Session 

Cognitive therapy works under the assumption 

that a client can be educated to approach his 

problems rationally. Because of this emphasis 

on rational understanding, the cognitive 

therapist will typically begin therapy by 

explaining the nature of her approach (see 

Figure 4-12 for a sample opening script). 

In the opening session of cognitive therapy, 

the therapist will assess the client’s view of his 

problems and their causes. The therapist pays 

careful attention to the meaning the client 

assigns to significant events and how that 

meaning is related to subsequent feelings and 

unwanted behavior. In the middle to late 

phases of the first session, the therapist will 

emphasize the collaborative aspect of the 

therapy process and introduces the cognitive 

model to the client. There are three major steps 

in this process: 

1. The therapist establishes rapport by 

listening carefully to the client, using 

questions and reflective listening to try to 

understand how the client thinks about his 

66 
Brief Cognitive–Behavioral Therapy 

Figure 4-12 

Introducing Cognitive Therapy: A Sample Script 

“I want to spend a few minutes telling you about my approach. Basically, it comes from the 

observation by many people that our feelings and behaviors in particular situations follow directly from 

how we think about these situations. My goal in working with you is to focus on trying to understand 

how you see things—the important things in your life that are related to substance use—and to help you 

look at them objectively and honestly. We may find that you are seeing them correctly, and we’ll have 

to address these realities. Sometimes, though, people get into automatic ways of thinking about 

themselves and their situation without examining them more carefully. Let’s look at these possibilities 

and see if they can be changed to help you. How does that sound to you?” 

life circumstances and how those thoughts 

relate to problematic feelings and behavior. 

The client educates the therapist about 

himself and his problems. 

2. The therapist educates the client about the 

cognitive model of therapy and determines 

if he is satisfied with the model.

3. The therapist asks the client to describe a 

recent event that has triggered some recent 

negative feelings, as a way of illustrating the 

cognitive therapy process. 

Later Sessions 

Cognitive therapy tends to follow a standard 

within-session structure to make the maximum 

use of time, to focus on the most important 

current problems, to set the tone for a working 

atmosphere, and to maintain continuity between 

sessions. Beck structures sessions into eight 

elements, listed below, which he describes in 

greater detail (Beck et al., 1993): 

1. Setting the agenda—to focus on primary goals 

for treatment 

2. Mood check—to monitor the feelings of the 

client, especially changes 

3. Bridge from last session—to maintain 

continuity between sessions 

4. Discussion of today’s agenda—to prioritize 

topics, avoid irrelevant tangents, determine 

the best possible use of time, and solicit the 

client’s topics for discussion 

5. Socratic questioning—to encourage the client 

to contemplate, evaluate, and synthesize 

diverse sources of information; also known 

as “guided discovery” 

6. Capsule summaries—to maintain focus and a 

connection to the goals of the therapy 

7. Homework assignments—to serve as a bridge 

between sessions and to ensure that the 

client continues to work on problems by 

collecting information, testing beliefs, and 

trying new behaviors 

8. Feedback in the therapy sessions—to ensure 

that the client and therapist are 

communicating 

Duration of Therapy and 

Frequency of Sessions 

Cognitive therapy adheres to the basic goals of 

planned brief therapy, but treatment times can 

vary. It typically lasts from 12 to 20 weeks, with 

the client and therapist meeting once per week. 

(Freeman et al., 1990). However, it can be 

conducted in less time—for instance, once per 

week for six to eight sessions. The number of 

sessions will depend on the nature of the 

problem. 

Because cognitive therapy is usually planned 

for comparatively short treatment times, there 

has not been much research to study the relative 

effectiveness of longer term cognitive therapy. 

However, Lyons and Woods in their metaanalysis of 70 different rational-emotive therapy 

67 
Chapter 4 

studies found that increased effects correlated 

with longer treatment times (Lyons and Wood, 

1991). More research needs to be conducted 

looking at the effect of treatment duration on the 

efficacy of these therapies. 

In a brief version of this therapy, there is less 

time to understand and restructure all of the 

cognitions that may be influencing substance 

abuse. The therapist must use the early sessions 

to determine the most productive focus of the 

therapy, given the short timeframe. If the client 

used substances primarily to cope with negative 

mood states, then therapy may focus on 

understanding how the client’s interpretation of 

events led to the negative moods. Restructuring 

these thought processes may help decrease 

reasons for substance abuse. Alternatively, if 

the client drinks largely to party and have a 

good time with friends, a focus on expected 

effects may lead to the client’s gaining greater 

awareness of negative consequences and, 

perhaps, a reduced association of the substance 

with positive experiences. If the client is 

returning to therapy after a period of sobriety 

that ended in relapse, a focus on the 

circumstances leading to relapse and other 

resulting consequences may shape the therapy. 

A number of specific cognitive therapy 

techniques may be appropriate for use, 

depending on the phase of treatment and the 

issues raised by the client. Cognitive 

interventions can be introduced at any point 

throughout the treatment process, whenever the 

therapist feels it is important to examine a 

client’s inaccurate or unproductive thinking that 

may lead to the risk of substance abuse. They 

also can be used episodically with clients who 

leave and then return to treatment or during 

aftercare or continuing care following a more 

intensive treatment episode. 

Periods without therapy sessions allow 

clients time to practice the new skills of 

identifying and challenging unproductive 

thinking on their own. However, it is easy to 

fall back into old, automatic ways of thinking 

that may require a return to therapy. The 

therapist can productively build on what was 

learned in previous sessions, help the client see 

how she slipped into old patterns, and further 

reinforce the process of catching oneself in the 

process of thinking negative automatic 

thoughts. The therapist must be prepared to 

move from topic to topic while always adhering 

to the major theme—that how the client thinks 

determines how the client feels and acts, 

including whether the client abuses substances. 

Cognitive therapy can be quite successful as 

an option for brief therapy for several other 

reasons (Carroll, 1996a): 

 It is designed to be a short-term approach 

suited to the resource capabilities of many 

delivery systems. 

 It focuses on immediate problems and is 

structured and goal oriented. 

 It is a flexible, individualized approach that 

can be adapted to a wide range of clients, 

settings (both inpatient and outpatient), and 

formats, including groups. 

Cognitive–Behavioral 

Theory 

Early behavioral theories of substance abuse 

were nonmediational in nature (Donovan and 

Marlatt, 1993). They focused almost exclusively 

on overt, observable behaviors, and it was 

believed that understanding the antecedents and 

reinforcement contingencies was sufficient to 

explain behavior and to modify it. Over time, 

however, these behavioral theories began to 

incorporate cognitive factors into their 

conceptualizations of substance abuse disorders. 

These more recent models are mediational in 

nature; that is, a greater role is attributed to the 

interaction among a variety of individual 

difference variables such as beliefs, values, 

perceptions, expectations, and attributional 

processes in mediating the development and 

68 
Brief Cognitive–Behavioral Therapy 

continuation of substance abuse disorders 

(Abrams and Niaura, 1987; Mackay and 

Donovan, 1991; Marlatt et al., 1988; Marlatt and 

Donovan, 1981). This expanded, mediational 

model has been described as cognitive social 

learning or cognitive–behavioral theory. This 

theory postulates that cognitive factors mediate 

all interactions between the individual, 

situational demands, and the person’s attempts 

to cope effectively. 

Cognitive–behavioral theory represents the 

integration of principles derived from both 

behavioral and cognitive theories, and it 

provides the basis for a more inclusive and 

comprehensive approach to treating substance 

abuse disorders. However, a broader range of 

cognitions is included in cognitive–behavioral 

theory than had been involved in earlier 

versions of cognitive theory. These include 

attributions, appraisals, self-efficacy 

expectancies, and substance-related effect 

expectancies. Each of these will be reviewed 

briefly below. Common elements of brief 

cognitive–behavioral therapy are listed in 

Figure 4-13. 

Attributions 

An attribution is an individual’s explanation of 

why an event occurred. Abramson and 

colleagues proposed that individuals develop 

attributional styles (i.e., individual ways of 

explaining events in their lives that can play a 

role in the development of emotional problems 

and dysfunctional behaviors) (Abramson et al., 

1978). The basic attributional dimensions are 

internal/external, stable/unstable, and 

global/specific. For instance, clinically 

depressed persons tend to blame themselves for 

adverse life events (internal), believe that the 

causes of negative situations will last 

indefinitely (stable), and overgeneralize the 

causes of discrete occurrences (global). 

Healthier individuals, on the other hand, view 

negative events as due to external forces (fate, 

luck, environment), as having isolated meaning 

(limited only to specific events), and as being 

transient or changeable (lasting only a short 

time). Figure 4-14 lists and further defines the 

three dimensions of attribution that make up an 

“attributional style.” 

Attributional styles play a major role in the 

cognitive–behavioral theory of substance abuse 

disorders (Davies, 1992; Marlatt and Gordon, 

1985). The nature of substance abusers’ 

attributional styles is thought to have 

considerable bearing on their perception of their 

substance abuse problem and their approach to 

recovery. An alcohol-dependent client, for 

instance, may believe that he drank because he 

was weak (an internal attribution) or because he 

was surrounded by people encouraging him to 

have a beer (an external attribution). He may 

believe that his failure to maintain abstinence 

shows that he is a weak person who can never 

succeed at anything (a global attribution) or that 

a drinking episode does not represent a general 

weakness, but was instead due to the specific 

circumstances of the moment (a specific 

Figure 4-13 

Common Elements of Brief Cognitive–Behavioral Therapies 

 The therapist focuses on current problems. 

 She establishes attainable and contracted goals. 

 She seeks to obtain quick results for the most pressing problems. 

 She relies on a variety of empirically based techniques to increase the client’s ability to handle his own 

problems. 

Source: Adapted from Bloom, 1997; Peake et al., 1988. 

69 
Chapter 4 

Figure 4-14 

Attributional Styles 

Internal/External: Do you attribute events and their causes to yourself or to others? 

Stable/Unstable: Will this cause continue to affect your future or can it change or stop? 

Global/Specific: Does the cause of one bad circumstance affect all areas of your life or just one? 

attribution). He may believe that the cause of 

his slip is something he cannot change (a stable 

attribution) or that the next time, he will catch 

himself and exert better coping responses (an 

unstable attribution). Whereas the internal, 

global, and stable attribution for the use of 

alcohol is likely to lead to feelings of 

hopelessness and a return to drinking, the 

external, specific, unstable attribution is likely to 

lead to greater efforts to cope with similar 

situations in the future. 

Marlatt and Gordon described a negative 

attributional process that can occur after a slip 

(the first use of a substance after a period of 

abstinence) and that may lead to continued use 

in a full-blown relapse (Marlatt and Gordon, 

1985). This process, known as the abstinence 

violation effect (AVE), involves the attribution of 

the cause of an initial slip to internal, stable, and 

global factors. These clients may believe that 

they are hopeless addicts and failures, that they 

will never be able to achieve and maintain 

sobriety, and that there is no use in trying to 

change because they think that they cannot 

succeed. 

AVE also has an emotional component 

associated with it. Substance abusers who have 

slipped and have internal, stable, and 

generalized attributions will feel depressed, 

worthless, helpless, and hopeless. This 

attributional style tends to be associated with a 

form of “learned helplessness” that is 

perpetuated by the substance users’ distorted 

perceptions. Together, the sense of helplessness 

and the negative emotional state increase the 

likelihood that the initial lapse will develop into 

a full-blown relapse. Research with individuals 

dependent on alcohol, marijuana, opiates, and 

other illicit drugs, provides empirical support 

for the attributional style hypothesized to 

mediate the AVE (Birke et al., 1990; Bradley et 

al., 1992; Reich and Gutierres, 1987; Stephens et 

al., 1994; Walton et al., 1994). 

Cognitive Appraisal 

For the cognitive–behavioral therapist, an 

individual’s appraisal of stressful situations and 

his ability to cope with the demands of these 

situations are important influences on the 

initiation and maintenance of substance abuse, 

as well as relapse after cessation of use 

(Hawkins, 1992; Marlatt and Gordon, 1985; 

Shiffman, 1987, 1989; Wills and Hirky, 1996). 

Folkman and Lazarus described two 

different levels of cognitive appraisal (Folkman 

and Lazarus, 1988, 1991). The first level is a 

primary appraisal. This represents the 

individual’s perception of a situation and an 

estimation of the potential level of stress, 

personal challenge, or threat involved with the 

situation. Secondary appraisal represents the 

individual’s evaluation of her ability to meet the 

challenges and demands specific to the 

situation. This secondary appraisal, which will 

be influenced by the extent, nature, and 

availability of the individual’s coping skills, 

further mediates the individual’s perception of 

stress and the person’s emotional response. 

To the extent that the individual senses that 

she has the necessary behavioral, cognitive, or 

emotional coping skills to meet the challenges of 

the situation, it will be appraised as less 

threatening or stressful. Conversely, if the 

person judges that the necessary coping skills 

70 
are lacking, the situation is viewed as more 

threatening and stressful, and the person is 

likely to be frightened, anxious, depressed, or 

helpless. The results of Smith and colleagues 

suggest that such cognitive appraisals may play 

a more prominent role than attributions in 

mediating emotional responses to potentially 

threatening situations (Smith et al., 1993). 

Coping behaviors 

In substance use-related situations, coping 

“refers to what an individual does or thinks in a 

relapse crisis situation so as to handle the risk 

for renewed substance use” (Moser and Annis, 

1996, p. 1101). Cognitive–behavioral theory 

posits that substance users are deficient in their 

ability to cope with interpersonal, social, 

emotional, and personal problems. In the 

absence of these skills, such problems are 

viewed as threatening, stressful, and potentially 

unsolvable. Based on the individual’s 

observation of both family members’ and peers’ 

responses to similar situations and from their 

own initial experimental use of alcohol or drugs, 

the individual uses substances as a means of 

trying to deal with these problems and the 

emotional reactions they create. From this 

perspective, substance abuse is viewed as a 

learned behavior having functional utility for 

the individual—the individual uses substances 

in response to problematic situations as an 

attempt to cope in the absence of more 

appropriate behavioral, cognitive, and 

emotional coping skills. 

A number of dimensions are involved in the 

coping process as it relates to substance abuse 

(Donovan, 1996; Hawkins, 1992; Lazarus, 1993; 

Shiffman, 1987; Wills and Hirky, 1996). The first 

is the general domain in which the coping 

response occurs. Coping responses can occur 

within the affective, behavioral, and cognitive 

domains. Litman identified a number of 

behavioral and cognitive strategies that are 

protective against relapse (Litman, 1986). There 

are two behavioral classes of coping behavior: 

Brief Cognitive–Behavioral Therapy 

(1) basic avoidance of situations that have been 

previously associated with substance abuse and 

(2) seeking social support when confronted with 

the temptation to drink or use drugs. 

The cognitive domain also includes two 

general categories of coping: (1) negative 

thinking, or thinking about all the negative 

consequences that have resulted from substance 

abuse and a desire to no longer experience these, 

and (2) positive thinking, or thinking about all 

the benefits that are accrued by being clean and 

sober and not wanting to lose these. Litman 

suggests that these coping strategies operate in a 

somewhat sequential manner (Litman, 1986). 

Initially, when clients are attempting to initiate 

and stabilize abstinence from substances, they 

appear to rely more heavily on the behavioral 

strategies. As the period of abstinence increases, 

there appears to be a transition from 

predominantly behavioral strategies toward a 

greater reliance on cognitive methods of coping. 

Coping strategies have a number of other 

dimensions. They can be emotion focused, 

problem focused, or avoidant. A distinction is 

also made between those that are general coping 

strategies and those that are expressly 

attempting to cope with urges, craving, and 

temptation to use in settings associated with 

past substance abuse. Another important 

dimension of coping strategies is the stage at 

which they are used in response to a potentially 

difficult substance-related situation (Shiffman, 

1989). Anticipatory coping is employed as one 

anticipates and attempts to plan how to deal 

with upcoming situations. They take the form 

of “What can I do if....” There are also coping 

strategies that are employed in the moment that 

one is having to deal with the difficult 

substance-related situations. They take the form 

of “What can I do now....” Finally, there are 

restorative coping strategies that can be 

employed if one fails to cope and finds himself 

using in the situation. These take the form of 

“What can I do now that I’ve...” It is these 

71 
Chapter 4 

restorative coping strategies that play a role in 

determining whether an initial drink or use of 

drugs will escalate into a full-blown relapse. 

Research on coping behavior as it relates to 

substance abuse disorders has generally 

supported the basic tenet of cognitive– 

behavioral approaches, namely that these clients 

are deficient in their coping skills, that these 

deficiencies contribute to their continued 

substance abuse, and that those whose deficits 

are not remedied are at a greater risk of relapse 

than those who increase their coping through 

treatment (Wills and Hirky, 1996). Another 

study found that the number of coping attempts 

and the type of coping will influence both 

relapse and the return to abstinence (Moser and 

Annis, 1996). Attempting to cope with a relapse 

crisis led to higher rates of abstinence than not 

trying to cope, and the greater the number of 

coping strategies employed, the less likely the 

person was to use. If one coping response was 

performed, the probability of abstinence was 40 

percent; the probability rose to 80 percent if two 

coping attempts were made. Similarly, the 

greater the number of coping strategies used by 

an individual following a relapse, the greater the 

likelihood of returning to abstinence. Exclusive 

use of active coping strategies (e.g., engaging in 

alternative activities that are incompatible with 

drinking, problemsolving, seeking support from 

others, thinking of consequences of using, using 

positive/negative self-talk) was associated with 

maintaining abstinence in contrast to exclusive 

reliance on avoidant strategies (e.g., ignoring the 

situation, dealing with it indirectly by eating, or 

relying on willpower). 

Neidigh and colleagues investigated the 

strategies employed to cope with stress and the 

temptation to drink among individuals 

attempting to control their drinking (Neidigh et 

al., 1988). They found that both cognitive and 

behavioral coping strategies were effective in 

resisting a drink. Two other important findings 

were obtained. First, there appears to be a 

considerable degree of situational specificity in 

the coping process. That is, different types of 

substance-related situations seem to require 

different types of coping responses rather than a 

general coping strategy’s being equally effective 

across situations. Second, strategies used to 

cope with nonspecific stress appear to be 

somewhat different from those used to cope 

with temptation. These findings suggest that 

treatment not only should rectify deficiencies in 

coping abilities, but that it may be necessary to 

focus on skills to deal with both general stress 

and substance-related temptation. Furthermore, 

it may be necessary to develop coping skills 

specific to several possible situations in which 

the client may use substances. 

Self-Efficacy Expectancies 

The apparent lack of coping skills among 

substance users is an important contributor to 

another key construct in cognitive–behavioral 

approaches, namely self-efficacy expectancies 

(Bandura, 1977). These expectancies refer to an 

individual’s beliefs about his ability to 

successfully execute an appropriate response in 

order to cope with a given situation. Selfefficacy expectancies are determined in part by 

the individual’s repertoire of coping skills and 

an appraisal of their relative effectiveness in 

relation to the specific demands of the situation. 

Bandura has hypothesized that expectations of 

personal efficacy determine whether coping 

behavior will be initiated or not, the amount of 

effort that will be expended in attempting to 

cope, and how long a coping attempt will 

continue in the face of obstacles and aversive 

experiences (Bandura, 1977). He also suggested 

that self-efficacy exerts an influence on the 

individual’s behavior through cognitive, 

motivational, and emotional systems (Bandura, 

1994). If a person has low self-efficacy due to a 

lack of necessary coping skills, she might be 

expected to have negative or distorted thoughts 

and beliefs about herself and her situation, have 

72 
Brief Cognitive–Behavioral Therapy 

reduced motivation to even try to cope, and may 

be depressed and perceive herself as helpless. 

Cognitive–behavioral approaches to 

substance abuse disorders postulate that low 

levels of self-efficacy are related to substance use 

and an increased likelihood of relapse after 

having achieved abstinence (Annis and Davis, 

1988b, 1989b; DiClemente and Fairhurst, 1995; 

Marlatt and Gordon, 1985). A model of relapse 

that is based on the role of self-efficacy and 

coping is depicted in Figure 4-15. 

Self-efficacy has been thought of as both the 

degree of a client’s temptation to use in 

substance-related settings and his degree of 

confidence in his ability to refrain from using in 

those settings (Annis and Davis, 1988b; 

DiClemente et al., 1994; Sklar et al., 1997). The 

role of self-efficacy has been examined for 

alcohol (Evans and Dunn, 1995; Solomon and 

Annis, 1990), cocaine (Coon et al., 1998; RoundsBryant et al., 1997), marijuana (Stephens et al., 

1993), opiates (Reilly et al., 1995), and across all 

of these substances of abuse (Sklar et al., 1997). 

This research generally supports the hypothesis 

that those with lower levels of self-efficacy are 

more likely to abuse substances. 

Substance-Related Effect 

Expectancies 

As substance use is reinforced by the positive 

effects of the substance being taken, it is also 

likely that the individual will develop a set of 

cognitive expectancies about these anticipated 

effects on her feelings and behavior. They 

Figure 4-15 

Relapse Prevention Model Based on Self-Efficacy Theory 

High-Risk 

Drinking 

Situation 

Cognitive 

Appraisal 

Process 

Efficacy 

Expectation Drinking/Non-drinking 

represent the individual’s expectation that 

certain effects will predictably result from 

substance use. Although there has been more 

research on alcohol-related effect expectancies 

(Goldman, 1994), there has been an increased 

interest in drug-related expectancies (Brown, 

1993). Given that drugs have differing effects, it 

has been necessary to develop measures specific 

to the effects anticipated from these different 

drugs, such as marijuana (Schafer and Brown, 

1991) and cocaine (Jaffe and Kilbey, 1994; 

Schafer and Brown, 1991). 

The initial focus in studying alcohol-related 

expectancies was on the positive effects that 

individuals anticipated from alcohol (Goldman 

and Brown, 1987). Drinkers anticipated that 

alcohol would serve as a global elixir, having 

positive effects on mood, social and 

interpersonal behavior, sexual behavior, 

assertiveness, and tension reduction. Positive 

effect expectancies for marijuana include 

relaxation and tension reduction, social and 

sexual facilitation, and perceptual and cognitive 

enhancement (Schafer and Brown, 1991). 

Positive cocaine-related expectancies include 

global positive effects, generalized arousal, 

euphoria, enhanced abilities, and relaxation and 

tension reduction (Jaffe and Kilbey, 1994; 

Schafer and Brown, 1991). 

More recently, there has been an increased 

interest in the expectations of negative outcomes 

that individuals hold about substances. 

Negative expectancies about alcohol include 

cognitive and behavioral impairment, risk and 

Source: Annis and Davis, 1991, p. 205. 

73 
Chapter 4 

aggression, and negative self-perception 

(Fromme et al., 1993). Negative consequences 

expected from cocaine include global negative 

effects, anxiety, depression, and paranoia (Jaffe 

and Kilbey, 1994; Schafer and Brown, 1991). It is 

thought that the anticipated positive effects of 

substances serve as an incentive or motivation to 

use. Conversely, negative expectancies are 

thought to act as a disincentive and contribute to 

reduced drinking or drug use (McMahon and 

Jones, 1993; Michalec et al., 1996). 

Research supports these hypothesized 

actions of positive and negative expectancies 

(Jaffe and Kilbey, 1994; Jones and McMahon, 

1994b; Rounds-Bryant et al., 1997). Positive 

alcohol- and cocaine-related expectancies are 

associated with a greater likelihood of relapse 

and poorer substance-related outcomes (Brown 

et al., 1998; Rounds-Bryant et al., 1997), whereas 

negative alcohol effect expectancies are related 

to decreased likelihood of relapse and less 

alcohol consumption (Jones and McMahon, 

1994a; McMahon and Jones, 1996). 

Research also indicates that alcohol-related 

effect expectancies were negatively correlated 

with clients’ ratings of self-efficacy at the 

beginning of treatment (Brown et al., 1998); that 

is, the lower the perceived self-efficacy, the 

greater the level of anticipated positive effects of 

alcohol. Both these sets of expectancies changed 

over the 4-week course of treatment, with selfefficacy increasing and alcohol effect 

expectancies decreasing. Lower self-efficacy 

judgments, positive alcohol expectancies, and 

reliance on avoidant, emotion-focused coping 

strategies were significantly associated with 

increased alcohol consumption and alcoholrelated problems among heavy drinking college 

students (Evans and Dunn, 1995). 

High-Risk Situations 

Over time, with repeated exposure, aspects of a 

situational context (e.g., the people, places, 

feelings, activities) can come to serve as 

conditioned cues that can elicit a strong craving 

or desire to use. To the extent that substance 

abuse allows the individual to avoid or escape 

such problem situations or their resultant 

emotional reactions, the use of substances will 

be reinforced through operant learning. Thus 

the likelihood is increased that substances will 

be abused and will come to be relied on in the 

future when the individual encounters similar 

situations. 

Marlatt and colleagues have characterized a 

number of situations in which substances are 

abused (Chaney et al., 1982; Cummings and 

Gordon, 1980; Marlatt and Gordon, 1980, 1985). 

While the original taxonomy of these situations 

focused on settings in which relapse occurred 

following a period of abstinence from a 

substance, the settings appear to represent 

situations in which substance use in general will 

be more likely to occur (Annis and Davis, 1988a; 

Marlatt, 1996). The situations as originally 

categorized are found in Figure 4-16. 

These situations have been classified into 

categories. At the broadest level, they are 

considered either interpersonal (i.e., involving a 

present or recent interaction with someone else) 

or intrapersonal–environmental (i.e., factors that 

are either internal to the individual or reactions 

to nonpersonal environmental events). There 

are a number of more specific situations within 

each of these broader categories. These 

situations include many emotional, 

interpersonal, and environmental settings in 

which people commonly abuse substances and 

where they are likely to relapse. Therefore, 

these are called “high-risk” situations. These 

situations also serve as the foundation from 

which a number of measures of substancerelated self-efficacy have been developed (Annis 

and Davis, 1988b; DiClemente et al., 1994; Sklar 

et al., 1997). 

While there appears to be considerable 

overlap in high-risk situations across substances 

(Cummings and Gordon, 1980), there are also a 

74 
Brief Cognitive–Behavioral Therapy 

Figure 4-16 

Taxonomy of High-Risk Situations Based on 

Marlatt’s Original Categorization System 

Intrapersonal–Environmental Determinants 

 Coping with negative emotional states 

i Coping with frustration and anger 

i Coping with other negative emotional states (e.g., fear, anxiety, tension, depression, loneliness, 

sadness, boredom, grief, loss, guilt) 

 Coping with negative physical/physiological states 

i Coping with physical states associated with prior substance use (e.g., withdrawal distress) 

i Coping with other negative physical states (e.g., pain, illness, injury, fatigue) 

 Enhancement of positive emotional states (e.g., using substances to enhance pleasure, for celebration) 

 Testing personal control (e.g., using to test “willpower” to see if treatment worked, to see if one can 

drink or use in a moderate way) 

 Giving in to temptations or urges 

i In the presence of substance-related cues 

i In the absence of substance-related cues 

Interpersonal Determinants 

 Coping with interpersonal conflict 

i Coping with frustration and anger 

i Coping with other interpersonal conflict 

 Social pressure to drink or use 

i Direct social pressure 

i Indirect social pressure 

 Enhancement of positive emotional states 

Source: Marlatt, 1996. 

number of substance-specific patterns. 

Emotional and situational risk factors have been 

examined among a clinical sample of 

individuals who were primary abusers of 

alcohol, cocaine, marijuana, sedatives and 

tranquilizers, or heroin/opiates. They found 

that positive social experiences and negative 

emotional states were important risk factors for 

patients who were dependent on alcohol or 

cocaine. Positive emotional and situational 

factors were most important for those using 

marijuana. Individuals dependent on sedatives 

and tranquilizers or heroin/opiates reported 

that negative physical states and interpersonal 

conflict were the most important risk factors. 

Again, it is the individual’s appraisal of such 

situations, in terms of its threat to maintaining 

abstinence relative to their available coping 

abilities, that determines the situational risk for 

the individual (Myers et al., 1996). 

The Cognitive–Behavioral 

Approach to Substance Abuse 

Disorders 

The cognitive–behavioral approach attempts to 

integrate all of these theoretical details into a 

meaningful model of substance abuse disorders 

(Mackay et al., 1991; Marlatt et al., 1988). Figure 

4-17 presents a flowchart that depicts this model 

of substance abuse and dependence. 

The cognitive–behavioral model assumes 

that substance abusers are deficient in coping 

75 
Confronts a high-risk situation 

Chooses and makes use 

of appropriate coping 

response 

Response does not use adequate coping 

Experiences decrease in self-efficacy, 

with a resulting sense of helplessness 

or passivity and decreased self-control 

Has expectation that a drink would 

help the situation (positive outcome 

expectancies) 

These perceptions and expectancies 

lead to initial use of alcohol 

Results in “abstinence violation effect” 

Feels guilt and loss of control 

Experiences a sense of 

mastery and an ability to 

cope with the situation 

These perceptions 

decrease the likelihood of 

relapse 

These feelings increase the probability 

of relapse 

Client 

Source: Adapted from Kadden, 1995. 

Chapter 4 

Figure 4-17 

A Cognitive–Behavioral Model of the Relapse Process 

76 
Brief Cognitive–Behavioral Therapy 

skills, choose not to use those they have, or are 

inhibited from doing so (Monti et al., 1994, 

1995). It also assumes that over the course of 

time, substance abusers develop a particular set 

of effect expectancies based on their 

observations of peers and significant others 

abusing substances to try to cope with difficult 

situations and through their own experiences of 

the positive effects of substances. They have 

come to believe that substances have positive 

benefits that are more immediate and prominent 

than their negative consequences. They also 

come to rely on substances as a means of trying 

to cope with these situations. 

To the extent that the individual is lacking in 

the coping skills necessary to deal with the 

demands of high-risk substance abuse or relapse 

situations, his sense of self-efficacy decreases. 

As personal efficacy decreases, the anticipated 

positive effects of substance abuse increase and 

become more salient (Brown et al., 1998). Under 

such conditions, the individual is likely to use 

(Moser and Annis, 1996). When confronted by 

similar situations in the future, the likelihood of 

using continues to be quite high, unless new 

coping skills have been learned. Given the 

interaction of self-efficacy, substance-related 

effects expectancies, and high-risk situations, 

“the decision to drink or exercise restraint (selfcontrol) is ultimately determined by self-efficacy 

and outcome expectations formulated around a 

current situational context” (Abrams and 

Niaura, 1987, p. 152). 

Attributional processes and emotional 

responses also play a role in an individual’s 

decision to use (Marlatt and Gordon, 1985). 

Should the client attribute her substance abuse 

to internal, stable, and global characteristics 

(e.g., “I’m nothing but an addict; there’s nothing 

that I can do to stop using”), then it is likely that 

she will feel angry, depressed, hopeless, and 

helpless. These reactions are less likely to occur 

and to be less pronounced for individuals who 

are more firmly committed to the goal of 

abstinence or moderation and for those who 

have maintained such goals longer. These 

negative emotions represent yet another highrisk situation. If the individual does not have 

the necessary restorative coping skills to deal 

with them and to counteract the impact of a 

negative attributional style, it is more likely that 

an initial slip will continue on as a full-blown 

relapse (Stephens et al., 1994). 

Cognitive–Behavioral 

Therapy 

Cognitive–behavioral therapy (CBT) derives, in 

part, from both behavioral and cognitive 

theories. While sharing a number of procedures 

in common, CBT is also distinct in many ways 

from these other therapies (Carroll, 1998). In 

comparison to cognitive therapy, CBT places 

less emphasis on identifying, understanding, 

and changing underlying beliefs about the self 

and the self in relationship to substance abuse. 

It focuses instead on learning and practicing a 

variety of coping skills, only some of which are 

cognitive. A greater emphasis is also placed on 

using behavioral coping strategies, especially 

early in therapy. CBT tries to change what the 

client both does and thinks. 

In comparison to behavioral treatments such 

as the community reinforcement approach, CBT 

focuses more on cognitions, beliefs, and 

expectancies. Also, CBT generally does not 

incorporate contingency management 

approaches such as the use of vouchers to 

reinforce desired behaviors. CBT is usually 

confined to the treatment session (although 

therapists often give homework to clients to be 

completed outside the therapy session), whereas 

the community reinforcement approach stresses 

the importance of incorporating interventions 

into real world settings and taking advantage of 

community resources. Figure 4-18 lists a 

number of features thought to be unique to 

cognitive–behavioral interventions. 

77 
Chapter 4 

Figure 4-18 

Essential and Unique Elements of Cognitive–Behavioral Interventions 

The key ingredients that distinguish CBT from other some other therapies and that must be included in a 

CBT treatment include the following: 

 A functional analysis of substance abuse 

 Individualized training in recognizing and coping with craving, managing thoughts about substance 

abuse, problemsolving, planning for emergencies, recognizing seemingly irrelevant decisions, and 

using refusal skills 

 An examination of the client’s cognitive processes related to substance abuse 

 The identification and debriefing of past and future high-risk situations 

 The encouragement and review of extra-session implementation of skills 

 Practice of skills within sessions 

Source: Carroll, 1998. 

CBT uses learning processes to help 

individuals reduce their drug use. It works by 

helping clients recognize the situations in which 

they are likely to use, find ways of avoiding 

those situations, and cope more effectively with 

situations, feelings, and behaviors related to 

their substance abuse (Carroll, 1998). To achieve 

these therapeutic goals, cognitive–behavioral 

therapies incorporate three core elements: (1) 

functional analysis, (2) coping skills training, 

and (3) relapse prevention (Rotgers, 1996). 

Functional Analysis 

Behavioral, cognitive, and cognitive–behavioral 

treatments all rely heavily on an awareness of 

the antecedents and consequences of substance 

abuse. In all of these therapeutic approaches, 

the client and therapist typically begin therapy 

by conducting a thorough functional analysis of 

substance abuse behavior (Carroll, 1998; Monti 

et al., 1994; Rotgers, 1996). This analysis 

attempts to identify the antecedents and 

consequences of substance abuse behavior, 

which serve as triggering and maintaining 

factors. Antecedents of use can come from 

emotional, social, cognitive, situational/ 

environmental, and physiological domains 

(Miller and Mastria, 1977). The functional 

analysis should also focus on the number, range, 

and effectiveness of the individual’s coping 

skills. While a major emphasis in cognitive– 

behavioral therapy is on identifying and 

remediating deficits in coping skills, it is also 

important to assess the client’s strengths and 

adaptive skills (DeNelsky and Boat, 1986). 

The functional analysis will also assess 

features in the client’s emotional states and 

thoughts and in her environment that are highly 

associated with substance abuse. This allows 

the identification of situations that are 

particularly high risk for the individual. In 

addition, it is important to determine what the 

person thought, felt, and did both during and 

after high-risk situations. Gaining information 

about high-risk situations in which the person 

drank or used drugs and those in which a 

relapse crisis was encountered but averted is 

helpful in assessing coping abilities, self-efficacy 

perceptions, substance-related effect 

expectancies, and attributional processes. 

Without such a thorough assessment, CBT 

treatment cannot proceed and is likely to fail 

(Rotgers, 1996). This detailed analysis serves to 

inform the treatment process and individualize 

the specific interventions and treatment plan for 

the client. The therapist and client can then use 

the results of the functional analysis to 

78 
Brief Cognitive–Behavioral Therapy 

anticipate high-risk situations and develop 

specific methods to avoid or cope with them. 

Questionnaires, interviews, and role-playing 

measures are available to assist the therapist in 

the assessment and functional analysis. The 

therapist should try to evaluate the number and 

type of high-risk situations, the temptation to 

use in these situations, confidence that one will 

not use in high-risk situations, substance abuserelated self-efficacy, frequency and effectiveness 

of coping, and substance-specific effect 

expectancies. More detailed information on the 

assessment process in cognitive–behavioral 

approaches to substance abuse and its treatment 

is available in a number of sources (Donovan, 

1998; Donovan and Marlatt, 1988; Monti et al., 

1994; Sobell et al., 1988; and Sobell et al., 1994). 

For a review of assessment tools that can be 

used in developing a functional analysis see TIP 

35, Enhancing Motivation for Change in Substance 

Abuse Treatment (CSAT, 1999c). 

Coping Skills Training 

A major component in cognitive–behavioral 

therapy is the development of appropriate 

coping skills. Deficits in coping skills among 

substance abusers may be the result of a number 

of possible factors (Carroll, 1998). They may 

have never developed these skills, possibly 

because the early onset of substance abuse 

impaired the development of age-sensitive 

skills. Previously developed coping skills may 

have been compromised by an increased 

reliance on substances use as a primary means 

of coping. Some clients continue to use skills 

that are appropriate at an earlier age but are no 

longer appropriate or effective. Others have 

appropriate coping skills available to them but 

are inhibited from using them. Whatever the 

origin of the deficits, a primary goal of CBT is to 

help the individual develop and employ coping 

skills that effectively deal with the demands of 

high-risk situations without having to resort to 

substances as an alternative response. 

A number of published treatment manuals 

are available to guide skills training with 

substance users (Carroll, 1998; Kadden et al., 

1992; Monti et al., 1989). These manuals provide 

a session-by-session overview of the 

intervention. The material covered in these 

interventions can be categorized into a number 

of broad classes. The skills to be taught are 

either specific to substance abuse (e.g., coping 

with craving, refusing an offer of alcohol or 

drugs) or apply to more general interpersonal 

and emotional areas (e.g., communication skills, 

coping with anger or depression). They are 

either cognitive or behavioral in nature. Some 

might be viewed as essential and would be 

expected to be used for all clients, while others 

would be viewed as more elective in nature and 

would be selected for a particular individual 

based on the functional analysis. The ability to 

individually tailor the skills training to the 

client’s needs represents one of the strengths of 

CBT. 

Figure 4-19 presents a list of session topics 

(Monti et al., 1989) which served as the 

foundation for the CBT delivered in Project 

MATCH (Matching Alcohol Treatment to Client 

Heterogeneity Project) (Kadden et al., 1992), a 

large multisite study of treatment matching 

funded by the National Institute on Alcohol 

Abuse and Alcoholism (NIAAA). While the 

topics used in this particular example were 

developed for use with clients with alcohol 

abuse disorders, they are easily adapted to the 

needs of clients who are abusing other 

substances. 

According to Carroll, teaching coping skills 

is the core of CBT (i.e., helping clients recognize 

the high-risk situations in which they are most 

likely to abuse substances and to develop other, 

more effective means of coping with them) 

(Carroll, 1998). The therapist teaches the client 

specific behavioral skills for forming and 

maintaining interpersonal relationships. For 

example, a client may be taught how to refuse a 

79 
Chapter 4 

Figure 4-19 

Intrapersonal and Interpersonal Skills Training Elements 

Intrapersonal Skills 

 Managing thoughts about substance abuse 

 Problemsolving 

 Decisionmaking 

 Relaxation training and stress management 

 Becoming aware of anger 

 Managing anger 

 Becoming aware of negative thinking 

 Managing negative thinking 

 Increasing pleasant activities 

 Planning for emergencies 

 Coping with persistent problems 

Interpersonal Skills 

 Refusing offers to drink or use drugs 

 Starting conversations 

 Using body language 

 Giving and receiving compliments 

 Assertiveness training 

 Refusing requests 

 Communicating emotions 

 Communicating in intimate relationships 

 Giving criticism 

 Receiving criticism 

 Receiving criticism about substance abuse 

 Enhancing social support networks 

Source: Kadden, 1995, adapted from Monti et al., 1989. 

drink in a social situation (which might include 

some form of assertiveness training, as 

described in Figure 4-20). Learning how to 

develop new social contacts with people who 

are not substance abusers is another example. 

Skills training sessions follow a relatively 

standardized format. The client is given an 

overview of the session, describing the area to 

be addressed and the rationale for the specific 

intervention to be used. This is facilitated by 

skill guidelines that focus attention on the most 

important aspects of the approach as it applies 

to substance abuse. After discussing the issues 

involved in the session, the therapist models the 

effective coping skill for the particular topic. 

The therapist then asks the client to participate 

in a role-playing scenario in which he can 

rehearse the new coping behaviors. The 

therapist provides feedback and guidance while 

the client continues in the behavioral rehearsal. 

Between sessions, therapists often give 

homework assignments that provide the client 

with an opportunity to try behaviors learned in 

sessions in real-life settings. The next session 

usually begins with a review of this homework 

and the client’s reactions to it. 

Figure 4-20 

Assertiveness Training 

The client is encouraged to disclose and express emotions and needs, to stand up for his rights, to do 

what is best for himself, and to express negative emotions constructively. This is useful for clients with 

substance abuse disorders because being unable to express their emotions and needs may lead to relapse. 

As a client becomes more assertive, he will be better able to control his impulsive behavior as well as the 

environmental factors that may lead to relapse. Assertiveness training is usually combined with other 

psychotherapy because it requires a change in attitude as well as in behavior. 

80 
Brief Cognitive–Behavioral Therapy 

Skills training approaches have been 

evaluated more than many other approaches to 

substance abuse disorders. Monti and 

colleagues evaluated a coping skills training 

intervention for cocaine-dependent clients 

(Monti et al., 1997). A cocaine-specific skills 

training intervention, administered as 

individual counseling, was added to a more 

comprehensive treatment program along with a 

placebo control. The approach involved the 

identification of high-risk situations based on a 

functional analysis and the teaching of coping 

skills to deal with these situations. In 

comparison to the control condition, clients who 

received individualized coping skills training 

had significantly fewer days of cocaine use and 

significantly shorter periods of binge use of 

cocaine over a 3-month followup period. 

Although the two groups did not differ in their 

rates of relapse, the pattern of use and the harm 

associated with it clearly favored the skills 

training condition. 

Relapse Prevention 

The third core element of CBT is relapse 

prevention. While there are a number of 

different models of relapse (Donovan and 

Chaney, 1985), the two best articulated within 

the cognitive–behavioral model are those 

presented by Annis and Davis and Marlatt and 

Gordon (Annis and Davis, 1988b; Marlatt and 

Gordon, 1985). Relapse prevention approaches 

rely heavily on functional analyses, 

identification of high-risk relapse situations, and 

coping skills training, but also incorporate 

additional features. These approaches attempt 

to deal directly with a number of the cognitions 

involved in the relapse process and focus on 

helping the individual gain a more positive selfefficacy. 

Although self-efficacy is related to the 

availability of coping skills and would be 

expected to increase as the client learns new 

skills, this does not always occur spontaneously. 

It is often necessary to help the client change the 

passivity and sense of helplessness that often 

accompany low self-efficacy. Bandura noted 

that there are a number of ways to increase selfefficacy (Bandura, 1977). However, the model 

that appears to have the greatest impact and 

lasting influence uses the idea of performance 

accomplishments to enhance client self-efficacy. 

In this model, the client is coached to do 

something that she previously was unable to do. 

Annis and Davis use graduated homework 

assignments to help in this process (Annis and 

Davis, 1988b). The client gradually exposes 

herself to increasingly difficult situations with 

greater relapse risk but does so without using. 

The rate of the exposure is calculated to be at a 

level that can be handled by the client. The 

accomplishment of these homework tasks serves 

as a point of discussion to reinforce the client’s 

growing sense of self-efficacy. 

The therapist practicing CBT will also 

challenge the attributional process and 

emotional aftermath of a relapse. If a slip 

occurs, the therapist should try to bring the 

more negative attributions for relapse (internal, 

stable, and generalized) to the client’s attention 

so that he can identify these tendencies and 

learn how to change them. Clients can be 

helped to see the relapse as caused by a lack of 

appropriate coping skills for the particular 

situation (i.e., external), alterable with training 

or practice (i.e., unstable), and not implying that 

everything the person does is wrong (i.e., 

specific). This change in perspective will help 

reduce the client’s sense of helplessness and loss 

of control. Addressing the attributional process 

should be done in the broader context of 

educating the client about the relapse process. 

Research has consistently shown that people 

who expect more positive effects from 

substances are more likely to abuse them 

(Brown, 1993; Goldman and Rather, 1993). It 

has also become clear more recently that 

individuals who are aware of and concerned 

81 
Chapter 4 

about the more negative consequences 

associated with substance abuse are less likely to 

use (Jones and McMahon, 1996). There are also 

significant differences in the way men and 

women react to expectancies concerning 

substances; males are more affected by positive 

expectancies, whereas the positive expectancies 

of females are more balanced by negative 

expectancies (Romach and Sellers, 1998). 

The therapist can work to challenge a client’s 

positive expectancies about the effects of 

substances. There are two strategies that the 

therapist can use concerning expectancies in 

order to decrease substance abuse: change the 

client’s belief in the positive effects of the 

substance or get her to pay more attention to her 

knowledge and experience of its negative 

effects. 

For a long time, researchers did not believe 

that positive expectancies concerning substance 

effects could be changed, but a study on heavydrinking college students showed that 

expectations regarding alcohol effects could be 

altered (Darkes and Goldman, 1993). In group 

sessions, several techniques were used to make 

the students aware that some of their alcoholrelated expectancies were false. For example, 

the heavy-drinking college students were told 

that the beverages they were drinking contained 

alcohol, but they were actually given 

nonalcoholic drinks, disguised to look, smell, 

and even taste like alcohol. They then engaged 

in group party games, in which most displayed 

the uninhibited behavior that is associated with 

alcohol intoxication. Later, when they were told 

that their beverages were actually placebos, they 

were surprised. Group discussion and other 

information on placebo effects altered their 

perceptions of the positive effects of alcohol. A 

significant decrease in alcohol consumption was 

noted in this group after the intervention, 

compared to a control group that received 

conventional information on the effects of 

alcohol. Challenging social beliefs about the 

effects of a substance may alter its use. 

Another way to use substance expectancy 

information in therapy is to have the client 

consider both the positive and negative effects 

of the substance. Many clients have automatic 

scripts like “I’ll feel more relaxed if I drink” 

without considering other scenarios, like: “I’ll 

drink too much. I’ll have a fight with my 

girlfriend, and then I’ll sleep in and not go to 

class.” The therapist helps the client 

acknowledge that the other consequences exist 

and are not being attended to. It is possible to 

use a decisional balance procedure in this 

process, wherein the client is asked to list all the 

positive and negative things associated with 

drug use. By acknowledging the substance’s 

positive effects, the therapist gains credibility 

and reduces resistance from the client. The 

client can more easily acknowledge the negative 

aspects of substance abuse and make those 

beliefs more salient. This technique is a 

mainstay of motivation enhancement therapies 

that are largely cognitive in nature (Miller and 

Rollnick, 1991). (TIP 35, Enhancing Motivation for 

Change in Substance Abuse Treatment [CSAT, 

1999c], gives more detailed information on these 

approaches.) 

Relapse prevention also stresses the 

importance of preparing for the possibility of a 

relapse and planning ways to avoid it or, failing 

this, stop the process quickly and with minimal 

harm when it does occur. Clients are sometimes 

apprehensive about talking so directly about the 

possibility of relapse. The therapist can help 

dispel these concerns by using an analogy of fire 

drills. Having a drill and being prepared for a 

fire does not necessarily mean that a fire will 

occur. However, if one does, it will be possible 

to get out of the situation without getting 

burned. It is helpful to have very concrete 

emergency plans, including the phone numbers 

of individuals supportive of the client’s recovery 

82 
Client: Well, when I got out I still had some 

doubts about whether I would make it 

or not. I mean I felt better about myself, 

but there was still a lot of crap going on 

in my life. I had bills to pay. My 

relationship was falling apart. I was 

still being hassled by my probation 

officer. I was feeling kind of 

overwhelmed. Here I thought I would 

walk out of there a new man, but I 

walked out with all the same problems. 

Therapist: Was there any time after treatment 

when you felt you could handle all the 

problems facing you? 

Client: Well, for a while, then I started to feel 

depressed. I mean you go through 

treatment, and this stuff shouldn’t be 

happening. 

Therapist: What did you try to do to deal with it 

all? 

Client: At first I thought I would get myself 

organized and get a plan. But it didn’t 

work. As much as I tried, I couldn’t 

figure out a way to put all this stuff in 

its place and handle it. So I just threw 

up my hands and said, “Screw it!” I 

felt like the best thing to do was to pull 

Therapist: I wouldn’t give up hope yet. We’ll work 

together to help you get a better look at 

your cocaine use, some of the things 

that trigger it, and some of the benefits 

you think you get from it. Sometimes 

by looking at your use from a different 

perspective, you can help put it into 

context and things don’t seem so 

hopeless. Now why don’t you tell me 

about how you slipped and started 

using after your last time in treatment. 

What was going on in your life? What 

were you feeling? What were you 

thinking about yourself and your life? 

When I look at my track record, I don’t 

see much of a future. 

Brief Cognitive–Behavioral Therapy 

process. Including family members in the 

planning process is important because they are 

often better able than the client to see the 

warning signs of an impending relapse. 

Relapse prevention also stresses the 

development of a more balanced and healthier 

lifestyle. Marlatt and Gordon posit that one 

source of possible relapse risk has to do with the 

degree of stress or daily hassles that the client 

experiences (Marlatt and Gordon, 1985). They 

suggest that when the demands and obligations 

a client feels (“shoulds”) outweigh the pleasures 

the individual can engage in (“wants”), then his 

life is out of balance. This often results in 

feelings of deprivation and resentment. In 

response to these feelings, the individual could 

begin making decisions that gradually lead 

toward possible relapse. The goal is to help the 

individual find a better balance, increasing 

involvement in pleasant and rewarding 

activities while reducing the level and sources of 

stress. 

A Case Study Using CBT 

The following case study involves a young male 

cocaine user who has sought outpatient 

treatment. It reflects interactions early in the 

course of the session and is meant to depict 

some of the questions the therapist could ask to 

gain information about the antecedents, 

consequences, and cognitive mediators involved 

in his use. 

Therapist: So, can you tell me about your cocaine 

use and why you are coming to 

treatment now? 

Client: Well, I finally came to the end of my 

rope. I kept using even though I didn’t 

want to, and I felt that I was nothing 

but a junkie who had no future. It’s 

just hopeless. 

Therapist: What makes you say that? 

Client: Well, I just can’t stop using. Even 

when I’ve gone through treatment in 

the past, I end up using in no time. 

83 
Chapter 4 

the blankets over my head and hope that 

it would all blow over. 

Therapist: So, did it blow over? 

Client: No. Things just kept getting worse. I 

couldn’t pay my bills. My relationship 

was gone, and I got booted out of my 

apartment. 

Therapist: As all this was happening, did you 

think about using cocaine? 

Client: You bet I did! I kept thinking, “Damn, 

it sure would feel good to get all this off 

my mind.” And I knew that if I used 

coke it would all go away—at least for a 

while. 

Therapist: So, as you thought about the cocaine, 

what positive things did you think you 

would feel if you used? 

Client: I knew I’d feel a rush, I’d feel damn 

good—and I’d just forget. I could get 

out of the depression and funk I’d been 

in. I was just looking to feel better. 

Therapist: Did you think of any negative things 

about using? 

Client: Yeah. I always seem to crash after 

using. So I lose the high and find 

myself sometimes even more depressed 

than before. But that didn’t seem to 

bother me. I’m willing to put up with it 

for a while. I’ll take the high any day. 

It lets me get away from all this crap— 

at least for a while. 

Therapist: So what were the circumstances of your 

starting to use again? 

Client: Well, like I said, I got booted from my 

apartment. And I couldn’t go stay with 

my girlfriend since she booted me too. 

So I had to find a place to stay. I called 

an old friend who said I could stay at 

his place for a while. We used to do a lot 

of drugs together. I knew he might not 

be the best person to be staying with, 

but he was the only one I felt would put 

up with me. So, I moved in. I was 

feeling pretty low, thinking about 

84 

everything that had happened to me and 

was not sure what I was going to do. 

My friend pulled out some coke and 

asked if I’d like some. I just kept 

thinking of how lousy I felt and how 

good I would feel if I used. So I said 

yeah, why not. 

In this case study, it is clear that the client has 

a low sense of self-efficacy predicated in part by 

his past treatment failures and his inability to 

cope with difficult situations. As a result, he 

feels depressed and helpless. He makes a halfhearted attempt at problemsolving but fails in 

this attempt. Then he switches to passiveavoidant approaches in order to cope (e.g., 

pulling the blanket over his head and hoping it 

will all blow away). His depression continues 

unabated as the daily hassles mount. The 

positive expectancies he has about cocaine as the 

“magic elixir” are quite strong and seem to 

outweigh potential negative consequences. His 

situational context contains two high-risk 

situations. The first is the negative mood states 

that he experiences, when he has abused 

substances in the past. The second is the 

indirect social pressure involved in returning to 

a setting that had been associated with 

substance abuse in his past. There is also the 

proximal influence of the direct social pressure 

to use from his friend. The likelihood of relapse 

was high, and, in fact, relapse occurred. 

The therapist in this case might consider 

using skills training that focuses on 

problemsolving, stress management to alleviate 

his depression, developing communication 

skills, practicing substance refusal skills, and 

developing a social support network. The 

therapist should target both this client’s low selfefficacy and his positive cocaine-effect 

expectancies. Clearly the full intervention plan 

would require further assessment and a 

functional analysis; however, a direction for 

further treatment can already be seen in this 

brief interchange. 
Brief Cognitive–Behavioral Therapy 

Duration of Therapy and 

Frequency of Sessions 

Two advantages of CBT are that it is relatively 

brief in duration and quite flexible in 

implementation. CBT typically has been offered 

in 12 to 16 sessions, usually over 12 weeks 

(Carroll, 1998). The form of CBT used in 

NIAAA’s Project MATCH (Kadden et al., 1992) 

consisted of 12 sessions, administered as 

individual therapy, meeting once per week. The 

sessions included eight “core” sessions that 

dealt with alcohol-related issues (e.g., coping 

with craving, drink refusal, relapse emergency 

planning) and general problem-solving skills 

that all clients were expected to receive, and four 

“elective” topic areas chosen from a menu of 

more general social and interpersonal issues 

based on individually assessed problem areas. 

A 12-session CBT for cocaine addicts suggested 

that this length of treatment is sufficient to 

achieve and stabilize abstinence from cocaine 

(Carroll, 1998). However, not all clients will 

respond in that amount of time. In such cases, 

an initial trial CBT can serve as preparatory to a 

more intensive treatment experience. 

When To Use Cognitive– 

Behavioral Therapy 

Varieties of cognitive–behavioral therapy are 

applicable to a wide range of substance abusers. 

The outpatient CBT program developed by 

Carroll for cocaine users excluded a number of 

different clients as inappropriate for that form of 

treatment (see Figure 4-21). However, even 

though these criteria were derived from cocaine 

users, they appear to be applicable to clients 

using other substances. 

While reliance on the results of the functional 

analysis makes skills training particularly well 

suited for individual therapy, these 

interventions can easily be adapted for use in 

group settings (Monti et al., 1989). Similarly, 

they can be used with inpatients or outpatients 

and can be administered as part of an intensive 

phase of treatment or as part of less intensive 

aftercare or continuing care. CBT is also 

compatible with a number of other elements in 

treatment and recovery, ranging from 

involvement in self-help groups to 

pharmacotherapy (Carroll, 1998). 

Efficacy for Treating Substance 

Abuse Disorders 

In contrast to many other therapies, cognitive– 

behavioral therapy for the treatment of 

substance abuse disorders has substantial 

research evidence in support of its effectiveness. 

The research findings on the use of coping 

skills training with alcohol- and cocainedependent clients indicate that this strategy has 

strong empirical support. A review of outcome 

studies evaluating the efficacy of relapse 

prevention interventions indicates that the 

support for relapse prevention is more equivocal 

(Carroll, 1996b). Relapse prevention was found 

to be superior to no treatment, but the results 

have been less consistent when it is compared to 

various control conditions or to other active 

Figure 4-21 

Types of Clients for Whom Outpatient CBT Is Generally Not Appropriate 

 Those who have psychotic or bipolar disorders and are not stabilized on medication 

 Those who have no stable living arrangements 

 Those who are not medically stable (as assessed by a pretreatment physical examination) 

 Those who have concurrent substance dependence disorders, with the possible exception of alcohol or 

marijuana dependence 

Source: Carroll, 1998. 

85 
Chapter 4 

treatments. There are some outcomes on which 

relapse prevention may have considerable 

impact (Carroll, 1996b); for instance, although 

not necessarily reducing the rate of relapse, 

clients treated in relapse prevention appear to 

have less severe relapses when they occur. 

Overall, behavioral, cognitive, and cognitive– 

behavioral interventions are effective, can be 

used with a wide range of substance abusers, 

and can be conducted within the timeframe of 

brief therapies. 

86 
5 Brief Strategic/Interactional 

Therapies 

S

trategic/interactional therapies attempt to 

identify the client’s strengths and actively 

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 serious and persistent mental 

illnesses (Rapp and Wintersteen, 1989; Saleebey, 

1996; Solomon, 1992). It has also been used with 

persons who have problems related to substance 

abuse (Juhnke and Coker, 1997; Miller and Berg, 

1991; Ratner and Yandoli, 1996; Watzlawick et 

al., 1967). Although the research to date on 

these therapies (using nonexperimental designs) 

has not focused exclusively on substance abuse 

disorders, the use of these therapies in treating 

substance abuse 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. 

All of these models stem in part from the 

work of Milton Erikson. He coined the term 

strategic therapy 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, who were influenced by the MRI 

approach, shifted the focus of treatment from 

problems to solutions, calling their modality 

solution-focused therapy. Their approach, 

originally developed to work in brief marriage 

and family therapy, has since been used in a 

variety of situations for a variety of presenting 

problems, including substance abuse disorders. 

(See Chapter 8 for more information on the 

application of all these therapies to the 

treatment of families.) 

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 problem-solving skills that will help the 

client in her interactions with others. For the 

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Chapter 5 

purpose of this discussion, however, the 

combined term strategic/interactional therapy is 

used. This broader term allows solutionfocused therapy, which is certainly interactional, 

to be included in this section. Although it has a 

strong kinship with strategic approaches, not all 

practitioners consider solution-focused therapy 

to be “strategic.” 

The significance of these different 

approaches can be found in their presentation of 

an alternative approach to understanding how 

substance abuse disorders evolve and how new 

innovative solutions could be generated to assist 

with the resolution of these problems. 

The Consensus Panel believes that these 

therapeutic approaches are potentially useful for 

clients with substance abuse disorders and 

should be introduced to offer new knowledge 

and techniques for treatment providers to 

consider. This chapter presents one 

strategic/interactional approach, solutionfocused therapy, which has been used in 

substance abuse treatment. Information on 

when to use solution-focused brief therapy with 

substance abuse clients, a case study using 

strategic/interactional approaches with a 

substance-abusing client, and the general 

theories that provide the basis for 

strategic/interactional therapies are 

discussed below. 

Solution-Focused 

Therapy for 

Substance Abuse 

While this chapter covers several strategic and 

interactional theories and practices, most of the 

work currently being done on substance abuse 

treatment uses a solution-focused approach. 

Solution-focused therapy is always brief, and to 

date there has not been a great deal of research 

comparing it to other models. 

Research by Iguchi and colleagues supports 

some of the theoretical claims made by solutionfocused therapists (Iguchi et al., 1997). The 

solution-focused therapist believes that helping 

clients with substance abuse disorders to 

address any life problems they find significant 

will help them to reduce their substance use. 

What is important is finding a solution to the 

problems the client identifies as significant, then 

reinforcing the client’s success in solving those 

problems. This procedure helps the client to 

recognize her own ability to solve her problems. 

The study by Iguchi and colleagues compared 

the role of urine testing, traditional substance 

abuse counseling services, and the 

reinforcement of nonsubstance–use-related 

positive life changes and found that the latter 

resulted in the most significant reduction in 

substance use even after reinforcement 

contingencies ended. 

The solution-focused therapy model has been 

used to respond to a range of problems and 

complaints. Researchers Berg and Miller were 

the first to apply the model specifically to the 

treatment of alcohol-related problems, but 

others also have used these techniques for 

treating substance abuse disorders (Berg, 1995; 

Berg and Miller, 1992; Berg and Reuss, 1998; 

Ratner and Yandoli, 1996). This treatment 

model is not necessarily a useful treatment 

strategy for all clients with substance abuse 

disorders; no one model is. However, this 

model is a “complex and varied package of 

strategies that can be applied in an 

individualized, eclectic fashion to those seeking 

treatment” for a multifaceted and complex 

problem (Berg and Miller, 1992, p. xix). Berg 

and Reuss delve into greater detail regarding the 

applications of solution-focused brief therapy to 

the treatment of substance abuse disorders (Berg 

and Reuss, 1998). 

One technique of solution-focused therapy is 

to focus on the exceptions to the client’s 

problems. For example, in providing solutionfocused brief therapy for a client with a 

substance abuse disorder, the therapist should 

88 
Brief Strategic/Interactional Therapies 

direct the client’s attention to periods when he 

was substance free. To identify these periods, 

the therapist must listen carefully to the client’s 

responses, then ask the client to discuss those 

periods. The purpose is to help the client realize 

that he can maintain sobriety and has, in fact, 

done so in the past. The idea of focusing on the 

exception to any presenting problem is an aspect 

of strategic therapy that has particular relevance 

to the substance abuser because, as Berg notes, 

almost every substance abuser has had some 

period of abstinence—in many cases this period 

may have lasted months or years (Berg, 1995). 

Exceptions to presenting problems may fall 

into two categories, deliberate exceptions and 

random exceptions (see Figure 5-1 for definitions). 

The more deliberate the behavior on the part of 

the client, the easier it will be for her to repeat it. 

But even substance-free periods that seemed to 

result from outside influences (i.e., random 

exceptions) can be used to help the client realize 

her own ability to stay sober. 

As discussed above, a therapist using a 

solution-focused approach works closely with 

the client to understand the client’s own 

perspective on her problems. By focusing on 

those areas the client considers significant (e.g., 

relationships, work, financial security), the 

therapist assists the client in understanding how 

her substance abuse affects those significant 

areas of concern. The therapist helps the client 

solve those significant problems while strongly 

reinforcing the client’s success. After the initial 

session, the therapist keeps the client focused on 

how her situation is improving by asking, 

“What’s better this time?” 

Compatibility of 

Strategic/Interactional 

Therapies and 12-Step 

Programs 

Strategic/interactional approaches can be used 

in conjunction with other treatments, even those 

that require a longer term commitment. 

Strategic/interactional therapies are guided by 

an intent to generate a unique set of techniques, 

approaches, or modalities that are effective for a 

particular client. For some clients, a 

combination of brief therapy with longer term 

participation in another treatment program, 

such as a self-help group, will be most effective. 

In spite of some theoretical differences, 

strategic/interactional approaches can be used 

successfully in conjunction with 12-Step 

programs. These approaches, especially 

identifying triggers that can lead to relapse or 

Figure 5-1 

Deliberate and Random Exceptions to Substance Abuse Behaviors 

Deliberate exceptions are situations in which a client has intentionally maintained a period of sobriety or 

reduced use for whatever reason. For example, a client who did not use substances for a month in order 

to pass a drug test for a new job has made a deliberate exception to his typical pattern of daily substance 

use. If he is reminded that he did do this in the past it will demonstrate that he can repeat the behavior. 

Random exceptions are occasions when a client reduces use or abstains because of circumstances that 

are apparently beyond her control. The client may say, for example, that she was just “feeling good” and 

did not feel the urge to use at a particular time but cannot point to any intentional behaviors on her part 

that enabled her to stay sober. This type of exception is more difficult for the therapist to work with but 

can also be used to help the client perceive her own efficacy. In such instances the therapist can ask the 

client to try to predict when such a period of “feeling good” might occur again, which will force her to 

begin thinking about the behaviors that may have had an effect on creating the random exception. 

89 
Chapter 5 

exploring barriers that can prevent the client 

from going to Alcoholics Anonymous (AA) 

meetings or calling his sponsor, can be applied 

to critical points in maintaining sobriety. For 

example, the therapist can help the client 

identify the “payoff” for not attending the 

meeting and the key players in the system that 

maintains the client’s substance abuse. Even a 

client who feels he is powerless over substance 

abuse without the help of a higher power can 

recognize he has some control over the choices 

that lead to substance abuse. 

Some therapists familiar with 12-Step 

programs may be concerned that the 

strategic/interactional approach is opposed to 

viewing addiction as a disease. The focus on 

empowering the client may seem incompatible 

with the first step (i.e., “we admitted we were 

powerless over...”). However, the key to 

therapeutic success with this approach is the 

ability to work within a client’s frame of 

reference. Therapists can acknowledge that 

addiction is a disease but still use the 

strategic/interactional approach to enhance 

clients’ coping skills and help them to control 

the use-related behaviors that clients may 

believe are random and spontaneous. Strategic 

therapists who do not accept a disease model 

may tell a client, “You have a disorder of the 

pleasure centers in your brain,” and work with 

the client to find healthier ways to activate those 

“pleasure centers.” 

When To Use Strategic/ 

Interactional Therapies 

No matter which type of strategic/interactional 

therapy is used, this approach can help to 

 Define the situations that contribute to 

substance abuse in terms meaningful to the 

client 

 Identify steps needed to control or end 

substance use 

 Heal the family system so it can better 

support change 

 Maintain behaviors that will help control 

substance use 

 Respond to situations in which the client has 

returned to substance use after a period of 

abstinence 

More specifically, strategic/interactional 

approaches are useful in 

 Learning how the client’s relationships deter 

or contribute to substance abuse 

 Shifting power relationships 

 Addressing fears 

Most strategic/interactional therapies ask a 

client to consider the question, “How do you 

understand your using?” (Solution-focused 

therapy is an exception because it concentrates 

instead on improving the situation.) Often, as 

the therapist and client explore the client’s 

understanding of the abuse, critical relationship 

issues surface—even when the client appears to 

be isolated from family and friends. Even if a 

client seems to have no existing family 

connections, the family sometimes plays a role 

in her substance abuse. Her family, or her 

reaction to it, may have influenced her decision 

to begin using or her decision to stop. Messages 

from the family (internalized or actual) can also 

play an ongoing role in the client’s choice to 

continue using. 

One therapist treated a woman whose entire 

family appeared to have alcohol-related 

problems and who believed that everyone 

drank, but at different levels. For this client, a 

strategic/interactional approach helped her 

become aware of new possibilities, develop 

social skills, and identify sober activities. She 

learned to see the world as a richer place with 

many options. The therapist in this case chose 

to be directive and showed the client the 

possibilities for change that exist. To many 

clients who are trying to change their behavior, 

it is reassuring to believe that “there is someone 

90 
Brief Strategic/Interactional Therapies 

who knows the way.” The therapist using this 

strategic/interactional approach should convey 

a sense of hope that bridges the chasm between 

what is and what could be and support the 

client through the change process with respect. 

The strategic/interactional approach can also 

help break through a stalemate in a relationship 

that blocks healing, particularly if there has been 

a power struggle that has left both parties 

exhausted and with an apparently restricted 

range of options. In a power struggle, each 

person says she is right and the other is wrong; 

one of them must give in. When the 

strategic/interactional approach is applied to 

power struggles it can help to “open up the 

system,” working to change the clients’ 

perceptions of each other and their relationship 

and enable them to see a broad range of options. 

Both parties are assisted in seeing themselves as 

strong, capable, and in control. Because the 

substance abuser typically feels helpless, 

inadequate, and condescended toward, the 

therapist often has to rebalance the power 

structure to promote more effective interactions. 

For example, in a situation where one 

partner pushes the other to stop drinking, the 

partner who has been drinking may feel 

controlled and demeaned and therefore may 

withdraw in a passive manner or react with an 

explosive temper. He then gets drunk to further 

express his anger or to get even. The partners’ 

respective behaviors maintain the problem. The 

therapist works to help each partner perceive 

the other more positively. As this is 

accomplished, each person becomes more 

receptive to new solutions. The therapist then 

helps the partners identify specific changes they 

can make, thus dismantling the old system and 

laying the foundation for a new one that can 

support different behavioral choices. 

The strategic/interactional approach is also 

an appropriate way to address a client’s fear of 

change. Often, clients feel that “something 

worse” may happen when they quit using. In 

the Eriksonian model, a therapist might ask the 

client to project herself into the future and 

describe what it will be like when the changes 

just discussed have been made, or talk about a 

“future self” who has resolved current problems 

and for whom current fears are no longer an 

issue. Such strategies are useful in confronting 

common fears and helping clients see beyond 

them. 

Duration of Therapy and 

Frequency of Sessions 

Most forms of strategic/interactional therapies 

are brief by the definition used in this TIP. 

Strategic/interactional therapies normally 

require 6 to 10 sessions, with 6 considered 

typical. Sessions are usually weekly, and it is 

not advisable to have more than two sessions 

per week. This type of therapy often involves 

assigning “homework” for the client to observe 

how specific changes in behavior affect the 

problem, and time is needed to determine how a 

new strategy is working and see how the system 

is affected by the change. 

In solution-focused brief therapy, the client is 

encouraged to determine the length of time 

needed between sessions. This approach helps 

the client take ownership of the process and 

recognize his power to control change (realizing 

that one has the power to choose often is the 

solution itself). 

Applicability to Different 

Types of Clients 

In strategic/interactional approaches, clients are 

traditionally defined as customers, complainers, 

or visitors. Customers are clients who state that 

they have a problem, they can not cope with the 

problem on their own, and they need the 

therapist’s help. Strategic/interactional 

approaches are particularly helpful for the latter 

two types of clients—those who think someone 

else should change to resolve the presenting 

problem (complainers) and those who see their 

91 
Chapter 5 

presence in treatment as involuntary (visitors). 

Strategic/interactional therapies offer these 

kinds of clients a way to make effective changes 

within their own frames of reference. 

For example, consider a client who feels her 

boss overreacted to her substance abuse and 

believes she should not have been forced to 

enter treatment to retain her job. Instead of 

working to try to convince the client she really 

does have a problem, the therapist can make 

progress working within her view of the 

situation, perhaps by saying, “So your boss 

thinks you have a problem. What would it take 

to get him off your back?“ The assumption that 

the client wants to be free of the problems 

caused by this other person gives the therapist 

something to focus on without challenging the 

client’s view of the situation. 

Most clients with substance abuse disorders 

can be viewed as “hidden customers” who 

desire some sort of change in their behavior, 

even if they are not willing to articulate that fact 

(Berg, 1995). Given that, the therapist’s task is to 

make the “complainer” or “visitor” aware that 

he is in fact a “customer” of the therapist’s 

services. 

When Might a Strategic/ 

Interactional Approach Not 

Be the Best? 

Eriksonian approaches may be contraindicated 

for clients with severe disorders. Clients who 

have personality disorders (Axis II) may jump 

quickly from one suggestion to another without 

a clear sense of how to make use of therapeutic 

suggestions. Because they feel a need to stay in 

therapy they may resist solutions that would 

bring an end (albeit a successful one) to their 

relationship with the therapist. Clients with 

impaired brain function as a result of substance 

abuse may not be good candidates for this 

approach either. (For these clients, a more 

directive approach is helpful.) However, even 

when it is difficult to use this approach directly 

with the client, it may still be an effective 

modality to use with family members to help 

them change behaviors that support the client’s 

substance abuse (Fisch et al., 1982). 

For other populations, the approach may 

have to be adapted to work effectively. The 

therapist may have to use supportive props such 

as handouts of the agreed-upon plan of action 

and a list of goals to help keep the client on 

track. Strategic/interactional strategies can be 

simplified for people who have a cognitive 

impairment. Because this approach works with 

the client’s language and functional level, a 

client with a cognitive disability may be able to 

identify and meet goals appropriate to her skills 

and abilities. Many therapists believe that the 

solution-focused approach is useful with clients 

who have schizophrenia, and research supports 

its effectiveness with some clients who have 

serious mental illnesses (Saleebey, 1996; 

Solomon, 1992). 

Case Study 

Figure 5-2 presents a portion of a dialog 

between a counselor and a client, a 45-year-old 

real estate agent who was treated 4 years ago in 

an inpatient treatment program and thereafter 

attended a 12-Step group to help him stop his 

polysubstance abuse (cocaine and alcohol). 

After experiencing 3 clean and sober years, he 

began to use again. The client started gambling, 

then using cocaine and alcohol while gambling. 

His real estate license is now in jeopardy 

because of customer complaints and reports to 

the State Licensing Board. He was recently 

convicted for a second time for driving under 

the influence (DUI), and his wife and family 

moved out. The client tells the therapist that his 

renewed abuse of substances was the result of 

the gambling. Unlike the negative feedback 

from family, colleagues, and other professionals, 

92 
Figure 5-2 

Strategic/Interactional Therapy in Practice: A Case Study 

Conversation Observations

Client: Things were going great. I was going to a lot 

of meetings. I felt life was getting better. I was 

getting along with my kids. Getting in touch with 

the spiritual part of the problem. I don’t know what 

happened. 

Therapist: What led you to go gambling? 

Client: I guess I’d been gambling for a few months The first trigger (boredom) has been identified; this 

before I got high. I was bored. will have to be reframed as treatment progresses. 

Therapist: What is the experience of gambling like? 

Client: I really feel alive. 

Therapist: When did you first use again? 

Client: I spent too much money on gambling, and my An important interactional element surfaces. 

wife yelled at me the same way she used to when I Sometimes the things that spouses or significant 

got high on cocaine. I won a whole lot, really. It others do or say can either reinforce the client’s 

wasn’t fair. substance abuse or help him out of the problem. 

Therapist: What do you do when your wife gets angry 

at you for spending money? 

Client: I just say, “Yeah, you’re right.” And then I go 

away. Then she hassles me some more. There are 

times I blow up, but normally I just try to let it go by. 

Therapist: Sounds like when you were gambling, you Nonjudgmental language is used to enter the client’s 

were excited. So I don’t get it—what went wrong? frame of reference/world-view. It is best if the client is 

Why did you need the cocaine, too? Is it possible able to define the substance abuse as a problem he 

gambling wasn’t enough? wants to overcome rather than have the therapist 

define this for the client. 

Client: I guess I just needed more of the high, you 

know. My wife and I were fighting more. The 

pressure was getting to me. I guess that’s when I 

started on the cocaine. 

Therapist: How did that cocaine work for you? 

Brief Strategic/Interactional Therapies 

93 
Figure 5-2 (continued) 

Strategic/Interactional Therapy in Practice: A Case Study 

Conversation Observations

Client: I was excited. I felt really powerful. 

Therapist: What went wrong? What led you start 

using alcohol, too? 

Client: I got scared. I was up for 3 days. The alcohol 

helped me come down and sleep. 

Therapist: Sounds scary to me. How did you get 

through that scared period? You tolerated it 

somehow for 3 days. 

Client: It was kind of a blank, mostly. I felt I had to 

fix it somehow. That’s when I started drinking. 

Therapist: How did you know alcohol would work? 

Client: I’ve used it to bring me down before. 

Therapist: I hear that you realized something needed 

to be done, and you knew you needed something to 

slow you down, and you took action. 

Therapist: So how is this a problem for you now? 

Client: Well, I lost my family, almost lost my 

business, and I’m facing another DUI. 

Here the therapist gets some understanding of the 

sequence of the client’s substance abuse. 

The therapist validates the client’s experience, rather 

than criticizing the client’s behavior. 

The therapist is pointing out that the client’s action 

was an attempt at regulation, though not a long-term 

solution. The statement reminds the client that he is 

in control and making choices. It reaffirms the 

client’s strength and coping skills—the client made an 

adaptive response to a difficult situation and may 

make a different choice next time. 

This question brings the client back to defining the 

problem for himself, rather than letting the therapist 

or someone else (spouse, boss, probation officer, etc.) 

define it for him. 

This “hopeless and helpless” stance should be shifted. 

Solution-focused and MRI approaches would try to 

promote effective strategies and eliminate ineffective 

ones. An Eriksonian might challenge the client to 

compare his positive and negative self-image (i.e., the 

way it feels to go to AA and stay sober versus how it 

feels after getting high). 

Chapter 5 

94 
Figure 5-2 (continued) 

Strategic/Interactional Therapy in Practice: A Case Study 

Conversation Observations

Therapist: So where do you want to go now? Why are This therapist is using a strategic approach to shift the 

you here? client off helplessness to a self-motivational statement: 

“I really need to change my life.” 

Client: I want to get sober again. I went back to AA, 

but now I can’t stay sober more than a day. 

Therapist: When you were determined to stay sober, 

you were successful. What’s different about the way 

you’re trying to do this now? 

Client: Well, now, I’ll leave the meeting and go get 

high. 

Therapist: And how is that working for you? 

Client: It’s not working! I just start feeling worse 

about myself. I’ve been through so much already. I 

really just need to stop. 

Therapist: It sounds to me like you have incredible Here is a “make it or break it” point in treatment. 

inner strength. What keeps you going? The therapist is seeking a key that will move the client 

to action (e.g., his love of his children, his desire to get

Client: I don’t want to die. his wife back, his concern about his job). In this case, 

the therapist has just learned that the client fears he 

will die as a result of his use. 

Therapist: It sounds like you have a very strong, Some therapists would call the competent self the

competent side that wants the best for you and wants “recovery self.” 

to live. Let’s use that competent part of you to get 

back on track and rebuild your life. What do you 

think? 

Client: I would like that. 

Therapist: Let’s begin by figuring out where you are The “readiness ruler” is an effective way to determine

now. On a scale of 1 to 10, on which “1” is the worst the client’s readiness to change and identify next 

you could feel and “10” is “clean, sober, and steps. The therapist is using this technique to identify

successful,” where are you now? a baseline to measure progress and focus the client in 

the direction of change and progress. 

Brief Strategic/Interactional Therapies 

95 
Figure 5-2 (continued) 

Strategic/Interactional Therapy in Practice: A Case Study 

Conversation Observations

Client: Well, now I feel like an “8,” but I know it’s 

temporary. When I go back home, I’ll probably get 

back to a “2” right away. 

Therapist: That’s good because slow change is more At this point, the therapist is ready to define some 

important than fast change. You really can’t count on kind of action and seek commitment to change. The 

fast change to last. So if you did slip back to a “2,” response is also intended to encourage the client by 

what would it take to move you to a “3”? identifying small, feasible steps 

Client: I guess more of what I know works or what 

used to work, anyway. Going to meetings or calling 

my sponsor. That kind of thing. 

Therapist: Sounds good. You said now you go to AA The therapist is looking for exceptions: times when 

meetings and get high afterward. What did you do something the client did worked and he experienced 

afterwards when you didn’t do that, when you success. 

stayed sober? 

Client: Went home. Watched TV. Had fun with my 

wife; sometimes we made love. Now that she’s not 

there, I really dread the evenings. They are so empty. 

I just go back and stare at the ceiling. 

Therapist: So when you don’t have things to The therapist is reframing the problem to open the 

do, you get antsy. door to a solution. 

Client: Yeah. I guess so. I get lonesome. 

Therapist: Yes, it is difficult to go home to an empty The therapist is acknowledging the difficulty, but also 

place. But it sounds like you have not given up on pointing out the positive direction implicit in the 

people. People are still important to you. You want client’s statement. The therapist empathizes with the 

human contact—to care about people and have them client, validating his experiences and feelings, but also 

care about you. pointing out the positive direction implicit in the 

client’s statement. 

Client: If nobody’s around, I feel empty. I get bored. 

Then I want to use. I want to make something 

happen. 

Chapter 5 

96 
Brief Strategic/Interactional Therapies 

Figure 5-2 (continued) 

Strategic/Interactional Therapy in Practice: A Case Study 

Conversation Observations 

Therapist: Are you bored now? 

Client: Sort of. Not really here all the way, you 

know what I mean? Sort of empty. 

Therapist: That’s interesting. Despite the fact that 

you feel empty, you can still function. I think there 

is something internally powerful in you that has not 

come out. For some reason, it has been suppressed. 

My guess is that the boredom comes when you 

suppress that side of you. 

Client: You keep talking about this powerful side. I 

don’t get it. I lost everything. Where’s this great 

power I’m supposed to have? 

Therapist: I think it’s right here—let’s see if we can 

bring it out a bit. Tell me about a time when you felt 

tremendous pleasure and control, but you were 

sober. 

Client: Well, I have to go pretty far back. When I 

was ten, though, I remember playing baseball and 

hitting this home run. I really hit that ball. 

Therapist: Some time this week if you’re willing to 

try something, and only if you’re willing, try to 

bring back that experience. Take note of what it was 

like and how difficult it was to get there. 

Client: Okay. Maybe I’ll try that. 

This question gives the therapist information on how 

the client feels and acts when bored and can help the 

therapist recognize signals of boredom in the future. 

Sometimes the therapist will have great participation, 

and the client will still describe himself as bored. It is 

also important to ascertain whether the boredom 

results from depression or a sense of emptiness. A 

better understanding of what “bored” means will 

enable the therapist to help the client figure out 

“what’s different” and find a solution. 

The therapist is framing the client’s self-image 

positively, suggesting a change in the way the client 

now sees himself. 

A natural response from a client who is mostly 

focusing on negative perceptions and experiences. The 

therapist’s focus continues to be on shifting the client’s 

perception to positive strengths and constructive 

action. 

At this point, the therapist might encourage the client 

to feel that vibration and run across the bases in his 

mind or ask whether the activity mentioned is one the 

client could do in his present life. The therapist could 

suggest here that a local recreation center, or another 

way of being physically active, would be an option for 

restoring the sense of power and control as well as 

connecting with people. 

97 
Figure 5-2 (continued) 

Strategic/Interactional Therapy in Practice: A Case Study 

Therapist: I’m sure there have been a number of The therapist should make the client work here. If the 

things in your life that you’ve done right, otherwise client is blank, he could be asked to free associate. In a 

you wouldn’t have survived all of the difficulties group setting, others could give suggestions. 

you’ve had. It would help if you could think about 

those successful or effective behaviors. 

Client: I can try. 

Therapist: Now that we’ve identified that you have 

all this strength inside of you—and you still do— 

how do we use it? 

Client: I guess if I could go to AA and stay sober 

when I get home, that would at least be a start. 

Therapist: What do you think is going to happen at 

AA? 

Client: It’s going to be good to sit there and know Part of what’s happening is that the external and 

I’m not hiding. internal pressure resulting from the shame is being 

reduced; consequently, the feeling about going is 

changing. 

Chapter 5 

the therapist, using strategic/interactional 

approaches, praises the client for coming back to 

treatment: “Look at what you have done! 

You’re in this chair instead of still out there.” 

The therapist assures the client that relapse is 

part of the recovery process and suggests that 

the experience can be seen as educational. In 

contrast to emphasizing the client’s failure, the 

therapist sends the message, “You’re a survivor, 

not a victim.” The therapist affirms the client’s 

ability to stay sober and begins to seek ways to 

emphasize and draw on the client’s strengths. 

The therapist seeks to understand the events 

that led up to renewed use but also searches for 

the behaviors that previously helped the client 

stay abstinent for 3 years. 

This case study is an example of how a brief 

strategic/interactional therapist might work 

with a client who has previously been successful 

at controlling his substance abuse problem but 

has relapsed. The approach described is a 

generic strategic/interactional approach and 

does not represent a pure model of any one type 

of strategic/interactional therapy. Because the 

client has relapsed, an important guiding 

principal is to discover what has caused him to 

deviate from those behaviors, thoughts, and 

activities that had previously been effective in 

controlling his substance abuse. The therapist 

must then assist the client either to return to 

those things that have been working before or to 

add or replace them with strategies that are 

more effective. 

98 
Brief Strategic/Interactional Therapies 

Strategic/Interactional 

Therapies 

The primary strength of strategic/interactional 

approaches is that they shift the focus from the 

client’s weaknesses to the client’s strengths. The 

therapist’s task is to help the client identify, 

recognize, and use these strengths to make the 

changes the client sees as beneficial. 

Strategic/interactional therapies are based on 

three primary theoretical assumptions: 

1. These therapies take a constructivist view of 

reality. They assert that reality is 

determined by individual perceptions, 

which are influenced by cultural, 

sociopolitical, and psychological factors. 

2. These therapies stress the importance of 

attribution of meaning. According to this 

theoretical approach, it is the meaning we 

attribute to situations that determines 

whether a problem exists. In this model, an 

important therapeutic goal is to understand 

the meanings that clients attribute to 

events—often referred to as the client’s 

“frame of reference”—and to use this 

knowledge to promote constructive change. 

This can involve helping clients to construct 

a different meaning that is more useful to 

them in the recovery process. 

3. These therapies focus on human interactions 

and the problems that evolve from 

ineffective ways of coping with situations. 

There is always some element of social 

interaction in the development, 

maintenance, and change process for any 

problem. By taking these interactions into 

account, the therapist can better support the 

client through the change process. 

A basic tenet of this approach is the assertion 

that human problems can be understood by 

applying the principles of human systems. 

Problems do not exist in a vacuum; they exist 

because of relationships with others. The 

strategic therapist believes that a positive 

change to one part of a system will positively 

affect the rest of the system. This approach is 

distinct from a structural view of systems, 

however; whereas the structuralist sees the need 

to consider and try to change dysfunctional 

aspects of the larger family structure, the 

strategic therapist does not necessarily posit a 

systemwide dysfunction—only the existence of 

ineffective interactions within the system. 

A strategic approach accepts the fact that 

clients may not always provide accurate 

information about the real nature of their 

problems. It is possible to work with the client’s 

view of what is happening and make progress, 

even if that view is only partially “correct.” For 

example, consider a client who enters therapy 

complaining, “My boss drives me to drink.” In 

a cognitive or confrontational approach, the 

therapist might strive to change this way of 

looking at reality. The therapist using a form of 

strategic/interactional therapy might say that 

this approach represents the client’s view of the 

world and, rather than correcting or altering it in 

some way, the therapist can make more progress 

by working within that frame of reference to 

accomplish strategic objectives. The therapist 

might ask, “If your boss is driving you to drink, 

how does that happen and what can you do 

about that?” The therapist implies that the client 

must be more effective in interactions with his 

boss, and this becomes a treatment issue. By 

working within the client’s frame of reference, 

the therapist can define what the client might do 

to change key interactions that contribute to 

substance abuse, without buying into the 

premise that it is only his boss’ behavior that 

must change. 

Initial Session 

The first question that a therapist using a 

strategic/interactional approach should ask is, 

“Why are you here?” The first session should be 

spent trying to understand the client’s problem. 

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Chapter 5 

However, different models (discussed later in 

this section) use different tactics to explore the 

nature of the problem, as follows: 

 The therapist using Eriksonian therapy seeks 

to define the client’s problem in the client’s 

terms and probe the way she understands 

the problem (i.e., the “frame”). Compared to 

other strategic interactional models, the 

Eriksonian approach moves more quickly to 

action, seeks to effect change more quickly, 

and places greater emphasis on the 

unconscious processes underlying change. 

 The therapist using solution-focused brief 

therapy spends most of the first session 

defining goals. Throughout the session, the 

word “problem” is avoided. 

 The therapist using the MRI model seeks to 

define the problem in the client’s terms and 

understand the “frame” in a manner similar 

to the Eriksonian approach. However, this 

modality focuses on modifying ineffective 

solutions that have been previously 

attempted. 

 The therapist using Haley’s problem-solving 

therapy pays special attention to gaining an 

understanding of power issues in 

relationship to the problem (e.g., who 

controls key decisions). 

Later Sessions 

Once the therapist has encouraged a person 

with a substance abuse disorder to take further 

steps toward change, the subsequent sessions 

will focus on identifying and supporting 

additional steps in the same direction. The 

following are examples of techniques that might 

be used in the remaining sessions with the client 

in this case study. 

 Set up a termination point. The therapist 

could ask the client to describe the signs that 

things are getting better for him, or ask, 

“What things will you be doing differently?” 

 The therapist could continue to develop 

effective strategies and increase their use. 

She could use affirmations, continue to use 

scaling questions, and “join” with the client 

by acknowledging how difficult it is to 

change and rebuild his life. 

 The therapist should also be aware of the 

client’s motivation to change and continue to 

ask the client what he thinks will happen if 

changes take place. This technique 

demonstrates respect for the client’s values. 

 The therapist could continue to gather 

information about the stressors that trigger 

the client’s substance abuse and help him to 

determine how he can handle them 

differently. The therapist should ask the 

client about ways he has successfully 

handled stressors in the past and expand on 

those successes. 

 The therapist could use images and symbols 

to help the client see the problem in a helpful 

way. For example, the client might find a 

new job and throw himself completely into it. 

The therapist could tell him that he is a 

shining star: “You’re shining bright right 

now. What can you do to keep shining?” 

This starts a discussion about how to last 

longer, work smarter, achieve more, and use 

restraint. 

 The therapist might also focus on assisting 

the client to improve other aspects of his life. 

 The client’s continued belief in his own 

strength and basic goodness should be 

supported. The therapist should help him 

see himself as an individual who wants 

what’s best for both himself and his family. 

 One effective strategy is to encourage the 

client to adopt a “helper” role in some area of 

his life. This shifts the focus further from his 

view of himself as a helpless, incompetent 

addict to a strong, caring, competent person 

who can help others. This client’s 

100 
 participation in AA might give him the 

opportunity to help others in this manner. 

As the end of the therapeutic process nears, 

the therapist helps the client prepare for the 

future. Following are suggestions for how the 

therapist can do this. 

 Prepare the client to maintain positive change 

through difficult times. It is useful to convey 

the idea that the learning curve is never a 

straight slope; rather, it is a curvy line, with 

peaks and dips. There will be slips. It is 

unrealistic to expect perfection. Life will 

continuously have “ups and downs”—the 

goal is not to make things even but to cope 

effectively with these ups and downs. 

 Identify what the potential next stressors and 

challenges will be. Work through the 

following question with the client: “Given 

what we’ve learned, how would you cope 

with the next stressor/challenge?” 

 Devote some time to preparing the client for 

changes to the environment. For example, how 

will significant people in his life react to his 

change in behavior? 

 Ask the client to look into the future at the end of 

the treatment period and tell the therapist where 

he intends to be at a certain time (this is an 

Eriksonian approach). The therapist could ask 

for a specific date when the client expects to 

get there and ask the client to call the 

therapist on that date. This process sets up 

an expectation of progress and 

accountability. 

Ericksonian Therapy 

All forms of strategic/interactional therapies 

have their roots in the work of Milton Erikson, 

an innovative psychotherapist who was one of 

the first theorists to suggest the importance of 

working within the client’s “frame.” With his 

unique use of hypnotherapy he fostered rapid 

changes in his clients, often in an indirect 

fashion. Through this work he came to 

Brief Strategic/Interactional Therapies 

emphasize unconscious factors in change and 

the importance of indirect ways to shift 

meanings and behavior. His approach is active, 

building on clients’ resources to help them attain 

their goals. The therapist and client cooperate in 

building an awareness of the client’s experience 

and an understanding of its meaning. Together, 

they build a context for change. 

Erikson’s interventions emphasize the 

following: 

 Suggestion as a means of bypassing an 

impasse, reframing the problem, and taking a 

first step toward solving it 

 Metaphor as indirect intervention—a way to 

help the client retrieve resources and create a 

unique response that builds a bridge for 

learning; the therapist uses the client’s 

metaphors (e.g., if the client sees recovery as 

a road, then the therapist can speak of 

bridges or of smoothing the way, thus 

activating the client’s imagination in the 

service of the change process) 

 The symptom as a communication that 

conveys information about developmental 

needs 

 An orientation toward the future (e.g., 

depression is seen as the result of focusing on 

past associations; as the client works toward 

change and begins to accomplish goals, she 

lets go of depression) 

 Acquiring new skills to meet the 

requirements of new situations (such as the 

different ways of socializing associated with 

abstinence) and to handle developmental 

tasks 

 The cure conceptualized as the loss of the 

symptom and as the development of new 

relational patterns that allow a creative 

response to the environment 

While Erikson was able to work with 

virtually all clients using these techniques, his 

work has been especially useful in helping 

people let go of trauma, break through a 

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Chapter 5 

resistance to change, and alter obsessive– 

compulsive, phobic, or addictive behavior. 

Solution-Focused Brief Therapy 

Solution-focused brief therapy was developed 

by Steve De Shazer and his colleagues at the 

Brief Family Therapy Center in Milwaukee, 

Wisconsin. In solution-focused brief therapy, 

the emphasis is placed on building exceptions to 

the presenting problem and making rapid 

transitions to identifying and developing 

solutions intrinsic to the client or problem 

(Cooper, 1995). Basic tenets of this approach 

include the following: 

 Focusing on competence rather than 

pathology 

 Finding a unique solution for each person 

 Using exceptions to the problem to open the 

door to optimism 

 Using past successes to foster confidence 

 Looking to the client as the expert 

 Using goal-setting to chart a path toward 

change 

 Sharing the responsibility for change with 

the client 

The basic tenets of the solution-focused 

model are fairly simple; they are the same when 

used for treating substance abuse disorders as 

they are for treating other mental health 

concerns. A therapist uses these same principles 

for an individual client, family, or group. The 

therapist emphasizes finding solutions to a 

problem, not on discovering the cause or origins 

of the problem. According to Giorlando and 

Schilling, 

The innovative perspective of solution-focused 

therapy shifts the emphasis from problems to 

solutions, empowering the client to access her 

internal resources, strengths, and past 

successes, with therapist and client working 

collaboratively to achieve change in a shorter 

time than that required by traditional schools 

of psychotherapy (Giorlando and Schilling, 

1996). 

Berg and Miller relate the “central 

philosophy” of solution-focused therapy in the 

following three rules (Berg and Miller 1992, 

p. 17): 

1. “If it ain’t broke, don’t fix it!” 

2. Once you know what works, do more of it! 

3. If it doesn’t work, then don’t do it again—do 

something different! 

Solution-focused interviewing strategies 

include the following (based on Giorlando and 

Schilling, 1996), presented in a typical sequence. 

These strategies can be applied at different 

points in the therapeutic process as appropriate. 

 Ask the “miracle question” (i.e., “If a miracle 

happened and [your condition] were 

suddenly not a problem for you, how would 

your life be different?”). 

 Ask about exceptions (e.g., “Are there ever 

times you see pieces of the miracle?”). 

 Explore differences between current status 

and the desired problem-free state (e.g., 

“What is the difference between the times 

when you can see pieces of the miracle and 

the times when you can see only the 

problem?”). 

 Use scaling to determine how well the client 

thinks things are going, how willing she is to 

work toward the “miracle,” her confidence in 

her ability to change, and the steps needed to 

improve the situation from one rating on the 

scale to the next highest. 

 Try taking “time-outs” and suggest to the 

client “While I step out, I want you to think 

of the next smallest step you could take that 

would bring you to the next number on the 

scale.” 

 Affirm client competencies (e.g., tell the 

client, “I am impressed you are sitting in that 

chair again after what you just went 

through”). Many of these clients have never 

had this success acknowledged before. 

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Brief Strategic/Interactional Therapies 

 Suggest tasks that the client can perform to 

improve her situation (e.g., ask her to do 

something achievable that would provide 

useful information or move her closer to the 

“miracle” she has chosen). 

The MRI Therapeutic Model 

The Mental Research Institute’s brief therapy 

model is based on the belief that problems 

develop from, and are maintained by, the way 

that normal life difficulties are perceived and 

handled (Fisch et al., 1982). Normal difficulties 

become problems when an individual 

continually mishandles a situation, using the 

same ineffective approach each time. A client’s 

belief system can cause him to develop 

ineffective approaches to problems that result in 

maintaining or even exacerbating the difficulty. 

The more the client uses an ineffective solution 

to solve a problem, the more the problem is 

reinforced and maintained. The solution lies in 

helping the client change his perception of the 

problem, then either modify the attempted 

solution so it has a greater chance of success or 

devise a more effective solution. These new 

solutions (generally referred to as second order 

change) work best if they are sufficiently 

different from the ineffective, previously 

attempted solutions. 

In each session, practitioners using the MRI 

brief therapy model should try to do the 

following: 

 Define the problem in behavioral terms. For 

example, a client may say, “I feel compelled 

to join the others at work in drinking, 

although as a result I have such a ‘short fuse’ 

that I get in fights and even hurt my wife.” 

 Determine how the client understands the 

problem. What is her “frame of reference” or 

“position”? It is important to understand 

how the client views her problem and what 

attitudes she has toward the problem. For 

example, a client might insist that her 

substance abuse is the result of pressures at 

work. However, the therapist notes that she 

began using after the death of her spouse and 

therefore hypothesizes that the substance 

abuse is related to her deep grief. The 

challenge for the therapist is to work with the 

client’s position in a way that allows for a 

more useful understanding of the problem, 

and therefore for new, more effective 

solutions. 

 State goals. What behaviors are to be changed 

and what would be the signs of change? 

 Review attempted solutions. What has the 

client done to try to solve the problem? 

What has worked, and what has not worked? 

 Reframe the situation. Help the client change 

his perception of himself, others involved, or 

the problem situation so that new options 

can appear. 

 Develop second order change. Help the client 

generate more effective solutions that lead in 

a different direction from the ineffective 

ones—either by modifying attempted 

solutions or by developing new ones. In the 

case of a client who has tried to control her 

drinking by obsessing over her need to stop 

drinking, the therapist might perceive that 

every time she thinks about controlling her 

drinking she activates her fears that she is 

weak and out of control. The more she 

obsesses over controlling her drinking the 

more overwhelmed she becomes about the 

impossibility of the task. The therapist 

would try to help this client to stop obsessing 

over this task and instead view the situation 

as manageable and changeable in a step-wise 

fashion. The therapist would help her see 

that she has been strong and capable in other 

aspects of her life and that she can make use 

of these strengths and competencies to 

handle his drinking problem. 

 Plan for maintenance of the new behaviors. 

Support continued improvement by 

preparing the client to meet future challenges 

and crises. 

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Chapter 5 

The speed with which a therapist is able to 

move through these steps will depend on the 

client’s particular problem, overall 

development, cognitive capacities, and his stage 

of readiness to change. 

Haley’s Problem-Solving Therapy 

Jay Haley wrote that “therapy can be called 

strategic if the therapist initiates what happens 

during the therapy and designs a particular 

approach for each problem” (Haley, 1973, p. 17). 

To do this the therapist will have to identify 

solvable problems, design interventions to 

resolve them, correct those interventions based 

on responses from the client, and evaluate the 

effectiveness of the therapy. 

Haley’s problem-solving therapy emphasizes 

obtaining a clear statement of the problem and 

an accurate picture of the interactional 

sequences that maintain it. Moreover, 

symptoms (i.e., presenting dysfunctions) or 

problem behaviors serve a function in families 

and carry metaphorical information about 

hierarchical dysfunction (Haley, 1987). Through 

observing the client’s symptomatic behavior, the 

therapist can often understand the underlying 

problem metaphorically. For example, if a child 

runs away it can indicate that the family is 

“running away” from confronting an issue. This 

behavior often signals a solution as well, calling 

attention to what needs to be changed. 

To map out a family’s organization, the 

therapist should observe communication 

sequences—who talks to whom, and in what 

order. The therapist should try to answer 

questions such as, “What function does the 

symptom serve in stabilizing the family?” and, 

“What is the central theme around which the 

problem is organized?” 

Haley’s approach assumes that substance 

abuse by a family member is a symptom of a 

family’s desire to avoid confronting 

dysfunctional family dynamics. The individual 

is not necessarily responsible for having created 

the symptom (which would fit in well with a 

disease concept addiction). According to 

Haley’s model, a wife may drink to avoid 

expressing her rage at her husband for having 

an affair. The husband implicitly understands 

that by confronting his wife’s drinking, a 

confrontation might ensue over his infidelity 

and that could destroy the marriage. This 

approach recommends negotiating a path to 

change by changing the family pattern that 

militates against it. The therapist could work 

with the family to set goals and design a 

strategic series of directives to meet these goals, 

usually involving a change in the sequences of 

interaction that maintain the problem. In the 

above example, the wife’s drinking serves to 

stabilize the family and avoid the real issues of 

the wife’s anger and the husband’s infidelity. 

The therapist would work with the wife to 

express her anger in a way other than drinking, 

and define the issue as one of trust in the 

marriage. 

104 
6 Brief Humanistic and 

Existential Therapies 

Humanistic and existential 

psychotherapies use a wide range of 

approaches to case conceptualization, 

therapeutic goals, intervention strategies, and 

research methodologies. They are united by an 

emphasis on understanding human experience 

and a focus on the client rather than the 

symptom. Psychological problems (including 

substance abuse disorders) are viewed as the 

result of inhibited ability to make authentic, 

meaningful, and self-directed choices about how 

to live. Consequently, interventions are aimed 

at increasing client self-awareness and selfunderstanding. 

Whereas the key words for humanistic 

therapy are acceptance and growth, the major 

themes of existential therapy are client 

responsibility and freedom. This chapter broadly 

defines some of the major concepts of these two 

therapeutic approaches and describes how they 

can be applied to brief therapy in the treatment 

of substance abuse disorders. A short case 

illustrates how each theory would approach the 

client’s issues. Many of the characteristics of 

these therapies have been incorporated into 

other therapeutic approaches such as narrative 

therapy. 

Humanistic and existential approaches share 

a belief that people have the capacity for selfawareness and choice. However, the two 

schools come to this belief through different 

theories. The humanistic perspective views 

human nature as basically good, with an 

inherent potential to maintain healthy, 

meaningful relationships and to make choices 

that are in the interest of oneself and others. The 

humanistic therapist focuses on helping people 

free themselves from disabling assumptions and 

attitudes so they can live fuller lives. The 

therapist emphasizes growth and selfactualization rather than curing diseases or 

alleviating disorders. This perspective targets 

present conscious processes rather than 

unconscious processes and past causes, but like 

the existential approach, it holds that people 

have an inherent capacity for responsible selfdirection. For the humanistic therapist, not 

being one’s true self is the source of problems. 

The therapeutic relationship serves as a vehicle 

or context in which the process of psychological 

growth is fostered. The humanistic therapist 

tries to create a therapeutic relationship that is 

warm and accepting and that trusts that the 

client’s inner drive is to actualize in a healthy 

direction. 

The existentialist, on the other hand, is more 

interested in helping the client find 

philosophical meaning in the face of anxiety by 

choosing to think and act authentically and 

responsibly. According to existential therapy, 

the central problems people face are embedded 

in anxiety over loneliness, isolation, despair, 

and, ultimately, death. Creativity, love, 

authenticity, and free will are recognized as 

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Chapter 6 

potential avenues toward transformation, 

enabling people to live meaningful lives in the 

face of uncertainty and suffering. Everyone 

suffers losses (e.g., friends die, relationships 

end), and these losses cause anxiety because 

they are reminders of human limitations and 

inevitable death. The existential therapist 

recognizes that human influence is shaped by 

biology, culture, and luck. Existential therapy 

assumes the belief that people’s problems come 

from not exercising choice and judgment 

enough—or well enough—to forge meaning in 

their lives, and that each individual is 

responsible for making meaning out of life. 

Outside forces, however, may contribute to the 

individual’s limited ability to exercise choice 

and live a meaningful life. For the existential 

therapist, life is much more of a confrontation 

with negative internal forces than it is for the 

humanistic therapist. 

In general, brief therapy demands the rapid 

formation of a therapeutic alliance compared 

with long-term treatment modalities. These 

therapies address factors shaping substance 

abuse disorders, such as lack of meaning in 

one’s life, fear of death or failure, alienation 

from others, and spiritual emptiness. 

Humanistic and existential therapies penetrate 

at a deeper level to issues related to substance 

abuse disorders, often serving as a catalyst for 

seeking alternatives to substances to fill the void 

the client is experiencing. The counselor’s 

empathy and acceptance, as well as the insight 

gained by the client, contribute to the client’s 

recovery by providing opportunities for her to 

make new existential choices, beginning with an 

informed decision to use or abstain from 

substances. These therapies can add for the 

client a dimension of self-respect, selfmotivation, and self-growth that will better 

facilitate his treatment. Humanistic and 

existential therapeutic approaches may be 

particularly appropriate for short-term 

substance abuse treatment because they tend to 

facilitate therapeutic rapport, increase selfawareness, focus on potential inner resources, 

and establish the client as the person responsible 

for 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 reach their full potential. 

Because these approaches attempt to address 

the underlying factors of substance abuse 

disorders, they may not always directly confront 

substance abuse itself. Given that the substance 

abuse is the primary presenting problem and 

should remain in the foreground, these 

therapies are most effectively used in 

conjunction with more traditional treatments for 

substance abuse disorders. However, many of 

the underlying principles that have been 

developed to support these therapies can be 

applied to almost any other kind of therapy to 

facilitate the client–therapist relationship. 

Using Humanistic and 

Existential Therapies 

Many aspects of humanistic and existential 

approaches (including empathy, encouragement 

of affect, reflective listening, and acceptance of 

the client’s subjective experience) are useful in 

any type of brief therapy session, whether it 

involves psychodynamic, strategic, or cognitive– 

behavioral therapy. They help establish rapport 

and provide grounds for meaningful 

engagement with all aspects of the treatment 

process. 

While the approaches discussed in this 

chapter encompass a wide variety of therapeutic 

interventions, they are united by an emphasis on 

lived experience, authentic (therapeutic) 

relationships, and recognition of the subjective 

nature of human experience. There is a focus on 

helping the client to understand the ways in 

which reality is influenced by past experience, 

present perceptions, and expectations for the 

future. Schor describes the process through 

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Brief Humanistic and Existential Therapies 

which our experiences assume meaning as 

apperception (Schor, 1998). Becoming aware of 

this process yields insight and facilitates the 

ability to choose new ways of being and acting. 

For many clients, momentary circumstances 

and problems surrounding substance abuse may 

seem more pressing, and notions of integration, 

spirituality, and existential growth may be too 

remote from their immediate experience to be 

effective. In such instances, humanistic and 

existential approaches can help clients focus on 

the fact that they do, indeed, make decisions 

about substance abuse and are responsible for 

their own recovery. 

Essential Skills 

By their very nature, these models do not rely 

on a comprehensive set of techniques or 

procedures. Rather, the personal philosophy of 

the therapist must be congruent with the 

theoretical underpinnings associated with these 

approaches. The therapist must be willing and 

able to engage the client in a genuine and 

authentic fashion in order to help the client 

make meaningful change. Sensitivity to 

“teachable” or “therapeutic” moments is 

essential. 

When To Use Brief Humanistic and 

Existential Therapies 

These approaches can be useful at all stages of 

recovery in creating a foundation of respect for 

clients and mutual acceptance of the significance 

of their experiences. There are, however, some 

therapeutic moments that lend themselves more 

readily to one or more specific approaches. The 

details of the specific approaches are laid out 

later in this chapter. Client-centered therapy, for 

example, can be used immediately to establish 

rapport and to clarify issues throughout the 

session. Existential therapy may be used most 

effectively when a client is able to access 

emotional experiences or when obstacles must 

be overcome to facilitate a client’s entry into or 

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

who insists on remaining helpless to accept 

responsibility). Narrative therapy may be used 

to help the client conceptualize treatment as an 

opportunity to assume authorship and begin a 

“new chapter” in life. Gestalt approaches can 

also be used throughout therapy to facilitate a 

genuine encounter with the therapist and the 

client’s own experience. Transpersonal therapy 

can enhance spiritual development by focusing 

on the intangible aspects of human experience 

and awareness of unrealized spiritual capacity. 

These approaches increase self-awareness, 

which promotes self-esteem and allows for more 

client responsibility, thus giving the client a 

sense of control and the opportunity to make 

choices. All of these approaches can be used to 

support the goals of therapy for substance abuse 

disorders. 

Duration of Therapy and 

Frequency of Sessions 

Although many aspects of these approaches are 

found in other therapeutic orientations, concepts 

like empathy, meaning, and choice lie at the 

very heart of humanistic and existential 

therapies. They are particularly valuable for 

brief treatment of substance abuse disorders 

because they increase therapeutic rapport and 

enhance conscious experience and acceptance of 

responsibility. Episodic treatment could be 

designed within this framework, with the 

treatment plan focusing on the client’s tasks and 

experience between sessions. Humanistic and 

existential therapies assume that much growth 

and change occur outside the meetings. When 

focused on broader problems, these therapies 

can be lifelong journeys of growth and 

transformation. At the same time, focusing on 

specific substance abuse issues can provide a 

framework for change and more discrete goals. 

These techniques will also work well in 

conjunction with other types of therapy. 

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Chapter 6 

Initial Session 

The opening session is extremely important in 

brief therapy for building an alliance, 

developing therapeutic rapport, and creating a 

climate of mutual respect. Although the 

approaches discussed in this chapter have 

different ways of addressing the client’s 

problems, the opening session should attempt 

the following: 

 Start to develop the alliance 

 Emphasize the client’s freedom of choice and 

potentialIRUmeaningful change 

 Articulate expectations and goals of therapy 

(how goals are to be reached) 

Developing the alliance can be undertaken through reflective listening, demonstrating 

respect, honesty, and openness; eliciting trust 

and confidence; and applying other principles 

that emerge from these therapies. The therapist’s 

authentic manner of encountering the client can 

set the tone for an honest, collaborative 

therapeutic relationship. Emphasizing freedom 

of choice and potential for meaningful change 

may be deepened by a focus on the current 

decision (however it has been reached) to 

participate in the opening session. Expectations 

and goals can be articulated through strategic 

questions or comments like, “What might be 

accomplished in treatment that would help you 

live better” or “You now face the choice of how 

to participate in your own substance abuse 

recovery.” 

Because of time constraints inherent in 

approaches to brief substance abuse treatment, 

the early phase of therapy is crucial. Unless the 

therapist succeeds in engaging the client during 

this early phase, the treatment is likely to be less 

effective. “Engaging” includes helping the 

client increase motivation for other aspects of 

substance abuse treatment such as group 

therapy. Moreover, the patterns of interaction 

established during the early phase tend to 

persist throughout therapy. The degree of 

motivation that the client feels after the first 

session is determined largely by the degree of 

significance experienced during the initial 

therapeutic encounter. A negative experience 

may keep a highly motivated client from coming 

back, whereas a positive experience may induce 

a poorly motivated client to recognize the 

potential for treatment to be helpful. 

Compatibility of Humanistic 

And Existential Therapies and 

12-Step Programs 

Humanistic and existential approaches are 

consistent with many tenets of 12-Step 

programs. For example, existential and 

humanistic therapists would embrace the 

significance stressed by the “serenity prayer” to 

accept the things that cannot be changed, the 

courage to change what can be changed, and the 

wisdom to know the difference. However, some 

would argue against the degree to which 

Alcoholics Anonymous (AA) identifies the 

person’s “disease” as a central character trait, or 

the way in which some might interpret the 

notion of “powerlessness.” The principles of 

existentialism, free choice, and free will may 

appear incompatible with the 12-Step 

philosophy of acceptance and surrender. Yet, 

such surrender must result from conscious 

decisions on an individual’s part. The AA 

concept of rigorous self-assessment—of 

accepting one’s own personal limitations and 

continually choosing and rechoosing to act 

according to certain principles as a way of living 

life—are compatible with both existential and 

humanistic principles. 

Research Orientation 

The predominant research strategy or 

methodology in social science is rooted in the 

natural science or rational–empirical 

perspective. Such approaches generally attempt 

to identify and demonstrate causal relationships 

by isolating specific variables while controlling 

for other variables such as personal differences 

108 
Brief Humanistic and Existential Therapies 

among therapists as well as clients. For 

example, variations in behavior or outcomes are 

often quantified, measured, and subjected to 

statistical procedures in order to isolate the 

researcher from the data and ensure objectivity. 

Such strategies are particularly useful for 

investigating observable phenomena like 

behavior. Traditional approaches to 

understanding human experience and meaning, 

however, have been criticized as an insufficient 

means to understanding the lived reality of 

human experience. Von Eckartsberg noted, 

“Science aims for an ideal world of dependent 

and independent variables in their causal 

interconnectedness quite abstracted and 

removed from personal experience of the 

everyday life-world” (Von Eckartsberg, 1983, 

p. 199). Similarly, Blewett argued, “The 

importance of human experience relative to 

behavior is beyond question for experience 

extends beyond behavior just as feeling extends 

beyond the concepts of language” (Blewett, 

1969, p. 22). Thus, traditional methodological 

approaches seem ill-suited for understanding 

the meaning of human experience and the 

process by which self-understanding manifests 

itself in the context of a therapeutic relationship. 

A humanistic science or qualitative 

approach, which has its roots in 

phenomenology, is claimed to be more 

appropriate for the complexities and nuances of 

understanding human experience (Giorgi, 1985). 

The personal and unique construction of 

meaning, the importance of such subtleties as 

“the relationship” and the “fit” in therapy, and 

shifts in internal states of consciousness can be 

quantified and measured only in the broadest of 

terms. A more subtle science is required to 

describe humans and the therapeutic process. 

Rather than prediction, control, and 

replication of results, a humanistic science 

approach emphasizes understanding and 

description. Instead of statistical analysis of 

quantifiable data, it emphasizes narrative 

descriptions of experience. Qualitative 

understanding values uniqueness and 

diversity—the “little stories” (Lyotard, 1984)—as 

much as generalizability or grander 

explanations. Generally, this approach assumes 

that objectivity, such as is presumed in rational 

empirical methods, is illusory. For the 

qualitative researcher and the therapist, the 

goals are the same: openness to the other, active 

participation, and awareness of one’s own 

subjectivity, rather than illusory objectivity. 

Intersubjective dialog provides a means of 

comparing subjective experiences in order to 

find commonality and divergence as well as to 

avoid researcher bias. 

Because humanistic and existential therapies 

emphasize psychological process and the 

therapeutic relationship, alternative research 

strategies may be required in order to 

understand the necessary and sufficient 

conditions for therapeutic change. For example, 

Carl Rogers “presented a challenge to 

psychology to design new models of scientific 

investigation capable of dealing with the inner, 

subjective experience of the person” (Corey, 

1991, p. 218). Some 50 years ago, he pioneered 

the use of verbatim transcripts of counseling 

sessions and employed audio and video taping 

of sessions long before such procedures became 

standard practice in research and supervision. 

The Humanistic 

Approach to Therapy 

Humanistic psychology, often referred to as the 

“third force” besides behaviorism and 

psychoanalysis, is concerned with human 

potential and the individual’s unique personal 

experience. Humanistic psychologists generally 

do not deny the importance of many principles 

of behaviorism and psychoanalysis. They value 

the awareness of antecedents to behavior as well 

as the importance of childhood experiences and 

unconscious psychological processes. 

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Chapter 6 

Humanistic psychologists would argue, 

however, that humans are more than the 

collection of behaviors or objects of unconscious 

forces. Therefore, humanistic psychology often 

is described as holistic in the sense that it tends 

to be inclusive and accepting of various 

theoretical traditions and therapeutic practices. 

The emphasis for many humanistic therapists is 

the primacy of establishing a therapeutic 

relationship that is collaborative, accepting, 

authentic, and honors the unique world in 

which the client lives. The humanistic approach 

is also holistic in that it assumes an 

interrelatedness between the client’s 

psychological, biological, social, and spiritual 

dimensions. Humanistic psychology assumes 

that people have an innate capacity toward selfunderstanding and psychological health. 

Some of the key proponents of this approach 

include Abraham Maslow, who popularized the 

concept of “self-actualization,” Carl Rogers, who 

formulated person-centered therapy, and Fritz 

Perls, whose Gestalt therapy focused on the 

wholeness of an individual’s experience at any 

given moment. Some of the essential 

characteristics of humanistic therapy are 

 Empathic understanding of the client’s frame of 

reference and subjective experience 

 Respect for the client’s cultural values and 

freedom to exercise choice 

 Exploration of problems through an authentic 

and collaborative approach to helping the 

client develop insight, courage, and 

responsibility 

 Exploration of goals and expectations, including 

articulation of what the client wants to 

accomplish and hopes to gain from treatment 

 Clarification of the helping role by defining the 

therapist’s role but respecting the self 

determination of the client 

 Assessment and enhancement of client motivation 

both collaboratively and authentically 

 Negotiation of a contract by formally or 

informally asking, “Where do we go from 

here?” 

 Demonstration of authenticity by setting a tone 

of genuine, authentic encounter 

These characteristics may prove useful at all stages of substance abuse treatment. For 

example, emphasizing the choice of seeking help 

as a sign of courage can occur immediately; 

placing responsibility and wisdom with the 

client may follow. Respect, empathy, and 

authenticity must remain throughout the 

therapeutic relationship. Placing wisdom with 

the client may be useful in later stages of 

treatment, but a client who is currently using or 

recently stopped (within the last 30 days) may 

not be able to make reasonable judgments about 

his well-being or future. 

Each therapy type discussed below is 

distinguished from the others by how it would 

respond to the case study presented in 

Figure 6-1. 

Client-Centered Therapy 

Carl Rogers’ client-centered therapy assumes 

that the client holds the keys to recovery but 

notes that the therapist must offer a relationship 

in which the client can openly discover and test 

his own reality, with genuine understanding 

and acceptance from the therapist. Therapists 

must create three conditions that help clients 

change: 

1. Unconditional positive regard 

2. A warm, positive, and accepting attitude 

that includes no evaluation or moral 

judgment 

3. Accurate empathy, whereby the therapist 

conveys an accurate understanding of the 

client’s world through skilled, active 

listening 

According to Carson, the client-centered therapist believes that 

110 
Brief Humanistic and Existential Therapies 

Figure 6-1 

A Case Study 

This case study will be referred to throughout this chapter. It will provide an example to which each type of 

humanistic or existential therapy will be applied. 

Sandra is a 38-year-old African-American woman who has abused a number of substances, including 

cocaine, heroine, alcohol, and marijuana over the past 15 years. She left high school and was a 

prostitute for 5 years. Later she found a job as a sales clerk at a home furnishings store. Sandra had 

two children in her early twenties, a daughter who is now 15, and a son, aged 18. Because of her 

substance abuse problems, they live with other relatives who agreed to raise them. Sandra has been in 

treatment repeatedly and has remained substance free for the last 5 years, with several minor relapses. 

She has been married for 2 years, to Steve, a carpenter; he is substance free and supports her attempts 

to stay away from substances. 

Last month she became symptomatic with AIDS. She has been HIV-positive for 5 years but had not 

developed any illnesses related to the disease. Sandra has practiced safe sex with her husband who 

knew of her HIV status. Recently, after learning from the physician at her clinic about her HIV 

symptoms, she began to “shoot up,” which led her back into treatment. Out of fear, she came to the 

treatment center and asked to see a counselor at the clinic one day after work. She is worried about her 

marriage and that her husband will be devastated by this news. She is afraid she is no longer strong 

enough to stay away from drugs since discovering the onset of AIDS. She is also concerned about her 

children and her job. Uncertain of how she will keep on living, she is also terrified of dying. 

 Each individual exists in a private world of 

experience in which the individual is the 

center. 

 The most basic striving of an individual is 

toward the maintenance, enhancement, and 

actualization of the self. 

 An individual reacts to situations in terms of 

the way he perceives them, in ways 

consistent with his self-concept and view of 

the world. 

 An individual’s inner tendencies are toward 

health and wholeness; under normal 

conditions, a person behaves in rational and 

constructive ways and chooses pathways 

toward personal growth and selfactualization (Carson, 1992). 

A client-centered therapist focuses on the client’s self-actualizing core and the positive 

forces of the client (i.e., the skills the client has 

used in the past to deal with certain problems). 

The client should also understand the 

unconditional nature of the therapist’s 

acceptance. This type of therapy aims not to 

interpret the client’s unconscious motivation or 

conflicts but to reflect what the client feels, to 

overcome resistance through consistent 

acceptance, and to help replace negative 

attitudes with positive ones. 

Rogers’ techniques are particularly useful for 

the therapist who is trying to address a 

substance-abusing client’s denial and motivate 

her for further treatment. For example, the 

techniques of motivational interviewing draw 

heavily on Rogerian principles (see TIP 35, 

Enhancing Motivation for Change in Substance 

Abuse Treatment [CSAT, 1999c], for more 

information on motivational interviewing). 

Response to the case study 

A client-centered therapist would engage in 

reflective listening, accepting the client and her 

past, and clarifying her current situation and 

feelings. As Sandra developed trust in the 

therapist, he would begin to emphasize her 

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Chapter 6 

positive characteristics and her potential to 

make meaningful choices to become the person 

she wants to (and can) become. Another goal of 

therapy would be to help her develop sufficient 

insight so that she can make choices that reflect 

more closely the values and principles to which 

she aspires. For example, she may want to tell 

her husband about her symptoms and try to 

strengthen her marriage. 

If Sandra began to feel guilt about her past as 

a prostitute, the therapist would demonstrate 

appreciation of her struggle to accept that aspect 

of herself, highlighting the fact that she did 

eventually choose to leave it. He may note that 

she did the best she could at that time and 

underscore her current commitment to choose a 

better life. Sandra would be supported and 

accepted, not criticized. She would be 

encouraged to express her fear of death and the 

effect this fear has on her. This might be the first 

time in her life that someone has been 

unconditionally accepting of her or focused on 

her strengths rather than her failings. She 

apparently has the ability to solve problems, 

which is reflected by her return to therapy and 

her insight about needing help. By being 

understood and accepted, her self-esteem and 

sense of hope would increase and her shame 

would decrease. She would feel supported in 

making critical choices in her life and more 

confident to resume her recovery. 

Narrative Therapy 

Narrative therapy emerges from social 

constructivism, which assumes that events in 

life are inherently ambiguous, and the ways in 

which people construct meaning are largely 

influenced by family, culture, and society. 

Narrative therapy assumes that people’s lives, 

including their relationships, are shaped by 

language and the knowledge and meaning 

contained in the stories they hear and tell about 

their lives. Recent approaches to understanding 

psychological growth have emphasized using 

storytelling and mythology to enhance selfawareness (see Campbell, 1968; Feinstein and 

Krippner, 1997; Middelkoop, 1989). 

Parker and Horton argue that “Studies in a 

variety of disciplines...have suggested that all 

cognition is inherently metaphorical” and note 

“the vital role that symbolism plays in 

perception” (Parker and Horton, 1996, p. 83). 

The authors offer the “perspective that the 

universe is made up of stories rather than 

atoms” and suggest, “Myth and ritual are 

vehicles through which the value-impregnated 

beliefs and ideas that we live by, and for, are 

preserved and transmitted” (p. 82). From this 

perspective, narratives reveal a deeper truth 

about the meanings of our experience than a 

factual account of the events themselves. As 

Feinstein and Krippner note, “Personal 

mythologies give meaning to the past, 

understanding to the present, and direction to 

the future” (Feinstein and Krippner, 1997, p. 

138). 

When people tell and retell their life stories 

(with the help of a therapist), the stories evolve 

into increasingly meaningful and healing 

constructions. As narrative therapists listen to 

the stories clients tell, they assist them by 

identifying alternative ways of understanding 

events in their lives. Thus, they help clients to 

assume authorship of their lives in order to 

rewrite their stories by breaking patterns and 

developing new solutions. Narrative therapy 

helps clients resolve their problems by 

 Helping them become aware of how events 

in their lives have assumed significance 

 Allowing them to distance themselves from 

impoverishing stories by giving new 

meaning to their past 

 Helping them to see the problem of 

substance abuse as a separate, influential 

entity rather than an inseparable part of who 

they are (note the discrepancy between this 

and the AA member’s statement, “My name 

is Jane, and I am an alcoholic”) 

112 
 Collaboratively identifying exceptions to selfdefeating patterns 

 Encouraging them to challenge destructive 

cultural influences they have internalized 

 Challenging clients to rewrite their own lives 

according to alternative and preferred scripts 

Narrative therapy can be a powerful approach for engaging clients in describing their 

lives and providing them with opportunities to 

gain insight into their life stories and to change 

those “scripts” they find lacking. Storytelling is 

a way of articulating a subjective, experiential 

truth, and it is important for the therapist and 

client to become aware of the significance of the 

story being told and its potential therapeutic 

value. 

Narrative approaches to psychological 

healing have been used across various cultures 

for thousands of years (Katz, 1993), but they 

have often been overlooked by mainstream 

mental health professionals. Contemporary 

approaches to narrative therapy recognize the 

importance of understanding how human 

experience becomes meaningful. A person’s life 

is influenced by the narratives he constructs, 

which are in turn influenced by the narratives of 

those around him. Thus, therapy is viewed as a 

collaborative attempt to increase clients’ 

awareness of the ways in which events in their 

lives become significant. In effect, the therapist 

says, “Let’s be curious about your story 

together.” 

The narrative approach often involves posing 

questions in a way that situates the problem as 

an external influence. “When the problem is 

externalized, it’s as if the person can peek out 

from behind it” (Nichols and Schwartz, 1998, p. 

412). In substance abuse treatment, for example, 

a client might be asked, “How has substance 

abuse influenced your life?” or “Have there 

been times when you did not allow addiction to 

take over?” Such questions can help identify 

positive aspects and potential resources 

occurring in people’s narratives that can be 

Brief Humanistic and Existential Therapies 

enhanced, as well as deficits that must be 

overcome. 

In an effort to be understood, clients 

sometimes tell a story as a way of educating the 

therapist to their culture or lifestyle. Therefore, 

it is essential for the therapist to appreciate the 

unique influences (positive and negative) of the 

client’s specific cultural experiences and 

identity. Often these stories do not constitute 

sharing in its usual meaning. When listening to 

them, one may sense that these stories have been 

told repeatedly over the years. It is through this 

sense of storytelling—as oral history—that we 

reveal our values, expectations, hopes, and fears. 

For the therapist, a story provides insight into 

the clients’ responses, their need to act on the 

responses, and their desire to be heard or 

understood. A story can become a way for a 

client to become both participant and observer 

in order to find new solutions or break down 

barriers. 

Response to the case study 

The therapist may initially ask Sandra to 

describe some of the important transitional 

moments in her life. These may include 

examples of loss of innocence occurring early in 

her life, her experience of school, circumstances 

and influences surrounding prostitution and 

drug use, the experience of being supported by 

her husband, and internal resources that 

enabled her to enter treatment and maintain 

sobriety. The therapist would ask questions 

about expectations she felt from family, society, 

and herself. She may be asked questions like, 

“How did addiction interfere with your 

attempts to be a good mother” or “How has fear 

contributed to your recent relapse and feelings 

of hopelessness?” Positive aspects of her story 

and exceptions to destructive aspects of her 

narrative could be identified by asking 

questions like, “Were there times that you didn’t 

allow addiction to make choices for you?” and 

“How has your ability to accept love and 

support from your husband helped you?” 

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Chapter 6 

The focus of therapeutic dialog could then 

shift toward developing alternatives to hopeless 

aspects of personal and cultural expectations. It 

would be helpful to remind her that recent 

advances in medical treatments mean that AIDS 

may not be the death sentence it was once 

thought to be. Other important questions can 

help her to begin to create an alternative story: 

“As you begin to understand the positive and 

negative influences in your life, what qualities 

must you possess in order to remain sober and 

develop better relationships with your husband 

and children?” She may need help replacing 

these stories with more positive narratives about 

herself. As Sandra talks about the people and 

events in her life, such as her childhood and her 

children, she can discover some of her feelings, 

as well as the personal meaning in her story. 

She can experience a great deal of healing 

through the therapist’s feedback and questions 

that uncover the desires and emotions beneath 

her story. A continued focus on identifying, 

practicing, or even imagining changes in her 

story can begin the process of developing new 

ways of living. 

Transpersonal Therapy 

Transpersonal psychology emerged as a “fourth 

force” in psychology in the late 1960s and has 

strong roots in humanistic and existential 

psychologies, Jungian analysis, the East–West 

dialog, and ancient wisdom traditions. 

Transpersonal therapy may be thought of as a 

bridge between psychological and spiritual 

practice. 

A transpersonal approach emphasizes 

development of the individual beyond, but 

including, the ego. It acknowledges the human 

spiritual quest and recognizes the human 

striving for unity, ultimate truth, and profound 

freedom. It cultivates intuitive ways of knowing 

that complement rational and sensory modes. 

This approach also recognizes the potential for 

growth inherent in “peak” experiences and 

other shifts in consciousness. Although 

grounded in psychological theory, transpersonal 

practitioners also tend to incorporate 

perspectives from ancient wisdom traditions. 

The practice of transpersonal therapy is 

defined more by its orientation and scope rather 

than by a particular set of techniques or 

methods (Boorstein, 1980). Wittine suggests five 

postulates for a transpersonal psychotherapy 

(Wittine, 1989): 

1. Transpersonal psychotherapy is an 

approach to healing and growth that 

recognizes the centrality of the self in the 

therapeutic process. 

2. Transpersonal psychotherapy values 

wholeness of being and self-realization on 

all levels of the spectrum of identity (i.e., 

egoic, existential, transpersonal). 

3. Transpersonal psychotherapy is a process of 

awakening from a limited personal identity 

to expanded universal knowledge of self. 

4. Transpersonal psychotherapy makes use of 

the healing restorative nature of subjective 

awareness and intuition in the process of 

awakening. 

5. In transpersonal psychotherapy, the 

therapeutic relationship is a vehicle for the 

process of awakening in both client and 

therapist. 

Integrating insights and practices in 

everyday life is the goal of every therapy. 

Bringing the transpersonal dimension to the 

forefront may involve the following: 

 Exploration of “inner voices” including those 

of a higher self that provides guidance for 

growth of the individual (Rowan, 1993) 

 Refinement of intuition or nonrational 

knowing 

 Practice of creativity in “formal” (art) or 

informal (personal relationships) encounters 

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Brief Humanistic and Existential Therapies 

 Meditation 

 Loving service 

 Cultivation of mindfulness 

 Use of dreams and imagery 

These techniques may be taught and 

supported explicitly in the therapy session. At 

times, a therapist may directly cultivate shifts in 

consciousness (e.g., through meditation [Weil, 

1972], or imaginal work [Johnson, 1987]), 

providing immediate insight and inspiration 

that may not be available through more 

conventional means (Hart, 1998). This may 

provide clients with a skill they can practice on 

their own; initiating such activity represents a 

potential for brief intervention. 

Transpersonal therapy recognizes the need 

for basic psychological development to be 

integrated with spiritual growth (Nelson, 1994). 

Without such integration there is danger of 

“spiritual bypassing,” where issues of basic 

psychological functioning are avoided in the 

name of spiritual development. In other words, 

the basic psychological work should be 

undertaken first. 

Substance abuse disorders may be seen 

broadly as an attempt to fill a spiritual void. 

They may also be understood as a means for the 

ego to defend itself against a natural drive for 

growth. If growth were to occur, the ego might 

find its dominance relinquished. Addiction, like 

spirituality, also raises questions of surrender 

(May, 1991): for example, to what and to whom 

do we surrender? In a culture and a psychology 

that are dominated by issues of rational ego 

control, what is the role of constructive 

surrender (regularly described in spiritual 

traditions)? How does constructive surrender 

become destructive and distorted in substance 

dependency? In addition, substance abuse may 

be understood as a means for shifting out of a 

normal waking state of consciousness. This may 

be an attempt to fulfill an innate drive (Weil, 

1972) for nonrational consciousness. 

Response to the case study 

As the existentialists remind us, there is nothing 

like death to rivet our attention. A glimpse of 

death—for example, seeing the aftermath of a 

serious car crash—reminds the witness of how 

valuable life is, bringing up other issues as well. 

Sandra is now confronted with death due to 

AIDS. This opportunity to face death and life 

squarely provides a chance to reconsider and 

reprioritize her life. In fact, it could be argued 

that the best catalyst to brief therapy may be a 

death sentence precisely because it has the 

potential to wake up an individual. In many 

respects, helping the client wake from habitual, 

mechanical routines that are often based on ego 

protection and move toward an appreciation 

that the individual is not bound to or defined by 

a limited ego, is the goal of transpersonal 

therapy. This can be seen as a transformation of 

identity. 

Many inspiring instances of people facing 

death, including death through AIDS, have 

shown that emergent spirituality can change the 

quality and direction of existence very quickly. 

For treatment, the basic sharing of these 

experiences with a group of others in a similar 

predicament often quickly moves the client 

beyond isolation and a sense of self-separateness 

to connect intimately with others who 

understand her situation. This community may 

not only bring comfort and support but also a 

deep sense of communion with humanity. In 

this instance, breaking through the shell of 

isolation may enable Sandra to begin to make 

new connections with her family and with 

herself. A sense of interconnection, a central 

postulate and experience in the wisdom 

traditions, may replace her perceived isolation. 

Sandra may use this opportunity of facing 

possible death to begin to encounter and let go 

of such feelings as guilt, shame, disappointment, 

and anger that have kept her life less satisfying 

than it could be. Accessing the imaginal 

through art or dreams, for example, can provide 

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Chapter 6 

a clear and symbolic expression of unresolved 

issues. The use of rituals or rites-of-passage 

inspired by the wisdom traditions can provide 

some catalyst for shifting her consciousness 

through forgiveness and release. 

The therapist may engage in a wide variety 

of methods (e.g., imagery, art, or dream work, 

meditation, rituals), but the heart of the work is 

in the simple and humane spirituality that is 

embodied by the therapist’s loving presence 

along with the therapist’s openness to explore 

the full range of human experience directly. For 

Sandra, this experience may be seen as an 

opportunity for practicing love and forgiveness, 

moving out from behind rigid self-separateness, 

facing fears, and transforming her selfdefinition. 

Gestalt Therapy 

Gestalt theory holds that the analysis of parts 

can never provide an understanding of the 

whole. In a therapeutic setting, this approach 

opposes the notion that human beings can be 

understood entirely through a rational, 

mechanistic, scientific process. The proponents 

of Gestalt therapy insist that the experiential 

world of a client can be understood only 

through that individual’s direct experience and 

description. Gestalt therapists seek to help their 

clients gain awareness of themselves and the 

world. Discomfort arises from leaving elements 

and experiences of the psyche incomplete— 

primarily past relationships and intrapsychic 

conflicts that are unresolved, which Perls calls 

“unfinished business” (Perls, 1969). According 

to Gestalt theory 

 The organism should be seen as a whole 

(physical behavior is an important 

component, as is a client’s mental and 

emotional life). 

 Being in the “here and now” (i.e., being 

aware of present experience) is of primary 

importance. 

 How is more important than why (i.e., causes 

are not as important as results). 

 The individual’s inner experience is central. 

For Gestalt therapists the “power is in the 

present” (Polster and Polster, 1973). This means 

that the “now” is the only place where 

awareness, responsibility, and change can occur. 

Therefore, the process of therapy is to help the 

client make contact with the present moment. 

Rather than seeking detailed intellectual 

analysis, the Gestalt therapist looks to create a 

“safe emergency” in the therapeutic encounter. 

Perls’ invocation to “lose your mind and come 

to your senses” implies that a feeling-level, 

“here and now” experience is the optimal 

condition for therapeutic work. This may be 

accomplished in a fairly short amount of time by 

explicitly asking clients to pay attention (e.g., 

“What are you aware of now? How does your 

fear feel to you?”). The therapist may point out 

how the client could be avoiding the present 

moment through inauthentic “games” or ways 

of relating such as “talking about” feelings 

rather than experiencing them directly. Clients 

may be asked to exaggerate certain expressions 

(e.g., pounding a fist) or role-play certain 

internal dialogs (e.g., through an empty chair 

technique). These may all serve the goal of 

helping clients move into the immediacy of their 

experience rather than remaining distant from it 

through intellectualization or substance abuse. 

The term contact in Gestalt refers to meeting 

oneself and what is other than oneself. Without 

appropriate contact and contact boundaries 

there is no real meeting of the world. Instead, 

one remains either engulfed by the world on one 

hand or, on the other hand, distant from the 

world and people. 

Substance abuse interrupts the flow of what 

Perls called “organismic self-regulation.” The 

result is that individuals do not achieve 

satisfaction of their needs and can remain 

unaware of what their needs are. The substance 

116 
Brief Humanistic and Existential Therapies 

abuser may distort or thwart the natural cycle at 

any of the following points: 

 Experiencing the need 

 Mobilization of energy 

 Contact 

 Satisfaction 

 Withdrawal 

 Rest 

Treatment involves bringing awareness to 

each of these dimensions and the client’s 

strategies of avoidance. 

Substance abuse may also be understood as 

“introjection” in which the client attempts to 

“swallow whole” or “drink in” his environment 

without contact and discrimination. This type of 

client bypasses and blocks other experiences 

that might enable contact and the development 

of discrimination. Perls maintains that such a 

client seeks immediate confluence without 

preparatory contact. This pattern of interaction 

extends to other relationships (besides the 

substance) as well. 

In order for this work to proceed, the 

therapist must maintain a fine-tuned, presentmoment immediacy, even serving as a 

“resonance chamber” (Polster and Polster, 1973) 

for the client’s experience. They, too, must be 

able to make and sustain contact with the client 

and with their own reactions. 

Response to the case study 

The Gestalt therapist begins with Sandra’s 

current experience of the world, starting with 

awareness and attention. The therapist may 

simply help her become aware of basic sights, 

sounds, somatic reactions, feelings, and 

thoughts as well as what her attention drifts to. 

The immediate contact between therapist and 

client is a component of the “now” where these 

sensations are explored directly. The therapist 

might notice and ask about her style of eye 

contact, or her fidgeting body, or stream of 

thoughts (e.g., “What is it like to make eye 

contact now? What is the sensation in your 

body at this moment?”). 

Sandra may also identify certain issues such 

as substance abuse, relationship difficulties, and 

the threat of death from AIDS that seem to 

dominate her life. The therapist might invite her 

to name and explore the sensation that the 

thought of death, for example, brings; perhaps 

this involves a sense of a void, or feeling cold 

and dark, or a feeling of engulfment. She then 

may be asked to become these sensations—for 

example, the therapist may ask her to be “the 

void” and encourage her to speak as if she were 

that void. This may then open possibilities for a 

dialog with the void through acting out the 

opposite polarity: separateness and choice. This 

might involve using an empty chair technique in 

which the client would literally move into the 

chair of the “void,” speak as if she were that, 

and then move into an opposite chair and 

respond in a dialog. A therapist could also 

explore her introjection through questions such 

as, “How is this void different or the same as 

from the feeling of alcohol or in relationships 

with your children or husband?” She might also 

use this same technique to dialog with family 

members, or certain aspects of herself. 

Sandra seems to have a great deal of 

“unfinished business” that involves 

unexpressed feelings (e.g., anger, longing, hurt). 

Experimentation with these sensations may 

begin to free her to express and meet these 

feelings more directly. All of this work 

encourages Sandra’s experimentation with new 

ways of relating both during and outside of the 

session in order to move into the “here and 

now” and work toward the resolution of 

“unfinished business.” 

The Existential Approach 

To Therapy 

The existential approach to therapy emphasizes 

the following six propositions: 

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Chapter 6 

1. All persons have the capacity for selfawareness. 

2. As free beings, everyone must accept the 

responsibility that comes with freedom. 

3. Each person has a unique identity that can 

only be known through relationships with 

others. 

4. Each person must continually recreate 

himself. The meaning of life and of 

existence is never fixed; rather, it constantly 

changes. 

5. Anxiety is part of the human condition. 

6. Death is a basic human condition that gives 

significance to life. 

The core question addressed in existential therapy is “How do I exist?” in the face of 

uncertainty, conflict, or death. An individual 

achieves authenticity through courage and is 

thus able to define and discover his own 

meaning in the present and the future. There 

are important choices to be made (e.g., to have 

true freedom and to take responsibility for one’s 

life, one must face uncertainty and give up a 

false sense of security). 

A core characteristic of the existential view is 

that an individual is a “being in the world” who 

has biological, social, and psychological needs. 

Being in the world involves the physical world, 

the world of relationships with others, and one’s 

own relationship to self (May and Yalom, 1995, 

p. 265). The “authentic” individual values 

symbolization, imagination, and judgment and 

is able to use these tools to continually create 

personal meaning. 

Existential therapy focuses on specific 

concerns rooted in the individual’s existence. 

The contemporary existential psychotherapist, 

Irvin Yalom, identifies these concerns as death, 

isolation, freedom, and emptiness. Existential 

therapy focuses on the anxiety that occurs when 

a client confronts the conflict inherent in life. 

The role of the therapist is to help the client 

focus on personal responsibility for making 

decisions, and the therapist may integrate some 

humanistic approaches and techniques. Yalom, 

for example, perceives the therapist as a “fellow 

traveler” through life, and he uses empathy and 

support to elicit insight and choices. He 

strongly believes that because people exist in the 

presence of others, the relational context of 

group therapy is an effective approach (Yalom, 

1980). 

Preliminary observations and research 

indicate individuals with low levels of perceived 

meaning in life may be prone to substance abuse 

as a coping mechanism. Frankl first observed 

this possibility among inpatient drug abusers in 

Germany during the 1930s (Frankl, 1959). 

Nicholson and colleagues found inpatient drug 

abusers had significantly lower levels of 

meaning in life when compared to a group of 

matched, nonabusing control subjects 

(Nicholson et al., 1994). Shedler and Block 

performed a longitudinal study and found that 

lower levels of perceived life meaning among 

young children preceded substance abuse 

patterns in adolescence (Shedler and Block, 

1990). 

In the context of treating substance abuse 

disorders, the existential therapist often serves 

as a coach helping the client confront the anxiety 

that tempts him to abuse substances. The client 

is then focused on taking responsibility and 

making his own choices to remain substance 

free. If he chooses to avoid the anxiety through 

substances, he cannot move forward to find 

truth and authenticity. The challenge for the 

existential therapist is to help the client make 

personal decisions about how to live, drawing 

upon creativity and love, instead of letting 

outside events determine behavior. 

Time and Existential Therapy 

Although existential therapy may not have been 

designed for practice in a time-limited fashion, 

its underlying principles relating to the client’s 

struggle for meaning in the face of death can be 

applied to a time-limited setting. Brief therapy 

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Brief Humanistic and Existential Therapies 

(no matter what the modality) must be 

concerned with the “here and now.” Both 

existential and brief therapies are also concerned 

with the limitations of time. Hoyt suggests that 

in brief therapy time should always be an issue 

for discussion, and the therapist should make a 

point of reminding the client of his use of time 

and the time scheduled for terminating therapy 

(Hoyt, 1995). 

Mann’s model of time-limited psychotherapy 

(Mann, 1973; Mann and Goldman, 1994), 

although based in part on psychodynamic 

theory, also uses an existential approach to the 

primacy of time. In Mann’s approach, the time 

limitation of brief therapy is emphasized to help 

the client confront issues of separateness and 

isolation. This facilitates the client’s becoming 

engaged in and responsible for the process of 

recovery. 

Response to the case study 

An existential therapist may help Sandra 

understand that her diagnosis of AIDS forces 

her to confront the possibility of death and, 

consequently, face the responsibilities thrust 

upon her by life. The therapist could accomplish 

this by helping her understand that her life (like 

everyone else’s) is finite. Therefore, she is 

challenged to forge meaning from her life and 

make difficult decisions about her relationships 

and ways of dealing (or not dealing) with 

choices about substance abuse. The focus in her 

therapy would be on choosing the life she wants 

to live. The therapist would assist her in dealing 

constructively with anxiety so that she can find 

meaning in the rest of her life. This could be 

accomplished by engaging her in the struggle to 

assume authorship of her choices. She may be 

encouraged to “play out” scenarios of choices 

she faces and acknowledge the accompanying 

fears and anxieties. She might be asked, “What 

keeps you from sharing your fears with your 

husband, and accepting the possibility of his 

support?” or “Imagine yourself expressing your 

love for your children and regret for the 

mistakes you have made.” Thus, the therapist 

would help her understand that making difficult 

choices in the face of death is actually a way to 

find integrity, wholeness, and meaning. 

The teachings of the existential therapist, 

Yalom, can be a useful resource in dealing with 

issues related to death, since he has worked with 

terminally ill cancer patients for many years, 

helping them to use their crisis and their danger 

as an opportunity for change (Yalom, 1998). 

Yalom explains that although death is a primary 

source of anxiety for a client, incorporating 

death into life can enrich life and allow one to 

live more purposefully. 

119 

7 Brief Psychodynamic Therapy

Psychodynamic therapy focuses on 

unconscious processes as they are 

manifested in the client’s present 

behavior. The goals of psychodynamic therapy 

are client self-awareness and understanding of 

the influence of the past on present behavior. In 

its brief form, a psychodynamic approach 

enables the client to examine unresolved 

conflicts and symptoms that arise from past 

dysfunctional relationships and manifest 

themselves in the need and desire to abuse 

substances. 

Several different approaches to brief 

psychodynamic psychotherapy have evolved 

from psychoanalytic theory and have been 

clinically applied to a wide range of 

psychological disorders. A growing body of 

research supports the efficacy of these 

approaches (Crits-Christoph, 1992; Messer and 

Warren, 1995). 

Short-term psychodynamic therapies can 

contribute to the armamentarium of treatments 

for substance abuse disorders. Brief 

psychodynamic therapies probably have the 

best chance to be effective when they are 

integrated into a relatively comprehensive 

substance abuse treatment program that 

includes drug-focused interventions such as 

regular urinalysis, drug counseling, and, for 

opioid-dependents, methadone maintenance 

pharmacotherapy. Brief psychodynamic 

therapies are perhaps more helpful after 

abstinence is well established. They may be 

more beneficial for clients with no greater than 

moderate severity of substance abuse. It is also 

important that the psychodynamic therapist 

know about the pharmacology of abused drugs, 

the subculture of substance abuse, and 12-Step 

programs. 

Psychodynamic therapy is the oldest of the 

modern therapies. As such, it is based in a 

highly developed and multifaceted theory of 

human development and interaction. This 

chapter demonstrates how rich it is for 

adaptation and further evolution by 

contemporary therapists for specific purposes. 

The material presented in this chapter provides 

a quick glance at the usefulness and the complex 

nature of this type of therapy. 

Background 

The theory supporting psychodynamic therapy 

originated in and is informed by psychoanalytic 

theory. There are four major schools of 

psychoanalytic theory, each of which has 

influenced psychodynamic therapy. The four 

schools are: Freudian, Ego Psychology, Object 

Relations, and Self Psychology. 

Freudian psychology is based on the theories 

first formulated by Sigmund Freud in the early 

part of this century and is sometimes referred to 

as the drive or structural model. The essence of 

Freud’s theory is that sexual and aggressive 

energies originating in the id (or unconscious) 

are modulated by the ego, which is a set of 

functions that moderates between the id and 

external reality. Defense mechanisms are 

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Chapter 7 

constructions of the ego that operate to 

minimize pain and to maintain psychic 

equilibrium. The superego, formed during 

latency (between age 5 and puberty), operates to 

control id drives through guilt (Messer and 

Warren, 1995). 

Ego Psychology derives from Freudian 

psychology. Its proponents focus their work on 

enhancing and maintaining ego function in 

accordance with the demands of reality. Ego 

Psychology stresses the individual’s capacity for 

defense, adaptation, and reality testing (Pine, 

1990). 

Object Relations psychology was first 

articulated by several British analysts, among 

them Melanie Klein, W.R.D. Fairbairn, D.W. 

Winnicott, and Harry Guntrip. According to 

this theory, human beings are always shaped in 

relation to the significant others surrounding 

them. Our struggles and goals in life focus on 

maintaining relations with others, while at the 

same time differentiating ourselves from others. 

The internal representations of self and others 

acquired in childhood are later played out in 

adult relations. Individuals repeat old object 

relationships in an effort to master them and 

become freed from them (Messer and Warren, 

1995). 

Self Psychology was founded by Heinz 

Kohut, M.D., in Chicago during the 1950s. 

Kohut observed that the self refers to a person’s 

perception of his experience of his self, 

including the presence or lack of a sense of selfesteem. The self is perceived in relation to the 

establishment of boundaries and the 

differentiations of self from others (or the lack of 

boundaries and differentiations). “The 

explanatory power of the new psychology of the 

self is nowhere as evident as with regard to...the 

addictions” (Blaine and Julius, 1977, p. vii). 

Kohut postulated that persons suffering from 

substance abuse disorders also suffer from a 

weakness in the core of their personalities—a 

defect in the formation of the “self.” Substances 

appear to the user to be capable of curing the 

central defect in the self. 

[T]he ingestion of the drug provides him with 

the self-esteem which he does not possess. 

Through the incorporation of the drug, he 

supplies for himself the feeling of being 

accepted and thus of being self-confident; or 

he creates the experience of being merged with 

the source of power that gives him the feeling 

of being strong and worthwhile (Blaine and 

Julius, 1977, pp. viiviii). 

Each of the four schools of psychoanalytic 

theory presents discrete theories of personality 

formation, psychopathology formation, and 

change; techniques by which to conduct 

therapy; and indications and contraindications 

for therapy. Psychodynamic therapy is 

distinguished from psychoanalysis in several 

particulars, including the fact that 

psychodynamic therapy need not include all 

analytic techniques and is not conducted by 

psychoanalytically trained analysts. 

Psychodynamic therapy is also conducted over a 

shorter period of time and with less frequency 

than psychoanalysis. 

Several of the brief forms of psychodynamic 

therapy are considered less appropriate for use 

with persons with substance abuse disorders, 

partly because their altered perceptions make it 

difficult to achieve insight and problem 

resolution. However, many psychodynamic 

therapists work with substance-abusing clients, 

in conjunction with traditional drug and alcohol 

treatment programs or as the sole therapist for 

clients with coexisting disorders, using forms of 

brief psychodynamic therapy described in more 

detail below. 

Introduction to Brief 

Psychodynamic Therapy 

The healing and change process envisioned in 

long-term psychodynamic therapy typically 

requires at least 2 years of sessions. This is 

because the goal of therapy is often to change an 

122 
aspect of one’s identity or personality or to 

integrate key developmental learning missed 

while the client was stuck at an earlier stage of 

emotional development. 

Practitioners of brief psychodynamic therapy 

believe that some changes can happen through a 

more rapid process or that an initial short 

intervention will start an ongoing process of 

change that does not need the constant 

involvement of the therapist. A central concept 

in brief therapy is that there should be one major 

focus for the therapy rather than the more 

traditional psychoanalytic practice of allowing 

the client to associate freely and discuss 

unconnected issues (Malan, 1976). In brief 

therapy, the central focus is developed during 

the initial evaluation process, occurring during 

the first session or two. This focus must be 

agreed on by the client and therapist. The 

central focus singles out the most important 

issues and thus creates a structure and identifies 

a goal for the treatment. In brief therapy, the 

therapist is expected to be fairly active in 

keeping the session focused on the main issue. 

Having a clear focus makes it possible to do 

interpretive work in a relatively short time 

because the therapist only addresses the 

circumscribed problem area. When using brief 

psychodynamic approaches to therapy for the 

treatment of substance abuse disorders, the 

central focus will always be the substance abuse 

in association with the core conflict. Further, the 

substance abuse and the core conflict will 

always be conceptualized within an 

interpersonal framework. 

The number of sessions varies from one 

approach to another, but brief psychodynamic 

therapy is typically considered to be no more 

than 25 sessions (Bauer and Kobos, 1987). CritsChristoph and Barber included models allowing 

up to 40 sessions in their review of short-term 

dynamic psychotherapies because of the 

divergence in the scope of treatment and the 

types of goals addressed (Crits-Christoph and 

Brief Psychodynamic Therapy 

Barber, 1991). For example, some brief 

psychodynamic models focus mainly on 

symptom reduction (Horowitz, 1991), while 

others target the resolution of the Oedipal 

conflict (Davanloo, as interpreted by Laikin et 

al., 1991). The length of therapy is usually 

related to the ambitiousness of the therapy 

goals. Most therapists are flexible in terms of 

the number of sessions they recommend for 

clinical practice. Often the number of sessions 

depends on a client’s characteristics, goals, and 

the issues deemed central by the therapist. 

Psychodynamic 

Psychotherapy for 

Substance Abuse 

Supportive-expressive (SE) psychotherapy 

(Luborsky, 1984) is one brief psychodynamic 

approach that has been adapted for use with 

people with substance abuse disorders. It has 

been modified for use with opiate dependence 

in conjunction with methadone maintenance 

treatment (Luborsky et al., 1977) and for cocaine 

use disorders (Mark and Faude, 1995; Mark and 

Luborsky, 1992). There have been many studies 

of the use of SE therapy for substance abuse 

disorders, resulting in a significant body of 

empirical data on its effectiveness in treating 

these problems (see below). 

Mark and Faude asserted that although their 

therapeutic approach was devised specifically 

for cocaine-dependent clients, these people often 

have multiple dependencies, and this approach 

can be used to treat a variety of substance abuse 

disorders. However, clients should be 

reasonably stable in terms of their substance 

abuse before beginning this type of therapy 

(Mark and Faude, 1995). 

Mark and Faude theorized that substances of 

abuse substitute a “chemical reaction” in place 

of experiences and that these chemically 

induced experiences can block the impact of 

123 
Chapter 7 

other external events. The person with a 

substance abuse disorder will therefore have a 

“tremendously impoverished and impaired 

capacity to experience,” and traditional 

psychotherapy might have to be augmented 

with techniques that focus on increasing a 

client’s ability to experience (Mark and Faude, 

1995, p. 297). 

Effective SE therapy depends on appropriate 

use of what is termed the core conflictual 

relationship theme (CCRT), a concept first 

introduced by Lester Luborsky. According to 

Luborsky, a CCRT is at the center of a person’s 

problems. The CCRT develops from early 

childhood experiences, but the client is unaware 

of it and how it developed. It is assumed that 

the client will have better control over behavior 

if he knows more about what he is doing on an 

unconscious level. This knowledge is acquired 

by better understanding of childhood 

experiences (Bohart and Todd, 1988). The CCRT 

develops out of a core response from others (RO), 

which represents a person’s predominant 

expectations or experiences of others’ internal 

and external reactions to herself, and a core 

response of the self (RS), which refers to a more or 

less coherent combination of somatic 

experiences, affects, actions, cognitive style, selfesteem, and self-representations. 

Most people with substance abuse disorders 

have particularly negative expectations of 

others’ attitudes toward them (that is, the RO), 

although it remains unclear which came first— 

this response or the substance abuse disorder. 

Either way, the two become mutually 

reinforcing. Following are examples of 

statements that reflect the core RO of a person 

with a substance abuse disorder: 

 “Everybody hates me.” 

 “I am just being used.”

 “People laugh at me.” 

 “No one understands how I feel.” 

 “Everybody wants me to be something I’m 

not.” 

 “They’re just waiting for me to make a fool of 

myself.” 

For many people with substance abuse 

disorders, alcohol or drug use is a way of selfmedicating against feelings of low self-worth 

and low self-esteem that reflect the client’s RS. 

A negative RO reinforces a negative RS and can 

lead to the deceptive and manipulative behavior 

that is sometimes observed in this population. 

The client’s RS is based on the individual’s 

somatic experiences, actions, and perceived 

needs. Following are examples of statements 

that could reflect a client’s core RS: 

 “I’m so stupid and gullible.” 

 “I can’t do anything right.” 

 “If I didn’t use drugs, I would lose my 

mind.” 

 “I can’t help myself.” 

 “I’m not a very nice or honest person.” 

A third component of CCRT is a person’s 

wish; it reflects what the client yearns for, wishes 

for, or desires. The client’s “wish” is largely 

based on individual personality style. Those 

with substance abuse disorders often have a 

wish to continue using the substance without 

having to endure the consequences. Put another 

way, they would like to be accepted (or loved or 

appreciated) as they are, without having to give 

up the pleasure they get from their use 

(Levenson et al., 1997). Many people who have 

substance abuse disorders have much invested 

in denying that they really have a problem, in 

portraying themselves as helpless victims, and 

in disclaiming their role in the behavior that has 

brought them into treatment. 

Once therapy has been initiated, the therapist 

and client can work together to put the client’s 

goals into the CCRT framework and explore the 

meaning, function, and consequence of her 

substance abuse, looking in particular at how 

the RO and RS have contributed to the problem. 

The CCRT framework also can be used to 

identify potential obstacles in the recovery 

124 
Brief Psychodynamic Therapy 

process as the therapist and client explore the 

client’s anticipated responses from others and 

from herself and discuss how these perceptions 

will change when she stops abusing substances. 

The CCRT concept also can help clients deal 

with relapse, which is regarded by virtually all 

experts in the field as an integral and natural 

part of recovery. Relapse offers the client and 

the SE therapist the opportunity to examine how 

the RO and RS can serve as triggers and to 

devise strategies to avoid these triggers in the 

future. Finally, SE therapy is conducive to client 

participation in a self-help group such as 

Alcoholics Anonymous, or it can be used as a 

mechanism to examine a client’s unwillingness 

to participate in these groups. 

Stella and Christopher: 

A Case Study 

The case study in this section came from the 

NIDA Collaborative Cocaine Study (Mark and 

Faude, 1997; adapted with permission). SE is 

the therapeutic approach used. 

While dependent and impulsive, Stella, a 28-

year-old cocaine-dependent woman, would be 

seen under many circumstances as warm and 

open. She appears to be the kind of person who 

wears her heart on her sleeve, but it is a big 

heart nonetheless, capable of caring for others 

with loyalty and compassion. In addition, she 

has a tenacity of spirit; despite a horrific 

personal history she completed her training as a 

medical technician and has worked in that 

capacity for much of the last 4 years. Her 

therapist, Christopher, is a well-trained 

psychodynamically oriented therapist. He is an 

intelligent, serious, and measured person, 

whose well-meaning nature comes through 

under most circumstances despite his natural 

reserve. 

Stella has a history of polysubstance abuse, 

including the abuse of prescription drugs, both 

anxiolytics and opioids. She worked as a 

medical technician until she injured her back 3 

months ago. At the beginning of treatment, she 

told Christopher that she was going to request 

medication from her physician for her back pain. 

After her eighth session, with her reluctant 

agreement, Christopher informed the physician 

that she was in treatment for cocaine 

dependence. Christopher asked the physician to 

find a medication other than diazepam (Valium) 

for Stella’s back pain. 

Stella began the 19th session complaining 

that ever since the physician found out she was 

a drug user, he has treated her differently. “He 

thinks I’m a scumbag drug addict,” she said. 

Christopher acted uncharacteristically: he 

offered some advice. He suggested that Stella 

consider telling her physician how she feels 

about his treatment. The intervention strikingly 

altered the mood and productivity of the 

session. After a brief expression of sympathy for 

her position, he focused on her extreme distress 

over the physician’s treatment. He attempted to 

explain the intensity of her reaction in terms of 

projection: that she responded so strongly 

because of her negative view of herself. 

Matters got worse as the session continued. 

Stella related a second negative incident when 

she described her treatment by the physician in 

a group therapy session. The group therapist 

responded, “Well, you manipulate doctors!” 

Stella had been furious. 

Christopher encouraged her to say more. 

Stella became frustrated at Christopher’s lack of 

understanding and explained that again, she felt 

she was being treated like a “scumbag,” this 

time by the group therapist. Christopher 

suggested that Stella might tell both the 

physician and the group therapist how she felt. 

The tension in the session disappeared, and 

Stella remarked that she has always had trouble 

sticking up for herself. 

In supervision, Christopher realized 

immediately that he was indirectly letting Stella 

know that he understood and agreed with her. 

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Chapter 7 

Diagnostically speaking, Stella has a 

borderline personality disorder as defined by 

the Diagnostic and Statistical Manual of Mental 

Disorders, 4th Edition [DSM-IV] (American 

Psychiatric Association, 1994). When she was 

between 6 and 8 years old, Stella’s maternal 

grandfather sexually abused her. Her parents 

divorced when she was 10, and she lived with 

her mother, who was often drunk and 

physically abusive. Stella said she was closer to 

her father, whom she described as gentle. He 

appeared to others as weak and ineffectual. 

At age 15, Stella ran off with a boyfriend who 

was also her pimp. After 2 weeks she returned 

home, was unable to leave her mother, and was 

diagnosed as having agoraphobia, for which she 

took chlordiazepoxide (Librium). Two years 

later she ran away with another man, a 

particularly sadistic pimp. For 5 years she was 

too terrified to leave him. It was during this 

period that she started using cocaine. 

The cocaine both “disclaims action” and 

affirms her “badness.” Her cocaine use enabled 

her to avoid examining why she stayed with her 

boyfriend and simultaneously affirmed her 

badness. So, she deserves her fate. She would 

use the cocaine to clear her painful feelings and 

feel “strong and independent,” then “feel like a 

big baby for having to use the drugs.” She 

thought of herself as a “big baby,” for returning 

to her mother at age 15 and for being unable to 

leave her current boyfriend. Her reactions to 

cocaine are typical; a brief surge or a “high,” 

followed by a crash. However, these typical 

reactions also fit her core theme: she wants to be 

loved and cared for but believes she will be 

thwarted and exploited by others because of this 

wish. Her response then is to use drugs, which 

makes her feel strong and independent for a 

brief time and also makes her see herself as 

deserving of being thwarted and exploited, 

which has happened repeatedly in interpersonal 

contexts in her life. 

Stella’s drug use became a part of the therapy 

in two ways. In the first session, Stella told 

Christopher that she had taken 

chlordiazepoxide for several days before their 

appointment, to relieve her anxiety. She pointed 

out that it had been prescribed by a doctor. 

Presumably, Christopher would have known 

the results of her drug screen, which was part of 

the program. She thus confessed before being 

confronted by drug screen results. Her claim 

that the prescription was legitimate facilitated 

her denial that she has anything to be concerned 

about. 

Second, Stella announced her intention to ask 

her physician for diazepam, a commonly abused 

medication. By contacting her physician, 

Christopher replayed a common scenario in her 

life: she signals that someone should take 

control or care for her, then resents it when they 

do, feeling that she is being treated like a 

“scumbag drug addict.” She can create the 

largely illusory sense of being cared for when 

someone treats her as a helpless incompetent. 

Was this how Christopher was treating her 

when he called her physician? 

When Christopher suggested that she tell the 

physician and the group therapist how she felt 

about the way they had treated her, his words 

may have given advice, but his communication 

actually conveyed agreement with Stella’s 

position that she had been unfairly treated. 

Stella experienced Christopher’s agreement 

and support through his intervention. 

However, what could have made this a more 

powerful therapeutic interaction would have 

been either for Christopher to directly 

acknowledge his misgivings about having taken 

charge and contacted the physician or to explore 

how Stella came to hear his initial obliqueness as 

giving her what she wanted—his care and 

support. 

126 
Brief Psychodynamic Therapy 

Research on the Efficacy of 

Supportive-Expressive Therapy 

It is only since the 1980s that psychosocial 

components of the treatment of substance abuse 

disorders have become the subject of scientific 

investigation. Most research on the efficacy of 

psychotherapy for the treatment of substance 

abuse disorders has concluded that it can be an 

effective treatment modality (Woody et al., 

1994). Comparisons among specific models of 

therapy have become the focus of much interest. 

As mentioned above, SE psychotherapy has 

been modified for use with methadonemaintained opiate dependents and for cocaine 

dependents. In SE therapy, the client is helped 

to identify and talk about core relationship 

patterns and how they relate to substance abuse. 

One study compared SE therapy and cognitive– 

behavioral therapy with standard drug 

counseling for opiate dependents in a 

methadone maintenance program. Clients were 

offered once-weekly therapy for 6 months. 

Adding professional psychotherapies (either SE 

or cognitive–behavioral) to drug counseling 

benefited clients with higher levels of 

psychopathology more than using drug 

counseling alone. However, drug counseling 

alone was helpful for clients with lower levels of 

psychopathology (Woody et al., 1983). Another 

study involving three methadone programs was 

also positive regarding the efficacy of SE 

therapy (Woody et al., 1995). In this study, 

clients receiving SE therapy required less 

methadone than those who received only 

standard substance abuse counseling, and after 

6 months of treatment these clients maintained 

their gains or showed continuing improvement. 

Gains tended to dissipate in those who received 

drug counseling only (Woody et al., 1995). 

One study compared SE psychotherapy with 

structural family therapy for the treatment of 

cocaine dependence (Kang et al., 1991; Kleinman 

et al., 1990). Both types of therapy were offered 

once a week. The researchers found that onceweekly therapy, of either type, was not 

associated with significant progress. Dropout 

rates were high, and overall abstinence in both 

groups did not appear to differ from that 

expected from spontaneous remission. The 

main conclusions were that the lack of treatment 

effects may have resulted because these 

treatments did not offer enough frequency and 

intensity of contact to be effective for cocainedependent people in the initial stages of 

recovery. This study had at least two flaws, 

however. One was that the therapists were not 

well-trained in SE therapy; therefore, it is 

questionable whether or not the treatment they 

provided was actually SE therapy. The other 

was that the therapy was provided in a 

municipal office building where courts and 

social services were administered, thus this 

setting lacked many features of traditional 

substance abuse treatment settings. 

More recently, a large multisite study of 487 

persons receiving treatment compared SE 

therapy with cognitive therapy and drug 

counseling for cocaine dependence (CritsChristoph et al., 1997). Each of the three 

conditions included, in addition to the 

individual treatment, a substance abuse 

counseling group. A fourth condition received 

group counseling without additional individual 

therapy. This study was a theoretical 

descendant of the methadone studies mentioned 

earlier. It was hypothesized that SE and 

cognitive therapy might be more effective than 

individual drug counseling for clients with 

higher levels of psychiatric severity. The results 

showed that each type of treatment was 

associated with significantly reduced cocaine 

use. However, for this population of outpatient 

cocaine-dependent clients, drug counseling was 

more successful at reducing substance use than 

SE or cognitive therapy (Crits-Christoph et al., 

1999). One implication of this finding is that 

drug-focused interventions are perhaps the 

127 
Chapter 7 

optimal approach for providing treatment for 

substance abuse disorders (Strean, 1994). 

What this means for practitioners of 

psychodynamically oriented treatments is that 

in addition to providing the more dynamic 

interventions, it is important to also incorporate 

direct, drug-focused interventions. This can be 

accomplished by one therapist combining both 

models or, in a comprehensive treatment 

program for substance users, one therapist 

providing dynamic therapy and an alcohol and 

drug counselor providing direct, drug-focused 

counseling. It can be argued that this is why SE 

therapy was so helpful in the methadone 

studies. In those studies, psychodynamic 

therapy was well integrated into a 

comprehensive methadone maintenance 

program. In other words, in addition to the 

dynamic therapy, clients received substance 

abuse disorder counseling along with 

methadone (Woody et al, 1998). 

One study conducted a small, controlled trial 

comparing SE therapy to a brief (one-session) 

intervention for marijuana dependence. The SE 

approach was adapted for use in treatment of 

cannabis dependence (Grenyer et al., 1995) and 

was offered once a week for 16 weeks. Results 

showed that both interventions were helpful but 

SE therapy produced significantly larger 

reductions in cannabis use, depression, and 

anxiety, and increases in psychological health 

(Grenyer et al., 1996). The authors concluded 

that SE therapy could be an effective treatment 

for cannabis dependence. 

Clients Most Suitable for 

Psychodynamic Therapy 

Brief psychodynamic therapy is more 

appropriate for some types of clients with 

substance abuse disorders than others. For 

some, psychodynamic therapy is best 

undertaken when they are well along in 

recovery and receptive to a higher level of selfknowledge. 

Although there is some disagreement in the 

details, this type of brief therapy is generally 

thought more suitable for the following types of 

clients: 

 Those who have coexisting psychopathology 

with their substance abuse disorder 

 Those who do not need or who have 

completed inpatient hospitalization or 

detoxification 

 Those whose recovery is stable 

 Those who do not have organic brain 

damage or other limitations due to their 

mental capacity 

Psychodynamic Concepts 

Useful in Substance 

Abuse Treatment 

Psychodynamic theories endeavor to provide 

coherent explanations for intrapsychic and 

interpersonal workings. Because of the 

importance of this approach in the development 

of modern therapy, the techniques that stem 

from these theories are inevitably used in any 

type of psychotherapy, whether or not it is 

identified as “psychodynamic.” For example, 

people who have worked with those who have 

substance abuse disorders are familiar with 

“denial,” even if they are not aware that this 

process is one of the psychodynamic defense 

mechanisms. Counselors whose clients have an 

immediate and strong negative reaction to them 

often benefit from an understanding of the 

concept of “transference.” It also is helpful for 

an alcohol and drug counselor who is left feeling 

hopeless and confused after a session to 

understand how “countertransference” could be 

at work. Therefore, counselors who treat clients 

with substance abuse disorders can benefit from 

understanding the basic concepts of general 

psychodynamic theory discussed in this section, 

even if they do not use a strictly psychodynamic 

intervention. 

128 
Brief Psychodynamic Therapy 

The Therapeutic Alliance 

The alliance that develops between therapist 

and client is a very important factor in 

successful therapeutic outcomes (Luborsky, 

1985). This is true regardless of the modality of 

therapy. The psychodynamic model has always 

viewed the therapist–client relationship as 

central and the vehicle through which change 

occurs. Of all the brief psychotherapies, 

psychodynamic approaches place the most 

emphasis on the therapeutic relationship and 

provide the most explicit and comprehensive 

explanations of how to use this relationship 

effectively. Luborsky and colleagues are among 

those who have documented the profound effect 

that the therapistclient relationship has on the 

success of treatment, however brief (Luborsky et 

al., 1985). 

The psychodynamic model offers a 

systematic explanation of how the therapeutic 

relationship works and guidelines for how to 

use it for positive change and growth. In all 

psychodynamic therapies, the first goal is to 

establish a “therapeutic alliance” between 

therapist and client. In most cases, the 

development of a therapeutic alliance is partially 

a process of the passage of time. The more 

severe the client’s disorder, the more time it will 

take. The capabilities of the therapist to be 

honest and empathic and of the client to be 

trusting are also factors. A therapeutic alliance 

requires intimate self-disclosure on the part of 

the client and an empathic and appropriate 

response on the part of the therapist. However, 

in brief psychodynamic therapy this alliance 

must be established as soon as possible, and 

therapists conducting this sort of therapy must 

be able to establish a trusting relationship with 

their clients in a short time. 

One study of the therapeutic alliance and its 

relationship to alcoholism treatment found that 

for alcoholic outpatients, ratings of the 

therapeutic alliance by the patient or therapist 

were significant predictors of treatment 

participation and of drinking behavior during 

treatment and at 12-month followup, though the 

amount of variance explained was small 

(Connors et al., 1997). Among cocainedependent patients, another study found that 

patients’ ratings of the therapeutic alliance 

predicted the level of current drug use at 1 

month but not at 6 months (Barber et al., 1999). 

The alliance at 1 month, however, predicted 

improvement in depressive symptoms at 6 

months. These findings suggest that the 

therapeutic alliance exerts a moderate but 

significant influence on outcome in the 

treatment of substance abuse disorders. The 

specific outcomes measured vary from study to 

study but include length of participation in 

treatment, reduction in drug use, and reduction 

in depressive symptoms. 

Developmental Level 

Psychodynamic theory emphasizes that the 

client’s level of functioning should determine 

the nature of any intervention. In Freudian 

psychoanalytic theory, substance abuse is 

considered a symptom associated with the oral 

or most primitive stage of development and 

represents an attempt to establish a needgratifying symbiotic state (Leeds and 

Morgenstern, 1996). Analytic theorists within 

the Object Relations school hold that substances 

stand in for the functions usually attributed to 

the primary maternal (or care-giving) object. As 

a result, the substance abuser relates to the 

substance based on the disturbed pattern of 

relating that he experienced with the maternal 

object (Krystal, 1977). This would be considered 

a variant of borderline psychopathology, which 

is viewed as a fairly severe disturbance of ego 

functioning and object relations. It is for this 

reason that substance-abusing clients were and 

perhaps still are often considered unsuitable for 

psychoanalysis and also unsuitable for many of 

the short-term analytic models that involve a 

129 
Chapter 7 

very focused and active uncovering of the 

unconscious. 

Contemporary analytic theorists who 

concern themselves with substance abuse 

disorders typically do not focus on the idea that 

addiction is linked to a developmentally 

primitive level of ego functioning, although they 

may endorse it. One reason is that this idea 

leads to a rather pessimistic belief regarding the 

outcome of analytic treatments for substance 

abuse disorders. Another reason is that it does 

not contribute helpful information to the 

therapeutic approach, and it can impede the 

development of an empathic and respectful 

therapeutic alliance. Furthermore, there is 

increasing empirical evidence for the idea that 

severe substance abuse is largely driven by 

biobehavioral forces and that individual 

psychological factors are of lesser importance 

(Babor, 1991). Although analytic theories have 

tended to ignore this (Leeds and Morgenstern, 

1996), it has become increasingly a part of the 

knowledge base in understanding substance 

abuse disorders. 

Insight 

Another critical underlying concept of 

psychodynamic theory—and one that can be of 

great benefit to all therapists—is the concept of 

insight. Psychodynamic approaches regard 

insight as a particular kind of self-realization or 

self-knowledge, especially regarding the 

connections of experiences and conflicts in the 

past with present perceptions and behavior and 

the recognition of feelings or motivations that 

have been repressed. Insight can come through 

a sudden flash of understanding or from 

gradual acquisition of self-knowledge. So, for 

example, a client who feels depressed and angry 

and subsequently drinks comes to realize that 

his feelings toward his father are stimulated by 

an emotionally abusive supervisor at work. This 

type of realization gives the client new options. 

These options include learning to separate his 

reactions to the supervisor from his feelings 

about his father, working through his feelings 

about his father (of which he may not have been 

previously aware), actively choosing alternative 

behaviors to drinking when he feels bad (e.g., 

attending a 12-Step meeting), and accepting 

greater responsibility for his feelings and 

behaviors. 

A broader definition of insight, also 

promoted by brief psychodynamic therapies, is 

simply any realization about oneself, one’s inner 

workings, or one’s behavior. For example, a 

client who says, “the only emotion I really feel is 

anger,” has opened the door to understanding 

the effect others have on her, and vice versa. 

She can then begin to develop alternative 

behaviors to those that previously followed 

automatically from her anger (such as drinking), 

as well as to understand why her emotional 

repertoire is so limited. 

Insight involves both thoughts and feelings. 

A purely intellectual exercise will not lead to 

behavior change. True insight involves a 

powerful emotional experience as well as a 

cognitive component and leads to a greater 

acceptance of responsibility for feelings and 

behavior. In treating substance abuse disorders, 

it is important to recognize that insight alone is 

often not sufficient to create change. Substances 

of abuse are powerful behavioral reinforcers and 

the therapist needs to help the client counter the 

strong compulsive desire for them. Thus, in 

addition to insight, it could be helpful to offer 

psychoeducation and make behavioral 

interventions, which might include encouraging 

attendance and participation in self-help 

programs and requiring regular testing by 

urinalysis and/or BreathalyzerTM. Many 

therapists who conduct substance abuse 

treatment from a psychodynamic perspective 

are comfortable combining insight-oriented 

therapy with concrete, behavioral interventions. 

130 
Brief Psychodynamic Therapy 

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, distort, or falsify reality, 

and they operate unconsciously. Some defense 

mechanisms are adaptive and support the 

mature functioning of the individual, while 

others are maladaptive and hinder the 

individual’s growth. Generally the defenses 

hamper the process of exploration in therapy, 

and for this reason they are often confronted in 

the more expressive models of 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 change—changes that inevitably 

involve eliminating or at least reducing drug 

use. Mark and colleagues noted that two 

defenses frequently seen in those with substance 

abuse disorders are denial and grandiosity 

(Mark and Luborsky, 1992). Particularly with 

this group of clients, handling defenses can 

degenerate into an adversarial interaction, laden 

with accusations; for example, when a therapist 

admonishes the client by saying, “You are in 

denial” (Mark and Luborsky, 1992). They 

recommend avoiding ineffective adversarial 

interactions around the client’s use of defenses 

by using the following strategies: 

 Working with the client’s perceptions of 

reality rather than arguing 

 Asking questions 

 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. 

Transference 

Effective use of the therapeutic relationship 

depends on an understanding of transference. 

Transference is the process of transferring 

prominent characteristics of unresolved 

conflicted relationships with significant others 

onto the therapist. For example, a client whose 

relationship with his father is deeply conflicted 

may find himself reacting to the therapist as if 

he were the 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 foster transference by building the 

therapeutic relationship. Only then can the 

therapist help the client begin to understand her 

reasons for abusing substances and to consider 

alternative, more positive behavior. A longer 

term goal—necessitated by the brevity of the 

process—is to increase the client’s motivation 

and participation in other modalities of 

treatment for substance abuse disorders. 

Etiology 

Four contemporary analytic theorists have 

offered valuable psychodynamic perspectives 

on the etiology of substance abuse disorders. 

131 
Chapter 7 

Wurmser, a traditional drive theorist, 

suggests that those with substance abuse 

disorders suffer from overly harsh and 

destructive superegos that threaten to 

overwhelm the person with rage and fear. 

Abusing substances is an attempt to flee from 

such dangerous affects. These affects are the 

result of conflict between the ego and superego, 

brought about by the harshness of the superego. 

Given this understanding, Wurmser’s main 

focus is the analysis of the superego. He 

believes that a moralistic stance toward the 

substance-abusing behavior is 

counterproductive and that substance abusers’ 

problems consist of too much, rather than too 

little, superego. Wurmser recommends that the 

therapist provide a strong emotional presence 

and a warm, accepting, flexible attitude. 

Figure 7-1 

Defense Mechanisms 

 Denial. Pretending that a threatening situation does not exist because the situation is too distressing 

to cope with. A child comes home, and no one is there. He says to himself, “They are here. I’ll find 

them soon.” 

 Displacement. Feelings and thoughts directed toward one person or object are directed toward 

another person. For example, an employee has feelings of anger toward his boss but is unaware of 

these feelings because of his internal conflict over acknowledging them. Instead he becomes 

disproportionately angry at his wife over a minor problem at home. 

 Grandiosity. Although not one of the originally identified analytic defenses, grandiosity is frequently 

employed by substance abusers (Mark and Luborsky, 1992). Grandiosity defends against 

unconscious low self-esteem by invoking self-deceptive, overly positive opinions about oneself. An 

example of grandiosity in a substance-abusing client is the client who insists that he can maintain 

control of drug use despite the fact that he was using an increasingly large amount of drugs with 

increasing frequency. This example can be seen as denial as well because denial involves denying or 

minimizing the consequences of the addiction. However, the grandiosity is evident in the user’s 

unrealistic belief that he is in control of his drug use when it would seem that his use is compulsive 

and clearly out of control at this point. 

 Identification with the aggressor. The activity of doing unto someone else what aroused anxiety when 

it was done to oneself. A child has a tonsillectomy. She then puts on a toy stethoscope and goes 

around pretending to take out the tonsils of her playmates. 

 Introjection. The individual “takes inside” himself what is threatening. For example, a child feels 

strong anxiety about losing a parent’s love when the latter admonishes her for not cleaning her 

room. To cope with the anxiety she tells herself, “You are a bad girl.” 

 Isolation. Painful ideas are separated from feelings associated with them. To face the full impact of 

sexual or aggressive thoughts and feelings, the ideas and affects are kept apart. For example, the 

thought of shouting obscenities in a church is kept separate from all the rage about being in church. 

Thus, in isolation the individual may have fleeting thoughts of an aggressive or sexual nature 

without any emotional accompaniment. 

 Projection. This is the opposite of introjection; an intolerable idea or feeling is ascribed to someone 

else. For example, it could be hypothesized that because the late Senator Joseph McCarthy could not 

tolerate his own homosexual wishes, he spent much time compiling lists of men in the State 

Department who, according to McCarthy, were hiding their homosexuality. 

132 
Brief Psychodynamic Therapy 

Figure 7-1 (continued) 

Defense Mechanisms 

 Reaction formation. A painful idea or feeling is replaced by its opposite. A young girl, for example, 

who cannot tolerate her hateful feelings toward her new baby brother keeps saying, “I love my new 

brother!” 

 Regression. A retreat to an earlier form of behavior and psychic organization because of anxiety in 

the present. For example, under the impact of anxiety stirred up by wishes to masturbate, a 

teenager returns to an earlier form of behavior and resumes sucking his thumb. 

 Repression. An attempt to exclude from awareness feelings and thoughts that evoke anxiety. In 

repression, the feelings and thoughts may have been experienced consciously at one time, or the 

repressive work may have stopped ideas and feelings from ever reaching consciousness. For 

example, an individual may have consciously experienced hateful feelings toward a parent or 

sibling but, because of the anxiety evoked, blocked the feelings from awareness. Or to protect 

herself from feeling the unpleasantness and dread of hate and anger, a woman never allows any 

hostile thoughts or feelings to reach consciousness. 

 Undoing. Trying to remove an offensive act, either by pretending it was not done or by atoning for 

it. For example, a boss hates an employee and wishes to fire him. Instead he promotes the 

employee, thereby diminishing in his mind what he thinks he has done. 

Adapted from: Strean, 1994, pp. 13–15. 

Khantzian theorizes that deficits, rather than 

conflicts, underlie the problems of those with 

substance abuse disorders. That is, weakness or 

inadequacies in the ego or self are at the root of 

the problem. Khantzian and colleagues 

developed Modified Dynamic Group Therapy 

(MDGT) to address these issues in a group 

therapy format, and this approach has some 

empirical support. Khantzian put forth the selfmedication hypothesis, which essentially states 

that substance abusers will use substances in an 

attempt to medicate specific distressing 

psychiatric symptoms (Khantzian, 1985). It 

follows, then, that substance-dependent persons 

will express a strong preference for a particular 

drug of choice to medicate their particular set of 

symptoms. For example, those dependent on 

opioids are thought to be medicating intense 

anger and aggression that their egos are unable 

to contain. Cocaine-dependent people are 

believed to be seeking relief from intense 

depression or emotional lability (as in bipolar 

disorders) or attention deficit disorder. This 

continues to be a popular theory although most 

researchers and therapists now would say that 

this can offer only partial answers to the 

questions of how abusers develop drug 

preferences and what the meaning is of such 

preferences. It is important to consider the 

social and physical environmental context of 

substance abuse as well. That is, whatever 

drugs are most readily available in a person’s 

community and what his peers and associates 

are using also have a strong influence on a 

user’s drug preference. 

Krystal offers two possible theories of the 

etiology of substance abuse disorders. One is 

based on an object-relations conceptualization. 

In this theory, the substance abuser experiences 

the substance as the primary maternal object. 

The substance abuser relates to the substance in 

the same maladaptive relationship patterns that 

she experienced developmentally with the 

mother. The second theory focuses on the 

substance abuser’s disturbed affective functions, 

known as alexithymia. It is thought that 

133 
Chapter 7 

individuals with alexithymia do not recognize 

the cognitive aspects of feeling states. Instead, 

they experience an uncomfortable, global state 

of tension in response to all affective stimuli. 

Thus they seek to relieve this discomfort with 

substances. 

McDougall views substance abuse as a 

psychosomatic disorder. It is a way of dealing 

with distress that involves externalizing and 

making physical what is essentially a 

psychological disturbance. Substance abuse 

then is the habitual use of an externalizing 

defense against painful or dangerous affects. 

McDougall suggests that these painful affects 

are the response to deep uncertainty about one’s 

right to exist, one’s right to a separate identity, 

and one’s right to have control over one’s body 

limits and behavior. The abuse of drugs is part 

of a “false self” that the individual creates to 

ward off these painful feelings. 

Some critics have argued that a major 

limitation of those psychoanalytic theories is 

that they do not make allowances for the 

biological bases of substance abuse disorders 

(Babor, 1991). However, contemporary 

psychoanalytic theorists acknowledge that 

biology plays a role in behaviors related to 

substance abuse. But the unanswered question 

remains whether biological or psychological 

factors come first: Why does a person start using 

substances? Analytic concepts are useful here, 

in that they can be said to facilitate the 

resolution of problems that contribute to 

emotional distress and to help explore the 

connection among interpersonal patterns, 

emotions, and substance abuse. 

Levenson and colleagues offer such a theory 

(Levenson et al., 1997). They describe a 

biopsychosocial conceptualization of substance 

abuse disorders that can, in part, be addressed 

by brief psychodynamic therapy. In this model, 

substance abuse disorders are particularly 

difficult to treat because, unlike other 

psychological disorders, there is a “primary 

urge” to abuse substances—an urge that can 

take precedence over every other aspect of life. 

Furthermore, the symptom (substance abuse) is 

often considered pleasurable by the client, in 

contrast to the symptoms of other psychological 

disorders (such as anxiety or depression). Thus, 

“[psychodynamic] therapy should be considered 

as part of an overall treatment plan that includes 

some kind of drug counseling and possibly 

other interventions as well, such as medications 

and family therapy” (Levenson et al., 1997, 

p. 125). 

Integrating Psychodynamic 

Concepts Into Substance Abuse 

Treatment 

Many of the concepts and principles used in 

psychodynamic therapy with clients who have 

substance abuse disorders are similar to those 

used with clients who have other psychiatric 

disorders. However, most therapists agree that 

people with substance abuse disorders comprise 

a special population—one that often requires 

more structure and a combined treatment 

approach if treatment is to be successful. To 

effectively treat these clients, it is important to 

combine skill in the provision of the model of 

therapy with knowledge of the general factors in 

the treatment of substance abuse disorders. 

These include knowledge of the pharmacology 

and the intoxication and withdrawal effects of 

drugs, familiarity with the subculture of 

substance abuse and with substance-dependent 

lifestyles, and knowledge of self-help programs. 

It also helps to feel comfortable working with 

substance abusers and for one’s therapeutic style 

to express acceptance of and empathy for the 

client. In modifying SE psychotherapy for use 

with clients with substance abuse disorders, 

Luborsky and colleagues identified certain 

emphases that are particularly important 

(Luborsky et al., 1977, 1989). These emphases, 

listed below, are relevant for applying other 

134 
Brief Psychodynamic Therapy 

types of psychotherapy to substance-dependent 

clients as well. 

 Much of the therapist’s time and energy are 

required to introduce and engage the client 

in treatment. 

 The treatment goals must be formulated 

early and kept in sight. 

 The therapist must pay careful attention to 

developing a good therapeutic alliance and 

supporting the client. 

 The therapist must stay abreast of the client’s 

compliance with the overall treatment 

program (if the client is involved in a 

comprehensive treatment program). This 

includes such things as the client’s 

attendance at all facets of the program, 

submission to regular urinalysis, and use of 

any drugs. 

 If the client is receiving substitution therapy, 

such as methadone maintenance, attention 

should be given to the time of the client’s 

daily dose and when, in relation to the 

dosing, the client feels therapy is best 

conducted. 

Therapists whose orientations are not 

psychodynamic may still find these techniques 

and approaches useful. Therapists whose 

approaches are psychodynamic will be more 

successful if they also have a knowledge of the 

general factors in the treatment of substance 

abuse disorders and conduct psychotherapy in a 

way that complements the full range of services 

that clients with substance abuse disorders 

receive in a relatively comprehensive program. 

Models of Brief 

Psychodynamic Therapy 

Ten major approaches to short-term 

psychodynamic psychotherapy are briefly 

summarized in this section (for more detailed 

information, see Crits-Christoph and Barber, 

1991). These approaches differ depending on 

the extent to which they use expressive or 

supportive techniques, focus on acute or chronic 

problems, have a goal of symptomatic change or 

personality change, and pay attention to 

intrapsychic or interpersonal dynamics. 

Interpersonal psychotherapy is included 

because it is one of the important and better 

researched therapeutic approaches for treating 

substance abuse disorders. It is considered by 

some to be a psychodynamic model, but there 

are conflicting opinions on this. This list is not 

exhaustive; numerous other, perhaps less well 

known, approaches or modifications of these 

approaches are not mentioned. Many of these 

approaches have developed from clinical 

experience, and some are not well researched, if 

they are researched at all. Figure 7-2 

summarizes the length of treatment, focus, and 

major techniques of various models of brief 

psychodynamic therapy. 

Mann’s Time-Limited 

Psychotherapy (TLP) 

The goal of treatment in TLP is to diminish as 

much as possible the client’s negative self-image 

through resolution of the central issue (Mann, 

1991). Symptoms are reduced or eliminated as a 

byproduct of the process. TLP works via two 

main components of the treatment: the 

therapist’s identification of the central issue and 

the setting of the termination date at the start of 

treatment. The central issue is always 

conceptualized in terms of the client’s chronic 

and presently endured pain, resulting from 

painful life experiences. This pain is a privately 

held, affective statement about how the client 

feels about himself. Change comes about 

through the identification and exploration of the 

painful feelings about himself and through the 

feelings of loss surrounding termination. This 

model has a set treatment length of 12 sessions 

and promotes working through of termination 

issues. 

135 
Chapter 7 

Sifneos’ Short-Term AnxietyProvoking Psychotherapy (STAPP) 

STAPP is a focal, goal-oriented psychotherapy 

that is usually practiced in 12 to 15 sessions and 

sometimes fewer (Nielsen and Barth, 1991). 

During the first session, the therapist and client 

agree on a clear psychodynamic focus, rather 

like a treatment contract. The foci that respond 

best to STAPP are unresolved Oedipal conflicts, 

but loss, separation issues, and grief may also be 

acceptable. Change comes about through the 

client’s learning to resolve an emotional core 

problem, essentially problemsolving. Resolving 

the problem promotes a feeling of well-being 

and a corresponding positive change in attitude. 

Davanloo’s Intensive Short-Term 

Dynamic Psychotherapy (ISTDP) 

In ISTDP, therapeutic techniques are used to 

provoke emotional experiences and, through 

this, to facilitate corrective emotional 

experiences or the positive reenactments, in 

therapy, of past conflictual relationships (Laikin 

et al., 1991). Change comes about by bringing to 

consciousness these past unresolved conflicts 

through intense emotional experiences, 

reexperiencing them in a more cognitive way, 

and linking them to current symptoms and 

problematic interpersonal patterns. Extensive 

use of analysis of the transference relationship 

also helps to bring the unresolved conflicts to 

Figure 7-2 

Brief Psychodynamic Therapy 

Therapy 

(Theorist) 

Length of 

Treatment 

Focus Major Techniques 

Time-Limited 12 sessions Central issue related to  Formulation, presentation, and 

Psychotherapy conflict about loss interpretations of the central issue 

(Mann) (lifelong source of pain, 

attempts to master it, 

and conclusions drawn 

from it regarding the 

client’s self-image) 

 Interpretation around earlier 

losses 

 Termination 

Short-Term Usually 12 Unresolved conflict  Early transference interpretation 

Anxiety-Provoking to 15 defined during the  Confrontation/clarification/interPsychotherapy sessions evaluation pretations 

(Nielsen and Barth) 

Intensive Short- 5 to 30 ses- Experiencing and  Relentless confrontation of 

Term Dynamic sions; up to linking interpersonal defenses 

Psychotherapy 40 sessions conflicts with impulses,  Early transference interpretation 

(Laikin, Winston, for severe feelings, defenses, and  Analysis of character defenses 

and McCullough) personality 

disorders 

anxiety 

SE Therapy 16 for major Focus on the core  Supportive: creating therapeutic 

(Luborsky and depression, conflictual relationship alliance through sympathetic 

Mark) 36 for 

cocaine 

dependence 

theme listening 

 Expressive: formulating and interpreting the CCRT; relating symptoms to the CCRT and explaining 

them as coping attempts 

136 
Figure 7-2 (continued) 

Brief Psychodynamic Therapy 

Therapy Length of Focus Major Techniques

(Theorist) Treatment 

Vanderbilt Time- 25 to 30 Change in interpersonal  Transference analysis within an 

Limited Dynamic sessions functioning, especially interpersonal framework 

Psychotherapy change in cyclical  Recognition, interpretation of the 

(Binder and Strupp) maladaptive patterns cyclical maladaptive pattern and 

fantasies associated with it 

Brief Adaptive Up to 40 Maladaptive and  Maintenance of focus 

Psychotherapy sessions inflexible personality  Interpretation of the transference 

(Pollack, traits and emotions and  Recognition, challenge, 

Flegenheimer, and cognitive functioning, interpretations, and resolution of 

Winston) especially in the early resistance 

interpersonal domain  High level of therapist activity 

Dynamic Supportive Up to 40 Increase self-esteem,  Self-esteem boosters: reassurance, 

Psychotherapy sessions adaptive skills, and ego praise, encouragement 

(Pinsker, Rosenthal, functions  Reduction of anxiety 

and McCullough)  Respect adaptive defenses, 

challenge maladaptive ones 

 Clarifications, reflections, 

interpretations 

 Rationalizations, reframing, advice 

 Modeling, anticipation, and 

rehearsal 

Self Psychology 12 to 30 Change intrapsychic  Analysis of the mirroring, 

(Baker) sessions, not patterns. Incorporate idealizing, and merger 

rigidly more diverse transferences 

adhered to representations of others  Supportive, empathic 

and changes in 

information processing 

Interpersonal Time Eliminating or reducing  Exploration, clarification, 

Psychotherapy limited; for the primary symptom; encouragement of affect, analysis 

(Klerman) substance improvement in handling of communication, use of the 

abuse, the current interpersonal therapeutic relationship and 

trials have problem areas, behavior-change techniques 

been 3 and 6 particularly those 

months associated with substance 

abuse 

Sources: Crits-Christoph and Barber, 1991; Klerman and Weissman, 1993; Rounsaville and Carroll, 1993. 

Brief Psychodynamic Therapy 

137 
Chapter 7 

the client’s consciousness so that they can then 

be explored and resolved. 

SE Psychoanalytic Psychotherapy 

This model of dynamic therapy can be offered as 

an open-ended or a time-limited approach 

(Luborsky, 1984; Luborsky and Mark, 1991). 

The term “supportive” refers to the techniques 

aimed at directly maintaining the client’s level 

of functioning—that is, “supporting” the client. 

The term “expressive” refers to techniques that 

intend to facilitate the client’s expression of 

problems and conflicts and their understanding. 

Therapists using this approach will 

 Develop a good therapeutic alliance 

 Formulate and respond to central 

relationship patterns 

 Understand and respond to how the 

symptom fits into the central relationship 

pattern 

 Attend to and respond to concerns about 

separation (therapy termination) 

 Make interpretations that are appropriate to 

the client’s level of awareness 

 Recognize the client’s need to test the 

therapeutic relationship (in transference 

terms) 

 Frame the symptoms as problem-solving or 

coping attempts 

Change comes about through three curative 

factors: a positive helping relationship, gains in 

self-understanding, and internalization of these 

gains. 

The Vanderbilt Approach to TimeLimited Dynamic Psychotherapy 

(TLDP) 

The primary goal of this therapy is to foster 

positive change in interpersonal functioning, 

which will then have beneficial effects on the 

more circumscribed symptoms (Binder and 

Strupp, 1991). Interpersonal problems are 

conceptualized in a specific format termed the 

“cyclical maladaptive pattern,” which includes 

four categories of information: 

 Acts of the self toward others 

 Expectations about others’ reactions 

 Acts of others toward the self 

 Acts of the self toward the self (introjection) 

The theory of change is that therapy is a set 

of interpersonal transactions through which the 

client learns and is then able to change the 

maladaptive interpersonal patterns in her life. 

Analysis of the transference relationship and the 

therapeutic relationship as a model for healthier 

relationships are important components of the 

therapy. 

Short-Term Dynamic Therapy of 

Stress Response Syndromes 

This approach to brief dynamic therapy was 

developed for use with clients who are dealing 

with recent stressful events, such as traumatic 

experiences or the death of a loved one 

(Horowitz, 1991). The therapist establishes a 

working alliance with the client and then, using 

techniques appropriate to the client’s state of 

mind and control processes, helps the client to 

integrate the life event and its meaning into his 

schema (a schema is one’s way of understanding 

oneself in relation to others). The therapist 

fosters this process of integration and 

understanding by focusing attention, correcting 

distortions, making linkages, and counteracting 

defensive avoidance. For research, this model is 

offered as a 12-session therapy, but it can also be 

used as an open-ended therapy in clinical 

practice. 

Brief Adaptive 

Psychotherapy (BAP) 

BAP is a short-term analytic model developed to 

treat clients with personality disorders, although 

it is applicable to other groups of clients as well 

(Pollack et al., 1991). The theory of change is 

that through cognitive and affective 

138 
Brief Psychodynamic Therapy 

understanding of the origins and operations of 

the maladaptive pattern, the client can change 

and construct more adaptive patterns. The 

techniques used include maintenance of a focus, 

much work on transference, and a high level of 

activity on the part of the therapist. The major 

maladaptive pattern is an interpersonal pattern, 

and it is explored in the present, in the past, and 

in the client-therapist relationship. These three 

areas are repeatedly linked to one another. The 

maximum number of sessions offered is 40, 

which Pollack and colleagues point out is more 

than some of the other brief models because of 

the higher level of psychopathology of the 

clients. 

Dynamic Supportive Psychotherapy 

Supportive therapy is widely practiced clinically 

but historically is defined mainly by the absence 

of expressive or interpretive components of 

psychoanalytic therapies (Pinsker et al., 1991). It 

evolved as the psychodynamically based 

therapy used for lower functioning or more 

fragile clients for whom the expressive work of 

therapy might be too distressing. The therapist 

has a cohesive psychodynamic formulation of 

the client but only shares parts of it in a manner 

intended to foster the client’s adaptive 

functioning. The goals of supportive therapy 

are to ameliorate symptoms and to maintain, 

restore, or improve self-esteem, adaptive skills, 

and ego function. Change comes about from 

learning and from identification with or 

introjection of an accepting therapist with whom 

the client has a good relationship. The 

techniques used include reducing anxiety, 

respecting defenses, clarification, limiting 

confrontation and interpretation, enhancing selfesteem, reframing, offering encouragement, 

advising, and modeling. 

A Self-Psychological Approach 

The essential aspects of the theory of Self 

Psychology (Baker, 1991) include the following: 

 Empathy 

 The concept of the selfobject 

 The importance of the self in motivating 

behavior 

 The role of symptoms as the client’s way of 

restoring self-cohesion 

In this brief self-psychological therapy 

approach, one or two goals are established 

collaboratively in the initial sessions. The 

duration of treatment typically is 20 to 30 

sessions, with fewer or more as needed. A 

selfobject is something or someone else that is 

experienced and used as if it were part of one’s 

own self (Baker, 1991). For example, a child is 

dependent on the parent’s love and praise to 

develop a sense of self-worth and self-esteem. 

In that way, the child internalizes a part of the 

parent as the selfobject. The theory of change is 

that understanding, followed by interpretation, 

leads to change. Success in therapy requires that 

dysfunctional intrapsychic structures be 

changed and/or that compensating new 

structures be added. 

Interpersonal Psychotherapy (IPT) 

IPT was developed initially as a time-limited, 

weekly psychotherapy for nonbipolar, 

nonpsychotic, depressed clients (Klerman et al., 

1984). It has since been summarized in a 

manual for research and modified for treatment 

of other types of depression (dysthymia), other 

populations (adolescents and couples), and 

other problems (substance abuse disorders and 

bulimia). The goals of this approach are 

primarily symptom reduction and improvement 

in interpersonal functioning. The main 

techniques include the following: 

 The problem is explicitly diagnosed and the 

client is given the “sick” role. 

 The client is educated about the problem, its 

causes, and the treatments available. 

 The interpersonal context of the problem and 

its development are identified. 

139 
Chapter 7 

 Strategies for dealing with the interpersonal 

context emerge and are tried by the client 

(problemsolving). 

Other Research 

In addition to Supportive-Expressive 

psychotherapy, both IPT and MGDT have been 

studied as therapies for use in the treatment of 

substance abuse disorders. 

IPT has been evaluated as an adjunctive 

treatment for a full-service methadone clinic 

(Rounsaville et al., 1983). This was a 

collaborative research project that paralleled a 

study by Woody and colleagues (Woody et al., 

1983). Seventy-two methadone-maintained, 

opiate-dependent subjects who were diagnosed 

with a psychiatric disorder (e.g., depression) 

were randomly assigned to one of two treatment 

conditions, each lasting 6 months. The 

treatments were IPT offered once a week and 

low contact, consisting of one 20-minute 

meeting per month, when symptoms and social 

functioning were reviewed. Both groups also 

received treatment as usual in the methadonemaintenance program that included a weekly 

90-minute session of group counseling. The 

main findings were that it was extremely 

difficult to recruit and retain clients in the 

program and that although both treatments 

were associated with significant clinical 

improvements during the 6-month period, there 

was essentially no advantage to IPT over low 

contact. This study was done in a program in 

which clients were suspended after 3 months if 

they continued to use illicit drugs, thus 

providing a potent behavioral intervention. For 

the control group, clients were forced to do well 

or leave the program. 

A second study (Carroll et al., 1991) 

compared IPT with Relapse Prevention (RP), a 

cognitive–behavioral therapy (Marlatt and 

Gordon, 1985) for the treatment of ambulatory 

cocaine-using clients. This study evaluated the 

efficacy of 12 sessions of weekly individual 

psychotherapy, without adjunctive 

pharmacotherapy, as the sole treatment for 42 

subjects who were randomly assigned to either 

IPT or RP. Rates of attrition were significantly 

higher for IPT than for RP, with only 38 percent 

of those in IPT compared to 66 percent of those 

in RP completing the 12-week course of 

treatment (Rounsaville and Carroll, 1993). On 

most outcome measures there were no 

significant differences between the two 

treatment conditions; both were associated with 

favorable outcomes. However, for clients with 

more severe psychiatric symptoms or more 

severe drug use, those who received RP were 

more likely to become abstinent than those who 

received IPT. Clients with more severe 

substance abuse disorders may require the 

greater structure and direction offered by the 

relapse prevention approach (Rounsaville and 

Carroll, 1993). This is entirely consistent with 

the observation that substance-focused 

interventions are perhaps the optimal approach 

for treating substance abuse disorders (Strain, 

1999). Based on the rather modest empirical 

support, Rounsaville and Carroll suggested that 

the role of IPT in the treatment of substance 

abuse disorders might be the following: 

 To introduce clients into treatment 

 To treat clients with lower levels of substance 

abuse 

 To treat clients who did not benefit from 

other modalities 

 To complement other ongoing treatment 

modalities 

 To help clients maintain and solidify gains 

following the establishment of stable 

abstinence 

Khantzian and colleagues developed MGDT 

to address the characterological underpinnings 

of substance abuse disorders (Khantzian et al., 

1990). The group has four main goals: 

140 
1. The development of affect tolerance 

2. The building of self-esteem 

3. The discussion and improvement of 

interpersonal relationships 

4. The development of appropriate self-care 

strategies 

Brief Psychodynamic Therapy 

This approach has shown efficacy for abuse 

in research, but the research was not 

comparative, so it is not known how effective 

this approach is in contrast to other approaches. 

141 

S

ubstance abuse diso

in isolation. For ma

substance abuse dis

with the family of origin, 

8 Brief Family Therapy

rders do not develop 

ny individuals with

orders, interactions 

as well as the current 

family, set the patterns and dynamics for their 

problems with substances. Furthermore, family 

member interactions with the substance abuser 

can either perpetuate and aggravate the problem 

or substantially assist in resolving it. Family 

therapy is suggested when the client exhibits 

signs that substance abuse is strongly influenced 

by family members’ behaviors or 

communications with them. Family therapy 

might be contraindicated if other family 

members are active substance abusers, violent, 

deny that the client’s substance abuse is 

problematic, or remain excessively angry. 

Family therapy is often used to examine 

factors that maintain a client’s substance abuse 

behavior. To understand these factors, the 

therapist considers the family’s various 

structural elements and how they contribute to 

the substance abuse. These elements might 

include the power hierarchy, roles, rules, 

alignments, and communication patterns within 

the family. Through family therapy, the 

clinician can help the family identify 

dysfunctional areas, adjust its hierarchy, change 

various roles that members play, change 

dysfunctional rules, alter dysfunctional 

alignments between family members, and 

replace dysfunctional communications with 

clear, direct, and effective communication. 

Family involvement is often critical for 

success in treating many substance abuse 

disorders—most obviously in cases where 

elements of the family are inadvertently 

reinforcing or supporting the problem. In some 

cases, another family member has a different 

agenda from the rest of the family. For example, 

the husband of a recovering substance abuser 

may have taken on additional roles in the family 

as a result of the vacuum left when his wife was 

abusing substances. The husband may be 

unwilling to let her resume her place in the 

family or share control of the family budget, for 

example. Unless family therapy can shift his 

position, the client’s recovery is likely to be 

impeded. When the whole family is involved in 

therapy, changes are faster and easier to 

maintain. In addition, the client gains a built-in 

support system. 

Complex interactions between family 

dynamics and substance abuse have long been 

recognized (Lewis, 1937). Whalen suggested 

spousal psychopathology was a contributing 

factor in the onset and maintenance of substance 

abuse (Whalen, 1953). Jackson argued on the 

basis of interviews with members of Al-Anon 

that the depression, anxiety, and distress seen so 

often in family members of substance abusers 

stem from, rather than cause substance abuse 

disorders (Jackson, 1954). 

Contrary to what had long been the popular 

opinion, most individuals with substance abuse 

disorders maintain close ties with their families. 

143 
Chapter 8 

Research has consistently shown that people 

with substance abuse disorders are in closer 

contact with their families of origin than the 

members of the general population of 

comparable age (Bekir et al., 1993; Douglas, 

1987). 

A number of reviews have found strong 

support for the use of family therapy methods 

for substance abuse treatment. Recent research 

even suggests that family and marital treatment 

produces better marital and drinking outcomes 

than nonfamily methods (Lowinson et al., 1997). 

At least one study that compared long-term and 

short-term family therapy (16 and 8 casework 

interventions over an 8- and a 4-month period, 

respectively) found that shorter services were 

often more beneficial (Garvin et al., 1976). 

However, comparable studies specifically on 

family therapy as applied to substance abuse 

disorders are lacking. 

The Harvard Medical School Department of 

Psychiatry successfully used couples counseling 

in the context of treatment for alcoholdependent clients. Studies of participants in the 

Harvard Counseling for Alcoholics’ Marriages 

Project (Project CALM) showed that more than 

50 percent of husbands with alcohol abuse 

disorders who participated remained alcohol 

free in the first year after treatment, compared 

with less than 30 percent of husbands treated in 

individual therapy. Participants in the program 

also had fewer marital separations. With the 

addition of a relapse prevention program, the 

results improved even further (Rotunda and 

O’Farrell, 1997). 

Family therapy should be conducted by a 

clinician with a good understanding of family 

systems, dysfunctional family patterns, power 

struggles, and communication. Alcohol and 

drug counselors can learn to work with families, 

especially if they do not hold the family 

responsible for the substance abuse. 

If possible, an appropriately trained family 

therapist should be available to conduct sessions 

involving a client’s family. 

Appropriateness of Brief 

Family Therapy 

Long-term family therapy is not usually 

necessary within the context of treatment for 

substance abuse disorders. An exception is 

long-term residential treatment, during which 

the involvement of the client’s family is highly 

recommended and often is an integral part of 

the therapeutic process. Making real progress 

with a family over a long period is challenging. 

Stumbling blocks, barriers, and pathology seem 

to emerge. Family members drop out and 

reenter the therapeutic process, and it becomes 

increasingly difficult for the therapist to avoid 

making decisions. The family may try to 

incorporate the therapist into the family system, 

routinely seeking direction in a crisis. Boundary 

and projection issues must be addressed. In 

short-term family therapy, the boundary 

between the therapist and the family is more 

clear. In general, it is easier to continue to help 

an individual work within the family system 

through subsequent individual therapy. 

Some traditional approaches encourage 

clients to work on themselves in isolation from 

others, but there are very few instances in which 

the opportunity to work with a client’s family— 

for at least one or a few sessions—is not 

beneficial. Obviously, one such exception is 

when the client is unwilling to pursue this 

approach. Another instance best dealt with 

individually is when the client’s situation 

involves issues of separation and individuation 

although conjoint family work often helps 

complete this process. Physical, emotional, or 

sexual abuse of the client by a family member 

may also rule out family therapy. Short-term 

144 
Brief Family Therapy 

family therapy is an option that could be used in 

the following circumstances: 

 When resolving a specific problem in the 

family and working toward a solution 

 When the therapeutic goals do not require indepth, multigenerational family history, but 

rather a focus on present interactions 

 When the family as a whole can benefit from 

teaching and communication to better 

understand some aspect of the substance 

abuse disorder 

Family therapy offers an opportunity to 

 Focus on the expectation of change within 

the family (which may involve multiple 

adjustments) 

 Test new patterns of behavior 

 Teach how a family system works, and how 

the family supports symptoms and maintains 

needed roles 

 Elicit the strengths of every family member 

 Explore the meaning of substance abuse 

within the family 

An obvious prerequisite for family therapy 

would seem to be the existence of a family. 

However, some therapists, including Haley, 

believe it is possible to “create” a family by 

drawing on the client’s network of significant 

contacts. A more important question than 

whether the client is living with a family is, 

“Can the client’s problem be seen as having a 

relational component (that is, involving two or 

more people)?” Rather than simply trying to 

identify existent family members, therapists can 

begin by conducting an assessment of the 

client’s social network that would include 

significant others, friends, employers, and 

coworkers. These people are significant and 

helpful in the client’s life and can be important 

elements of a client’s recovery program. 

The definition of “family” also varies in 

different cultures and situations. For example, 

for a substance abuser in a Native American 

group, the notion of family may extend to 

community members, including healers or 

others who can help promote or block change. 

Young children, although not the most powerful 

members of the family, often have helpful 

perceptions to contribute to the therapy process. 

In determining how and when to include 

children, it is important to consider their age 

and the nature of the subject matter the family 

will address. Parental sexual relations, 

obviously, should be discussed by the parents 

alone. 

Family therapy approaches have been 

employed with a variety of specific substanceabusing subpopulations, including those who 

are dually diagnosed (Read et al., 1993; Reilly, 

1991; Ryglewicz, 1991), Vietnam veterans with 

substance abuse disorders and posttraumatic 

stress disorder (Fahnestock, 1993; Moyer, 1988), 

older adults with substance abuse disorders 

(Amodeo, 1990; Crawley, 1993; RathboneMcCuan and Hedlund, 1989), cocaine abusers 

(O’Malley and Kosten, 1988; Rice-Licare and 

Delaney-McLoughlin, 1990; Smokowski and 

Wodarski, 1996), HIV-positive clients with 

substance abuse disorders (Barth et al., 1993), 

and substance-abusing perpetrators of domestic 

violence (Flanzer, 1989; O'Sullivan, 1989). 

Definitions of “Family” 

The term “family therapy” evokes images of 

parents and children. However, as mentioned 

above, family therapy can involve a network 

beyond the immediate family, may involve only 

one family member in treatment or a few 

members of the family system, or may even 

include several families at once. 

Network therapy views substance abuse 

disorders from a cognitive–behavioral 

perspective (Galanter, 1993; Galanter et al., 1997; 

Keller et al., 1997). In network therapy, 

significant nonfamily members, such as friends, 

extended family members, cousins, and 

grandparents, as well as family members, are 

145 
Chapter 8 

regarded as useful resources available to assist 

the client. 

In contrast, some types of family systems 

therapy regard substance abuse as a symptom of 

an underlying pathology at work in the family. 

This approach seeks to restructure the family 

and the maladaptive behaviors which contribute 

to (or encourage) the client’s substance abuse 

(Keller et al., 1997). 

Conjoint couples therapy addresses couples 

issues within the family (Epstein and McCrady, 

1998; Zweben et al., 1988). Typically, couples 

carry out assignments in dealing with key 

therapeutic themes, such as listing the factors 

that attracted each partner to the other, 

discussing how the relationship could regain 

that attraction, and looking at expectations of 

each partner, needs from the other partner, and 

resentments. Couples may need to explore their 

ideas about gender roles within the relationship, 

or they may have to explore their views on 

parenting, especially in regard to the 

disciplining of children. They may also be asked 

to share ways in which they communicate 

dissatisfaction or negative feelings about the 

ongoing substance abuse. 

Multifamily groups are often used in 

substance abuse treatment for educational 

purposes and as support groups. They can 

explore ways to attain strategic objectives 

relevant to each family, offer an opportunity for 

sharing knowledge, address boundary and 

communication issues, and expose participants 

to new ways of managing challenges. 

Participants realize they are not alone and are 

helped to maintain their substance-free lifestyle 

through learning new coping techniques and 

ways to stop enabling substance abuse. The 

therapist can apply the experiences of one 

family to help another. After one family 

describes a solution, the therapist may ask 

another, “Would that work in your family?” 

This approach can promote accountability for 

maintaining agreements with less stress than 

would occur in single-family therapy. Typically, 

four or five families participate, often achieving 

meaningful results rapidly (Kaufman and 

Kaufman, 1979). 

This approach helps with boundary setting 

and reestablishment of the parent–child 

hierarchy. If a parent is the substance abuser, a 

family role reversal may have occurred in which 

the children have taken the parental role and 

become caretakers. In therapy and recovery, it 

is important that these boundaries be reclarified 

and that the correct parent–child hierarchy be 

reestablished. Not communicating is typical in 

families undergoing substance abuse treatment. 

One of the goals must be to reestablish lines of 

communication. 

The disadvantage of this approach is that the 

families involved may not have much common 

experience; also, some families feel ashamed in 

this sort of encounter and are not willing to 

share their experiences. At times, this approach 

can lead client families simply to complain to 

one another, without being motivated to find 

new solutions. One of the responsibilities of the 

therapist leading the group is to guide the 

family in exploring alternatives and choosing 

among them. 

Multiple family therapy offers an 

opportunity to deal with four concerns for 

families in which substance abuse has been a 

problem (Brill, 1981): 

1. Inadequate internal family development 

2. Family systems and role imbalance 

3. Selected socialization variances within the 

family (i.e., differences in the desire and 

ability of family members to socialize) 

4. Dysfunctional, ineffective family behaviors 

that maintain the problem 

Some researchers believe that multiple 

family therapy is especially useful for families 

dealing with substance abuse disorders 

(Kaufman and Kaufman, 1979). In families 

where one or more members have a substance 

146 
Brief Family Therapy 

abuse disorder, deterioration in the family 

system is usually seen. Multiple family therapy 

allows a quick assessment of the deterioration 

and stimulates a confrontation and strategy to 

reverse this process. 

Furthermore, it is most useful in residential 

settings where the family is easily accessible, 

although it has also been successfully used in 

outpatient settings. Kaufman and Kaufman also 

found that it works best with highly motivated 

and involved clients and 

[R]educes the incidence of premature 

dropouts, acts as a preventive measure for 

other family members, builds a subculture that 

acts as an extended ‘good family,’ and creates 

and supports structural family changes that 

interdict the return of drug abuse (Kaufman 

and Kaufman, 1979, p. 84). 

Theoretical Approaches 

Many therapists are unfamiliar with effective 

ways to utilize supportive family members and 

significant others when treating substance abuse 

disorders (Bale, 1993; French, 1987; McCrady, 

1991). This may stem in part from reliance on 

popular concepts drawn from the traditional 

“family disease” model, in which family 

members of the substance user are seen as 

suffering from the disease of “codependency” 

(Beattie, 1987; Coudert, 1972). Cermak even 

defines codependency using criteria similar to 

those used in the Diagnostic and Statistical 

Manual for Mental Disorders, 4th Edition [DSMIV] (Cermak, 1986). According to Schutt, 

[T]he woman who lives with an alcoholic 

develops an enabling illness. She constantly 

stands between the alcoholic and his crises, 

thus enabling and condoning the further usage 

of the drug (Schutt, 1985, p. 5). 

From this perspective, family members of the 

person with a substance abuse disorder “enable” 

the substance abuse to continue and so are 

thought to need help “detaching” or 

disengaging from their overresponsible 

involvement with the substance user (Al-Anon, 

1979; Bepko, 1985). As a result, treatment often 

consists of a referral to Al-Anon and (less 

frequently) separate therapy groups for family 

members that exclude the substance user 

(Frankel, 1992; Friedman, 1990; McCrady, 1989; 

Regan et al., 1983). 

Family systems models, on the other hand, 

instead of focusing on individual personality 

disorders, generally regard substance abuse and 

dependence as symptoms of dysfunctional 

interpersonal dynamics within the family 

(Bowen, 1974; Gorad et al., 1971). From this 

perspective, the substance abuse meets a need 

on some level for the family as a whole and 

inadvertently reinforces the substance abuse 

(Davis et al., 1974; Stanton, 1977). Chafetz and 

colleagues, for example, cite a family who 

laughed and joked together while the father was 

intoxicated during an experimental session in 

contrast to the same family’s rather flat affect 

during a session when the father was sober 

(Chafetz et al., 1974). The father’s alcohol abuse 

was seen as having become necessary for this 

family to express their positive emotions. Based 

on similar anecdotal evidence, many family 

treatment approaches have evolved that seek to 

identify the specific role or family-level 

“adaptive function” served by substance abuse, 

with the goal of bolstering interpersonal 

functioning in this area in order to reduce these 

secondary gains from substance abuse for the 

individual and the family (Bepko, 1985; Stanton 

and Todd, 1982; Steinglass et al., 1977). Several 

family treatment models are described below. 

Strategic family therapy (Haley, 1976) and the 

related Milan school of family therapy (SelviniPalazzoli et al., 1978) target the positive 

interpersonal aspects of substance abuse 

specifically, acknowledging directly its benefits 

to the family (e.g., “With your husband 

unemployed as a result of his drinking, he can 

be home when the children get out of school”), 

as well as the negative consequences the family 

147 
Chapter 8 

might face if the substance abuse were to end 

(Fisch et al., 1982; Haley, 1987). Together with 

such paradoxical interventions as suggesting the 

family may not yet be ready to change, these 

interventions often provoke “spontaneous” 

growth on the part of the family (Weeks and 

L’Abate, 1979; Winn, 1995). See Chapter 5 in 

this TIP for more information on strategic and 

interactional therapies, which often involve the 

family directly. 

Structural family therapy looks beyond the 

specific family dynamics around substance 

abuse disorders to more general imbalances in 

family relationships that might maintain 

substance abuse, such as extreme 

disengagements and inappropriate coalitions 

between family members, especially across 

generational lines (Minuchin, 1974). Salvadore 

Minuchin has had an enormous impact on both 

the theory and practice of structural family 

therapy, although many of his concepts have 

been modified as they have been incorporated 

into the spectrum of modalities. Minuchin 

stressed the importance of the hierarchy of 

power within the family and identifying 

dysfunctional uses of power (e.g., 

“scapegoating”). It is important to understand 

both healthy and dysfunctional roles within the 

family: alignments, collusions, and 

communication patterns. These key points are 

routinely explored in family therapy, although 

many therapists would not feel comfortable 

“imposing” their own model of health on a 

family—an issue that did not trouble Minuchin. 

Structural therapists explore current family 

organization, especially hierarchy and intimacy, 

while encouraging the family to loosen rules 

and expectations that might be locking the 

substance abuser into a dysfunctional role 

(Minuchin and Fishman, 1981; Stanton, 1977). In 

one of the earliest applications of family therapy 

for substance abuse disorders, Stanton and Todd 

worked successfully with families of young 

male heroin addicts to reestablish parental 

authority and define clearer intergenerational 

boundaries, especially between these men and 

their mothers (Stanton and Todd, 1982). 

Bowenian family therapy (Bowen, 1978) also 

focuses on family-of-origin emotional 

attachment patterns and unresolved separation 

issues to make sense of substance abuse 

disorders. Instead of working through the 

parental generation, however, adults and 

adolescents are helped to differentiate and 

define themselves as individuals by 

acknowledging and curtailing their residual 

emotional entanglements. As a result, substance 

abuse is no longer needed as a way to deny their 

family-of-origin attachments (Bowen, 1974). 

Contextual family therapy (Boszormenyi-Nagy 

and Spark, 1973) is another transgenerational 

family model that has been applied in work 

with families affected by substance abuse 

(Flores-Ortiz and Bernal, 1989). This approach 

emphasizes ethical legacies and unconscious 

loyalties passed along from one generation to 

the next. For example, the adolescent substance 

abuser loyally provides her parents the 

opportunity to vent unresolved anger left from 

their own upbringing. Treatment helps clarify 

the ways these unconscious “ledgers” are 

passed down from generation to generation, and 

parents are encouraged to deal with their 

childhood issues directly instead of acting them 

out through their own children. 

Other family therapy models deemphasize 

the systemic “function” of the substance abuse 

or family pathology and concentrate instead on 

utilizing family strengths and enlisting family 

members as agents of change to motivate the 

substance user and provide support for ongoing 

recovery (Liddle et al., 1992; Meyers et al., 1998; 

Noel and McCrady, 1993; Sisson and Azrin, 

1993). This is particularly the case with multiple 

family therapy models and family 

psychoeducational groups (Kaufman and 

Kaufman, 1979; Kymissis et al., 1995; O’Farrell et 

al, 1985). Frankel described conducting separate 

148 
Brief Family Therapy 

groups for parents and adolescents (Frankel, 

1992). Szapocznik and colleagues also extended 

the family group model to prevention with 

families of adolescents at high risk of 

developing a substance abuse disorder 

(Szapocznik et al., 1989). 

Behavioral marital therapy (BMT) models 

concentrate on teaching and practicing 

guidelines for clear communication and conflict 

resolution, marital enhancement, and substance 

abuse-specific coping skills such as ways to 

handle relapse productively. The BMT 

component was developed as part of the 

Program for Alcoholic Couples Treatment, a 

research study that received good empirical 

support after controlled trials (McCrady, 1989). 

Forty-five people with alcohol abuse disorders 

and their spouses were randomly assigned to 

one of three types of spouse involvement during 

outpatient treatment (approximately 15 

sessions) and then followed over a 2-year 

period. 

The first type of treatment was Minimal 

Spouse Involvement (MSI), where the spouse 

attended all sessions but only as an observer. 

Client and clinician worked together to prepare 

an inventory of the substance abuser’s 

incentives to change and a functional analysis of 

the substance abuse behavior utilizing the TimeLine Follow-Back Interview (Sobell et al., 1980) 

and a Drinking Patterns Questionnaire (Zitter 

and McCrady, 1993). Drinking-specific 

interventions geared to the client were then 

taught, including alcohol refusal skills, learning 

to self-monitor drinking urges and consumption 

rates on a daily basis, rearranging contingencies 

to support abstinence, restructuring irrational 

cognitions, plus developing alternative 

relaxation and assertiveness skills (McCrady et 

al., 1986). 

The second of the three treatment types, 

Alcohol-Focused Spouse Involvement (AFSI), 

included the same drinking-specific assessments 

and interventions but also assessed the couple 

using a modified version (Noel and McCrady, 

1993) of the Spouse Behavior Questionnaire 

(Orford et al., 1975). Spouses were trained using 

role-playing and rehearsals to reinforce 

abstinence and decrease any of their behaviors 

that could trigger renewed alcohol 

consumption. Spouses were also instructed to 

let the drinker experience negative 

consequences from drinking and to be more 

assertive regarding the impact of the alcohol 

use. 

The third type of treatment included all of 

the training above, plus a BMT component 

(McCrady et al., 1986). Each couple’s 

interactional behaviors were initially assessed 

using the Locke-Wallace Marital Adjustment 

Test (Locke and Wallace, 1959) and Areas of 

Change Questionnaire (Birchler and Webb, 

1977). Couples in the BMT group were taught 

ways to enrich their relationship by planning 

and carrying out shared fun activities, 

designating special “love days” to demonstrate 

their affection, and practicing good 

communications skills with planned family 

discussions, as well as techniques for 

problemsolving and negotiation. Finally, to 

offset the abstinence violation effect (a description 

of which is in Chapter 4) (Marlatt, 1978), couples 

were coached to regard any relapse that might 

occur as an opportunity to sharpen their efforts 

rather than give up. Booster sessions were 

sometimes scheduled up to 6 months 

posttreatment (Noel and McCrady, 1993). 

Based on followup assessments at 6 months, 

couples in the BMT group reported better 

marital satisfaction and relapsed more slowly 

after treatment than the other two groups. 

Clients with partners in the BMT group were 

also more likely than those with “Minimal 

Spouse Involvement” to complete treatment 

(McCrady et al., 1986). Eighteen months after 

treatment, couples who had received BMT 

reported enjoying greater relationship 

satisfaction with fewer marital separations. 

149 
Chapter 8 

In addition, the rate of abstinence among the 

BMT couples had gradually continued to 

improve after treatment ended rather than 

dropping off, as occurred with the other two 

groups in this study and most other substance 

abuse treatment programs (McCrady et al., 

1991). In support of this particular finding, 

Stout and colleagues reported the same pattern 

of improvement 2 years after a similar BMT trial 

with a different sample of 229 clients with 

alcohol use disorders (O’Farrell and Cowles, 

1989). 

According to Noel and McCrady, this longterm effectiveness suggests that marital therapy 

may prevent relapse during early recovery by 

stabilizing the substance user’s interpersonal 

context (Noel and McCrady, 1993). Similar BMT 

approaches have recently been successfully 

employed with male substance abusers and 

their partners (Fals-Stewart et al., 1996) and 

applied in relapse prevention (McCrady, 1993) 

with booster sessions spread out over the 

following year (O’Farrell et al., 1993). A BMT 

approach specifically for female substance 

abusers is also being studied (Wetchler et al., 

1993). 

Network therapy approaches (Favazza and 

Thompson, 1984; Galanter, 1993) recognize the 

potential support from those outside the 

immediate family, especially in terms of 

conducting effective substance abuse 

interventions. Gathering together those who 

genuinely care about the welfare of the 

substance abuser, especially friends and 

extended family members, helps encourage the 

substance abuser to stop using and remain 

abstinent. Galanter also points to the 

importance of the involvement of Alcoholics 

Anonymous (AA) in network therapy (Galanter, 

1993). Similarly, Selekman has involved peer 

group members in family therapy with 

adolescent substance users (Selekman, 1991). 

Piazza and DelValle have developed therapeutic 

interventions that actively incorporate larger 

systems available in the community such as 

churches and schools (Piazza and DelValle, 

1992). 

The community reinforcement approach (CRA) 

is a brief systemic/family intervention and 

therapy model that has shown good results 

through training the significant others, generally 

spouses, of treatment-resistant clients with 

alcohol abuse disorders (Hunt and Azrin, 1973; 

Sisson and Azrin, 1986, 1989). CRA participants 

learn to encourage sobriety by reinforcing 

abstinence while allowing the drinker to 

experience negative consequences from 

intoxication. Significant others also learn to 

identify a time when the drinker might be 

willing to enter treatment, in contrast to the 

confrontational methods advocated by the 

Johnson Institute (Johnson, 1986) and Unilateral 

Family Therapy models (Thomas and Ager, 

1993). CRA participants are prepared to 

contribute to the treatment process when and if 

the drinker agrees to this. Because domestic 

violence remains a significant risk throughout 

this process, spouses and significant others are 

helped to recognize and respond to warning 

signs by de-escalating conflict and ensuring 

their own safety. 

Once the drinker agrees to enter treatment, 

the significant other attends all further sessions 

and participates in communication-skills 

training and “reciprocity marriage counseling” 

to develop mutually reinforcing behaviors 

(Sisson and Azrin, 1989). The significant other is 

also asked to monitor the drinker’s disulfiram 

use (Antabuse) on a daily basis and to respond 

appropriately if the disulfiram is not taken 

(Sisson and Azrin, 1993). Besides disulfiram and 

marital counseling, drinkers in the CRA 

programs receive job and social skills counseling 

as needed. It is worth noting that some CRA 

sessions have been held in the family’s home 

(Hunt and Azrin, 1973), recognizing the 

potential for home-based treatments (Henggeler 

et al., 1996). 

150 
Brief Family Therapy 

In a study utilizing the CRA approach, 12 

significant others of treatment-resistant clients 

with alcohol abuse disorders were randomly 

divided to form a CRA group of seven and a 

control group of five who were referred to AlAnon. Of the CRA group, six of the seven 

resistant spouses entered treatment, compared 

with none of the Al-Anon group partners. The 

partners of CRA participants reduced their 

drinking days from 24 per month to 11 before 

entering treatment, and this rate dropped to 2 

drinking days per month once the couple started 

joint treatment (Sisson and Azrin, 1986). (More 

information on the CRA model can be found in 

Chapter 4 of this TIP.) 

The CRA has been modified into the 

community reinforcement and family training 

(CRAFT) procedure (Meyers et al., 1996) with 

clinical trials under way (Meyers et al., 1998). 

This brief systemic intervention and therapy 

model also works through the concerned other 

to analyze behavior patterns surrounding 

substance abuse. Substance abuse triggers and 

consequences are sought, as well as 

interpersonal cues and positive consequences 

that support more adaptive, sober behaviors. 

This analysis can include the Spouse Enabling 

Inventory or the Spouse Sobriety Influence 

Inventory (Thomas et al., 1994). The risk of 

domestic violence is assessed using the Conflict 

Tactics Scale (Straus, 1979), and strategies, 

including a safety plan, are developed. 

Communication skills are an important aspect of 

this model. The basic rules taught are to be 

brief, be positive, be specific and clear, label 

feelings, express understanding for the other’s 

perspective, accept partial responsibility when 

indicated, and offer to help (Meyers et al., 1998). 

A treatment setting is also lined up in 

anticipation that the substance abuser will agree 

to accept further help at some point. 

In one preliminary study of the CRAFT 

model, 130 significant others of treatmentresistant clients with alcohol abuse disorders 

were randomly assigned to either the CRAFT 

program, an Al–Anon-only group, or a Johnson 

Institute intervention group (Johnson, 1973, 

1986). Of the CRAFT participants with alcohol 

abuse disorders, 67 percent went into treatment, 

whereas only 13 percent of the Al-Anon group 

and 23 percent of the Johnson Institute 

intervention group entered treatment (Meyers et 

al., 1998). 

CRAFT also works with significant others to 

improve their social and emotional welfare. 

Significant others are encouraged to decrease 

stress by taking care of themselves and making 

changes to enhance their own well-being and 

positive social supports. Participants in the 

CRAFT program have reported reductions in 

anger, anxiety, and depression, regardless of the 

substance user’s treatment status. Although 

much of the focus of the CRA and CRAFT 

models centers on getting the substance abuser 

into treatment, both programs emphasize the 

importance of ongoing family or couples 

sessions employing communication skills 

training and marital reciprocity counseling 

(Meyers et al., 1998; Sisson and Azrin, 1986). 

Family therapy is often applied in the 

treatment of adolescents with substance abuse 

disorders, and many specific family therapy 

models have been developed for this 

population. These often weave together 

concepts and techniques from different schools 

of family therapy. Multidimensional family 

therapy (MDFT) (Liddle et al., 1992) is a brief 

family therapy model that has demonstrated 

significant long-term clinical effectiveness in 

treating adolescent substance abuse and conduct 

disorders during controlled trials (Schmidt et al., 

1996). MDFT integrates structural/strategic 

family therapy (Stanton, 1981; Todd, 1986) with 

research findings on adolescent development 

(Liddle et al., 1992). The MDFT model is 

designed to enhance a family’s ability to buffer 

adolescents against destructive peer and social 

influences by nurturing healthy teen 

151 
Chapter 8 

development through supportive rather than 

strictly authoritarian parent–child relationships. 

Individual sessions with the adolescent are 

interspersed with family sessions to allow the 

therapist an opportunity to form a supportive 

relationship with the teen and act as an 

intermediary between parent(s) and child. 

Besides relationship issues, the MDFT model 

recognizes the developmental tasks faced by the 

adolescent, such as learning to manage emotions 

and impulses, and tries to specifically address 

them. Therapy sometimes includes 

representatives of extrafamilial systems such as 

school and probationary personnel as well as 

peers. 

Recognizing that most substance-abusing 

teens and their parents are locked in conflict, the 

MDFT therapist works to find a common 

ground and create a context where a more 

trusting relationship can emerge. Adolescents 

are challenged to identify and articulate their 

own issues and goals for therapy and to take 

steps to achieve these. Parents are challenged to 

listen to their teens and let the parent–child 

relationship evolve into one of mutual respect, 

balancing the parental tasks of guidance with 

support. This involves charging both the 

adolescent and the parents with responsibility 

for change while conveying the clear expectation 

that the family can arrive at this point of 

reconciliation (Liddle et al., 1992). See TIP 32, 

Treatment of Adolescents With Substance Use 

Disorders (CSAT, 1999b), for more information 

on family therapy for adolescent substance 

users. 

In a diverse sample of families 

(approximately 45 percent African-American or 

Hispanic), 16 sessions of MDFT led 79 percent of 

the adolescents to reduce their average alcohol 

and marijuana use from a daily to a weekly 

basis. In addition, harder substance use 

dropped from every other month to zero. Of 

those who reduced their substance use, 30 

percent decided on complete abstinence. There 

was also a reduction in related conduct 

disorders among 68 percent of the teens with 

significant improvements seen in school 

performance (Schmidt et al., 1996). Most 

remarkably, these positive outcomes remained 

at followup 1 year later (Liddle and Dakof, 

1995). Based on nonparticipant raters who 

assessed family therapy videotapes, the 

reductions in substance use were significantly 

associated with improvements in the parent– 

adolescent relationship (Schmidt et al., 1996), a 

primary goal of MDFT (Liddle et al., 1992). 

Unfortunately, dropout rates using the MDFT 

treatment model reached 28 percent, and only 69 

percent of the parents were assessed as making 

progress in modifying their parenting styles 

(Liddle and Dakof, 1994). 

The Institute of Medicine (IOM) 

recommended that brief couples therapy be 

included as a treatment option for all alcoholabusing clients, especially for those still 

experiencing only mild to moderate problems 

(IOM, 1990). Based on their review of the 

treatment outcome literature, Edwards and 

Steinglass reached a similar conclusion: 

The weight of the evidence...seems so strong at 

this point as to support a recommendation that 

family involvement, especially inclusion of 

non-alcoholic family members in the 

assessment phase of treatment, be built in as a 

routine component of alcoholism treatment 

programs (Edwards and Steinglass, 1995, p. 

485). 

The brief family therapy approaches 

reviewed above have all shown positive longterm outcomes in controlled clinical trials. 

Together these approaches demonstrate the 

potential for brief family therapy in substance 

abuse treatment. 

Using Brief Family 

Therapies 

Involving family members or concerned others 

in family therapy can have a number of benefits. 

152 
The dynamics of the family are already a factor 

in the client’s substance-abusing behavior in a 

complex and unique relationship. In the same 

manner, the family can participate in the 

positive experience of treatment and recovery. 

Duration of Therapy and 

Frequency of Sessions 

The majority of family therapy is conducted on a 

short-term basis, with some exceptions (Object 

Relations therapy may take years). Sessions 

may be 11⁄2 to 2 hours in length. The preferred 

timeline for family therapy is not more than two 

sessions per week (except in residential settings) 

to allow time to practice new behaviors and 

experience change. Duration of therapy could 

be 6 to 10 sessions, depending on the purpose 

and goals of the intervention. 

In a residential treatment program, family 

therapy can take place in a variety of ways 

depending on program design and length of 

stay. Some programs have “family weeks” in 

conjunction with individual treatment. Others 

may require clients to bring in a significant other 

one to two nights weekly to work together on 

recovery issues. Adolescent treatment programs 

sometimes involve the family continuously 

throughout treatment. 

Certain forms of family therapy have been 

developed to achieve a high impact in a shorter 

period of time. One noted derivative of 

multifamily therapy is the Multiple Impact 

Model developed by Wegscheider-Cruse (1989), 

who brought together groups of four or five 

sober individuals who were previously 

substance dependent and their families for a 

concentrated, extended weekend of work. The 

purpose was to enable the families to support 

the continued sobriety of their formerly 

substance-dependent members. Family roles 

were recast so that each family member could 

take on a different role, such as who would 

make family financial decisions. New 

agreements between family members were 

Brief Family Therapy 

written out. Permanent changes often resulted 

with motivated families. Wegscheider-Cruse’s 

work has been replicated in several residential 

settings and training institutes (e.g., the On-Site 

and the Sierra Tucson Treatment Centers in 

Tucson, Arizona). 

Opening Session 

A typical opening session for a family in which a 

member has a substance abuse disorder might 

involve the following: 

 The therapist seeks to clarify the nature of 

the problem and to identify the family’s 

goals. The therapist asks each family 

member the same sort of open-ended 

questions typically used in individual 

therapy. For example: 

i “What you would like to see happen 

here?” 

i “What would you like to work on?” 

i “What is your goal in coming here?” 

i “How did you get here?” 

 The therapist educates the family in what is 

needed to participate effectively in the 

therapeutic process and to understand key 

biosocial issues related to substance abuse. 

 The therapist provides feedback to the family 

on what was said, demonstrating whose 

goals are similar or different. 

 The therapist can then move on to 

prioritizing directions for change or, if the 

direction is sufficiently clear, start work. 

Some therapists ask the family to engage in a 

“contract” that identifies the direction of 

therapy and delineates each member’s 

commitment to the process. 

Early on, practitioners of different theoretical 

models will make choices about what they will 

focus on and how to proceed, for example: 

 Therapists who practice solution-focused 

therapy would devote more time to 

gathering information and affirming family 

members at the first session, which would 

153 
Chapter 8 

probably conclude with the assignment of 

tasks designed to test the possibility of 

change in areas where change seems feasible. 

 Therapists applying Eriksonian therapy, after 

asking family members what they want, 

might ask, “How will you know when you 

get there?” A followup question would be, 

“Is there any reason you can think of why it 

would not be okay to get there?” This 

question tests for resistance and any 

constraints, such as the possibility of family 

violence, which could prevent open and 

honest communication. The therapist would 

then try to do something about that 

constraint in order to create safety (an action 

referred to as an “ecological check”). 

 Therapists using the Mental Research 

Institute (MRI) strategic model would 

examine solutions that have already been 

attempted because most families with a 

member struggling with a substance abuse 

disorder try a variety of solutions that have 

not worked before formal treatment. The 

family’s solution may be seen as the problem. 

Followup 

Therapists should plan for followup and 

support as part of the termination process. 

Residential programs, for example, can hold 

support groups run by alumni or counselors 

that are available weekly for family members 

who want to attend on a voluntary, as-needed 

basis. Some practitioners ask the client and 

family members to call them after 6 months or 1 

year for a followup conversation. Depending on 

the family’s needs, the therapist may be able to 

provide reinforcement without further meetings, 

or may suggest one or two followup sessions to 

address emerging issues. 

At a minimum, clients should be assured that 

they can call the therapist when necessary. 

Cultural Issues 

It is important that a family therapist 

understand the family’s ethnic and cultural 

background. (See the example in the text box 

below.) Failure to do so may be partially 

responsible for the large dropout rate by ethnic 

minorities after the first therapy session 

(Soo-Hoo, 1999). To successfully promote 

change within a family system, the therapist will 

need the family’s permission to share their 

closely held secrets. The therapist’s approach, 

however, must vary according to the cultural 

background of the family. Working with a 

Filipino family recently settled in the United 

States, one therapist had to request a letter from 

the family elder in the Philippines in order to 

allow members to reveal family matters to an 

outsider. Once the family opened up, however, 

the therapist was seen as an “elder” and was 

accorded the respect he needed to promote 

Native Americans in Brief Family Therapy 

A 26-year-old Native American man sought treatment for his alcohol abuse. In a residential treatment 

setting, the therapist learned that the client’s father was a fanatically religious ex-drinker who tried to 

force his son to go to church. As a result, the client began drinking heavily on Sunday mornings in 

order to avoid going to church. The client was torn between a culturally based belief that he should 

respect his elders and his own desire for independence. The therapist encouraged father and son to 

express both their resentment and their appreciation of each other in letters read aloud to each other. 

Through this process, the client began to remember what his father had been like as an alcoholic and 

saw that he himself was in danger of making the same mistake. This motivated the client to 

accomplish abstinence and to move out of his father’s home in order to establish his own household. 

154 
positive change. In another example, a therapist 

working with a client who belonged to the 

Southern Baptist fundamentalist movement 

found that the client was immobilized by the 

shame that surrounded drinking in her family 

and the difficulty of talking about it. The client 

approached the family’s minister to help frame 

the situation so that the family could face the 

problem together and find a solution. (For more 

information on family therapy for those from 

unfamiliar cultures, see McGoldrick et al., 1996; 

Sue and Sue, 1990.) 

The language used to describe dynamics 

within the family system is charged with 

specific cultural meaning. For example, if a 

client belongs to a culture that values lifelong 

interdependence among family members, the 

therapist would be ill advised to encourage 

greater independence from the family. 

However, the therapist might encourage the 

client to become more effective within his family 

and explain ways that would allow some 

freedom within the cultural parameters of the 

family. 

Brief Family Therapy 

Ablon (with middle-class Catholic families) 

and Kaufman and Borders have drawn attention 

to the importance of ethnic and cultural 

differences to understand and treat families with 

substance abuse problems (Ablon, 1980; 

Kaufman and Borders, 1988). Many substance 

abuse treatment programs have developed 

culturally specific family therapy 

models for Latino families (Flores-Ortiz and 

Bernal, 1989; Laureano and Poliandro, 1991; 

Panitz et al., 1983; Szapocznik et al., 1991), 

African-American families (Aktan et al., 1996; 

Ziter, 1987), and Native American families (Hill, 

1989), among others. 

A family therapy approach that has been 

successful with substance-using Hispanic 

adolescents combines elements from structural, 

strategic, and Milan therapies (Szapocznik and 

Kurtines, 1989; Szapocznik et al., 1988, 1991). 

This approach focuses considerable effort on 

overcoming initial resistance to treatment 

because the process embodies the family’s issues 

around the adolescent’s substance use 

(Santisteban and Szapocznik, 1994; Szapocznik 

and Kurtines, 1989). 

155 

9 Time-Limited Group Therapy

Group psychotherapy is one of the most 

common modalities for treatment of 

substance abuse disorders. Group 

therapy is defined as a meeting of two or more 

people for a common therapeutic purpose or to 

achieve a common goal. It differs from family 

therapy in that the therapist creates open- and 

closed-ended groups of people previously 

unknown to each other. The lessons learned in 

therapy are practiced in the normal social 

network. Although efficacy research on group 

therapy for substance abuse disorder clients has 

been limited, there is substantial anecdotal and 

clinical evidence that it can have a dramatic 

impact on participating clients. In TIP 8, 

Intensive Outpatient Treatment for Alcohol and 

Other Drug Abuse (CSAT, 1994a), group therapy 

is cited as the treatment modality of choice for a 

variety of reasons. In clinical practice, group 

psychotherapy offers individuals suffering from 

substance abuse disorders the opportunity to see 

the progression of abuse and dependency in 

themselves and in others; it also gives them an 

opportunity to experience their success and the 

success of other group members in an 

atmosphere of support and hopefulness. The 

curative factors associated with group 

psychotherapy, defined by Yalom, specifically 

address such issues as the instillation of hope, 

the universality experienced by group members 

as they see themselves in others, the opportunity 

to develop insight through relationships, and a 

variety of other concerns specific to the support 

of substance-abusing clients and their recovery 

(Yalom, 1995). For many years, Alcoholics 

Anonymous (AA) and Narcotics Anonymous 

(NA) have recognized the importance of 

breaking the isolation associated with substance 

abuse, while at the same time connecting 

individuals with others whose common purpose 

is to dramatically change their lives through 

connection and community. From these 

perspectives, time-limited group psychotherapy 

offers potent opportunities to maximize the 

treatment energies of both therapist and client. 

Research suggests that most client 

improvement as a result of group therapy occurs 

within a brief span of time—typically, 2 or 3 

months (Garvin et al., 1976). This research 

implies that short-term therapy can be as 

successful as long-term therapy in promoting 

change. Short-term group therapy should be 

more goal-oriented, more structured, and more 

directive than long-term group therapy. Some 

therapists also believe the experience should be 

intensified through the use of high-impact 

techniques such as psychodrama (see discussion 

later in this chapter). 

Appropriateness of 

Group Therapy 

Groups can be extremely beneficial to 

individuals with substance abuse problems. 

Levine and Gallogly have noted that groups for 

alcohol-dependent clients 

 Help reduce denial, process ambivalence, 

and facilitate acceptance of alcohol abuse 

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Chapter 9 

Group Effects 

One Consensus Panelist recalls a therapy session in which a member arrived, furious and hostile, 

shouting, “How much longer do I have to do this stupid program? None of it works anyway!” 

Another group member immediately asked, “So, how does the anger keep things going for you?” In 

the ensuing conversation, the group learned that the angry member’s ex-wife had just sent him a bottle 

of expensive whiskey with the following note: “Dying to get together again.” This revelation, and the 

supportive group listening that followed, occurred largely without verbal involvement from the 

therapist. 

 Increase motivation for sobriety and other 

changes 

 Treat the emotional conditions that often 

accompany drinking (e.g., anxiety, 

depression, hostility) 

 Increase the capacity to recognize, anticipate, 

and cope with situations that may precipitate 

drinking behavior 

 Meet the intense needs of alcohol-dependent 

clients for social acceptance and support 

(Levine and Gallogly, 1985) 

Many beneficial effects happen more easily 

in groups than in one-on-one therapy. Group 

members confront each other, do “reality 

checks,” practice reflective listening, mirror each 

other, and help each other reframe key issues. 

Individuals in earlier stages of dependence can 

witness what later stage experiences are like 

(and by inference where they could progress if 

they do not reduce their use). Often, group 

members can be more effective than the 

therapist in confronting a participant who is not 

facing an important issue (e.g., the client who 

believes she can quit drinking and still smoke 

marijuana). 

Group Therapy 

Approaches 

Several kinds of groups fall under the spectrum 

of time-limited group therapy. In the broadest 

sense, two fundamental models help define 

categories of group interventions: the processsensitive approach and the directive approach. 

The process-sensitive group approach finds its 

direction in the traditions of analytical theory 

and has a significant range of expression. 

Depending on the theoretical base and 

leadership style of the facilitator, a processsensitive group can examine the unconscious 

processes of the group as a whole, utilizing 

these energies to help individuals see 

themselves more clearly and therefore open up 

the opportunity for change. This “group-as-awhole” approach is best exemplified by the 

work of Bion, who sees healing as an extension 

of the individuals within the group as the group 

comes to terms with a commonly shared anxiety 

(Bion, 1961). 

Yalom offers a significant contrast to these 

group-as-a-whole interventions through his 

interactional group process model (Yalom, 

1995). By attending to the relationships within 

the group and helping individuals understand 

themselves within the relational framework, an 

interactional group process provides individuals 

with significant information about how their 

behavior affects others and how they are in turn 

affected by other members. In addition, 

focusing energy on the relationships within the 

context of group, the leader is careful not to 

assume a central role but, rather, recognizes that 

the group itself becomes the agent of change, 

with the leader supporting the process but not 

initiating it. Attention is focused on the nature 

and growth of the relationships manifested in 

the “here and now” as the group takes place. 

158 
Time-Limited Group Therapy 

The second approach, and one better known 

to alcohol and drug counselors, is a dramatically 

different form of group therapy, often referred 

to as a directive approach. It offers structured 

goals and therapist-directed interventions to 

enable individuals to change in desired ways. A 

short-term directed group may be used to 

address major issues of concern for clients with 

substance abuse disorders and to facilitate selfdiscovery and growth through appropriately 

sequential activities. Because the therapist is 

“central” and in charge, this type of group 

depends less for success on group members and 

their ability to create a cohesive sense of 

belonging. 

Compared with the process-sensitive group, 

which sees the cohesive power of the group as a 

primary curative factor, the directive approach 

addresses specific agenda items in a logical 

order with greater emphasis on content as the 

primary source of effective change. The 

directive approach, therefore, is perhaps more 

likely to be effective with those in early 

recovery. A potent example of directive, timelimited group experience, developed by 

Maultsby and Ellis, is known as Rational 

Behavioral Training (RBT) (Maultsby, 1976). 

This cognitive–behavioral therapy takes place 

over 13 weeks, one session per week. It uses 

fundamental cognitive–behavioral interventions 

and the clients’ growing awareness of their 

ability to control their own belief systems and 

self-talk and thus control their affective states. 

Clients are asked to share homework 

assignments and bring real-life situations into 

the group for exploration and examination. 

There is little effort in this group modality to 

analyze or direct energy to the relationships 

within the room. RBT affords a short-term 

intervention to develop the client’s skill in 

controlling emotions. The inference is that 

individuals who experience their emotional 

world as controllable will no longer need to use 

substances to exert “external” control. 

It is important to note that in any kind of 

group therapy, relationships are formed and 

process issues experienced. Even within the 

context of a cognitive–behavioral approach such 

as RBT, which is more educational than 

therapeutic, issues of process invariably arise. 

The experienced therapist can use the 

relationships within the group even in a 

psychoeducational framework to support and 

enhance the treatment experience. Whenever 

the opportunity arises, the group facilitator 

should help connect members to members. 

When shared histories are acknowledged, the 

sense of belonging is increased, and greater 

cohesion takes place. Cohesion may seem less 

important in a directive psychoeducational 

group. However, because of the very nature of 

substance abuse disorders, a feeling of 

belonging to a group committed to its own 

health rather than its own destruction is an 

important motivator for many clients. 

There has been significant debate within the 

field regarding the pros and cons of 

heterogeneous and homogeneous groups. The 

heterogeneous group, in which members have a 

variety of diagnoses, offers greater complexity 

and more opportunities for a wide range of 

relationships, which can be extremely helpful to 

many clients. However, the homogeneous 

group, particularly when composed of clients 

with substance abuse disorders, tends to lend 

itself more quickly to issues of cohesion and 

safety. For this reason, homogeneity has 

particular utility in the time-limited group 

intervention. 

An important issue within the context of the 

homogeneous substance abuse disorder group, 

whether time limited or not, is the group’s 

tendency to bond around its history of substance 

abuse rather than its commitment to recovery. 

Although the general focus of substance abuse 

treatment is on the abuse itself, the focus also 

must include issues of living within the context 

of the group. Through modeling and gentle 

159 
Chapter 9 

persuasion, the group facilitator can broaden the 

scope of a substance abuse treatment group to 

include relationships, concerns about daily 

living, and newly discovered personal integrity. 

Such are the struggles of all people in all 

circumstances. The movement from “what is 

wrong with us” to “how do we build better 

lives?” is an important transition in the timelimited group, whether psychoeducational or 

process sensitive. 

Group therapy can be conducted within the 

context of almost any theoretical framework 

familiar to the therapist and appropriate to 

group goals. Often the therapist will work with 

two or more models at the same time. The 

theoretical bases supporting both processsensitive groups and a more directive style can 

be combined effectively to address substanceabusing clients. 

Theories of Group 

Therapy 

The following group therapy models are 

discussed in this section: 

 Brief cognitive group therapy 

 Cognitive–behavioral group therapy 

 Strategic/interactional therapy 

 Brief group humanistic and existential 

therapies 

 Group psychodynamic therapy 

 Modified dynamic group therapy (MDGT) 

 Modified interactional group process (MIGP) 

The first five are summarized below and 

discussed at greater length in Chapters 4 though 

7 of this TIP. MIGP, considered a highly 

effective type of brief group treatment for 

substance abusers, is discussed in detail in this 

section. The 11 therapeutic factors identified by 

Yalom as the basis of successful group therapy 

are presented at the end of this section (Yalom, 

1995). 

Brief Cognitive Group Therapy 

Cognitive techniques work well in group 

therapy. The group is taught the basics of the 

cognitive approach, then individual members 

take turns presenting an event or situation that 

tempted them to abuse substances. Other 

members assist the therapist in asking for more 

information about the client’s thoughts on the 

event and how it did or did not lead to 

substance abuse (or to negative feelings that 

might have led to use). Finally, the group 

members provide the client with alternative 

ways of viewing the situation. Chapter 4 

discusses brief cognitive therapy in more depth. 

Cognitive–Behavioral 

Group Therapy 

The cognitive–behavioral approach focuses the 

group’s attention on self-defeating beliefs, 

relying on group members to identify such 

beliefs in each other. The therapist encourages 

group members to apply behavioral techniques 

such as homework and visualization to help 

participants think, feel, and behave differently. 

Chapter 4 discusses brief cognitive–behavioral 

therapy in more depth. 

Strategic/Interactional Therapies 

The strategic therapist uses techniques similar to 

those used in family therapy to challenge each 

group member to examine ineffective attempted 

solutions. The therapist encourages group 

members to evaluate and process these 

attempted solutions and recognize when they 

are not working, then engages the group in 

generating alternative solutions. The therapist 

also works, where appropriate, to change group 

members’ perceptions of problems and help 

them understand what is happening to them. 

Typically, the therapist guides the process, while 

members offer suggestions and encouragement 

to each other as they identify and implement 

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Time-Limited Group Therapy 

effective solutions. To address the problem of 

substance abuse, the group will often be 

directed to examine problems that might result 

in substance abuse and reframe their 

perceptions of these problems. 

The principles of solution-focused therapy 

are the same for group treatment as for 

individual therapy. These include client goalsetting through the use of the “miracle” 

question, use of scaling questions to monitor 

progress, and identification of successful 

strategies that work for each client. (These 

techniques are defined in Chapter 5 of this TIP.) 

The therapist works to create a group culture 

and dynamic that encourages and supports 

group members by affirming their successes. At 

the same time, the therapist works to restrain 

client digressions (“war stories”) and personal 

attacks. The therapist tries to challenge group 

members—all of whom, unlike in family 

therapy, are seen as “customers”—to take action 

to create positive change. Chapter 5 discusses 

brief strategic/interactional therapies in more 

depth. 

Brief Group Humanistic and 

Existential Therapies 

Several approaches fall within this category. 

The transpersonal approach is useful in 

meditation, stress reduction, and relaxation 

therapy groups and can be adapted for clients 

who have substance abuse disorders. In dealing 

with issues of religion or spirituality, it is helpful 

to have other people talk about their 

perspectives. In this way, past degrading or 

punitive experiences related to organized 

religion can be redefined in a more meaningful 

and useful context. 

Gestalt therapy in groups allows for more 

comprehensive integration in that each group 

member can provide a piece of shared personal 

experience. Each group member plays a role in 

creating the group, and all of their perceptions 

must be taken into account in making a change. 

Role-playing and dream analysis in groups are 

practical and relevant exercises that can help 

clients come to terms with themselves. 

One of the most influential contemporary 

experts on group therapy, Irvin D. Yalom, 

considers himself an existentialist because he is 

not concerned with past behavior except as it 

influences the “here and now.” A summary of 

his existential approach is presented in The 

Yalom Reader (Yalom, 1997) and consists of three 

sections: (1) therapeutic factors in group 

therapy, (2) a description of the “here and now” 

core concept, and (3) therapy with specialized 

groups, including a chapter on group therapy 

and alcoholism. This last chapter details specific 

techniques to diminish anxiety but still permit 

the group to maintain an interactional focus— 

for example, writing a candid summary of the 

session and mailing it to members before the 

next meeting. Yalom has worked closely with 

the National Institute on Alcohol Abuse and 

Alcoholism to apply basic principles of group 

therapy to alcohol abusers, and his ideas are 

applicable to those with other substance abuse 

disorders as well. See Chapter 6 for more 

discussion of humanistic and existential 

therapies. 

Group Psychodynamic Therapy 

Group psychodynamic therapy enables the 

group itself to become both the context and 

means of change through which its members 

stimulate each other to support, strengthen, or 

change attitudes, feelings, relationships, 

thinking, and behavior—with the assistance of 

the therapist. 

The context sought is one in which the group 

becomes an influential reference group for the 

individual. Participation of members 

according to their abilities leads to some 

degree of involvement of each in pursuing 

individual and group goals. The process of 

goal-setting and clarification for expectation 

provides an agreed upon framework for 

meeting of mutual needs. This, in turn, 

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Chapter 9 

contributes to the building of cohesive forces 

(Roberts and Northen, 1976, p. 141). 

Chapter 7 discusses psychodynamic therapy in 

more depth. 

Modified Dynamic Group Therapy 

On the basis of psychodynamic theory, a 

modified dynamic group therapy approach was 

defined for substance-abusing clients (Khantzian 

et al., 1990). Viewing substance abuse disorders 

as an expression of ego dysfunction, affect 

dysregulation, failure of self-care, and 

dysfunctional interpersonal relationships, 

MDGT falls in the intermediate length of timelimited group psychotherapy, with its basic 

structure defined by two meetings per week 

over a 26-week format. Based primarily on 

interventions to address cocaine addicts, MDGT 

focuses energy on the individuals within the 

group and conceptualizes the basic origins of 

substance abuse disorders as expressions of 

vulnerabilities within the characterological 

makeup of the client (Khantzian et al., 1990). As 

a supportive, expressive group experience, 

MDGT provides substance-abusing clients the 

opportunity to evaluate and change their 

vulnerabilities in four primary areas: 

(1) accessing, tolerating, and regulating feelings; 

(2) problems with relationships; (3) self-care 

failures; and (4) self-esteem deficits. Congruent 

with this understanding of the origins of 

substance abuse, MDGP emphasizes safety, 

comfort, and control within the group context. 

Group facilitation is defined primarily by the 

therapist’s ability to engage and retain substance 

abusers in treatment by providing structure, 

continuity, and activity in an empathic 

atmosphere. 

This supportive approach creates an 

atmosphere of safety, allowing the client to 

move away from the safety of the known 

behavior associated with substance abuse and 

into the less known world of recovery. As in 

other group experiences, this group theory 

encourages issues of universality as a means of 

overcoming isolation, while at the same time 

dealing with a common shame so often 

encountered in the substance-abusing client. 

Unlike interpersonally focused process groups, 

which look more at relational concerns, MDGT 

places greater emphasis on the clients’ growing 

understanding of their characterological 

difficulties and/or deficits, not entirely 

dissimilar to issues identified in self-help groups 

such as AA and NA. 

Modified Interactional 

Group Process 

Time-limited MIGP is a synthesis of the work of 

several theorists (Flores, 1988; Khantzian et al., 

1990; MacKenzie, 1990; Yalom, 1995). MIGP is 

distinguished in a variety of ways from the 

psychoeducational groups so important in 

substance abuse treatment. As referenced in TIP 

8, Intensive Outpatient Treatment for Alcohol and 

Other Drug Abuse (CSAT, 1994a), both processsensitive and psychoeducational group learning 

experiences are often necessary for the 

substance-abusing client. Even in a short-term, 

intensive treatment experience, combining a 

psychoeducational group and a process group 

has significant clinical impact. The 

psychoeducational group is more directive, with 

the therapist as the central figure. However, as 

will be explained, it is important to utilize the 

energy of group process itself, even in a 

psychoeducational format, to enable clients to 

make connections and build relationships that 

will support their recovery. 

The features that distinguish MIGP from a 

more traditional interactive process are the 

greater activity of the leader and the sensitivity 

to the development of a safe atmosphere that 

allows group members to examine relational 

issues without excessive emotional contagion. 

The atmosphere of safety is greatly enhanced by 

the therapist’s adherence to group agreements 

or group norms and by the continued 

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Time-Limited Group Therapy 

reinforcement of these agreements throughout 

the group process. The importance of 

confidentiality, the group’s accepting 

responsibility for itself, and self-disclosure are 

all supported by the facilitator. Procedural 

agreements, including beginning and ending the 

group session on time and ensuring that each 

member has a place within the circle, with any 

absences addressed, are part of the development 

of the safe environment. 

In this process, the therapist helps the clients 

recognize that they are the primary change 

agents. The group becomes a safe place both to 

give and to receive support. Although 

traditionally substance abuse groups tend to be 

confrontative, MIGP is far more supportive. 

This stems from the belief that denial and other 

defense mechanisms become more rigid when a 

person is attacked. Consequently, group 

members are encouraged to support one another 

and look for areas of commonality rather than 

use more shame-based interactive styles that 

attempt to “break through denial.” 

Intellectualization and MIGP 

Many therapists are told that clients should get 

in touch with their feelings and experience 

“what is in their gut.” Although awareness of 

the affective life is important to everyone, it is 

precisely the regulation of emotions that many 

substance-abusing clients have difficulty 

addressing. Consequently, although emotional 

exploration is encouraged within the context of 

MIGP, the facilitator is constantly monitoring 

the affective energy within the group, taking 

steps to break emotional contagion should it 

begin. In a particularly intense group 

experience, the therapist may ask the group as a 

whole to take a step back and look at what just 

took place. In this way, the group not only 

learns from its shared life but also experiences 

its ability to control intense emotional responses. 

This consistent effort to reduce high levels of 

anxiety or emotional catharsis and to prevent 

them from dominating the group is another 

hallmark of MIGP. 

General issues in MIGP 

Following the insights of Flores and Mahon, 

MIGP focuses special attention in four areas of 

the client’s life: gratification and support, 

vulnerability of self, regulation of affect, and 

self-care (Flores and Mahon, 1993). These four 

areas receive particular attention because they 

represent areas of vulnerability within the 

substance-abusing client that can easily lead to 

relapse and undermine recovery. 

Gratification and support 

Many clients come to treatment with profound 

issues of guilt and shame. Therefore, they lack 

the ability to give themselves gratification and 

support in the face of change. The active 

leadership style of MIGP allows group members 

to openly support one another and at the same 

time provides each group member with 

attention from the leader that leads to higher 

levels of gratification. Affirming group 

members’ willingness to share and support one 

another is an essential ingredient in time-limited 

group work. It creates a positive atmosphere 

and increases levels of safety and cohesiveness, 

which further supports the change process. 

Vulnerability of self 

Substance-abusing clients often enter treatment 

with shattered self-esteem. Defending against 

this internal vulnerability can become 

damaging, because clients project their fears 

onto others. They may try to hide internal 

vulnerability by appearing hostile and overly 

self-confident. An atmosphere of safety and 

empathy enables clients with profound 

vulnerabilities to enter the process of selfdisclosure, through which they become 

accessible not only to the group but also to 

themselves. The group facilitator actively 

encourages such self-disclosure but at the same 

time emphasizes that individual members need 

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Chapter 9 

not disclose any issue they are not yet ready to 

discuss. Clear boundaries and clear group 

agreements further support the possibility for 

self-disclosure. 

Regulation of affect 

Substance abuse disorders can be perceived as 

the consequences of trying to control one’s 

emotional life with external substances. This 

points to a failure of internal regulation that 

makes the client uncomfortable when feeling 

emotions that others might consider 

commonplace. Issues of grief, loss, sadness, and 

joy can be so affectively charged and linked to 

the client’s past alcohol and drug use that they 

threaten the client’s continued recovery. As 

mentioned above, the leader’s sensitivity to the 

levels of affective energy in the group is 

particularly important. Supporting group 

members to both feel what they are experiencing 

and at the same time move to a safer and more 

objective viewpoint regarding those feelings is 

inherent in MIGP. 

Self-care 

Substance-abusing clients often present to 

treatment unaware of internal stresses and pain, 

having lost sensitivity to physical cues that lead 

others to the normal self-care functions of daily 

living. These functions may be as simple as 

basic hygiene or more complex in terms of 

boundary setting and relational definitions. 

Setting boundaries within the group and 

encouraging heightened sensitivity to self-care 

are ways in which MIGP addresses this issue. 

Clients must hear a consistent message that they 

are worthy of the group’s support and, 

therefore, worthy of their own attention in 

regard to self-care. All of the above can 

comfortably be addressed within the context of 

MIGP, with the leader actively connecting 

members to members, who support one another 

on the importance of self-monitoring and care. 

Use of Psychodrama 

Techniques in a 

Group Setting 

Psychodrama has long been effectively used 

with the substance-abusing client population in 

a group setting. Wegscheider-Cruse effectively 

integrated psychodrama as a means to heal 

family-of-origin issues within the context of 

addictive behaviors (Wegscheider-Cruse, 1989). 

The utility of such an intervention seems to be 

clinically well established. The techniques can 

help the group move more quickly in terms of 

self-understanding and relational awareness. 

The insights gained from the experience of 

family sculpting (illustrated below) can be 

worthwhile and potent. However, it is 

important to stress that psychodrama and other 

similar expressive therapeutic interventions 

bring with them a clinical potency that needs to 

be understood. These interventions can raise 

anxiety and shame to the point where some 

clients may be pushed toward relapse or even 

feel the need to leave treatment to escape the 

internal conflicts encountered. As with any 

therapeutic technique, therapists should not 

utilize such techniques unless they are 

thoroughly trained and well supervised. Any 

intervention that has a powerful potential for 

growth almost always has an equal potential for 

damage if poorly conducted. Training and 

appropriate supervision are particularly 

important with expressive techniques because of 

their clinical potency. 

Psychodrama can be used with different 

models of group therapy. It offers persons with 

substance abuse disorders an opportunity to 

better understand past and present 

experiences—and how past experiences 

influence their present lives. This approach 

encourages clients to relearn forgotten skills, 

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Time-Limited Group Therapy 

imaginatively change apparent problems that 

block progress, rehearse new behaviors, practice 

empathy, and expand their emotional range by 

confronting feelings that have never been 

properly dealt with. As clients act, important 

concepts become real, internalized, and 

operational that might otherwise be purely 

theoretical. Changes experienced through 

acting become accessible to the psyche as part of 

the lived history of the individual. 

Some therapists use psychodrama to help 

transform internal dynamics that maintain old 

patterns relevant to substance abuse. For 

example, one therapist invites group members 

to list “rules” in their family of origin. These 

rules may be related to substance abuse (e.g., 

“Don’t ever say that Mother is drunk. She is 

taking a nap.”). After a client describes a 

situation in which the rule would be invoked, he 

assigns family roles to other participants, giving 

them instructions for how they would behave in 

this situation. The client is encouraged to break 

the rule—in the case of the “napping” mother, 

by insisting on bringing the truth into the 

open—with the verbal encouragement of all 

remaining group members who are not playing 

assigned roles. The client’s victory—which can 

be a transformative, powerful experience—is 

celebrated as the achievement it is. In this 

example, the individual experiences himself as a 

powerful truth-speaker rather than the 

powerless and voiceless participant he 

perceived himself to be in the past. This new 

experience can enhance his sense of self-efficacy 

and help foster change in his own pattern of 

substance abuse. 

In another example of psychodrama, group 

participants explore “character defects” such as 

grandiosity or isolation associated with their 

pattern of substance abuse. The defects are 

dramatized, with half the group engaged in the 

dramatization and half sitting as an audience. 

For example, persons who experience 

themselves as isolated sit in the corner or under 

a table with a “sponsor.” The therapist gives 

them sentences to complete, such as, “I like this 

corner because....“ or “The first time I remember 

isolating is....” Finally, they are asked to 

complete the sentence, “I have to get out of this 

corner because....” The sponsors then gather in 

a circle and invite the persons they have been 

supporting to join them, saying, “I want you to 

join this circle because....” This experience of 

connection often enhances participants’ 

motivation and ability to change. 

A common use of psychodrama in treatment 

for substance abuse disorders is “sculpting” 

family members in typical roles and enacting 

significant situations related to substance abuse 

patterns. In this process, developed by Papp, 

family members enact a scene to graphically 

depict the problem (Papp, 1977, 1983). The 

physical arrangement of the family members 

illustrates emotional relationships and conflicts 

within the family. For example, a family may 

naturally break up into a triad of the mother, 

sister, and brother, and a dyad of the father and 

another sibling. In that case, the therapist might 

highlight the fact that the mother and father 

communicate through one of their children and 

never talk to each other directly. 

In yet another form of psychodrama, one 

person in the group may be asked to give voice 

to different aspects of her own self that either 

help maintain dependency or speak for change 

(sometimes called the “disease” and “recovery” 

selves). The client might speak from a different 

chair or position for each of these voices. The 

intensity of psychodrama often helps 

compensate for the shorter time span now 

commonly funded for treatment. Although 

many participants express concern about acting, 

the barrier of shyness often drops completely as 

they enter the process with the assistance of a 

dynamic and committed facilitator. 

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Chapter 9 

Therapeutic Factors 

In his classic work, Theory and Practice of Group 

Psychotherapy, Irvin Yalom identified 11 primary 

“therapeutic factors” in group therapy (Yalom, 

1995). Each of these factors has particular 

importance for clients with substance abuse 

disorders and can be used to help explain why a 

group works in a particular way for this client 

population. These curative factors are present in 

all group interventions and are listed below. 

Instillation of Hope 

Many clients come to a treatment setting feeling 

defeated by life and overwhelmed by their 

failure to control their use of substances. They 

feel they have nowhere to go and no possibility 

for a better outcome in life. When individuals 

with this life view join a group of people 

struggling with similar problems, they have the 

remarkable opportunity of witnessing change in 

others while at the same time having their own 

small victories acknowledged and celebrated by 

group members. Through this process, hope 

begins to emerge. The energy of hope and the 

focused attention on this curative factor receive 

specific attention in the MIGP model. 

A variety of exercises can be utilized to 

further instill hope within substance-abusing 

clients. Clients can be asked to participate in a 

visualization exercise where they see themselves 

in a life without substance use, envisioning 

particularly how life would be different and 

better under such circumstances. The group 

energy fuels this experience and adds the 

intensity of other clients’ support. As with all 

“guided imagery exercises,” the group leader 

must move with caution. Many substanceabusing clients may not have a picture of life 

without substances, and consequently such an 

exercise can be humiliating if not handled 

sensitively. If the client is unable to visualize, he 

once again perceives failure. To guard against 

such potential shaming, the group facilitator can 

take an active role in the creation of the image, 

monitoring it for issues of safety with all 

members of the group as the exercise develops. 

Universality 

Substance abuse disorders tend to impede 

relationships and force clients into increased 

isolation. In a brief group experience, the clients 

encounter other individuals who have faced 

similar problems. They become aware that they 

are not alone in life and can feel tremendous 

satisfaction in this connection. The sense that 

their pain is not exclusive or unique and that 

others with similar problems are willing to 

support them can be profoundly healing. It 

helps clients move beyond their isolation, and it 

gives further energy to hope, which helps to fuel 

the change process. 

Imparting Information 

The inevitable exchange of information in a 

group setting helps members get from one day 

to the next. Particularly in conjunction with 

formal psychoeducational groups, MIGP affords 

group members the opportunity to reflect on 

what they have learned and at the same time 

apply that learning within the group setting. 

The information shared is personal and tends to 

be experienced as motivational. The client 

struggling with issues of substance abuse can 

hear from others how they have dealt with 

difficult concerns and how they have 

experienced success. This mutually shared 

success gives positive energy to the group and 

encourages change. 

Altruism 

Fundamental to the human condition is the 

desire to help others when they are in trouble. 

Clients struggling with substance abuse 

disorders tend to be focused on their own 

difficulties and have a hard time reaching out to 

help those in need. Group therapy offers the 

members opportunities to provide assistance 

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Time-Limited Group Therapy 

and insight to one another. Particularly within 

the model of MIGP, the facilitator pays great 

attention to altruistic moves on the part of 

members. They are celebrated and 

acknowledged. As individuals recognize that 

they have something of value to give their 

fellow group members, their self-esteem rises as 

change and self-efficacy are supported. 

Corrective Recapitulation of the 

Primary Family Group 

This therapeutic factor pertains to the 

importance of relationships within the client’s 

family of origin, which invariably finds 

expression within the group experience. 

“Recapitulation of the family group” happens 

when a client—both consciously and 

unconsciously—relates to another group 

member as if that person is a member of his 

family of origin with whom he has struggled in 

the past. This occurrence is clearly a projection, 

but it can be identified by the leader, and both 

group members involved can benefit as they 

investigate new ways of relating that break the 

old dysfunctional patterns of the family of 

origin. In a way, the group begins to serve as a 

substitute family. The group members are the 

siblings, and the group facilitator is in a parental 

role. Even in a time-limited group, issues of 

transference and countertransference may 

require attention. However, MIGP tends to 

dilute the transference by “spreading it 

throughout the group” rather than 

concentrating it within the dyadic counseling 

relationship. 

Development of Socializing 

Techniques 

Many substance abusers are “field-sensitive” or 

“field-dependent” individuals who are keenly 

conscious of the network of specific 

relationships as opposed to principles or 

generalizations that apply regardless of context. 

Group therapy can take advantage of this trait 

and use the energy of the relationships to 

facilitate change. As participants engage in 

relationships, they learn new social skills that 

can help them break through their isolation and 

connect with others in more meaningful ways. 

They also learn how to disconnect, which is 

equally important given the anxieties often 

associated with relational loss and grief. The 

group facilitator may at times deliberately focus 

on these social skills through role-playing or 

modeling exercises within the context of the 

group itself. The healing takes place as the 

clients take what they have learned and 

experienced in group and actively generalize it 

in their lives outside of the group. 

Imitative Behaviors 

Imitative behaviors are an important source of 

learning in group therapy. The process of 

modeling can be particularly important as 

clients learn new ways to handle difficult 

emotions without resorting to violence or drug 

use. Therapists must be acutely sensitive to the 

important role they play within this context; 

clients often look to the therapist to model new 

behaviors as they encounter new situations 

within the group context. Group members can 

also learn by imitating other members who are 

successfully dealing with difficult relational 

issues. It is helpful for a new group member to 

witness an ongoing group where people are 

confronting their problems appropriately, 

moving beyond old dysfunctional patterns, and 

forming new relationships that support change. 

The group becomes a living demonstration of 

these new behaviors, which facilitates and 

supports insight and change. 

Interpersonal Learning 

Groups provide an opportunity for members to 

learn about relationships and intimacy. The 

group itself is a laboratory where group 

members can, perhaps for the first time, 

honestly communicate with individuals who 

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Chapter 9 

will support them and provide them with 

respectful feedback. This interpersonal learning 

is facilitated by the MIGP model, in that special 

attention is given to relational issues within the 

context of group. 

Group Cohesiveness 

Often misunderstood, group cohesion is a sense 

of belonging that defines the individual not only 

in relation to herself but also to the group. It is a 

powerful feeling that one has meaning in 

relationships and that one is valued. 

Development of group cohesion is particularly 

important in the MIGP model, so that group 

members feel safe enough to take the risks of 

self-disclosure and change. The experience of 

belonging is both nurturing and empowering. 

Catharsis 

Sometimes group participants will gain a 

sudden insight through interaction with others, 

which can cause a significant internal shift in the 

way they respond to life. Such insights may be 

accompanied by bursts of emotion that release 

pain or anger associated with old psychological 

wounds. This process happens more easily in a 

group where cohesion has been developed and 

where the therapist can facilitate a safe 

environment in which emotions can be freely 

shared. It is important to recognize, however, 

that although catharsis is a genuine expression, 

it is not seen as curative in and of itself. High 

levels of emotional exchange not addressed in 

the group can become potential relapse triggers, 

which endanger the success of individual 

members. The therapist acknowledges the 

powerful emotions after the member has shared 

them but asks the group as well as the member 

to give those emotions meaning and context 

within the group. Thus, both the experience of 

the emotion and the understanding of how that 

emotion either interferes or supports 

relationships are healing. 

Existential Factors 

Existential factors of loss and death are often 

issues of great discomfort in the substanceabusing population. The brevity of a timelimited group experience forces these issues to 

the surface and allows members to discuss them 

openly in a safe environment. Time itself 

represents loss and also serves as a motivator, as 

the members face the ending of each group 

session and of the group treatment experience. 

As they become more aware of the frustrations 

of reality and the limits they face, clients can 

receive support from the group in accepting 

“life on life’s terms” instead of their past 

patterns of escape. 

Using Time-Limited 

Group Therapy 

The focus of time-limited therapeutic groups 

varies a great deal according to the model 

chosen by the therapist. Yet some 

generalizations can be made about several 

dimensions of the manner in which brief group 

therapy is implemented. 

Assessment and Preparation 

Client preparation is particularly important in 

any time-limited group experience. Clients 

should be thoroughly assessed before their entry 

into a group for therapy. In terms of 

exclusionary issues, persons with severe 

disorders or those who cannot accept support 

may need to be given more individual time 

before a group experience. Also, persons with 

significant deficits in cognition may not benefit 

as much from a time-limited group. 

Group participants should be given a 

thorough explanation of group expectations. 

For an MIGP group, for example, they need to 

understand their responsibility for speaking 

within the group and that the primary focus of 

168 
the group is relationships. A brief explanation 

of a “here and now” encounter is helpful—the 

group can become a place where feedback takes 

place in the “here and now,” as members learn 

how they are affected by the others and how 

they in turn affect other members. This “here 

and now” focus brings clients into the present 

and allows them to deal with real issues within 

the group that they can then apply in their daily 

lives. It also distinguishes MIGP from self-help 

support groups, which traditionally discourage 

relational “here and now” interactions. 

If time permits, it is particularly effective for 

group members as they are being assessed and 

prepared for group to either watch or participate 

in a practice group as a trial experience. A 

variety of group tapes are available; however, 

any program can videotape one of its own 

groups, with appropriate releases for client 

permission, to use for instructional purposes. 

This enables new clients to see what will happen 

in the group session and lowers anxiety. This 

intentional effort to make the group safe and 

reduce its inherent anxiety distinguishes MIGP 

from a more traditionally interactive process 

group. Introductions to group can also be 

provided in a psychoeducational format. 

Clients learn not only what is going to take place 

in the group but also why and how the group 

process brings about healing. The importance of 

relationships and open communications through 

self-disclosure and support can be explained. 

It is important to recognize that although a 

significant amount of client preparation takes 

place before the client ever enters a group, client 

preparation itself is also a process and not an 

event. Through continual references to the 

group agreements and group contracts, the 

therapist continues to prepare clients as they 

move into the experience. 

Initial Session 

Opening sessions for group therapy differ 

according to the type of group, its specific goals, 

Time-Limited Group Therapy 

and the personal style of the therapist. In 

homogeneous, problem-focused groups, for 

example, less time is needed to define what 

group members have in common. Opening 

sessions typically include the following: 

 New group members introduce themselves 

at the opening session, responding to a 

simple request such as, “Tell us what led you 

here.” Research suggests that if groups do 

not explicitly address the reason for each 

member’s participation, more members will 

drop out (Levine, 1967). In the context of 

substance abuse treatment, the therapist 

should therefore initially discuss with group 

members how substance abuse issues will be 

addressed so as to ensure that focus is 

maintained. 

 The “locus of control” for the group is 

clarified. Clients explore whether they 

believe they have the ability to choose 

effective actions or if they think of 

themselves as helpless victims of 

circumstance. For directive groups, in which 

the therapist exercises greater control, this 

process will be shorter than for group 

process groups, in which group members 

take turns as leaders. 

 Goals for the group (and often for 

individuals) are clarified. 

 The therapist seeks to establish a safe, warm, 

supportive environment. There may be a 

need to establish rules to increase safety—for 

example, that members will not engage in 

physical contact, will not discuss what was 

said outside the room, and will give feedback 

to each other in an agreed-upon manner. 

 The therapist helps group members establish 

connections with each other, pointing out 

common concerns and problems. 

Some therapists ask the group to evaluate the 

opening session. This may be done orally or in 

writing. The group’s success can be measured 

through the following questions: 

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Chapter 9 

 Was substance abuse discussed? 

 Did group members listen to each other? 

 Did members cooperate and support each 

other? 

 Did they give feedback? 

Later Sessions 

Often, to enhance continuity, the therapist will 

begin the next session by recalling the previous 

one and ensuring that “leftover” items are 

addressed. The therapist may ask group 

members how lessons learned in the group have 

affected their daily lives. Members may have 

tried to implement suggestions and found they 

did or did not work, or they may not have tried 

to do so at all, which is also an important topic 

of discussion. 

On an inpatient unit with clients going 

through withdrawal or struggling with 

coexisting psychiatric disorders, instilling hope 

is particularly important. For the newest clients 

on the unit, connecting with others who have 

just been through a similar difficult experience 

can be inspirational. Such a therapeutic 

encounter can also reduce issues of shame, as 

clients connect with others who both share and 

understand their journey. In addition, the 

inpatient group can serve as an example of what 

treatment will be like after discharge and allow 

the client to “practice” being in a group. Clients 

can experience the supportive nature of the 

group, which will reduce their anxiety about 

future group involvement. Underscoring the 

impact of brief group interventions, the 

inpatient process treatment group remains one 

of the cornerstones of continued change. 

Duration of Therapy and 

Frequency of Sessions 

The preferred timeline for time-limited group 

therapy is not more than two sessions per week 

(except in the residential settings), with as few 

as six sessions in all, or as many as 12, 

depending on the purpose and goals of the 

group. Sessions are typically 11⁄2 to 2 hours in 

length. Residential programs usually have more 

frequent sessions. 

Given the dramatically shortened inpatient 

and residential stays available under managed 

health care, some have questioned the utility of 

a process-sensitive treatment group and are 

focusing on directive educational groups. Even 

though clients often do not stay more than 3 to 5 

days on an inpatient unit, much can be 

accomplished in this brief timeframe. As 

mentioned before, directive educational groups 

are necessary but not always sufficient. Groups 

with active facilitation, but adhering to process 

sensitivity, can build cohesion quickly and act as 

powerful motivators for clients to follow 

through with the next level of care. 

Group process therapy is most effective if 

participants have had time to find their roles in a 

group, to “act” these roles, and to learn from 

them. The group needs time to define its 

identity, develop cohesion, and become a safe 

environment in which there is enough trust for 

participants to reveal themselves. (The 

exception is an educational group, which relies 

less on group process factors.) Consequently, 

prematurely terminated groups relying on 

group process may be less effective than they 

could be in promoting long-term change. 

Furthermore, participants may have to clear 

their systems of the most serious effects of 

substances before they can fully participate. 

Because of such factors, arbitrary time limits for 

groups, as opposed to timelines set according to 

the therapeutic goals of the particular group, can 

be ill advised. 

Gender and Cultural Issues 

Within Groups 

Researchers at Cornell University found that 

social contact with persons who have gone 

through the same crisis is highly beneficial 

(Manisses Communications Group, 1997a). 

Therefore, a common gender, culture and/or 

170 
Time-Limited Group Therapy 

sexual preference will help clients in group 

therapy share difficulties they may have 

encountered because of that common 

background. 

Participation in group therapy may be less 

effective for women than men, perhaps because 

groups are often dominated by men and reflect 

their issues and style of interaction (Jarvis, 1992). 

At this time, however, little research is available 

on the relative efficacy of women-only rather 

than mixed-gender groups. Weitz argues that 

women may have to be empowered in order to 

remain abstinent (Weitz, 1982). Group 

cognitive–behavioral therapy has been found to 

be an effective treatment for women with 

posttraumatic stress disorder and a substance 

abuse disorder (Najavits et al., 1996) as well as 

for women with both a substance abuse disorder 

and a history of physical or sexual abuse 

(Manisses Communication Group, 1997). 

Covington has written extensively about the 

importance of women-specific groups, 

particularly in early recovery. She accurately 

pointed out that the powerful role definitions 

within our culture tend to be played out in 

group and are often oppressive to women 

(Covington, 1997). In a mixed group, the 

women quickly become the “emotional 

containers” for the group and take care of the 

men. Although such activity is not defined as 

pathological, it expresses cultural norms 

wherein women’s needs become secondary to 

those of men, with the women primarily defined 

as caretakers. They are uncomfortable about 

bringing up issues of sexuality, particularly 

sexual abuse, given that men have generally 

been the abusers (Covington, 1997). 

The creation of gender-specific groups, 

particularly in small agencies or private practice, 

may pose logistical difficulties. However, there 

is growing consensus among therapists that, 

whenever possible, women need to have their 

own groups, particularly during early recovery 

(Byington, 1997). This does not suggest that 

women should be fully segregated from men. 

Participation in mutually shared 

psychoeducational experiences and multifamily 

groups is a therapeutic way of addressing 

gender issues (Byington, 1997). 

Concerns of ethnicity and race should be 

handled with sensitivity. This is not to suggest 

that in a time-limited group, the potency of 

homogeneity is such that each and every ethnic 

or racial subgroup should be segregated in order 

to reap the benefits of this intervention. 

However, cultural issues need to be addressed 

openly and with sensitivity. 

Cost-Effectiveness 

The clinical utility of time-limited groups has 

clearly been demonstrated, but the cost factor is 

not irrelevant to a consideration of the value of 

these groups. Although individual work and 

family work will likely always remain a part of 

even the briefest time-limited treatment 

experience, acceptance and use of group 

interventions are slowly growing. From a costmanagement perspective, the benefits are 

obvious. Not only can the therapist use the 

power of the group to support change within all 

group members, but one well-trained group 

therapist can meet the clinical needs of 8 to 12 

clients in roughly the same amount of time as an 

individual session. When these numbers are 

enlarged to include more directive approaches 

such as cognitive–behavioral or 

psychoeducational groups, the cost–benefit ratio 

increases. 

171 

Appendix A

Bibliography 

Abbott, P.J.; Weller, S.B.; Delaney, H.D.; and 

Moore, B.A. Community reinforcement 

approach in the treatment of opiate addicts. 

American Journal of Drug and Alcohol Abuse 

24(1):17–30, 1998. 

Ablon, J. The significance of cultural patterning 

for the “alcoholic family.” Family Process 

19(2):127–144, 1980. 

Abrams, D.B., and Niaura, R.S. Social learning 

theory. In: Blane, H.T., and Leonard, K.E., 

eds. Psychological Theories of Drinking and 

Alcoholism. New York: Guilford Press, 1987. 

pp. 131–178. 

Abramson, L.Y.; Seligman, M.E.; and Teasdale, 

J.D. Learned helplessness in humans: 

Critique and reformulation. Journal of 

Abnormal Psychology 87(1):49–74, 1978. 

Ackerman, R. Growing in the Shadow: Children of 

Alcoholics. Pompano Beach, FL: Health 

Communications, 1986. 

Ackerman, R. Motto for ACOAs: Let go and 

grow. Recovery Section, Alcoholism and 

Addiction 7(5):R10, 1987. 

Aktan, G.B.; Kumpfer, K.L.; and Turner, C.W. 

Effectiveness of a family skills training 

program for substance abuse prevention 

with inner city African-American families. 

Substance Use and Misuse 31(2):157–175, 1996. 

Al-Anon Family Groups, Inc. Al-Anon Faces 

Alcoholism. New York: Al-Anon Family 

Group Headquarters, 1984. 

Allen, J.P., and Columbus, M. Assessing Alcohol 

Problems: A Guide for Clinicians and 

Researchers. NIAAA Treatment Handbook 

Series, No. 4. Bethesda, MD: Department of 

Health and Human Services, 1995. 

Alonso, A., and Rutan, J.S. Women in group 

therapy. International Journal of Group 

Psychotherapy 29(4):481–491, 1979. 

American Psychiatric Association. Diagnostic 

and Statistical Manual of Mental Disorders, 3rd 

ed. Washington, DC: American Psychiatric 

Press, 1980. 

American Psychiatric Association. Diagnostic 

and Statistical Manual of Mental Disorders, 4th 

ed. Washington, DC: American Psychiatric 

Press, 1994. 

American Society of Addiction Medicine 

(ASAM). Principles of Addiction Medicine. 

Chevy Chase, MD: ASAM, 1994. 

American Society of Addiction Medicine 

(ASAM). Patient Placement Criteria for the 

Treatment of Substance-Related Disorders, 2nd 

ed. Chevy Chase, MD: ASAM, 1996. 

173 
Appendix A 

Amodeo, M. Treating the late life alcoholic: 

Guidelines for working through denial 

integrating individual, family, and group 

approaches. Journal of Geriatric Psychiatry 

23(2):91–105, 1990. 

Anderson, P., and Scott, E. The effect of general 

practitioners’ advice to heavy drinking men. 

British Journal of Addiction 87(6):891–900, 

1992. 

Anker, A.L., and Crowley, T.J. Use of 

contingency contracts in specialty clinics for 

cocaine abuse. In: Harris, L.S., ed. Problems 

of Drug Dependence, 1981. Proceedings of the 

43rd Annual Scientific Meeting, the Committee 

on Problems of Drug Dependence, Inc. NIDA 

Research Monograph Series, Number 41. 

HHS Pub. No. (ADM) 83-1264. Rockville, 

MD: National Institute on Drug Abuse, 1982. 

pp. 452–459. 

Annis, H.M., and Davis, C.S. Assessment of 

expectancies. In: Donovan, D.M., and 

Marlatt, G.A., eds. Assessment of Addictive 

Behaviors. New York: Guilford Press, 1988a. 

pp. 84–111. 

Annis, H.M., and Davis, C.S. Self-efficacy and 

the prevention of alcoholic relapse: Initial 

findings from a treatment trial. In: Baker, 

T.B., and Cannon, D.S., eds. Assessment and 

Treatment of Addictive Disorders. New York: 

Praeger Publishers, 1988b. pp. 88–112. 

Annis, H.M., and Davis, C.S. Relapse 

prevention. In: Hester, R.K., and Miller, 

W.R., eds. Handbook of Alcoholism Treatment 

Approaches. Elmsford, NY: Pergamon Press, 

1989a. pp. 170–182. 

Annis, H.M., and Davis, C.S. Relapse 

prevention training: A cognitive-behavioral 

approach based on self-efficacy theory. 

Journal of Chemical Dependency Treatment 

2(2):81–103, 1989b. 

Annis, H.M., and Davis, C.S. Relapse 

prevention. Alcohol Health & Research World 

15(3):204–212, 1991. 

Azrin, N.H. Improvements in the communityreinforcement approach to alcoholism. 

Behaviour Research and Therapy 14(5):339–348, 

1976. 

Babor, T.F. Nosological considerations in the 

diagnosis of substance abuse disorders. In: 

Glantz, M., and Pickens, R., eds. Vulnerability 

to Drug Abuse. Washington, DC: American 

Psychological Association, 1991. pp. 53–73. 

Babor, T.F. Avoiding the horrible and beastly 

sin of drunkenness: Does dissuasion make a 

difference? Journal of Consulting and Clinical 

Psychology 62(6):1127–1140, 1994. 

Babor, T.F., and Grant, M., eds. Project on 

Identification and Management of AlcoholRelated Problems. Report on Phase II: A 

Randomized Clinical Trial of Brief Interventions 

in Primary Health Care. Geneva, Switzerland: 

World Health Organization, 1991. 

Babor, T.F.; Grant, M.; Acuda, W.; Burns, F.H.; 

Campillo, C.; Del Boca, F.K.; Hodgson, R.; 

Ivanets, N.N.; Lukomskya, M.; Machona, M.; 

Rollnick, S.; Resnick, R.; Saunders, J.B.; 

Skutle, A.; Connor, K.; Ernberg, G.; Kranzler, 

H.; Lauerman, R.; and McRee, B. A 

randomized clinical trial of brief 

interventions in primary health care: 

Summary of a WHO project. Addiction 

89(6):657–660, 1994. 

Babor, T.F.; Ritson, E.B.; and Hodgson, R.J. 

Alcohol-related problems in the primary 

health care setting: A review of early 

intervention strategies. British Journal of 

Addiction 81:23–46, 1986. 

174 
Bibliography 

Baker, H.S. Shorter term psychotherapy: A selfpsychological approach. In: Crits-Christoph, 

P., and Barber, J.P., eds. Handbook of ShortTerm Dynamic Psychotherapy. New York: 

Basic Books, 1991. pp. 287–322. 

Bale, R. Family treatment in short-term 

detoxification. In: O’Farrell, T. J., ed. 

Treating Alcohol Problems: Marital and Family 

Interventions. New York: Guilford Press, 

1993. pp. 117–144. 

Bandura, A. Self-efficacy: Toward a unifying 

theory of behavioral change. Psychological 

Review 84(2):191–215, 1977. 

Bandura, A. Social Foundations of Thought and 

Action: A Social Cognitive Theory. Englewood 

Cliffs, NJ: Prentice-Hall, 1986. 

Bandura, A. Regulative function of perceived 

self-efficacy. In: Rumsey, M.G.; Walker, C.B.; 

and Harris, J.H., eds. Personnel Selection and 

Classification. Hillsdale, NJ: Lawrence 

Erlbaum Associates, 1994. pp. 261–271. 

Barber, J.P., and Crits-Christoph, P. Comparison 

of the brief dynamic therapies. In: CritsChristoph, P., and Barber, J.P., eds. Handbook 

of Short-Term Dynamic Psychotherapy. New 

York: Basic Books, 1991. pp. 323–357. 

Barber, J.P.; Luborsky, L.; Crits-Christoph, P.; 

Thase, M.E.; Weiss, R.; Frank, A.; Onken, L.; 

and Gallop, R. Therapeutic alliance as a 

predictor of outcome in treatment of cocaine 

dependence. Psychotherapy Research 9:54–73, 

1999. 

Barry, K.L. Alcohol and drug abuse. In: 

Mengel, M.B., and Holleman, W.L., eds. 

Fundamentals of Clinical Practice: A Textbook on 

the Patient, Doctor, and Society. New York: 

Plenum Medical Book Co., 1997. pp. 335– 

357. 

Barry, K.L., and Blow, F.C. Basic Health 

Promotion Workbook. Ann Arbor, MI: 

University of Michigan Press, 1998. 

Barth, R.P.; Ramler, M.; and Pietrzak, J. Toward 

more effective and efficient programs for 

drug- and AIDS-affected families. In: Barth, 

R.P.; Pietrzak, J.; and Ramler, M., eds. 

Families Living With Drugs and HIV: 

Intervention and Treatment Strategies. New 

York: Guilford Press, 1993. pp. 337–353. 

Bauer, G.P., and Kobos, J.C. Brief Therapy: ShortTerm Psychodynamic Intervention. Northvale, 

NJ: Jason Aronson, 1987. 

Beattie, M. Co-Dependent No More. Center City, 

MN: Hazelden, 1987. 

Beck, A.T. Cognitive Therapy and the Emotional 

Disorders. New York: International 

Universities Press, 1976. 

Beck, A.T., and Freeman, A. Cognitive Therapy of 

Personality Disorders. New York: Guilford 

Press, 1990. 

Beck, A.T., and Wright, F.D. Cocaine abuse. In: 

Freeman, A., and Dattilio, F., eds. 

Comprehensive Casebook of Cognitive Therapy. 

New York: Plenum Press, 1992. pp. 185–192. 

Beck, A.T.; Wright, F.D.; Newman L.; and Liese, 

B. Cognitive Therapy of Substance Abuse. New 

York: Guilford Press, 1993. 

Beck, J.S. Cognitive Therapy: Basics and Beyond. 

New York: Guilford Press, 1995. 

Beck, J.S., and Liese, B.S. Cognitive therapy. In: 

Frances, R.J., and Miller, S.I., eds. Clinical 

Textbook of Addictive Disorders. New York: 

Guilford Press, 1998. pp. 547–573. 

Bekir, P.; McLellan, T.; Childress, A.R.; and 

Gariti, P. Role reversals in families of 

substance misusers: A transgenerational 

phenomenon. International Journal of the 

Addictions 28(7):613–630, 1993. 

Bepko, C. The Responsibility Trap: A Blueprint for 

Treating the Alcoholic Family. New York: Free 

Press, 1985. 

175 
Appendix A 

Berg, I.K. Solution-focused brief therapy with 

substance abusers. In: Washton, A.M., ed. 

Psychotherapy and Substance Abuse: A 

Practitioner’s Handbook. New York: Guilford 

Press, 1995. pp. 223–242. 

Berg, I.K., and Miller, S.D. Working With the 

Problem Drinker. New York: W.W. Norton, 

1992. 

Berg, I.K., and Reuss, N. Solution-focused brief 

therapy: Treating substance abuse. Current 

Thinking and Research in Brief Therapy 2:57–83, 

1998. 

Bernstein, S., ed. Explorations in Group Work. 

Boston: Boston University School of Social 

Work, 1965. 

Bien, T.H.; Miller, W.R.; and Tonigan, J.S. Brief 

interventions for alcohol problems: A review. 

Addiction 88:315–336, 1993. 

Bigelow, G.E.; Stitzer, M.L.; and Liebson, I.A. 

The role of behavioral contingency 

management in drug abuse treatment. In: 

Grabowski, J.; Stitzer, M.L.; and Henningfeld, 

J.E., eds. Behavioral Intervention Techniques in 

Drug Abuse Treatment. NIDA Research 

Monograph Series, Number 46. HHS Pub. 

No. (ADM) 84-1282. Rockville, MD: National 

Institute on Drug Abuse, 1984. pp. 36–52. 

Binder, J.L., and Strupp, H.H. The Vanderbilt 

approach to time-limited dynamic 

psychotherapy. In: Crits-Christoph, P., and 

Barber, J.P., eds. Handbook of Short-Term 

Dynamic Psychotherapy. New York: Basic 

Books, 1991. pp. 137–165. 

Bion, W.R. Experiences in Groups, and Other 

Papers. New York: Basic Books, 1961. 

Birchler, G.R., and Webb, L.J. Discriminating 

interaction behaviors in happy and unhappy 

marriages. Journal of Consulting and Clinical 

Psychology 45:494–495, 1977. 

Birke, S.A.; Edelmann, R.J.; and Davis, P.E. An 

analysis of the abstinence violation effect in a 

sample of illicit drug users. British Journal of 

Addiction 85(10):1299–1307, 1990. 

Blaine, J.D., and Julius, D.A., eds. 

Psychodynamics of Drug Dependence. NIDA 

Research Monograph Series, Number 12. 

DHEW Pub. No. (ADM) 77-470. Rockville, 

MD: National Institute on Drug Abuse, 

Division of Research, 1977. 

Blatt, S.J.; Quinlan, D.M.; Pilkonis, P.A.; and 

Shea, M.T. Impact of perfectionism and need 

for approval on the brief treatment of 

depression: The National Institute of Mental 

Health Treatment of Depression 

Collaborative Research Program revisited. 

Journal of Consulting and Clinical Psychology 

63(1):125–132, 1995. 

Blewett, D.B. The Frontiers of Being. New York: 

Award, 1969. 

Bloom, B.L. Planned Short-Term Psychotherapy: A 

Clinical Handbook, 2nd ed. Boston: Allyn and 

Bacon, 1997. 

Bohart, A.C., and Todd, J. Foundations of Clinical 

and Counseling Psychology. New York: 

Harper & Row, 1988. 

Boorstein, S., ed. Transpersonal Psychotherapy. 

Palo Alto, CA: Science and Behavior Books, 

1980. 

Boszormenyi-Nagy, I., and Spark, G. Invisible 

Loyalties: Reciprocity in Intergenerational Family 

Therapy. Hagerstown, MD: Harper & Row, 

1973. 

Bowen, M. Alcoholism as viewed through 

family systems theory and family 

psychology. Annals of the New York Academy 

of Sciences 233:115–122, 1974. 

176 
Bowen, M. Family Therapy in Clinical Practice. 

New York: Jason Aronson, 1978. 

Bowlby, J. Attachment and Loss. New York: 

Basic Books, 1969. 

Bradley, B.P.; Gossop, M.; Brewin, C.R.; Phillips, 

G.; and Green, L. Attributions and relapse in 

opiate addicts. Journal of Consulting and 

Clinical Psychology 60(3):470–472, 1992. 

Brill, L. The Clinical Treatment of Substance 

Abusers. New York: Free Press, 1981. 

Brooks, C.S.; Zuckerman, B.; Bamforth, A.; Cole, 

J.; and Kaplan-Sanoff, M. Clinical issues 

related to substance-involved mothers and 

their infants. Infant Mental Health Journal 

15(2):202–217, 1994. 

Brown, J.M., and Miller, W.R. Impact of 

motivational interviewing on participation 

and outcome in residential alcoholism 

treatment. Psychology of Addictive Behaviors 

7:211–218, 1993. 

Brown, S.A. Drug effect expectancies and 

addictive behavior change. Experimental and 

Clinical Psychopharmacology 1(1–4):55–67, 

1993. 

Brown, S.A.; Carrello, P.D.; Vik, P.W.; and 

Porter, R.J. Change in alcohol effect and selfefficacy expectancies during addiction 

treatment. Substance Abuse 19(4):155–167, 

1998. 

Brown, S.A.; Christiansen, B.A.; and Goldman, 

M.S. Alcohol Expectancy Questionnaire: An 

instrument for the assessment of adolescent 

and adult alcohol expectancies. Journal of 

Studies on Alcohol 48(5):483–491, 1987. 

Budman, S.H., and Gurman, A.S. A Theory and 

Practice of Brief Therapy. New York: Guilford 

Press, 1988. 

Bibliography 

Budney, A.J., and Higgins, S.T. Therapy Manuals 

for Drug Addiction. Manual 2: A Community 

Reinforcement Approach: Treating Cocaine 

Addiction. Rockville, MD: National Institute 

on Drug Abuse, 1998. 

Burglass, M.E. Imaginal Education for the 

Correctional Counselor. Cambridge, MA: 

Correctional Solutions Foundation Press, 

1971. 

Burglass, M.E. The Thresholds Program. A 

Community-Based Intervention in Correctional 

Therapeutics. Cambridge, MA: Correctional 

Solutions Foundation Press, 1972. 

Burglass, M.E.; Bremer, D.H.; and Evans, R.J. 

The artform process: A clinical technique for 

the enhancement of affect management in 

drug-dependent individuals. In: Schecter, 

A.; Alksne, H.; and Kaufman, E., eds. Critical 

Concerns in the Field of Drug Abuse. New 

York: Marcel Dekker, 1976. pp. 494–498. 

Burglass, M.E., and Duffy, M.G. Thresholds: A 

Manual for the Correctional Counselor. 

Cambridge, MA: Correctional Solutions 

Foundation Press, 1974. 

Burns, D.D. The Feeling Good Handbook. New 

York: Plume Book, 1989. 

Butterfield, P.S. and Leclair, S. Cognitive 

characteristics of bulimic and drug-abusing 

women. Addictive Behaviors 13(2):131–138, 

1988. 

Byington, D.B. Applying relational theory to 

addiction treatment. In: Straussner, S., and 

Zelvin, E., eds. Gender and Addictions: Men 

and Women in Treatment. Northvale, NJ: 

Jason Aronson, 1997. 

Cade, B., and O’Hanlon, W.H. A Brief Guide to 

Brief Therapy. New York: W.W. Norton, 1993. 

177 
Appendix A 

Campbell, J. The Hero With a Thousand Faces, 2nd 

ed. Princeton, NJ: Princeton University 

Press, 1968. 

Campbell, T. Parental conflicts between 

divorced spouses: Strategies for intervention. 

Journal of Systemic Therapies 12(4):27–38, 1993. 

Cappell, H. Alcohol and tension reduction: 

What’s new? In: Gottheil, E.; Druly, K.A.; 

Pashko, S.; and Weinstein, S.P., eds. Stress 

and Addiction. New York: Brunner/Mazel, 

1987. pp. 237–247. 

Carroll, K.M. Integrating psychotherapy and 

pharmacotherapy in substance abuse 

treatment. In: Rotgers, F.; Keller, D.S.; and 

Morgenstern, J., eds. Treating Substance 

Abuse: Theory and Technique. New York: 

Guilford Press, 1996a. 

Carroll, K.M. Relapse prevention as a 

psychosocial treatment: A review of 

controlled clinical trials. In: Marlatt, G.A., 

and VandenBos, G.R., eds. Addictive 

Behaviors: Readings on Etiology, Prevention, and 

Treatment. Washington, DC: American 

Psychological Association, 1996b. pp. 697– 

717. 

Carroll, K.M. Therapy Manuals for Drug 

Addiction. Manual 1: A Cognitive-Behavioral 

Approach: Treating Cocaine Addiction. 

Rockville, MD: National Institute on Drug 

Abuse, 1998. 

Carroll, K.M.; Rounsaville, B.J.; and Gawin, F.H. 

A comparative trial of psychotherapies for 

ambulatory cocaine abusers: Relapse 

prevention and interpersonal psychotherapy. 

American Journal of Drug and Alcohol Abuse 

17:229–247, 1991. 

Carson, R.C., and Butcher, J.N. Abnormal 

Psychology and Modern Life, 9th ed. New 

York: HarperCollins, 1992. 

Center for Substance Abuse Treatment. 

Screening and Assessment of Alcohol- and Other 

Drug-Abusing Adolescents. Treatment 

Improvement Protocol (TIP) Series, Number 

3. HHS Pub. No. (SMA) 93-2009. 

Washington, DC: U.S. Government Printing 

Office, 1993a. 

Center for Substance Abuse Treatment. 

Guidelines for the Treatment of Alcohol- and 

Other Substance-Abusing Adolescents. 

Treatment Improvement Protocol (TIP) 

Series, Number 4. HHS Pub. No. (SMA) 

93-2010. Washington, DC: U.S. Government 

Printing Office, 1993b. 

Center for Substance Abuse Treatment. Intensive 

Outpatient Treatment for Alcohol and Other 

Drug Abuse. Treatment Improvement 

Protocol (TIP) Series, Number 8. HHS Pub. 

No. (SMA) 94-2077. Washington, DC: U.S. 

Government Printing Office, 1994a. 

Center for Substance Abuse Treatment. 

Assessment and Treatment of Patients With 

Coexisting Mental Illness and Alcohol and Other 

Drug Abuse. Treatment Improvement 

Protocol (TIP) Series, Number 9. HHS Pub. 

No. (SMA) 94-2078. Washington, DC: U.S. 

Government Printing Office, 1994b. 

Center for Substance Abuse Treatment. 

Assessment and Treatment of Cocaine-Abusing 

Methadone-Maintained Patients. Treatment 

Improvement Protocol (TIP) Series, Number 

10. HHS Pub. No. (SMA) 94-3004. 

Washington, DC: U.S. Government Printing 

Office, 1994c. 

Center for Substance Abuse Treatment. Simple 

Screening Instruments for Outreach for Alcohol 

and Other Drug Abuse and Infectious Diseases. 

Treatment Improvement Protocol (TIP) 

Series, Number 11. HHS Pub. No. (SMA) 

94-2094. Washington, DC: U.S. Government 

Printing Office, 1994d. 

178 
Bibliography 

Center for Substance Abuse Treatment. The Role 

and Current Status of Patient Placement Criteria 

in the Treatment of Substance Use Disorders. 

Treatment Improvement Protocol (TIP) 

Series, Number 13. HHS. Pub. No. (SMA) 

95-3021. Washington, DC: U.S. Government 

Printing Office, 1995. 

Center for Substance Abuse Treatment. A Guide 

to Substance Abuse Services for Primary Care 

Clinicians. Treatment Improvement Protocol 

(TIP) Series, Number 24. HHS Pub. No. 

(SMA) 97-3139. Washington, DC: U.S. 

Government Printing Office, 1997. 

Center for Substance Abuse Treatment. 

Addiction Counseling Competencies: The 

Knowledge, Skills, and Attitudes of Professional 

Practice. Technical Assistance Protocol (TAP) 

Series, Number 21. HHS Pub. No. (SMA) 

98-3171. Washington, DC: Government 

Printing Office, 1998a. 

Center for Substance Abuse Treatment. 

Substance Abuse Among Older Adults. 

Treatment Improvement Protocol (TIP) 

Series, Number 26. HHS Pub. No. (SMA) 

98-3179. Washington, DC: U.S. Government 

Printing Office, 1998b. 

Center for Substance Abuse Treatment. 

Screening and Assessing Adolescents for 

Substance Use Disorders. Treatment 

Improvement Protocol (TIP) Series, Number 

31. HHS Pub. No. (SMA) 99-3282. 

Washington, DC: U.S. Government Printing 

Office, 1999a. 

Center for Substance Abuse Treatment. 

Treatment of Adolescents With Substance Use 

Disorders. Treatment Improvement Protocol 

(TIP) Series, Number 32. HHS Pub. No. 

(SMA) 99-3283. Washington, DC: U.S. 

Government Printing Office, 1999b. 

Center for Substance Abuse Treatment. 

Enhancing Motivation for Change in Substance 

Abuse Treatment. Treatment Improvement 

Protocol (TIP) Series, Number 35. HHS 

Pub. No. (SMA) 99-3354. Washington, DC: 

U.S. Government Printing Office, 1999c. 

Center for Substance Abuse Treatment. 

Substance Abuse Treatment for Persons With 

HIV/AIDS. Treatment Improvement Protocol 

(TIP) Series. Washington, DC: U.S. 

Government Printing Office, in press. 

Cermak, T.L. Diagnosing and Treating CoDependence: A Guide for Professionals Who 

Work With Chemical Dependents, Their Spouses, 

and Children. Minneapolis, MN: Johnson 

Institute, 1986. 

Chafetz, M.E.; Blane, H.T.; Abram, H.S.; Golner, 

J.; Lacy, E.; McCourt, W.F.; Clark, E.; and 

Meyers, W. Establishing treatment 

relationships with alcoholics. Journal of 

Nervous and Mental Disease 134(5):395–409, 

1962. 

Chafetz, M.E.; Hertzman, M.; and Berenson, D. 

Alcoholism: A positive view. In: Arieti, S., 

and Brody, E.B., eds. Adult Clinical 

Psychiatry, 2d ed. American Handbook of 

Psychiatry, Vol. 3. New York: Basic Books, 

1974. pp. 367–392. 

Chaney, E.F. Social skills training. In: Hester, 

R.K., and Miller, W.R., eds. Handbook of 

Alcoholism Treatment Approaches. Elmsford, 

NY: Pergamon Press, 1989. pp. 206–221. 

Chaney, E.F.; Roszell, D.K.; and Cummings, C. 

Relapse in opiate addicts: A behavioral 

analysis. Addictive Behaviors 7(3):291–297, 

1982. 

Chapman, P.L., and Huygens, I. An evaluation 

of three treatment programmes for 

alcoholism: An experimental study with 6-

and 8-month follow-ups. British Journal of 

Addiction 83(1):67–81, 1988. 

179 
Appendix A 

Chermack, S.T.; Blow, F.C.; Hill, E.M.; and 

Mudd, S.A. The relationship between alcohol 

symptoms and consumption among older 

drinkers. Alcoholism: Clinical and Experimental 

Research 20(7):1153–1158, 1996. 

Chiauzzi, E.J. Preventing Relapse in the 

Addictions: A Biopsychosocial Approach. New 

York: Pergamon Press, 1991. 

Chick, J.; Lloyd, G.; and Crombie, E. Counseling 

problem drinkers in medical wards: A 

controlled study. British Medical Journal 

290:965–967, 1985. 

Childress, A.R.; Ehrman, R.; McLellan, A.T.; 

MacRae, J.; Natale, M.; and O’Brien, C.P. 

Can induced moods trigger drug-related 

responses in opiate abuse patients? Journal of 

Substance Abuse Treatment 11(1):17–23, 1994. 

Childress, A.R.; McLellan, A.T.; Ehrman, R.; and 

O’Brien, C.P. Classically conditioned 

responses in opioid and cocaine dependence: 

A role in relapse? In: Ray, B.A. Learning 

Factors in Substance Abuse. NIDA Research 

Monograph Series, Number 84. HHS Pub. 

No. (ADM) 88-1576. Rockville, MD: National 

Institute on Drug Abuse, 1988. pp. 25–43. 

Chinen, A.B. The emergence of transpersonal 

psychiatry. In: Scotton, B.W.; Chinen, A.B.; 

and Battista, J.R., eds. Textbook of 

Transpersonal Psychiatry and Psychology. New 

York: Basic Books, 1996. pp. 9–18. 

Chopra, D. Overcoming Addiction: The Spiritual 

Solution. New York: Harmony Books, 1997. 

Chutuape, M.A.; Silverman, K.; and Stitzer, M.L. 

Use of methadone take-home contingencies 

with persistent opiate and cocaine abusers. 

Journal of Substance Abuse Treatment 16(1):23– 

30, 1999. 

Connors, G.J.; Carroll, K.M.; DiClemente, C.C.; 

Longabaugh, R.; and Donovan, D.M. The 

therapeutic alliance and its relationship to 

alcoholism treatment participation and 

outcome. Journal of Consulting and Clinical 

Psychology 65(4):588–598, 1997. 

Coon, G.M.; Pena, D.; and Illich, P.A. Selfefficacy and substance abuse: Assessment 

using a brief phone interview. Journal of 

Substance Abuse Treatment 15(5): 385–391, 

1998. 

Cooper, J.F. A Primer of Brief Psychotherapy. 

New York: W.W. Norton, 1995. pp. 13–34. 

Cooper, J.F. Brief therapy in clinical psychology. 

In: Cullari, S., ed. Foundations of Clinical 

Psychology. Boston: Allyn and Bacon, 1998. 

pp. 185–207. 

Copans, S. The invisible family member: 

Children in families with alcohol abuse. In: 

Combrinck-Graham, L., ed. Children in 

Family Contexts: Perspectives on Treatment. 

New York: Guilford Press, 1988. pp. 277– 

298. 

Corey, G. Theory and Practice of Counseling and 

Psychotherapy, 4th ed. Pacific Grove, CA: 

Brooks/Cole, 1991. 

Coudert, J. The Alcoholic in Your Life. New York: 

Stein and Day, 1972. 

Covington, S.S. Women, addiction, and 

sexuality. In: Straussner, S., and Zelvin, E., 

eds. Gender and Addictions: Men and Women 

in Treatment. Northvale, NJ: Jason Aronson, 

1997. 

Crawley, B. Self-medication and the elderly. In: 

Freeman, E.M., ed. Substance Abuse 

Treatment: A Family Systems Perspective. Sage 

Sourcebooks for the Human Services Series, 

Vol. 25. Newbury Park, CA: Sage 

Publications, 1993. pp. 217–238. 

180 
Bibliography 

Crits-Christoph, P. The efficacy of brief 

dynamic psychotherapy: A meta-analysis. 

American Journal of Psychiatry 149(2):151–158, 

1992. 

Crits-Christoph, P., and Barber, J.P., eds. 

Handbook of Short-Term Dynamic 

Psychotherapy. New York: Basic Books, 1991. 

Crits-Christoph, P.; Barber, J.P.; and Kurcias, J.S. 

Introduction and historical background. In: 

Crits-Christoph, P., and Barber, J.P., eds. 

Handbook of Short-Term Dynamic 

Psychotherapy. New York: Basic Books, 1991. 

pp. 1–16. 

Crits-Christoph, P.; Siqueland, L.; Blaine, J.; 

Frank, A.; Luborsky, L.; Onken, L.S.; Muenz, 

L.; Thase, M.E.; Weiss, R.D.; Gastfriend, D.R.; 

Woody, G.; Barber, J.P.; Butler, S.F.; Daley, 

D.; Bishop, S.; Najavits, L.M.; Lis, J.; Mercer, 

D.; Griffin, M.L.; Moras, K.; and Beck, A.T. 

The National Institute on Drug Abuse 

Collaborative Cocaine Treatment Study: 

Rationale and methods. Archives of General 

Psychiatry 54:721–726, 1997. 

Crits-Christoph, P.; Siqueland, L.; Blaine, J.; 

Frank, A.; Luborsky, L.; Onken, L.S.; Muenz, 

L.R.; Thase, M.E.; Weiss, R.D.; Gastfriend, 

D.R.; Woody, G.; Barber, J.P.; Butler, S.F.; 

Daley, D.; Salloum, I.; Bishop, S.; Najavits, 

L.M.; Lis, J.; Mercer, D.; Griffin, M.L.; Moras, 

K.; and Beck, A.T. Psychosocial treatments 

for cocaine dependence: National Institute on 

Drug Abuse Collaborative Cocaine 

Treatment Study. Archives of General 

Psychiatry 56(6):493–502, 1999. 

Crowley, T.J. Contingency contracting 

treatment of drug-abusing physicians, 

nurses, and dentists. In: Grabowski, J.; 

Stitzer, M.L.; and Henningfield, J.E., eds. 

Behavioral Intervention Techniques in Drug 

Abuse Treatment. NIDA Research 

Monograph Series, Number 46. HHS Pub. 

No. (ADM) 84-1282. Rockville, MD: National 

Institute on Drug Abuse, 1984. pp. 68–83. 

Cullari, S. Brief psychodynamic approaches. In: 

Cullari, S. ed. Foundations of Clinical 

Psychology. Boston: Allyn and Bacon, 1998. 

Cummings, C., and Gordon, J.R. Relapse: 

Strategies of prevention and prediction. In: 

Miller, W.R., ed. The Addictive Behaviors: 

Treatment of Alcoholism, Drug Abuse, Smoking 

and Obesity. Elmsford, NY: Pergamon Press, 

1980. pp. 291–321. 

Cummings, N.A. Brief intermittent 

psychotherapy throughout the life cycle. In: 

Zeig, J.K., and Gilligan, S.G., eds. Brief 

Therapy: Myths, Methods, and Metaphors. New 

York: Brunner/Mazel, 1990. pp. 169–184. 

Daily, S.G. Alcohol, incest, and adolescence. In: 

Lawson, G.W., and Lawson, A.W., eds. 

Adolescent Substance Abuse: Etiology, 

Treatment, and Prevention. Gaithersburg, MD: 

Aspen Publishers, 1992. pp. 251–266. 

Darkes, J., and Goldman, M.S. Expectancy 

challenge and drinking reduction: 

Experimental evidence for a mediational 

process. Journal of Consulting and Clinical 

Psychology 61(2):344–353, 1993. 

Davanloo, H., ed. Short-Term Dynamic 

Psychotherapy. New York: Jason Aronson, 

1980. 

181 
Appendix A 

Davies, J.B. The Myth of Addiction: An Application 

of the Psychological Theory of Attribution to 

Illicit Drug Use. Philadelphia: Harwood 

Academic Publishers, 1992. 

Davis, D.I.; Berenson, D.; Steinglass, P.; and 

Davis, S. The adaptive consequences of 

drinking. Psychiatry 37:209–215, 1974. 

DeNelsky, G.Y., and Boat, B.W. A coping skills 

model of psychological diagnosis and 

treatment. Professional Psychology: Research 

and Practice 17:322–330, 1986. 

Denoff, M.S. An integrated analysis of the 

contribution made by irrational beliefs and 

parental interaction to adolescent drug 

abuse. International Journal of the Addictions 

23(7):655–659, 1988. 

DiClemente, C.C.; Carbonari, J.P.; Montgomery, 

R.P.; and Hughes, S.O. The Alcohol 

Abstinence Self-Efficacy Scale. Journal of 

Studies on Alcohol 55(2):141–148, 1994. 

DiClemente, C.C., and Fairhurst, S.K. Selfefficacy and addictive behaviors. In: 

Maddux, J.E., ed. Self-Efficacy, Adaptation, 

and Adjustment: Theory, Research, and 

Application. New York: Plenum Press, 1995. 

pp. 109–141. 

DiClemente, C.C.; Prochaska, J.O.; Fairhurst, 

S.K.; Velicer, W.F.; Velasquez, M.M.; and 

Rossi, J.S. The process of smoking cessation: 

An analysis of precontemplation, 

contemplation, and preparation stages of 

change. Journal of Consulting and Clinical 

Psychology 59(2):295–304, 1991. 

DiClemente, C.C., and Scott, C.W. Stages of 

change: Interactions with treatment 

compliance and involvement. In: Onken, L.S.; 

Blaine, J.D.; and Boren, J.J., eds.. Beyond the 

Therapeutic Alliance: Keeping the DrugDependent Individual in Treatment. NIDA 

Research Monograph Series, Number 165. 

NIH Pub. No. 97-4142. Rockville, MD: 

National Institute on Drug Abuse, 1997. pp. 

131–156. 

Dolan, M.P.; Black, J.L.; Penk, W.E.; Rabinowitz, 

R.; and DeFord, H.A. Predicting the outcome 

of contingency contracting for drug abuse. 

Behavior Therapy 17:470–474, 1986. 

Donovan, D.M. Assessment issues and domains 

in the prediction of relapse. Addiction 

91(Suppl.):S29–S36, 1996. 

Donovan, D.M. Assessment and interviewing 

strategies in addictive behaviors. In: 

McCrady, B.S., and Epstein, E.E., eds. 

Addictions: A Comprehensive Guidebook for 

Practitioners. New York: Oxford University 

Press, 1999. pp. 187–215. 

Donovan, D.M., and Chaney, E.F. Alcoholic 

relapse prevention and intervention: Models 

and methods. In: Marlatt, G.A., and Gordon, 

J.R., eds. Relapse Prevention: Maintenance 

Strategies in the Treatment of Addictive 

Behaviors. New York: Guilford Press, 1985. 

pp. 351–416. 

Donovan, D.M., and Marlatt, G.A. Assessment of 

Addictive Behaviors. New York: Guilford 

Press, 1988. 

182 
Bibliography 

Donovan, D.M., and Marlatt, G.A. Recent 

developments in alcoholism: Behavioral 

treatment. Recent Developments in Alcoholism 

11:397–411, 1993. 

Dossman, R.; Kutter, P.; Heinzel, R.; and 

Wurmser, L. The long-term benefits of 

intensive psychotherapy: A view from 

Germany. In: Lazar, S.G., ed. Extended 

Dynamic Psychotherapy: Making the Case in an 

Era of Managed Care. Hillsdale, NJ: Analytic 

Press, 1997. pp. 74–86. 

Douglas, L.J. “Perceived family dynamics of 

cocaine abusers, as compared to opiate 

abusers and non-drug abusers.” Ph.D. diss., 

University of Florida at Gainesville, 1987. 

Drummond, D.C. Alcohol interventions: Do the 

best things come in small packages? 

Addiction 92(4):375–379, 1997. 

Drummond, D.C.; Thom, B.; Brown, C.; 

Edwards, G.; and Mullan, M.J. Specialist 

versus general practitioner treatment of 

problem drinkers. Lancet 336(8720):915–918, 

1990. 

Edwards, G., and Orford, J. A plain treatment 

for alcoholism. Proceedings of the Royal Society 

of Medicine 70:344–348, 1977. 

Edwards, G.; Orford, J.; Egert, S.; Guthrie, S.; 

Hawker, A.; Hensman, C.; Mitcheson, M.; 

Oppenheimer, E.; and Taylor, C. Alcoholism: 

A controlled trial of “treatment” and 

“advice.” Journal of Studies on Alcohol 

38(5):1004–1031, 1977. 

Edwards, M.E., and Steinglass, P. Family 

therapy treatment outcomes for alcoholism. 

Journal of Marital and Family Therapy 

21(4):475–509, 1995. 

Ehrman, R.N.; Robbins, S.J.; Childress, A.R.; and 

O’Brien, C.P. Conditioned responses to 

cocaine-related stimuli in cocaine abuse 

patients. Psychopharmacology (Berl) 

107(4):523–529, 1992. 

Elkin, I. The NLMH Treatment of Depression 

Collaborative Research Program: Where we 

began and where we are. In: Bergin, A.E., 

and Garfield, S.L., eds. Handbook of 

Psychotherapy and Behavior Change, 4th ed. 

New York: John Wiley and Sons, 1994. pp. 

114–139. 

Ellis, A. The treatment of alcohol and drug 

abuse: A rational-emotive approach. Rational 

Living 17(2):15–24, 1982. 

Ellis, A., and Grieger R., eds. Handbook of 

Rational-Emotive Therapy. New York: 

Springer, 1977. 

Ellis, A.; McInerney, J.F.; DiGiuseppe, R.; and 

Yeager, R.J. Rational-Emotive Therapy With 

Alcoholics and Substance Abusers. New York: 

Pergamon Press, 1988. 

Epstein, E.E., and McCrady, B.S. Behavioral 

couples treatment of alcohol and drug use 

disorders: Current status and innovations. 

Clinical Psychology Review 18(6):689–711, 

1998. 

Evans, D.M., and Dunn, N.J. Alcohol 

expectancies, coping responses and selfefficacy judgments: A replication and 

extension of Cooper et al.’s 1988 study in a 

college sample. Journal of Studies on Alcohol 

56(2):186–193, 1995. 

Fahnestock, R. Impact of substance abuse and 

post-traumatic stress disorder. In: Freeman, 

E.M., ed. Substance Abuse Treatment: A Family 

Systems Perspective. Sage Sourcebooks for the 

Human Services Series, Vol. 25. Newbury 

Park, CA: Sage Publications, 1993. pp. 157– 

188. 

Fals-Stewart, W.; Birchler, G.R.; and O’Farrell, 

T.J. Behavioral couples therapy for male 

substance-abusing patients: Effects on 

relationship adjustment and drug-using 

behavior. Journal of Consulting and Clinical 

Psychology 64(5):959– 972, 1996. 

183 
Appendix A 

Favazza, A.R., and Thompson, J.J. Social 

networks of alcoholics: Some early findings. 

Alcoholism: Clinical and Experimental Research 

8(1):9–15, 1984. 

Feinberg, F. Substance-abusing mothers and 

their children: Treatment for the family. In: 

Combrinck-Graham, L., ed. Children in 

Families at Risk: Maintaining the Connections. 

New York: Guilford Press, 1995. pp. 228– 

247. 

Feinstein, D., and Krippner, S. The Mythic Path: 

Discovering the Guiding Stories of Your Past— 

Creating a Vision for Your Future. New York: 

Putnam, 1997. 

Fisch, R.; Weakland, J.H.; and Segal, L. The 

Tactics of Change: Doing Therapy Briefly. San 

Francisco: Jossey-Bass, 1982. 

Flanzer, J.P. Alcohol and family violence: The 

treatment of abusing families. In: Einstein, 

S., ed. Drug and Alcohol Use: Issues and 

Factors. New York: Plenum Press, 1989. pp. 

261–274. 

Flanzer, J P., and Sturkie, D.K. Alcohol and 

Adolescent Abuse. Holmes Beach, FL: 

Learning Publications, 1987. 

Fleming, M.F.; Barry, K.L.; Manwell, L.B.; 

Johnson, K.; and London, R. Brief physician 

advice for problem drinkers: A randomized 

controlled trial in community-based primary 

care practices. JAMA 277(13):1039–1045, 

1997. 

Fleming, M.F.; Barry, K.; Manwell, L.; Johnson, 

K.; and London, R. A trial of early alcohol 

treatment (Project TrEAT): A randomized 

trial of brief physician advice in communitybased primary care practices. JAMA, in 

press. 

Fleming, M.F.; Manwell, L.B.; Barry, K.L.; 

Adams, W.; and Stauffacher, E.A. Brief 

physician advice for alcohol problems in 

older adults: A randomized communitybased trial. Journal of Family Practice 

48(5):378–384, 1999. 

Flores, P. Group Psychotherapy With Addicted 

Populations. New York: Haworth Press, 1988. 

Flores, P.J., and Mahon, L. Treatment of 

addiction in group psychotherapy. 

International Journal of Group Psychotherapy 

43(2):143–156, 1993. 

Flores-Ortiz, Y., and Bernal, G. Contextual 

family therapy of addiction with Latinos. 

Journal of Psychotherapy and the Family 6(1– 

2):123–142, 1989. 

Folkman, S., and Lazarus, R.S. Coping as a 

mediator of emotion. Journal of Personality 

and Social Psychology 54(3):466–475, 1988. 

Folkman, S., and Lazarus, R.S. Coping and 

emotion. In: Monat, A., and Lazarus, R.S., 

eds. Stress and Coping: An Anthology. New 

York: Columbia University Press, 1991. 

pp. 207–227. 

Frankel, A.J. Groupwork with recovering 

families in concurrent parent and children’s 

groups. Alcoholism Treatment Quarterly 9(3– 

4):23–37, 1992. 

Frawley, P.J., and Smith, J.W. Chemical 

aversion therapy in the treatment of cocaine 

dependence as part of a multimodal 

treatment program: Treatment outcome. 

Journal of Substance Abuse Treatment 7(1):21– 

29, 1990. 

Freeman, A.; Pretzer, J.M.; Fleming, B.; Simon, 

K.M. Clinical Applications of Cognitive 

Therapy. New York: Plenum Press, 1990. 

184 
Freeman, A., and Reinecke, M.A. Cognitive 

Therapy of Suicidal Behavior: A Manual for 

Treatment. New York: Springer Publishing, 

1993. 

French, S. Family approaches to alcoholism: 

Why the lack of interest among marriage and 

family professionals? Journal of Drug Issues 

17(4):359–368, 1987. 

Friedberg, L.M. Psychotherapy Works: A Review of 

“The Effectiveness of Psychotherapy: The 

Consumer Reports Study.” Ann Arbor, MI: 

Michigan Psychological Association, 1999. 

Friedman, A.S. Family therapy versus parent 

groups: Effects on adolescent drug abusers. 

In: Friedman, A.S., and Granick, S., eds. 

Family Therapy for Adolescent Drug Abuse. 

Lexington, MA: Lexington Books, 1990. 

pp. 201–215. 

Fromme, K.; Stroot, E.; and Kaplan, D. 

Comprehensive effects of alcohol: 

Development and psychometric assessment 

of a new expectancy questionnaire. 

Psychological Assessment 5(1):19–26, 1993. 

Gabbard, G.O.; Lazar, S.G.; Hornberger, J.; and 

Spiegel, D. The economic impact of 

psychotherapy: A review. American Journal of 

Psychiatry 154:147–155, 1997. 

Galanter, M. Network Therapy for Alcohol and 

Drug Abuse: A New Approach in Practice. New 

York: Basic Books, 1993. 

Galanter, M.; Keller, D.S.; and Dermatis, H. 

Network Therapy for addiction: Assessment 

of the clinical outcome of training. American 

Journal of Drug and Alcohol Abuse 23(3):355– 

367, 1997. 

Gambrill, E. A behavioral perspective of 

families. In: Tolson, E.R., and Reid, W.J., eds. 

Models of Family Treatment. New York: 

Columbia University Press, 1981. 

Bibliography 

Garvin, C.D.; Reid, W.; and Epstein, L. A taskcentered approach. In: Roberts, W.R., and 

Northen, H., eds. Theories of Social Work With 

Groups. New York: Columbia University 

Press, 1976. pp. 238–251. 

Gerstein, D.R., and Harwood, J.H., eds. Treating 

Drug Problems. Vol. 1. Washington, DC: 

National Academy Press, 1990. pp. 40–57. 

Giorgi, A., ed. Phenomenology and Psychological 

Research. Pittsburgh, PA: Duquesne 

University Press, 1985. 

Giorlando, M., and Schilling, R.J. On becoming 

a solution-focused physician: The MEDSTAT acronym. Families, Systems and Health 

14(4): 361–371, 1996. 

Goldman, M.S. The alcohol expectancy concept: 

Applications to assessment, prevention, and 

treatment of alcohol abuse. Applied and 

Preventive Psychology 3(3):131–144, 1994. 

Goldman, M.S., and Brown, S.A. Expectancy 

theory: Thinking about drinking. In: Blane, 

H.T., and Leonard, K.E., eds. Psychological 

Theories of Drinking and Alcoholism. New 

York: Guilford Press, 1987. pp. 181–226. 

Goldman, M.S., and Rather, B.C. Substance 

abuse disorders: Cognitive models and 

architecture. In: Kendall, P.C., and Dobson, 

K.S., eds. Psychopathology and Cognition. San 

Diego, CA: Academic Press, 1993. pp. 245– 

292. 

Gomberg, E.S. Women and alcohol: Use and 

abuse. Journal of Nervous and Mental Disease 

181(4): 211–219, 1993. 

Gomberg, E.S.; Nelson, B.W.; and Hatchett, B.F. 

Women, alcoholism, and family therapy. 

Family and Community Health 13(4):61–71, 

1991. 

Gorad, S.L.; McCourt, W.F.; and Cobb, J.C. A 

communications approach to alcoholism. 

Quarterly Journal of Studies on Alcohol 32:651– 

668, 1971. 

185 
Appendix A 

Gottheil, E.; Weinstein, S.P.; Sterling, R.C.; 

Lundy, A.; and Serota, R.D. A randomized 

controlled study of the effectiveness of 

intensive outpatient treatment for cocaine 

dependence. Psychiatric Services 49(6):782– 

787, 1998. 

Grenyer, B.F.; Luborsky, L.; and Solowij, N. 

Treatment Manual for Supportive-Expressive 

Dynamic Therapy: Special Adaptation for 

Treatment of Cannabis (Marijuana) Dependence. 

Technical Report 26. Sydney, Australia: 

National Drug and Alcohol Research Center, 

1995. 

Grenyer, B.F.; Solowij, N.; and Peters, R. 

“Psychotherapy for marijuana addiction: A 

randomized controlled trial of brief versus 

intensive treatment.” Paper presented at the 

conference of the Society for Psychotherapy 

Research, Amelia Island, FL, 1996. 

Grof, S. Beyond the Brain: Birth, Death, and 

Transcendence in Psychotherapy. Albany, NY: 

State University of New York Press, 1985. 

Hales, R.E.; Yudofsky, S.C.; and Talbott, J.A., 

eds. The American Psychiatric Press Textbook of 

Psychiatry, 2nd ed. Washington, DC: 

American Psychiatric Press, 1994. 

Haley, J. Strategies of Psychotherapy. New York: 

Grune and Stratton, 1963. 

Haley, J. Uncommon Therapy: The Psychiatric 

Techniques of Milton Erickson, M.D. New 

York: W.W. Norton, 1973. 

Haley, J. Problem-Solving Therapy: New Strategies 

for Effective Family Therapy. San Francisco: 

Jossey-Bass, 1976. 

Haley, J. Problemsolving Therapy, 2nd ed. San 

Francisco: Jossey-Bass, 1987. 

Harris, K.B., and Miller, W.R. Behavioral selfcontrol training for problem drinkers: 

Components of efficacy. Psychology of 

Addictive Behaviors 4(2):90–92, 1990. 

Hart, T. Inspiration: Exploring the experience 

and its meaning. Journal of Humanistic 

Psychology 38(3):7–35, 1998. 

Hawkins, R.C., II. Substance abuse and stresscoping resources: A life-contextual clinical 

viewpoint. In: Wallace, B.C., ed. The 

Chemically Dependent: Phases of Treatment and 

Recovery. New York: Brunner/Mazel, 1992. 

pp. 127–158. 

Heather, N. Brief interventions on the world 

map. Addiction 89(6):665–667, 1994. 

Heather, N. Interpreting the evidence on brief 

interventions for excessive drinkers: The 

need for caution. Alcohol and Alcoholism 

30(3):287–296, 1995. 

Heather, N.; Campion, P.D.; Neville, R.G.; and 

MacCabe, D. Evaluation of a controlled 

drinking minimal intervention for problem 

drinkers in general practice (the DRAMS 

scheme). Journal of the Royal College of General 

Practitioners 37:358–363, 1987. 

Henggeler, S.W.; Pickrel, S.G.; Brondino, M.J.; 

and Crouch, J.L. Eliminating (almost) 

treatment dropout of substance abusing or 

dependent delinquents through home-based 

multisystemic therapy. American Journal of 

Psychiatry 153(3):427–428, 1996. 

Herdman, J.W. Global Criteria: The 12 Core 

Functions of the Substance Abuse Counselor, 

2nd ed. Holmes Beach, FL: Learning 

Publications, 1997. 

Hester, R.K. Behavioral self-control training. In: 

Hester, R.K., and Miller, W.R., eds. Handbook 

of Alcoholism Treatment Approaches: Effective 

Alternatives, 2nd ed. Boston: Allyn and 

Bacon, 1995. pp. 149–159. 

Hester, R.K., and Delaney, H.D. Behavioral SelfControl Program for Windows: Results of a 

controlled clinical trial. Journal of Consulting 

and Clinical Psychology 65(4):686–693, 1997. 

186 
Bibliography 

Hester, R.K., and Miller, W.R. Self-control 

training. In: Hester, R.K., and Miller, W.R., 

eds. Handbook of Alcoholism Treatment 

Approaches. New York: Pergamon Press, 

1989. pp. 141–149. 

Higgins, S.T. The influence of alternative 

reinforcers on cocaine use and abuse: A brief 

review. Pharmacological and Biochemical 

Behaviors 57(3):419–427, 1997. 

Higgins, S.T. Potential contributions of the 

community reinforcement approach and 

contingency management to broadening the 

base of substance abuse treatment. In: 

Tucker, J.A.; Donovan, D.M.; and Marlatt, 

G.A., eds. Changing Addictive Behavior: 

Bridging Clinical and Public Health Strategies. 

New York: Guilford Press, 1999. pp. 283– 

306. 

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Foerg, 

F.E.; Donham, R.; and Badger, M.S. 

Incentives improve outcome in outpatient 

behavioral treatment of cocaine dependence. 

Archives of General Psychiatry 51:568–576, 

1994. 

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; 

Hughes, J.R.; Foerg, F.; and Badger, G. 

Achieving cocaine abstinence with a 

behavioral approach. American Journal of 

Psychiatry 150(5):763–769, 1993. 

Higgins, S.T.; Delaney, D.D.; Budney, A.J.; 

Bickel, W.K.; Hughes, J.R.; Foerg, F.; and 

Fenwick, J.W. A behavioral approach to 

achieving initial cocaine abstinence. 

American Journal of Psychiatry 148(9):1218– 

1224, 1991. 

Higgins, S.T.; Tidey, J.W.; and Stitzer, M.L. 

Community reinforcement and contingency 

management interventions. In: Graham, 

A.W.; Schultz, T.K.; and Wilford, B.B., eds. 

Principles of Addiction Medicine, 2nd ed. 

Chevy Chase, MD: American Society of 

Addiction Medicine, Inc., 1998. pp. 675–690. 

Higgins-Biddle, J.C.; Babor, T.F.; Mullahy, J.; 

Daniels, J.; and McRee, B. Alcohol screening 

and brief intervention: Where research meets 

practice. Connecticut Medicine 61(9):565–575, 

1997. 

Hill, A. Treatment and prevention of alcoholism 

in the Native American family. In: Lawson, 

G.W., and Lawson, A.W., eds. Alcoholism and 

Substance Abuse in Special Populations. 

Rockville, MD: Aspen Publishers, 1989. 

pp. 247–272. 

Hodgins, D.C.; Leigh, G.; Milne, R.; and Gerrish, 

R. Drinking goal selection in behavioral selfmanagement treatment of chronic alcoholics. 

Addictive Behaviors 22(2):247–255, 1997. 

Hodgson, R., and Rollnick, S. How brief 

intervention works: Representative cases as 

viewed by the health advisers. In: Babor, 

T.F., and Grant, M., eds. Project on 

Identification and Management of AlcoholRelated Problems. Report on Phase II: A 

Randomized Clinical Trial of Brief Interventions 

in Primary Health Care. Geneva, Switzerland: 

World Health Organization, 1991. pp. 221– 

232. 

Holder, H.; Longabaugh, R.; Miller, W.R.; and 

Rubonis, A.V. The cost effectiveness of 

treatment for alcoholism: A first 

approximation. Journal of Studies on Alcohol 

52(6):517–540, 1991. 

Hollon, S.D., and Beck, A.T. Cognitive and 

cognitive-behavioral therapies. In: Bergin, 

A.E., and Garfield, S.L., eds. Handbook of 

Psychotherapy and Behavior Change, 4th ed. 

New York: John Wiley and Sons, 1994. pp. 

428–466. 

Horowitz, M.J. Short-term dynamic therapy of 

stress response syndromes. In: CritsChristoph, P., and J.P. Barber, eds. Handbook 

of Short-Term Dynamic Psychotherapy. New 

York: Basic Books, 1991. pp. 166–198. 

187 
Appendix A 

Horvath, A.O., and Greenberg, L.S., eds. The 

Working Alliance: Theory, Research, and 

Practice. New York: John Wiley and Sons, 

1994. 

Howard, M.O.; Elkins, R.L.; Rimmele, C.; and 

Smith, J.W. Chemical aversion treatment of 

alcohol dependence. Drug and Alcohol 

Dependence 29(2):107–143, 1991. 

Hoyt, M.F. Brief Therapy and Managed Care: 

Readings for Contemporary Practice. San 

Francisco: Jossey-Bass, 1995. 

Hser, Y.I.; Joshi, V.; Anglin, M.D.; and Fletcher, 

B. Predicting posttreatment cocaine 

abstinence for first-time admissions and 

treatment repeaters. American Journal of 

Public Health 89(5):666–671, 1999. 

Hubbard, R.L.; Craddock, S.G.; Flynn, P.M.; 

Anderson, J.; and Etheridge, R.M. Overview 

of 1-year outcomes in the Drug Abuse 

Treatment Outcome Study (DATOS). 

Psychology of Addictive Behaviors 11(4):261– 

278, 1997. 

Hunt, G.M., and Azrin, N.H. A communityreinforcement approach to alcoholism. 

Behaviour Research and Therapy 11(1):91–104, 

1973. 

ICD-9-CM: The International Classification of 

Diseases, 9th Revision, Clinical Modification. 

New York: McGraw-Hill, 1995. 

Iguchi, M.Y.; Belding, M.A.; Morral, A.R.; Lamb, 

R.J.; Husband, S.D. Reinforcing operants 

other than abstinence in drug abuse 

treatment: An effective alternative for 

reducing drug use. Journal of Consulting and 

Clinical Psychology 65(3):421–428, 1997. 

Institute of Medicine. Broadening the Base of 

Treatment for Alcohol Problems. Washington, 

DC: National Academy Press, 1990. 

Institute of Medicine. Pathways of Addiction: 

Opportunities in Drug Abuse Research. 

Committee on Opportunities in Drug Abuse 

Research. Washington, DC: National 

Academy Press, 1996. 

Jackson, J. The adjustment of the family to the 

crisis of alcoholism. Quarterly Journal of 

Studies on Alcohol 15:562–586, 1954. 

Jaffe, A.J., and Kilbey, M.M. The Cocaine 

Expectancy Questionnaire (CEQ): 

Construction and predictive utility. 

Psychological Assessment 6(1):18–26, 1994. 

Janis, I.L., and Mann, L. Decision Making: A 

Psychological Analysis of Conflict, Choice, and 

Commitment. New York: Free Press, 1977. 

Jarvis, T.J. Implications of gender for alcohol 

treatment research: A quantitative and 

qualitative review. British Journal of Addiction 

87(9):1249–1261, 1992. 

Jesse, R.C. Children in Recovery. New York: 

W.W. Norton, 1989. 

Johnson, R. Ecstasy: Understanding the Psychology 

of Joy. San Francisco: Harper & Row, 1987. 

Johnson, V.E. I’ll Quit Tomorrow. New York: 

Harper & Row, 1973. 

Johnson, V.E. Intervention: How To Help Someone 

Who Doesn’t Want Help: A Step-by-Step Guide 

for Families and Friends of Chemically 

Dependent Persons. Minneapolis, MN: 

Johnson Institute Books, 1986. 

Jones, B.T., and McMahon, J. Negative alcohol 

expectancy predicts post-treatment 

abstinence survivorship: The whether, when 

and why of relapse to a first drink. Addiction 

89(12):1653–1665, 1994a. 

188 
Bibliography 

Jones, B.T., and McMahon, J. Negative and 

positive alcohol expectancies as predictors of 

abstinence after discharge from a residential 

treatment program: A one-month and threemonth follow-up study in men. Journal of 

Studies on Alcohol 55(5):543–548, 1994b. 

Jones, B.T., and McMahon, J. A comparison of 

positive and negative alcohol expectancy and 

value and their multiplicative composite as 

predictors of post-treatment abstinence 

survivorship. Addiction 91(1):89–99, 1996. 

Jones, B.T., and McMahon, J. Alcohol 

motivations as outcome expectancies. In: 

Miller, W.R., and Heather, N., eds. Treating 

Addictive Behaviors, 2nd ed. New York: 

Plenum Press, 1998. pp. 75–91. 

Juhnke, G.A., and Coker, J.K. Solution-focused 

intervention with recovering, 

alcohol-dependent, single parent mothers 

and their children. Journal of Addictions and 

Offender Counseling 17(2):77–87, 1997. 

Kadden, R.; Carroll, K.; Donovan, D.; Cooney, 

N.; Monti, P.; Abrams, D.; Litt, M.; and 

Hester, R., eds. Cognitive-Behavioral Coping 

Skills Therapy Manual: A Clinical Research 

Guide for Therapists Treating Individuals With 

Alcohol Abuse and Dependence. Project 

MATCH Monograph Series, Volume 3. 

Rockville, MD: National Institute on Alcohol 

Abuse and Alcoholism, 1992. 

Kahan, M.; Wilson, L.; and Becker, L. 

Effectiveness of physician-based 

interventions with problem drinkers: A 

review. Canadian Medical Association Journal 

152(6):851–859, 1995. 

Kang, S.Y.; Kleinman, P.H.; Woody, G.E.; 

Millman, R.B.; Todd, T.C.; Kemp, J.; and 

Lipton, D.S. Outcomes for cocaine abusers 

after once-a-week psychosocial therapy. 

American Journal of Psychiatry 148(5):630–635, 

1991. 

Kaplan, H., and Sadock, B., eds. Comprehensive 

Textbook of Psychiatry, 6th ed. Vol. 2. 

Baltimore, MD: Williams and Wilkins, 1995. 

Katz, R. The Straight Path: A Story of Healing and 

Transformation in Fiji. Reading, MA: 

Addison-Wesley, 1993. 

Kaufman, E., and Borders, L. Ethnic family 

differences in adolescent substance use. In: 

Coombs, R.H., ed. Family Context of 

Adolescent Drug Use. New York: Haworth 

Press, 1988. pp. 99–121. 

Kaufman, E., and Kaufmann, P. From multiple 

family therapy to couples therapy. In: 

Kaufman E., and Kaufmann, P., eds. Family 

Therapy of Drug and Alcohol Abuse. New 

York: Gardner Press, 1979. 

Kay, J. Brief psychodynamic psychotherapies: 

Past, present, and future challenges. Journal 

of Psychotherapy Practice and Research 

6(4):330–337, 1997. 

Keller, D.S.; Galanter, M.; and Weinberg, S. 

Validation of a scale for network therapy: A 

technique for systematic use of peer and 

family support in addiction treatment. 

American Journal of Drug and Alcohol Abuse 

23(1):115–127, 1997. 

Kendall, P.C., and Turk, D.C. Cognitivebehavioral strategies and health 

enhancement. In: Matarazzo, J.D.; Weiss, 

S.M.; and Herd, J.A., eds. Behavioral Health: A 

Handbook of Health Enhancement and Disease 

Prevention. New York: John Wiley and Sons, 

1984. pp. 393–405. 

Khantzian, E.J. The self-medication hypothesis 

of addictive disorders: Focus on heroin and 

cocaine dependence. American Journal of 

Psychiatry 142(11):1259–1264, 1985. 

189 
Appendix A 

Khantzian, E.J.; Halliday, K.S.; and McAuliffe, 

W.E. Addiction and the Vulnerable Self: 

Modified Dynamic Group Therapy for Substance 

Abusers. New York : Guilford Press, 1990. 

Kirby, K.C.; Marlowe, D.B.; Festinger, D.S.; 

Lamb, R.J.; and Platt, J.J. Schedule of 

voucher delivery influences initiation of 

cocaine abstinence. Journal of Consulting and 

Clinical Psychology 66:761–767, 1998. 

Kirmil-Gray, K.; Eagleston, J.R.; Thoresen, C.E.; 

and Zarcone, V.P., Jr. Brief consultation and 

stress management treatments for drugdependent insomnia: Effects on sleep quality, 

self-efficacy, and daytime stress. Journal of 

Behavioral Medicine 8(1):79–99, 1985. 

Kleber, H.D., and Gawin, F.H. Cocaine abuse: A 

review of current and experimental 

treatments. In: Grabowski, J., ed. Cocaine: 

Pharmacology, Effects, and Treatment of Abuse. 

NIDA Research Monograph Series, Number 

50. HHS Pub. No. (ADM) 84-1326. 

Rockville, MD: National Institute on Drug 

Abuse, 1984. pp. 111–129. 

Kleinman, P.H.; Woody, G.E.; Todd, T.C.; 

Millman, R.B.; Kang, S.; Kemp, J.; and Lipton, 

D.S. Crack and cocaine abusers in outpatient 

psychotherapy. In: Onken, L.S., and Blaine, 

J.D., eds. Psychotherapy and Counseling in the 

Treatment of Drug Abuse. NIDA Research 

Monograph Series, Number 104. HHS Pub. 

No. (ADM) 90-1722. Rockville, MD: National 

Institute on Drug Abuse, 1990. pp. 24–35. 

Klerman, G.L., and Weissman, M.M., eds. New 

Applications of Interpersonal Psychotherapy. 

Washington, DC: American Psychiatric Press, 

1993. 

Klerman, G.L.; Weissman, M.M.; and 

Rounsaville, B.J. Interpersonal Psychotherapy 

of Depression. New York: Basic Books, 1984. 

Koss, M.P.; Butcher, J.N.; and Strupp, H.H. Brief 

psychotherapy methods in clinical research. 

Journal of Consulting and Clinical Psychology 

54:60–67, 1986. 

Koss, M.P., and Shiang, J. Research on brief 

psychotherapy. In: Bergin, A.E., and 

Garfield, S.L., eds. Handbook of Psychotherapy 

and Behavior Change, 4th ed. New York: John 

Wiley and Sons, 1994. pp. 664–700. 

Krampen, G. Motivation in the treatment of 

alcoholism. Addictive Behaviors 14:197–200, 

1989. 

Kristenson, H.; Ohlin, H.; Hulten-Nosslin, B.; 

Trell, E.; and Hood, B. Identification and 

intervention of heavy drinking in middleaged men: Results and follow-up of 24–60 

months of long-term study with randomized 

controls. Alcoholism: Clinical and Experimental 

Research 7(2):203–209, 1983. 

Kristenson, H., and Osterling, A. Problems and 

possibilities. Addiction 89(6):671–674, 1994. 

Krystal, H. Aspects of affect theory. Bulletin of 

the Menninger Clinic 41:1–26, 1977. 

Kymissis, P.; Bevacqua, A.; and Morales, N. 

Multi-family group therapy with dually 

diagnosed adolescents. Journal of Child and 

Adolescent Group Therapy 5(2):107–113, 1995. 

Laikin, M.; Winston, A.; and McCullough, L. 

Intensive short-term dynamic 

psychotherapy. In: Crits-Christoph, P., and 

Barber, J.P., eds. Handbook of Short-Term 

Dynamic Psychotherapy. New York: Basic 

Books, 1991. pp. 80–109. 

Lamb, S.; Greenlick, M.R.; and McCarty, D. 

Bridging the Gap Between Research and 

Treatment. Washington, DC: National 

Academy Press, 1998. 

190 
Lambert, M.J., and Bergin, A.E. The 

effectiveness of psychotherapy. In: Bergin, 

A.E., and Garfield, S.L., eds. Handbook of 

Psychotherapy and Behavior Change, 4th ed. 

New York: John Wiley and Sons, 1994. 

pp. 143–189. 

Landry, M.J. Overview of Addiction Treatment 

Effectiveness. HHS Pub. No. (SMA) 96-3081. 

Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 1996. 

Larimer, M.E., and Marlatt, G.A. Applications 

of relapse prevention with moderation goals. 

Journal of Psychoactive Drugs 22(2):189–195, 

1990. 

Laureano, M., and Poliandro, E. Understanding 

cultural values of Latino male alcoholics and 

their families: A culture sensitive model. 

Journal of Chemical Dependency Treatment 

4(1):137–155, 1991. 

Lazarus, R.S. Coping theory and research: Past, 

present, and future. Psychosomatic Medicine 

55(3):234–247, 1993. 

Leeds J., and Morgenstern, J. Psychoanalytic 

theories of substance abuse. In: Rotgers, F.; 

Keller, D.S.; and Morgenstern, J., eds. 

Treating Substance Abuse: Theory and 

Technique. New York: Guilford Press, 1996. 

Lemere, F. Aversion treatment of alcoholism: 

Some reminiscences. British Journal of 

Addiction 82(3):257–258, 1987. 

Levenson, H.; Butler, S.F.; and Beitman, B.D. 

Concise Guide to Brief Dynamic Psychotherapy. 

Washington, DC: American Psychiatric Press, 

1997. 

Levin, J.D. Treatment of Alcoholism and Other 

Addictions: A Self Psychology Approach. 

Northvale, NJ: Jason Aronson, 1987. 

Levine, B. Fundamentals of Group Treatment. 

Chicago: Whitehall, 1967. 

Bibliography 

Levine, B., and Gallogly, V. Group Therapy With 

Alcoholics: Outpatient and Inpatient Approaches. 

Sage Human Services Guides, Number 40. 

Beverly Hills, CA: Sage Publications, 1985. 

Lewinsohn, P.M.; Clarke, G.N.; Hops, H.; and 

Andrews, J.A. Cognitive-behavioral 

treatment for depressed adolescents. 

Behavior Therapy 21:385–401, 1990. 

Lewis, M.L. Alcoholism and family casework. 

Social Casework 35:8–14, 1937. 

Liddle, H.A., and Dakof, G.A. “Effectiveness of 

family-based treatments for adolescent 

substance abuse.” Paper presented at the 

Annual Meeting of the Society for 

Psychotherapy Research, Santa Fe, NM, 1994. 

Liddle, H.A., and Dakof, G.A. Efficacy of family 

therapy for drug abuse: Promising but not 

definitive. Journal of Marital and Family 

Therapy 21(4):511–543, 1995. 

Liddle, H.A.; Dakof, G.; Diamond, G.; Holt, M.; 

Aroyo, J.; and Watson, M. The adolescent 

module in multidimensional family therapy. 

In: Lawson, G.W., and Lawson, A.W., eds. 

Adolescent Substance Abuse: Etiology, 

Treatment, and Prevention. Gaithersburg, MD: 

Aspen Publishers, 1992. pp. 165–186. 

Linehan, M.M. Cognitive-Behavioral Treatment of 

Borderline Personality Disorder. New York: 

Guilford Press, 1993. 

Litman, G.K. Alcohol survival: The prevention 

of relapse. In: Miller, W.R., and Heather, N., 

eds. Treating Addictive Behaviors: Processes of 

Change. New York: Plenum Press, 1986. 

pp. 391–405. 

Locke, H., and Wallace, K. Short marital 

adjustment and prediction tests: Their 

reliability and validity. Marriage and Family 

Living 21:251–255, 1959. 

191 
Appendix A 

Lowinson, J.H.; Ruiz, P.; and Millman, R.B. 

Substance Abuse: A Comprehensive Textbook, 

3rd ed. Baltimore: Williams & Wilkins, 1997. 

Luborsky, L. Principles of Psychoanalytic 

Psychotherapy: A Manual for SupportiveExpressive Treatment. New York: Basic Books, 

1984. 

Luborsky, L., and Mark, D. Short-term 

supportive-expressive psychoanalytic 

psychotherapy. In: Crits-Christoph, P., and 

Barber, J.P., eds. Handbook of Short-Term 

Dynamic Psychotherapy. New York: Basic 

Books, 1991. pp. 110–136. 

Luborsky, L.; McLellan, T.A.; Woody, G.E.; 

O’Brien, C.P.; and Auerbach, A. Therapist 

success and its determinants. Archives of 

General Psychiatry 42:602–611, 1985. 

Luborsky, L.; Woody, G.E.; Hole, A.V.; and 

Velleco, A. “Manual for supportiveexpressive dynamic psychotherapy: A 

special version for drug dependence.” 

Unpublished manuscript, University of 

Pennsylvania, 1977, rev. ed. 1989. 

Luborsky, L.; Woody, G.E.; Hole, A.V.; and 

Velleco, A. Supportive-expressive dynamic 

therapy for the treatment of opiate drug 

dependence. In: Barber, J.P., and CritsChristoph, P., eds. Dynamic Therapies for 

Psychiatric Disorders: Axis I. New York: Basic 

Books, 1995. pp. 131–160. 

Lyons, L.C., and Woods, P.J. The efficacy of 

rational-emotive therapy: A quantitative 

review of the outcome research. Clinical 

Psychology Review 11:357–369, 1991. 

Lyotard, J.F. The Post-Modern Condition: A Report 

on Knowledge. Minneapolis, MN: University 

of Minnesota Press, 1984. 

Mackay, P.W., and Donovan, D.M. Cognitive 

and behavioral approaches to alcohol abuse. 

In: Frances, R.J., and Miller, S.I., eds. Clinical 

Textbook of Addictive Disorders. New York: 

Guilford Press, 1991. pp. 452–481. 

MacKenzie, R.K. Introduction to Time-Limited 

Group Psychotherapy. Washington, DC: 

American Psychiatric Press, 1990. 

Magura, S.; Casriel, C.; Goldsmith, D.S.; and 

Lipton, D.S. Contracting with clients in 

methadone treatment. Social Casework 

68:485–493, 1987. 

Magura, S.; Casriel, C.; Goldsmith, D.S.; Strug, 

D.L.; Lipton, D.S. Contingency contracting 

with polydrug-abusing methadone patients. 

Addictive Behaviors 13(1):113–118, 1988. 

Malan, D.H. The Frontier of Brief Psychotherapy: 

An Example of the Convergence of Research and 

Clinical Practice. New York: Plenum Press, 

1976. 

Mangione, T.W.; Howland, J.; Amick, B.; Cote, J.; 

Lee, M.; Bell, N.; Levine, S. Employee 

drinking practices and work performance. 

Journal of Studies on Alcohol 60(2):261–270, 

1999. 

Manisses Communications Group. Group 

therapy works well for addiction: Identifying 

with others in group leads to self-awareness. 

Behavioral Health Treatment 2(1):1, 1997a. 

Manisses Communications Group. Researchers 

tout marital therapy for alcohol problems. 

Alcoholism and Drug Abuse Week 9(23), 6, 

1997. 

Manisses Communications Group. Study: 

Group therapy helps addicted women with 

abuse history. Alcoholism and Drug Abuse 

Week 9(33):5–6, 1997b. 

192 
Mann, J. Time-Limited Psychotherapy. 

Cambridge, MA: Harvard University Press, 

1973. 

Mann, J. Time-limited psychotherapy. In: CritsChristoph, P., and Barber, J.P., eds. Handbook 

of Short-Term Dynamic Psychotherapy. New 

York: Basic Books, 1991. pp. 17–44. 

Mann, J., and Goldman, R. A Casebook in TimeLimited Psychotherapy. Northvale, NJ: Jason 

Aronson, 1994. 

Marcus, B.H.; Selby, V.C.; Niaura, R.S.; and 

Rossi, J.S. Self-efficacy and the stages of 

exercise behavior change. Research Quarterly 

for Exercise and Sport 63(1):60–66, 1992. 

Mark, D., and Faude, J. Supportive-expressive 

therapy of cocaine abuse. In: Barber, J.P., and 

Crits-Christoph, P., eds. Dynamic Therapies 

for Psychiatric Disorders: Axis I. New York: 

Basic Books, 1995. pp. 294–331. 

Mark, D., and Faude, J. Psychotherapy of Cocaine 

Addiction: Entering the Interpersonal World of 

the Cocaine Addict. Northvale, NJ: Jason 

Aronson, 1997. 

Mark, D., and Luborsky, L. “A manual for the 

use of supportive-expressive psychotherapy 

in the treatment of cocaine abuse.” 

Unpublished manuscript, University of 

Pennsylvania, 1992. 

Marlatt, G.A. Craving for alcohol, loss of control 

and relapse: A cognitive behavioral analysis. 

In: Nathan, P.E.; Marlatt, G.A.; and LUberg, 

T., eds. Alcoholism: New Directions in 

Behavioral Research and Treatment. New York: 

Plenum Press, 1978. 

Marlatt, G.A. Section I: Theoretical perspectives 

on relapse. Taxonomy of high-risk situations 

for alcohol relapse: Evolution and 

development of a cognitive-behavioral 

model. Addiction 91(Suppl.):S37–S49, 1996. 

Bibliography 

Marlatt, G.A.; Baer, J.S.; Donovan, D.M.; and 

Kivlahan, D.R. Addictive behaviors: 

Etiology and treatment. Annual Review of 

Psychology 39:223–252, 1988. 

Marlatt, G.A., and Donovan, D.M. Alcoholism 

and drug dependence: Cognitive social 

learning factors in addictive behaviors. In: 

Craighead, W.E.; Mahoney, M.J.; and Kazdin, 

A.E., eds. Behavior Modification: Principles, 

Issues, and Applications, 2nd ed. Boston: 

Houghton Mifflin, 1981. pp. 264–285. 

Marlatt, G.A., and Gordon, J.R. Determinants of 

relapse: Implications for the maintenance of 

behavior change. In: Davidson, P., and 

Davidson, S.M., eds. Behavioral Medicine: 

Changing Health Lifestyles. New York, 

Brunner/Mazel, 1980. pp. 410–452. 

Marlatt, G.A., and Gordon, J.R. Relapse 

Prevention: Maintenance Strategies in the 

Treatment of Addictive Behaviors. New York: 

Guilford Press, 1985. 

Marlatt, G.A.; Somers, J.M.; and Tapert, S.F. 

Harm reduction: Application to alcohol 

abuse problems. In: Onken, L.S.; Blaine, J.D.; 

and Boren, J.J., eds. Behavioral Treatments for 

Drug Abuse and Dependence. NIDA Research 

Monograph Series, Number 137. NIH Pub. 

No. (ADM) 93-3684. Rockville, MD: National 

Institute on Drug Abuse, 1993. pp. 147–166. 

Maslow, A.H. Toward a Psychology of Being, 2nd 

ed. Princeton, NJ: Van Nostrand, 1968. 

Maslow, A.H. Motivation and Personality, 3rd ed. 

New York: Harper & Row, 1987. 

Matano, R.A., and Yalom, I.R. Approaches to 

chemical dependency: Chemical dependency 

and interactive group therapy: A synthesis. 

International Journal of Group Psychotherapy 

41(3):269–293, 1991. 

193 
Appendix A 

Mattick, R.P., and Jarvis, T. Brief or minimal 

intervention for ‘alcoholics’? The evidence 

suggests otherwise. Drug and Alcohol Review 

13:137–144, 1994. 

Maultsby, M.C. Group Leaders Guide for Rational 

Behavior Training. Provided for the United 

States District Court, Northern District of 

Texas, Dallas, TX. 1976. 

May, G.G. Addiction and Grace. San Francisco: 

Harper, 1991. 

May, R., and Yalom, I. Existential 

psychotherapy. In: Corsini, R.J., and 

Wedding, D., eds. Current Psychotherapies, 

5th ed. Itasca, IL: F.E. Peacock, 1995. 

pp. 262–292. 

McCrady, B.S. Outcomes of family-involved 

alcoholism treatment. In: Galanter, M., ed. 

Recent Developments in Alcoholism. Vol. 7. 

New York: Plenum Press, 1989. pp. 165–182. 

McCrady, B.S. Promising but underutilized 

treatment approaches. Alcohol Health & 

Research World 15(3):215–218, 1991. 

McCrady, B.S. Relapse prevention: A couplestherapy perspective. In: O’Farrell, T. J., ed. 

Treating Alcohol Problems: Marital and Family 

Interventions. New York: Guilford Press, 

1993. pp. 327–350. 

McCrady, B.S.; Noel, N.E.; Abrams, D.B.; Stout, 

R.L.; Nelson, H.F; and Hay, W.M. 

Comparative effectiveness of three types of 

spouse involvement in outpatient behavioral 

alcoholism treatment. Journal of Studies on 

Alcohol 47(6):459–467, 1986. 

McCrady, B.S.; Stout, R.; Noel, N.; Abrams, D.; 

and Nelson, H. Effectiveness of three types 

of spouse-involved behavioral alcoholism 

treatment. British Journal of Addiction 

86(11):1415–1424, 1991. 

McGoldrick, M.; Giordano, J.; and Pearce, J.K. 

Ethnicity and Family Therapy, 2nd ed. New 

York: Guilford Press, 1996. 

McLellan A.T.; Arndt, I.O.; Metzger, D.S.; 

Woody, G.E.; and O’Brien, C.P. The effects 

of psychosocial services in substance abuse 

treatment. JAMA 269(15):1953–1959, 1993. 

McMahon, J., and Jones, B.T. Negative 

expectancy in motivation. Addiction Research 

1(2):145–155, 1993. 

McMahon, J., and Jones, B.T. Post-treatment 

abstinence survivorship and motivation for 

recovery: The predictive validity of the 

Readiness to Change (RCQ) and Negative 

Alcohol Expectancy (NAEQ) Questionnaires. 

Addiction Research 4(2):161–176, 1996. 

McMullin, R.E. Handbook of Cognitive Therapy 

Techniques. New York: W.W. Norton, 1986. 

Messer, S.B., and Warren, C.S. Models of Brief 

Psychodynamic Therapy: A Comparative 

Approach. New York: Guilford Press, 1995. 

Meyers, R.J.; Dominguez, T.P.; and Smith, J.E. 

Community reinforcement training with 

concerned others. In: Van Hasselt, V.B., and 

Hersen, M., eds. Sourcebook of Psychological 

Treatment Manuals for Adult Disorders. New 

York: Plenum Press, 1996. pp. 257–294. 

Meyers, R.J., and Smith, J.E. Clinical Guide to 

Alcohol Treatment: The Community 

Reinforcement Approach. New York: Guilford 

Press, 1995. 

Meyers, R.J., and Smith, J.E. Getting off the 

fence: Procedures to engage treatmentresistant drinkers. Journal of Substance Abuse 

Treatment 14:467–472, 1997. 

Meyers, R.J.; Smith, J.E.; and Miller, E.J. 

Working through the concerned significant 

other. In: Miller, W.R., and Heather, N., eds. 

Treating Addictive Behaviors, 2nd ed. New 

York: Plenum Press, 1998. pp. 149–161. 

194 
Michaelec, E.M.; Rohsenow, D.J.; Monti, P.M.; 

Varney, S.M.; Martin, R.A.; Dey, A.N.; Myers, 

M.G.; and Sirota, A.D. Cocaine Negative 

Consequences Checklist: Development and 

validation. Journal of Substance Abuse 

8(2):181–193, 1996. 

Midanik, L. The validity of self-reported alcohol 

consumption and alcohol problems: A 

literature review. British Journal of Addiction 

77(4):357–382, 1982. 

Middelkoop, P. The Wise Old Man: Healing 

Through Inner Images. Trans., A. Dixon. 

Boston: Shambhala, 1989. 

Milby, J.B.; Schumacher, J.E.; Raczynski, J.M.; 

Caldwell, E.; Engle, M.; Michael, M.; and 

Carr, J. Sufficient conditions for effective 

treatment of substance abusing homeless 

persons. Drug and Alcohol Dependence 43(1– 

2):39–47, 1996. 

Miller, N.S., ed. Comprehensive Handbook of Drug 

and Alcohol Addiction. New York: Marcel 

Dekker, 1991. 

Miller, S.D. The resistant substance abuser: 

Court mandated cases can pose special 

problems. Commentary: A solution-focused 

approach. Networker 16(1):83–87, 1992. 

Miller, S.D. Some questions (not answers) for 

the brief treatment of people with drug and 

alcohol problems. In: Hoyt, M., ed. 

Constructive Therapies. New York: Guilford 

Press, 1994. 

Miller, S.D., and Berg, I. Working with the 

problem drinker: A solution-focused 

approach. Arizona Counseling Journal 

16(1):3–12, 1991. 

Bibliography 

Miller, W.R. Behavioral treatments for drug 

problems: Lessons from the alcohol 

treatment outcome literature. In: Onken, 

L.S.; Blaine, J.D.; and Boren, J.J., eds. 

Behavioral Treatments for Drug Abuse and 

Dependence. NIDA Research Monograph 

Series, Number 137. NIH Pub. No. (ADM) 

93-3684. Rockville, MD: National Institute on 

Drug Abuse, 1993. pp. 303–321. 

Miller, W.R.; Benefield, R.G.; and Tonigan, J.S. 

Enhancing motivation for change in problem 

drinking: A controlled comparison of two 

therapist styles. Journal of Consulting and 

Clinical Psychology 61:455–461, 1993. 

Miller, W.R.; Brown, J.M.; Simpson, T.L.; 

Handmaker, N.S.; Bien, T.H.; Luckie, L.F.; 

Montgomery, H.A.; Hester, R.K.; and 

Tonigan, J.S. What works? A 

methodological analysis of the alcohol 

treatment outcome literature. In: Hester, 

R.K., and Miller, W.R., eds. Handbook of 

Alcoholism Treatment Approaches: Effective 

Alternatives, 2nd ed. Boston: Allyn and 

Bacon, 1995. pp. 12–44. 

Miller, W.R.; Gribskov, C.J.; and Mortell, R.L. 

Effectiveness of a self-control manual for 

problem drinkers with and without therapist 

contact. International Journal of the Addictions 

16(7):1247–1254, 1981. 

Miller, W.R., and Hester, R.K. Inpatient 

alcoholism treatment: Who benefits? 

American Psychologist 41(7): 794–805, 1986a. 

Miller, W.R., and Hester, R.K. Treating Addictive 

Behaviors: Processes of Change. New York: 

Plenum Press, 1986b. 

195 
Appendix A 

Miller, W.R.; Jackson, K.A.; and Karr, K.W. 

Alcohol problems: There’s a lot you can do in 

two or three sessions. EAP Digest 14:18–21, 

35–36, 1994. 

Miller, W.R., and Munoz, R.F. How To Control 

Your Drinking. Englewood Cliffs, NJ: 

Prentice-Hall, 1982. 

Miller, W.R., and Rollnick, S. Motivational 

Interviewing: Preparing People To Change 

Addictive Behavior. New York: Guilford 

Press, 1991. 

Miller, W.R., and Sanchez, V.C. Motivating 

young adults for treatment and lifestyle 

change. In: Howard, G.S., and Nathan, P.E., 

eds. Alcohol Use and Misuse by Young Adults. 

Notre Dame, IN: University of Notre Dame 

Press, 1994. pp. 55–82. 

Miller, W.R., and Sovereign, R.G. The check-up: 

A model for early intervention in addictive 

behaviors. In: LUberg, T.; Miller, W.R.; 

Nathan, P.E.; and Marlatt, G.A., eds. 

Addictive Behaviors: Prevention and Early 

Intervention. Amsterdam: Swets and 

Zeitlinger, 1989. pp. 219–311. 

Miller, W.R., and Taylor, C.A. Relative 

effectiveness of bibliotherapy, individual and 

group self-control training in the treatment of 

problem drinkers. Addictive Behaviors 5:13– 

24, 1980. 

Miller, W.R.; Taylor, C.A.; and West, J.C. 

Focused versus broad-spectrum behavior 

therapy for problem drinkers. Journal of 

Consulting and Clinical Psychology 48(5):590– 

601, 1980. 

Mintz, J.; Mintz, L.I.; Arruda, M.J.; and Hwang, 

S.S. Treatments of depression and the 

functional capacity to work. Archives of 

General Psychiatry 49(10):761–768, 1992. 

Minuchin, S. Families and Family Therapy. 

Cambridge, MA: Harvard University Press, 

1974. 

Minuchin, S., and Fishman, H.C. Family Therapy 

Techniques. Cambridge, MA: Harvard 

University Press, 1981. 

Monti, P.M.; Abrams, D.B.; Kadden, R.M.; and 

Cooney, N.L. Treating Alcohol Dependence: A 

Coping Skills Training Guide. New York: 

Guilford Press, 1989. 

Monti, P.M.; Gulliver, S.B.; and Myers, M.G. 

Social skills training for alcoholics: 

Assessment and treatment. Alcohol and 

Alcoholism 29(6):627–637, 1994. 

Monti, P.M.; Rohsenow, D.J.; Colby, S.M.; and 

Abrams, D.B. Coping and social skills. In: 

Hester, R.K., and Miller, W.R., eds. Handbook 

of Alcoholism Treatment Approaches: Effective 

Alternatives, 2nd ed. Boston: Allyn and 

Bacon, 1995. pp. 221–241. 

Monti, P.M.; Rohsenow, D.J.; Michaelec, E.; 

Martin, R.A.; and Abrams, D.B. Brief coping 

skills treatment for cocaine abuse: Substance 

use outcomes at three months. Addiction 

92(12):1717–1728, 1997. 

Moser, A.E., and Annis, H.M. The role of coping 

in relapse crisis outcome: A prospective 

study of treated alcoholics. Addiction 

91(8):1101–1114, 1996. 

Moyer, M.A. Achieving successful chemical 

dependency recovery in veteran survivors of 

traumatic stress. Alcoholism Treatment 

Quarterly 4(4):19–34, 1988. 

Mudd, S.A.; Blow, F.C.; Walton, M.A.; Snedecor, 

S.M.; and Nord, J.L. Stages of change in 

elderly substance abusers. Alcohol: Clinical 

and Experimental Research 19 (Suppl.):90a, 

1995. 

Myers, M.G.; Martin, R.A.; Rohsenow, D.J.; and 

Monti, P.M. The Relapse Situation Appraisal 

Questionnaire: Initial psychometric 

characteristics and validation. Psychology of 

Addictive Behaviors 10(4):237–247, 1996. 

196 
Najavits, L.M.; Weiss, R.D.; and Liese, B.S. 

Group cognitive-behavioral therapy for 

women with PTSD and substance use 

disorder. Journal of Substance Abuse Treatment 

13(1):13–22, 1996. 

National Institute on Alcohol Abuse and 

Alcoholism (NIAAA). Assessing Alcohol 

Problems: A Guide for Clinicians and 

Researchers. NIAAA Treatment Handbook 

Series, Number 4. NIH Pub. No. 95-3745. 

Washington, DC: NIAAA, 1995. 

 Neidigh, L.W.; Gesten, E.L.; and Shiffman, S. 

Coping with the temptation to drink. 

Addictive Behaviors 13(1):1–9, 1988. 

Nelson, J.E. Healing the Split: Integrating Spirit 

Into Our Understanding of the Mentally Ill. 

Albany, NY: State University of New York 

Press, 1994. 

Nezu, A.M. Efficacy of a social problem-solving 

therapy approach for unipolar depression. 

Journal of Consulting and Clinical Psychology 

54(2):196–202, 1986. 

Nichols, M.P., and Schwartz, R.C. Family 

Therapy: Concepts and Methods. Boston: Allyn 

and Bacon, 1998. 

Nicholson, T.; Higgins, W.; Turner, P.; James, S.; 

Stickle, F.; and Pruitt, T. The relation 

between meaning in life and the occurrence 

of drug abuse: A retrospective study. 

Psychology of Addictive Behaviors 8(1):24–28, 

1994. 

Nielsen, G., and Barth, K. Short-term anxietyprovoking psychotherapy. In: CritsChristoph, P., and Barber, J.P., eds. Handbook 

of Short-Term Dynamic Psychotherapy. New 

York: Basic Books, 1991. pp. 45–79. 

Nietzel, M.T., ed. Abnormal Psychology. Boston: 

Allyn and Bacon, 1998. 

Bibliography 

Noel, N., and McCrady, B. Alcohol-focused 

spouse involvement with behavioral marital 

therapy. In: O’Farrell, T.J., ed. Treating 

Alcohol Problems: Marital and Family 

Interventions. New York: Guilford Press, 

1993. pp. 210–235. 

O’Brien, C.P., and Childress, A.R. A learning 

model of addiction. In: O’Brien, C.P., and 

Jaffe, J.H., eds. Addictive States. New York: 

Raven Press, 1992. pp. 157–177. 

O’Brien, C.P.; Childress; A.R.; McClellan, T.; and 

Ehrman, R. Integrating systemic cue 

exposure with standard treatment in 

recovering drug dependent patients. 

Addictive Behaviors 15(4):355–365, 1990. 

O’Farrell, T.J., and Bayog, R.D. Antabuse 

contracts for married alcoholics and their 

spouses: A method to maintain antabuse 

ingestion and decrease conflict about 

drinking. Journal of Substance Abuse 

Treatment 3:1–8, 1986. 

O’Farrell, T.J.; Choquette, K.A.; Cutter, H.S.; 

Brown, E.D.; and McCourt, W.F. Behavioral 

marital therapy with and without additional 

couples relapse prevention sessions for 

alcoholics and their wives. Journal of Studies 

on Alcohol 54:652–666, 1993. 

O’Farrell, T.J., and Cowles, K.S. Marital and 

family therapy. In: Hester, R.K., and Miller, 

W.R., eds. Handbook of Alcoholism Treatment 

Approaches: Effective Alternatives. New York: 

Pergamon Press, 1989. pp. 183–205. 

O’Farrell, T.J.; Cutter, H.S.; and Floyd, F.J. 

Evaluating behavioral marital therapy for 

male alcoholics: Effects on marital 

adjustment and communication from before 

to after treatment. Behavior Therapy 16:147– 

167, 1985. 

197 
Appendix A 

O’Malley, S.S.; Jaffe, A.J.; Chang, G.; 

Schottenfeld, R.S.; Meyer, R.E.; and 

Rounsaville, B.J. Naltrexone and coping 

skills therapy for alcohol dependence: A 

controlled study. Archives of General 

Psychiatry 49:881–887, 1992. 

O’Malley, S.S., and Kosten, T.R. Couples 

therapy with cocaine abusers. Family Therapy 

Collections 25:121–131, 1988. 

Orford, J.; Guthrie, S.; Nicholls, P.; 

Oppenheimer, E.; Egert, S.; and Hensman, C. 

Self-reported coping behavior of wives of 

alcoholics and its association with drinking 

outcome. Journal of Studies on Alcohol 

36:1254–1267, 1975. 

Orford, J.; Oppenheimer, E.; and Edwards, G. 

Abstinence or control: The outcome for 

excessive drinkers two years after 

consultation. Behavior Research and Therapy 

14:409–418, 1976. 

O’Sullivan, C.M. Alcoholism and abuse: The 

twin family secrets. In: Lawson, G.W., and 

Lawson, A.W., eds. Alcoholism and Substance 

Abuse in Special Populations. Rockville, MD: 

Aspen Publishers, 1989. pp. 273–303. 

Ouimette, P.C.; Finney, J.W.; and Moos, R.H. 

Twelve-step and cognitive–behavioral 

treatment for substance abuse: A comparison 

of treatment effectiveness. Journal of Clinical 

and Consulting Psychology 65:230–240, 1997. 

Panitz, D.R.; McConchie, R.D.; Sauber, S R.; and 

Fonseca, J.A. The role of machismo and the 

Hispanic family in the etiology and treatment 

of alcoholism in Hispanic American males. 

American Journal of Family Therapy 11(1):31– 

44, 1983. 

Papp, P. Family Therapy: Full Length Case Studies. 

New York: Gardner Press, 1977. 

Papp, P. The Process of Change. New York: 

Guilford Press, 1983. 

Parad, H.J., and Libbie, G., eds. Crisis 

Intervention. Book 2: The Practitioner’s 

Sourcebook for Brief Therapy. Milwaukee, WI: 

Family Service America, 1990. 

Parker, R., and Horton, H. A typology of ritual: 

Paradigms for healing and empowerment. 

Counseling and Values 40:82–97, 1996. 

Peake, T.H.; Borduin, C.M.; and Archer, R.P. 

Brief Psychotherapies: Changing Frames of Mind. 

Newbury Park, CA: Sage Publications, 1988. 

Pekarik, G., and Wierzbicki, M. The relationship 

between clients’ expected and actual 

treatment duration. Psychotherapy 23:532– 

534, 1986. 

Perls, F. Gestalt Therapy Verbatim. Lafayette, 

CA: Real People Press, 1969. 

Persson, J., and Magnusson, P.H. Early 

intervention in patients with excessive 

consumption of alcohol: A controlled study. 

Alcohol 6(5):403–408, 1989. 

Phillips, E.L. The ubiquitous decay curve: 

Service delivery similarities in 

psychotherapy, medicine, and addiction. 

Professional Psychology: Research and Practice 

18:650–652, 1987. 

Phillips, E.L., and Weiner, D.N. Short-Term 

Psychotherapy and Structured Behavior Change. 

New York: McGraw-Hill, 1966. 

Piazza, J., and DelValle, C.M. Community-based 

family therapy training: An example of work 

with poor and minority families. Journal of 

Strategic and Systemic Therapies 11(2):53–69, 

1992. 

Pine, F. Drive, Ego, Object, and Self. New York: 

Basic Books, 1990. 

Pinsker, H.; Rosenthal, R.; and McCullough, L. 

Dynamic supportive therapy. In: CritsChristoph, P., and Barber, J.P., eds. Handbook 

of Short-Term Dynamic Psychotherapy. New 

York: Basic Books, 1991. pp. 220–247. 

198 
Bibliography 

Pollack, J.; Flegenheimer, W.; and Winston, A. 

Brief adaptive psychotherapy. In: CritsChristoph, P., and Barber, J.P., eds. Handbook 

of Short-Term Dynamic Psychotherapy. New 

York: Basic Books, 1991. pp. 199–219. 

Polster, I., and Polster, M. Gestalt Therapy 

Integrated: Contours of Theory and Practice. 

New York: Vintage Books, 1973. 

Prochaska, J.O. How do people change and how 

can we change to help many more people? 

In: Hubble, M.A.; Duncan, B.L.; and Miller, 

S., eds. The Heart and Soul of Change: What 

Works in Therapy. Washington, DC: 

American Psychological Association, 1999. 

pp. 227–255. 

Prochaska, J.O., and DiClemente, C.C. The 

Transtheoretical Approach: Crossing the 

Traditional Boundaries of Therapy. 

Homewood, IL: Dorsey/Dow Jones-Irwin, 

1984. 

Prochaska, J.O., and DiClemente, C.C. Toward a 

comprehensive model of change. In: Miller, 

W.R., and Heather, N., eds. Treating 

Addictive Behaviors: Processes of Change. New 

York: Plenum Press, 1986. pp. 3–27. 

Prochaska, J.O.; DiClemente, C.C.; and Norcross, 

J.C. In search of the structure of change. In: 

Klar, Y.; Fischer, J.D.; Chinsky, J.M., eds. 

Self-Change: Social Psychological and Clinical 

Perspective. New York: Springer-Verlag, 

1992. pp. 87–114. 

Prochaska, J.O.; Velicer, W.F.; Rossi, J.S.; 

Goldstein, M.G.; Marcus, B.H.; Rakowski, W.; 

Fiore, C.; Harlow, L.L.; Redding, C.A.; and 

Rosenbloom, D. Stages of change and 

decisional balance for 12 problem behaviors. 

Health Psychology 131(1):39–46, 1994. 

Project MATCH Research Group. Matching 

alcoholism treatments to client heterogeneity: 

Project MATCH posttreatment drinking 

outcomes. Journal of Studies on Alcohol 

58(1):7–29, 1997. 

Project MATCH Research Group. Matching 

alcoholism treatments to client heterogeneity: 

Project MATCH three-year drinking 

outcomes. Alcoholism: Clinical and 

Experimental Research 22(6):1300–1311, 1998. 

Rapp, C., and Wintersteen, R. The strengths 

model of case management: Results from 

twelve demonstrations. Psychosocial 

Rehabilitation Journal 13(1): 23–32, 1989. 

Rathbone-McCuan, E., and Hedlund, J. Older 

families and issues of alcohol misuse: A 

neglected problem in psychotherapy. Journal 

of Psychotherapy and the Family 5(1–2):173– 

184, 1989. 

Ratner, H., and Yandoli, D. Solution-focused 

brief therapy: A co-operative approach to 

work with clients. In: Edwards, G., and 

Dare, C., eds. Psychotherapy, Psychological 

Treatments, and the Addictions. Cambridge: 

Cambridge University Press, 1996. pp. 124– 

138. 

Read, M.R.; Penick, E.C.; and Nickel, E.J. 

Treatment for dually diagnosed clients. In: 

Freeman, E.M., ed. Substance Abuse 

Treatment: A Family Systems Perspective. Sage 

Sourcebooks for the Human Services Series, 

Vol. 25. Newbury Park, CA: Sage 

Publications, 1993. pp. 123–156. 

Regan, J.M.; Connors, G.J.; O’Farrell, T.J.; and 

Jones, W.C. Services for the families of 

alcoholics: A survey of treatment agencies in 

Massachusetts. Journal of Studies on Alcohol 

44(6):1072–1082, 1983. 

199 
Appendix A 

Rehm, L.P.; Fuchs, C.Z.; Roth, D.M.; Kornblith, 

S.J.; and Romano, J.M. A comparison of selfcontrol and assertion skills treatments of 

depression. Behavior Therapy 10:429–442, 

1979. 

Reich, J.W., and Gutierres, S.E. Life event and 

treatment attributions in drug abuse and 

rehabilitation. American Journal of Drug and 

Alcohol Abuse 131(2):73–94, 1987. 

Reilly, P.G. Assessment and treatment of the 

mentally ill chemical abuser and the family. 

Journal of Chemical Dependency Treatment 

4(1):167–178, 1991. 

Reilly, P.M.; Sees, K.L.; Shopshire, M.S.; Hall, 

S.M.; Delucchi, K.L.; Tusel, D.J.; Banys, P.; 

Clark, H.W.; and Piotrowski, N.A. Selfefficacy and illicit opioid use in a 180-day 

methadone detoxification treatment. Journal 

of Consulting and Clinical Psychology 

63(1):158–162, 1995. 

Rice-Licare, J., and Delaney-McLoughlin, K. 

Cocaine Solutions: Help for Cocaine Abusers and 

Their Families. Haworth Series in Addictions 

Treatment, Vol. 4. New York: Harrington 

Park Press, 1990. 

Rimmele, C.T.; Howard, M.O.; and Hilfrink, 

M.L. Aversion therapies. In: Hester, R.K., 

and Miller, W.R., eds. Handbook of Alcoholism 

Treatment Approaches: Effective Alternatives, 

2nd ed. Boston: Allyn and Bacon, 1995. pp. 

134–147. 

Roberts, R.W., and Northen, H. Theories of Social 

Work with Groups. New York: Columbia 

University Press, 1976. 

Rohsenow, D.J., and Monti, P.M. Cue exposure 

treatment in alcohol dependence. In: 

Drummond, D.C.; Tiffany, S.T.; Glautier, S.; 

and Remington, R., eds. Addictive Behaviour: 

Cue Exposure Theory and Practice. Chichester, 

UK: John Wiley and Sons, 1995. pp. 169–196. 

Rohsenow, D.J.; Monti, P.M.; Zwick, W.R.; 

Nirenberg, T.D.; Liepman, M.R.; Binkoff, J.A.; 

and Abrams, D.B. Irrational beliefs, urges to 

drink and drinking among alcoholics. 

Journal of Studies on Alcohol 50(5):461–464, 

1989. 

Rohsenow, D.J.; Niaura, R.S.; Childress, A.R.; 

Abrams, D.B.; and Monti, P.M. Cue 

reactivity in addictive behaviors: Theoretical 

and treatment implications. International 

Journal of the Addictions 25(7A–8A):957–993, 

1991. 

Romach, M.K., and Sellers, E.M. Alcohol 

dependence: Women, biology, and 

pharmacotherapy. In: McCance-Katz, E.F., 

and Kosten, T.R., eds. New Treatments for 

Chemical Addictions. Washington, DC: 

American Psychiatric Press, 1998. pp. 35–73. 

Ross, S.M.; Miller, P.J.; Emmerson, R.Y.; and 

Todt, E.H. Self-efficacy, standards, and 

abstinence violation: A comparison between 

newly sober and long-term sober alcoholics. 

Journal of Substance Abuse 1(2):221–229, 1988– 

1989. 

Rotgers, F. Behavioral theory of substance 

abuse treatment: Bringing science to bear on 

practice. In: Rotgers, F.; Keller, D.S.; and 

Morgenstern, J., eds. Treating Substance 

Abuse: Theory and Technique. New York: 

Guilford Press, 1996. pp. 174–201. 

Rotunda, R.J., and O’Farrell, T.J. Marital and 

family therapy of alcohol use disorders: 

Bridging the gap between research and 

practice. Professional Psychology: Research and 

Practice 28(3):246–252, 1997. 

Rounds-Bryant, J.L.; Flynn, P.M.; and 

Craighead, L.W. Relationship between selfefficacy perceptions and in-treatment drug 

use among regular cocaine users. American 

Journal of Drug and Alcohol Abuse 23(3):383– 

395, 1997. 

200 
Bibliography 

Rounsaville, B.J., and Carroll, K.M. 

Interpersonal psychotherapy for patients 

who abuse drugs. In: Klerman, G.L, and 

Weissman, M.M., eds. New Applications of 

Interpersonal Psychotherapy. Washington, DC: 

American Psychiatric Press, 1993. 

Rounsaville, B.J.; Glazer, W.; Wilber C.H.; 

Weissman, M.M.; and Kleber, H.D. Shortterm interpersonal psychotherapy in 

methadone-maintained opiate addicts. 

Archives of General Psychiatry 40: 629–636, 

1983. 

Rowan, J. The Transpersonal: Psychotherapy and 

Counseling. London: Routledge, 1993. 

Rush, J., ed. Short-Term Psychotherapies for 

Depression: Behavioral, Interpersonal, Cognitive, 

and Psychodynamic Approaches. New York: 

Guilford Press, 1982. 

Ryglewicz, H. Psychoeducation for clients and 

families: A way in, out, and through in 

working with people with dual disorders. 

Psychosocial Rehabilitation Journal 15(2):79–89, 

1991. 

Saleebey, D. The strengths perspective in social 

work practice: Extensions and cautions. 

Social Work 44(3):296–305, 1996. 

Sanchez-Craig, M. Drink Wise: How To Quit 

Drinking or Cut Down. Toronto, ON: 

Addiction Research Foundation, 1995. 

Sanchez-Craig, M. Toward a public health 

model to preventing alcohol problems. 

Addiction 89(6):660–662, 1994. 

Sanchez-Craig, M.; Annis, H.M.; Bornet, A.R.; 

and MacDonald, K.R. Random assignment 

to abstinence and controlled drinking: 

Evaluation of a cognitive-behavioral 

program for problem drinkers. Journal of 

Consulting and Clinical Psychology 52(3):390– 

403, 1984. 

Sanchez-Craig, M.; Neumann, B.; SouzaFormigoni, M.; and Rieck, L. Brief treatment 

for alcohol dependence: Level of dependence 

and treatment outcome. Alcohol and 

Alcoholism (Suppl. 1):515–518, 1991. 

Santisteban, D.A., and Szapocznik, J. Bridging 

theory, research and practice to more 

successfully engage substance abusing youth 

and their families into therapy. Journal of 

Child and Adolescent Substance Abuse 3(2): 9– 

24, 1994. 

Sapiro, V. Women in American Society: An 

Introduction to Women’s Studies. Mountain 

View, CA: Mayfield, 1990. 

Saunders, B.; Wilkinson, C.; and Phillips, M. 

The impact of brief motivational intervention 

with opiate users attending a methadone 

programme. Addiction 90:415–424, 1995. 

Schafer, J., and Brown, S.A. Marijuana and 

cocaine effect expectancies and drug use 

patterns. Journal of Consulting and Clinical 

Psychology 59(4):558–565, 1991. 

Schmidt, S.E.; Liddle, H.A.; and Dakof, G.A. 

Changes in parenting practices and 

adolescent drug abuse during 

multidimensional family therapy. Journal of 

Family Psychology 10(1): 12–27, 1996. 

Schneider, R.; Casey, J.; and Kohn, R. 

Motivational versus confrontational 

interviewing: A comparison of substance 

abuse assessment practices at employee 

assistance programs. Journal of Behavioral 

Health Services and Research, in press. 

201 
Appendix A 

Schuster, C.R., and Silverman, K. Advancing 

the application of behavioral treatment 

approaches for substance dependence. In: 

Onken, L.S.; Blaine, J.D.; and Boren, J.J., eds. 

Behavioral Treatments for Drug Abuse and 

Dependence. NIDA Research Monograph 

Series, Number 137. NIH Pub. No. (ADM) 

93-3684. Rockville, MD: National Institute on 

Drug Abuse, 1993. pp. 5–17. 

Schutt, M. Wives of Alcoholics: From CoDependency to Recovery. Pompano Beach: FL: 

Health Communications, 1985. 

Schor, L.I. “Apperception as a primary process 

of the psyche: Implications for theory and 

practice.” Ph.D. diss., Auburn University, 

1998. 

Scott, E., and Anderson, P. Randomized 

controlled trial of general practitioner 

intervention in women with excessive 

alcohol consumption. Drug and Alcohol 

Review 10:313–321, 1991. 

Scotton, B.W.; Chinen, A.B.; and Battista, J.R., 

eds. Textbook of Transpersonal Psychiatry and 

Psychology. New York: Basic Books, 1996. 

Selekman, M. “With a little help from my 

friends”: The use of peers in the family 

therapy of adolescent substance abusers. 

Family Dynamics of Addiction Quarterly 

1(1):69–76, 1991. 

Seligman, M.E. What You Can Change and What 

You Can’t: The Complete Guide to Successful 

Self-Improvement. New York: Knopf, 1994. 

Seligman, M.E. The effectiveness of 

psychotherapy: The Consumer Reports study. 

American Psychologist 50(12):965–74, 1995. 

Selvini-Palazzoli, M.; Boscolo, L.; Cecchin, G.; 

and Prata, G. Paradox and Counter-Paradox: A 

New Model in the Therapy of the Family in 

Schizophrenic Transaction. New York: Jason 

Aronson, 1978. 

Shaffer, H., and Burglass, M.E., eds. Classic 

Contributions in the Addictions. New York: 

Brunner/Mazel, 1981. 

Shedler, J., and Block, J. Adolescent drug use 

and psychological health: A longitudinal 

inquiry. American Psychologist 45(5):612–630, 

1990. 

Shiffman, S. Maintenance and relapse: Coping 

with temptation. In: Nirenberg, T.D., and 

Maisto, S.A., eds. Developments in the 

Assessment and Treatment of Addictive 

Behaviors. Norwood, NJ: Ablex Publishing, 

1987. pp. 353–385. 

Shiffman, S. Conceptual issues in the study of 

relapse. In: Gossop, M., ed. Relapse and 

Addictive Behaviour. London: Tavistock/ 

Routledge, 1989. pp. 149–179. 

Sifneos, P.E. Short-Term Psychotherapy and 

Emotional Crisis. Cambridge, MA: Harvard 

University Press, 1972. 

Sifneos, P.E. Short-Term Dynamic Psychotherapy: 

Evaluation and Technique, 2nd ed. New York: 

Plenum, 1987. 

Silverman, K.; Chutuape, M.A.; Bigelow, G.E.; 

and Stitzer, M.L. Voucher-based 

reinforcement of attendance by unemployed 

methadone patients in a job skills training 

program. Drug and Alcohol Dependence 

41(3):197–207, 1996. 

202 
Bibliography 

Silverman, K.; Higgins, S.T.; Brooner, R.K.; 

Montoya, I.D.; Cone, E.J.; Schuster, C.R.; and 

Preston, K.L. Sustained cocaine abstinence in 

methadone maintenance patients through 

voucher-based reinforcement therapy. 

Archives of General Psychiatry 53:409–415, 

1996. 

Silverman, K.; Wong, C.J.; Umbricht-Schneiter, 

A.; Montoya, I.D.; Schuster, C.R.; and 

Preston, K.L. Broad beneficial effects of 

cocaine abstinence reinforcement among 

methadone patients. Journal of Consulting and 

Clinical Psychology 66(5):811–824, 1998. 

Sisson, R.W., and Azrin, N.H. Family-member 

involvement to initiate and promote 

treatment of problem drinkers. Journal of 

Behavior Therapy and Experimental Psychiatry 

17(1):15–21, 1986. 

Sisson, R.W., and Azrin, N.H. The community 

reinforcement approach. In: Hester, R.K., 

and Miller, W.R., eds. Handbook of Alcoholism 

Treatment Approaches: Effective Alternatives. 

New York: Pergamon Press, 1989. pp. 242– 

258. 

Sisson, R.W., and Azrin, N.H. Community 

reinforcement training for families: A 

method to get alcoholics into treatment. In: 

O’Farrell, T.J., ed. Treating Alcohol Problems: 

Marital and Family Interventions. New York: 

Guilford Press, 1993. pp. 34–53. 

Sitharthan, T.; Kavanagh, D.J.; and Sayer, G. 

Moderating drinking by correspondence: An 

evaluation of a new method of intervention. 

Addiction 91(3):345–355, 1996. 

Sitharthan, T.; Sitharthan, G.; Hough, M.J.; and 

Kavanagh, D.J. Cue exposure in moderation 

drinking: A comparison with cognitivebehavior therapy. Journal of Consulting and 

Clinical Psychology 65(5):878–882, 1997. 

Skinner, B.F. The operant side of behavior 

therapy. Journal of Behavior Therapy and 

Experimental Psychiatry 19(3):171–179, 1988. 

Sklar, S.M.; Annis, H.M.; and Turner, N.E. 

Development and validation of the DrugTaking Confidence Questionnaire: A 

measure of coping self-efficacy. Addictive 

Behaviors 22(5):655–670, 1997. 

Skutle, A., and Berg, G. Training in controlled 

drinking for early-stage problem drinkers. 

British Journal of Addiction 82(5):493–501, 

1987. 

Smith, C.A.; Haynes, K.N.; Lazarus, R.S.; and 

Pope, L.K. In search of the “hot” cognitions: 

Attributions, appraisals, and their relation to 

emotion. Journal of Personality and Social 

Psychology 65(5):916–929, 1993. 

Smith, J.E., and Meyers, R.J. The community 

reinforcement approach. In: Hester, R.K., 

and Miller, W.R., eds. Handbook of Alcoholism 

Treatment Approaches: Effective Alternatives, 

2nd ed. Boston: Allyn and Bacon, 1995. 

pp. 251–266. 

Smith, J.W., and Frawley, P.J. Treatment 

outcome of 600 chemically dependent 

patients treated in a multimodal inpatient 

program including aversion therapy and 

pentothal interviews. Journal of Substance 

Abuse Treatment 10(4):359–369, 1993. 

Smith, J.W.; Frawley, P.J.; and Polissar, N.L. Sixand twelve-month abstinence rates in 

inpatient alcoholics treated with either 

faradic aversion or chemical aversion 

compared with matched inpatients from a 

treatment registry. Journal of Addictive 

Diseases 16(1):5–24, 1997. 

203 
Appendix A 

Smith, J.W.; Schmeling, G.; and Knowles, P.L. A 

marijuana smoking cessation clinical trial 

utilizing THC-free marijuana, aversion 

therapy, and self-management counseling. 

Journal of Substance Abuse Treatment 5(2):89– 

98, 1988. 

Smokowski, P.R., and Wodarski, J.S. 

Cognitive-behavioral group and family 

treatment of cocaine addiction. In: The 

Hatherleigh Guide to Treating Substance Abuse, 

Part 1. The Hatherleigh Guides Series, Vol. 7. 

New York: Hatherleigh Press, 1996. pp. 171– 

189. 

Smyrinos, K.X., and Kirkby, R.J. Long-term 

comparison of brief versus unlimited 

psychodynamic treatments with children and 

their parent. Journal of Consulting and Clinical 

Psychology 61(6):1020–1027, 1993. 

Sobell, L.C., and Sobell, M.B. Self-report issues 

in alcohol abuse: State of the art and future 

directions. Behavioral Assessment 12:91–106, 

1990. 

Sobell, L.C.; Sobell, M.B.; and Nirenberg, T.D. 

Behavioral assessment and treatment 

planning with alcohol and drug abusers: A 

review with an emphasis on clinical 

application. Clinical Psychology Review 

8(1):19–54, 1988. 

Sobell, L.C.; Toneatto, T.; and Sobell, M.B. 

Behavioral assessment and treatment 

planning for alcohol, tobacco, and other drug 

problems: Current status with an emphasis 

on clinical applications. Behavior Therapy 

25(4):533–580, 1994. 

Sobell, M.B.; Maisto, S.; Sobell, L.; Cooper, A.; 

Cooper, T.; and Sanders, B. Developing a 

prototype for evaluating alcohol treatment 

effectiveness. In: Sobell, L.; Sobell, M.; and 

Ward E., eds. Evaluating Drug and Alcohol 

Abuse Treatment Effectiveness: Recent Advances. 

New York: Pergamon Press, 1980. 

Solomon, K.E., and Annis, H.M. Outcome and 

efficacy expectancy in the prediction of posttreatment drinking behaviour. British Journal 

of Addiction 85(5):659–665, 1990. 

Solomon P. The efficacy of case management 

services for severely mentally disabled 

clients. Community Mental Health Journal 

28(3):163–180, 1992. 

Soo-Hoo, T. Brief strategic family therapy with 

Chinese Americans. American Journal of 

Family Therapy 27(2):163–179, 1999. 

Spivak, K.; Sanchez-Craig, M.; and Davila, R. 

Assisting problem drinkers to change on 

their own: Effects of specific and non-specific 

advice. Addiction 89(9):1135–1142, 1994. 

Stanton, M.D. The addict as savior: Heroin, 

death, and the family. Family Process 16:191– 

197, 1977. 

Stanton, M.D. An integrated structural/ 

strategic approach to family therapy. Journal 

of Marital and Family Therapy 7:427–439, 1981. 

Stanton, M.D., and Heath, A.W. Family and 

marital therapy. In: Lowinson, J.H.; Ruiz, P.; 

Millman, R.B.; and Langrod, J.G., eds. 

Substance Abuse: A Comprehensive Textbook. 

Baltimore, MD: Williams & Wilkins, 1997. 

pp. 448–454. 

Stanton, M.D., and Todd, T.C. The Family 

Therapy of Drug Abuse and Addiction. New 

York: Guilford Press, 1982. 

Stasiewicz, P.R., and Maisto, S.A. Two-factor 

avoidance theory: The role of negative affect 

in the maintenance of substance use and 

substance use disorder. Behavior Therapy 

24(3):337–356, 1993. 

Steinglass, P.; Davis, D.I.; and Berenson, D. 

Observations of conjointly hospitalized 

“alcoholic couples” during sobriety and 

intoxication: Implications for theory and 

therapy. Family Process 16:1–16, 1977. 

204 
Bibliography 

Stephens, R.S.; Curtin, L.; Simpson, E.E.; and 

Roffman, R.A. Testing the abstinence 

violation effect construct with marijuana 

cessation. Addictive Behaviors 19(1):23–32, 

1994. 

Stephens, R.S.; Wertz, J.S.; and Roffman, R.A. 

Predictors of marijuana treatment outcomes: 

The role of self-efficacy. Journal of Substance 

Abuse 5(4):341–354, 1993. 

Stitzer, M.; Bigelow, G.; and Liebson, I. 

Contingent reinforcement of benzodiazepinefree urines from methadone maintenance 

patients. In: Harris, L.S., ed. Proceedings of 

the 43rd Annual Scientific Meeting, The 

Committee on Problems of Drug Dependence, 

Inc. NIDA Research Monograph Series, 

Number 41. HHS Pub. No. (ADM) 83-1264. 

Rockville, MD: National Institute on Drug 

Abuse, 1982. pp. 282–287. 

Stitzer, M.L.; Bigelow, G.E.; Liebson, I.A.; and 

Hawthorne, J.W. Contingent reinforcement 

for benzodiazepine-free urines: Evaluation of 

a drug abuse treatment intervention. Journal 

of Applied Behavior Analysis 15(4):493–503, 

1982. 

Stockwell, T. and Town, C. Anxiety and stress 

management. In: Hester, R.K., and Miller, 

W.R., eds. Handbook of Alcoholism Treatment 

Approaches: Effective Alternatives, 2nd ed. 

Boston: Allyn and Bacon, 1995. pp. 242–250. 

Stout, R.L.; McCrady, B.S.; Longabough, R.; 

Noel, N.E.; and Beattie, M.C. Marital therapy 

enhances the long-term effectiveness of 

alcohol treatment. Alcoholism: Clinical and 

Experimental Research 11:213. 1987. 

Strain, E.C. Psychosocial treatments for cocaine 

dependence: Rethinking lessons learned. 

Archives of General Psychiatry 56(6):503–504, 

1999. 

Straus, M. Measuring intrafamily conflict and 

violence: The Conflict Tactics (CT) Scale. 

Journal of Marriage and the Family 41:75–88, 

1979. 

Strean, H.S. Essentials of Psychoanalysis. New 

York: Brunner/Mazel, 1994. 

Strupp, H.H., and Hadley, S.W. Specific versus 

non-specific factors in psychotherapy: A 

controlled study of outcome. Archives of 

General Psychiatry 36(10):1125–1136, 1979. 

Strupp, H.H. Success and failure in time-limited 

psychotherapy. Archives of General Psychiatry 

37(8):947–954, 1980. 

Strupp, H.H., and Binder, J.L. Psychotherapy in a 

New Key: A Guide to Time-Limited 

Psychotherapy. New York: Basic Books, 1984. 

Sue, D.W., and Sue, D. Counseling the Culturally 

Different, 2nd ed. New York: John Wiley and 

Sons, 1990. 

Szapocznik, J., and Kurtines, W.M. 

Breakthroughs in Family Therapy With Drug 

Abusing and Problem Youth. New York: 

Springer Publishing, 1989. 

Szapocznik, J.; Perez-Vidal, A.; Brickman, A.L.; 

Foote, F.H.; Santisteban, D.; Herris, O.; and 

Kurtines, W.M. Engaging adolescent drug 

abusers and their families in treatment: A 

strategic structural systems approach. 

Journal of Consulting and Clinical Psychology 

56(4):552–557, 1988. 

Szapocznik, J.; Rio, A.; and Kurtines, W. Brief 

strategic family therapy for Hispanic 

problem youth. In: Beutler, L.E., and Crago, 

M., eds. Psychotherapy Research: An 

International Review of Programmatic Studies. 

Washington, DC: American Psychological 

Association, 1991. pp. 123–132. 

205 
Appendix A 

Szapocznik, J.; Santisteban, D.; Rio, A.; and 

Perez-Vidal, A. Family effectiveness 

training: An intervention to prevent drug 

abuse and problem behaviors in Hispanic 

adolescents. Hispanic Journal of Behavioral 

Sciences 11(1): 4–27, 1989. 

Thomas, E.J., and Ager, R.D. Unilateral family 

therapy with spouses of uncooperative 

alcohol abusers. In: O’Farrell, T.J., ed. 

Treating Alcohol Problems: Marital and Family 

Interventions. New York: Guilford Press, 

1993. pp. 3–33. 

Thomas, E.J.; Yoshioka, M.R.; and Ager, R.D. 

Spouse enabling inventory. In: Fischer, J., 

and Corcoran, K., eds. Measures for Clinical 

Practice: A Sourcebook, 2nd ed. Vol. 1. 

Couples, Families, and Children. New York: 

Free Press, 1994. pp. 177–178. 

Todd, T.C. Structural-strategic marital therapy. 

In: Jacobson, N.S., and Gurman, A.S., eds. 

Clinical Handbook of Marital Therapy. New 

York: Guilford Press, 1986. pp. 71–105. 

Tucker, J.A.; Vuchinich, R.E.; and Downey, K.K. 

Substance abuse. In: Turner, S.M.; Calhoun, 

K.S.; and Adams, H.E., eds. Handbook of 

Clinical Behavior Therapy. New York: John 

Wiley and Sons, 1981. pp. 203–223. 

Turner, F.J., ed. Differential Diagnosis and 

Treatment in Social Work. New York: Free 

Press, 1976. 

van Bilsen, H., and Whitehead, B. Learning 

controlled drug use: A case study. 

Behavioural and Cognitive Psychotherapy 

22(1):87–95, 1994. 

Van De Riet, V.; Korb, M.P.; and Gorrell, J.J. 

Gestalt Therapy: An Introduction. New York: 

Pergamon Press, 1980. 

Van Utt, G., and Burglass, M.E. The collectivist 

issue in client-therapist matching. In: Smith, 

D.E., ed. A Multicultural View of Drug Abuse: 

Proceedings of the National Drug Abuse 

Conference, 1977. Cambridge, MA: 

Schenkman Pub. Co., 1978. pp. 298–304. 

Velicer, W.F.; Prochaska, J.O.; Rossi, J.S.; and 

Snow, M.G. Assessing outcome in smoking 

cessation studies. Psychological Bulletin 

111(1):23–41, 1992. 

Volpicelli, J.R.; Alterman, A.I.; Hayashida, M.; 

and O’Brien, C.P. Naltrexone in the 

treatment of alcohol dependence. Archives of 

General Psychiatry 49(11):876–880, 1992. 

Von Eckartsberg, R. Existentialphenomenology, validity, and the transpersonal ground of psychological theorizing. 

In: Giorgi, A.; Barton, A.; and Maes, C., eds. 

Duquesne Studies in Phenomenology, Vol. 4. 

Pittsburgh: Duquesne University Press, 1983. 

pp. 199–201. 

Wallace, P.; Cutler, S.; and Haines, A. 

Randomised controlled trial of general 

intervention in patients with excessive 

alcohol consumption. British Medical Journal 

297:663–668, 1988. 

Walton, M.A.; Castro, F.G.; and Barrington, E.H. 

The role of attributions in abstinence, lapse, 

and relapse following substance abuse 

treatment. Addictive Behaviors 19(3):319–331, 

1994. 

Watzlawick, P.; Bavelas, J.B.; and Jackson, D.D. 

Pragmatics of Human Communication: A Study 

of Interactional Patterns, Pathologies, and 

Paradoxes. New York: W.W. Norton, 1967. 

Watzlawick, P.; Weakland, J.; and Fisch, R. 

Change: Principles of Problem Formation and 

Problem Resolution. New York: W.W. Norton, 

1974. 

206 
Bibliography 

Weeks, G.R., and L’Abate, L. A compilation of 

paradoxical methods. American Journal of 

Family Therapy 7:61–76, 1979. 

Wegscheider-Cruse, S. The Miracle of Recovery. 

Deerfield Beach, FL: Health 

Communications, 1989. 

Weil, A. The Natural Mind: An Investigation of 

Drugs and the Higher Consciousness. Boston: 

Houghton Mifflin, 1972. 

Weil, A., and Rosen, W. From Chocolate to 

Morphine: Everything You Need To Know About 

Mind-Altering Drugs. Boston: Houghton 

Mifflin, 1993. 

Weitz, R. Feminist consciousness raising, selfconcept, and depression. Sex Roles 8:213– 

241, 1982. 

Wetchler, J.L.; McCollum, E.E.; Nelson, T.S.; 

Trepper, T.S.; and Lewis, R.A. Systemic 

couples therapy for substance abusing 

women. In: O’Farrell, T.J., ed. Treating 

Alcohol Problems: Marital and Family 

Interventions. New York: Guilford Press, 

1993. pp. 236–260. 

Whalen, T. Wives of alcoholics: Four types 

observed in a family service agency. 

Quarterly Journal of Studies on Alcohol 14:632– 

641, 1953. 

Wilber, K. Sex, Ecology, and Spirituality: The 

Spirit of Evolution. Boston: Shambhala, 1995. 

Wilk, A.I.; Jensen, N.M.; and Havighurst, T.C. 

Meta-analysis of randomized control trials 

addressing brief interventions in heavy 

alcohol drinkers. Journal of General Internal 

Medicine 12(5):274–283, 1997. 

Wills, T.A., and Hirky, A.E. Coping and 

substance abuse: A theoretical model and 

review of the evidence. In: Zeidner, M., and 

Endler, N.S., eds. Handbook of Coping: Theory, 

Research, Applications. New York: John Wiley 

and Sons, 1996. pp. 279–302. 

Winn, M.E. Drawing upon the strengths of 

couples in the treatment of chronic drug 

addiction. Journal of Family Psychotherapy 

6(3):33–54, 1995. 

Wittine, B. Basic postulates for a transpersonal 

psychotherapy. In: Valle, R., and Halling, S., 

eds. Existential-Phenomenological Perspectives 

in Psychology: Exploring the Breadth of Human 

Experience. New York: Plenum Press, 1989. 

Wolberg, L.R. Handbook of Short-Term 

Psychotherapy. New York: Verlag, 1980. 

Wolman, B., ed. International Encyclopedia of 

Psychiatry, Psychology, Psychoanalysis and 

Neurology. Vol. 5. New York: Aesculapius 

Press, 1977. 

Woody, G.E.; Luborsky, L.; McLellan, A.T.; and 

O’Brien, C.P. Psychotherapy for opiate 

dependence. In: Ashery, R.S., ed. Progress in 

the Development of Cost-Effective Treatment for 

Drug Abusers. NIDA Research Monograph 

Series, Number 58. HHS Pub. No. (ADM) 

85-1401. Rockville, MD: National Institute on 

Drug Abuse, 1985. pp. 9–29. 

Woody, G.E.; Luborsky, L.; McLellan, A.T.; 

O’Brien, C.P.; Beck, A.T.; Blaine, J.; Herman, 

I.; and Hole, A. Psychotherapy for opiate 

addicts: Does it help? Archives of General 

Psychiatry 40:639–645, 1983. 

207 
Appendix A 

Woody, G.E.; McLellan, A.T.; Luborsky, L.; and 

O’Brien, C.P. Twelve-month follow-up of 

psychotherapy for opiate dependence. 

American Journal of Psychiatry 144(5):590–596, 

1987. 

Woody, G.E.; McLellan, A.T.; Luborsky, L.; and 

O’Brien, C.P. Psychotherapy and counseling 

for methadone-maintained opiate addicts: 

Results of research studies. In: Onken, L.S., 

and Blaine, J.D., eds. Psychotherapy and 

Counseling in the Treatment of Drug Abuse. 

NIDA Research Monograph 104. HHS 

Pub. No. (ADM) 91-1722, Rockville, MD: 

National Institute on Drug Abuse, 1990. 

pp. 9–23. 

Woody, G.E.; McLellan, A.T.; Luborsky, L.; and 

O’Brien, C.P. Psychotherapy in community 

methadone programs: A validation study. 

American Journal of Psychiatry 152(9):1302– 

1308, 1995. 

Woody, G.E.; McLellan, A.T.; Luborsky, L.; and 

O’Brien, C.P. Psychotherapy with opioiddependent patients. Psychiatric Times, 15(11), 

1998. 

Woody G.E.; Mercer D.; and Luborsky L. 

Psychotherapy for substance abuse. In: 

Michels, R., ed. Psychiatry Series. 

Philadelphia, PA: J.B. Lippincott Company, 

1994. 

Wright, J.H., and Beck, A. Cognitive therapy. 

In: Hales, R.E.; Yudofsky, S.C.; and Talbott, 

J.A., eds. American Psychiatric Press Textbook 

of Psychiatry, 2nd ed. Washington, DC: 

American Psychiatric Press, 1994. 

Yalom, I.D. Existential Psychotherapy. New 

York: Basic Books, 1980. 

Yalom, I.D. The Theory and Practice of Group 

Psychotherapy, 4th ed. New York: Basic 

Books, 1995. 

Yalom, I.D. The Yalom Reader: On Writing, 

Living, and Practicing Psychology. New York: 

Basic Books, 1997. 

Zients, A. Presentation to the Mental Health 

Work Group, White House Task Force for 

National Health Care Reform, April 23, 1993. 

Ziter, M.L.P. Culturally sensitive treatment of 

Black alcoholic families. Social Work 

32(2):130–135, 1987. 

Zitter, R., and McCrady, B.S. The Drinking 

Patterns Questionnaire. Unpublished 

questionnaire. Piscataway, NJ: Rutgers 

University, 1993. 

Zweben, A.; Pearlman, S.; and Li, S. A 

comparison of brief advice and conjoint 

therapy in the treatment of alcohol abuse: 

The results of the Marital Systems Study. 

British Journal of Addiction 83(8):899–916, 

1988. 

Zweben, J.E. Recovery-oriented psychotherapy: 

Patient resistances and therapist dilemmas. 

Journal of Substance Abuse Treatment 6(2):123– 

132, 198. 

208 
Appendix B

Information and Training

Resources 

General Brief Therapy 

American Psychological Association 

(APA)—Division 29: Psychotherapy 

Division of Psychotherapy 

P.O. Box 638 

Niwot, CO 80544-0638 

Phone: (303) 652-9154 

Fax: (303) 652-2723 

Web site: http://www.divisionofpsychotherapy.org/

E-mail: lpete@indra.com 

APA, headquarted in Washington, DC, is the 

world’s largest association of psychologists. 

APA’s membership includes more than 159,000 

researchers, educators, clinicians, consultants, 

and students. Through its divisions in 50 

subfields of psychology and affiliations with 59 

State, territorial, and Canadian provincial 

associations, APA works to advance psychology 

as a science, as a profession, and as a means of 

promoting human welfare. 

Division 29 promotes education, research, 

high standards of practice, and the exchange of 

information among psychologists interested in 

psychotherapy. 

Cognitive–Behavioral 

Therapy 

Aaron T. Beck Institute for 

Cognitive Studies 

Edmund F. O’Reilly, Ph.D. 

Founders Hall, Room 319 

Assumption College 

500 Salisbury Street 

P.O. Box 15005 

Worcester, MA 01615-0005 

Phone: (508) 767-7000, x 7554 

Web site: http://graduate.assumption.edu/

counseling-psychology/aaron-t-beck-institutecognitive-studies

E-mail: eoreill@eve.assumption.edu 

The Aaron T. Beck Institute for Cognitive 

Studies provides information that highlights the 

contributions of cognitive factors to the 

resolution of problems in living. The Institute 

hosts annual speakers and conferences that 

address research and therapeutic development 

in cognitive therapy as well as ethical and moral 

issues. It also sponsors education and training 

projects in cognitive therapeutic skills to 

students and to postgraduate professionals. 

209 
Appendix B 

The Albert Ellis Institute 

45 East 65th Street

New York, NY 10021

Phone: (800) 323-4738

Web site: http://www.rebt.org/ 

E-mail: info@REBT.org

The Albert Ellis Institute, formerly known as the 

Institute for Rational-Emotive Therapy, is a notfor-profit educational organization founded in 

1968. Rational Emotive Behavior Therapy 

(REBT) is a humanistic, action-oriented 

approach to emotional growth, first articulated 

by Dr. Albert Ellis in 1955, which emphasizes 

individuals’ capacity for creating their emotions; 

the ability to change and overcome the past by 

focusing on the present; and the power to 

choose and implement satisfying alternatives to 

current behavior patterns. An estimated 8,000 

mental health professionals participate in 

Institute training programs and workshops each 

year. 

The Association for %HKDYLRUDO

DQG&RJQLWLYHTherapLHV (AB&T) 

305 Seventh Avenue - 16th Floor 

New York, NY 10001-6008 

Phone: (212) 647-1890 

Fax: (212) 647-1865 

Web site: http://www.abct.org

E-mail: mebrown@abct.org

ABCT is a not-for-profit membership 

organization of over 4,500 mental health 

professionals and students. Founded in 1966, 

ABCT serves as a centralized resource and 

network for all facets of behavior therapy and 

cognitive–behavior therapy. It promotes these 

therapies through its journals, newsletters, 

annual conventions, Web site, and other 

educational publications and programs. It also 

provides opportunities for professional growth 

and offers information and referral services to 

the general public, the media, third-party 

payors, and governmental and 

nongovernmental agencies. 

National Association of Cognitive– 

Behavioral Therapists (NACBT) 

P.O. Box 2195 

Weirton, WV 26062 

Phone: (800) 853-1135 

Fax: (304) 723-3982 

Web site: http://www.nacbt.org/ 

E-mail: nacbt@nacbt.org 

NACBT provides information on Rational 

Emotive Behavior Therapy (Albert Ellis), 

Rational Behavior Therapy (Maxie Maultsby), 

Cognitive Therapy (Aaron T. Beck), Rational 

Living Therapy (Aldo Pucci), and other 

cognitive–behavioral approaches. NACBT is 

dedicated to promoting the teaching and 

practice of cognitive–behavioral therapy and to 

supporting cognitive–behavioral therapists. 

NACBT offers cognitive–behavioral workshops, 

seminars, conferences, and home study 

certification programs. 

Strategic/Interactional 

Therapies 

Brief Family Therapy Center (BFTC) 

P. O. Box 13736 

Milwaukee, WI 53213-0736 

Phone: (414) 302-0650 

Fax: (414) 302-0753 

Web site: http://www.brief-therapy.org 

E-mail: briefftc@aol.com 

A not-for-profit research and training center 

founded in 1978, BFTC has pioneered effective 

brief therapy methods. The model developed at 

the center has come to be known as SolutionFocused Brief Therapy. This model has been 

used successfully for more than a decade in a 

variety of settings including child protection 

agencies, community mental health clinics, 

private practices, sexual abuse programs, 

210 
Information and Training Resources 

substance abuse treatment, family-based 

services, and schools. 

The Milton H. Erickson 

Foundation, Inc. 

3606 North 24th Street 

Phoenix, AZ 85016 

Phone: (602) 956-6196 

Fax: (602) 956-0519 

Web site: http://erickson-foundation.org 

E-mail: office@erickson-foundation.org 

The Milton H. Erickson Foundation, Inc., is 

dedicated to promoting and advancing the 

contributions made to the health sciences by the 

late Milton H. Erickson, M.D., through training 

mental health professionals worldwide. More 

than 60 Milton H. Erickson Institutes and 

Societies in the United States and abroad have 

applied to the Foundation for permission to use 

Dr. Erickson’s name in the titles of their 

organizations. These institutes provide clinical 

services and professional training in major cities 

around the world. 

Institute for the Study of 

Therapeutic Change (ISTC) 

P.O.B. 578264 

Chicago, IL 60657-8264 

Phone: (773) 404-5130 

Fax: (773) 404-1840 

Web site: http://www.talkingcure.com/ 

E-mail: scottdmiller@talkingcure.com 

ISTC is a research, training, and consultation 

group dedicated to understanding and 

promoting human change, growth, and 

potential. ISTC studies how change occurs 

naturally, spontaneously, and on an everyday 

basis and then helps people and organizations 

apply that knowledge in solving problems. 

Mental Research Institute 

555 Middlefield Road 

Palo Alto, CA 94301 

Phone: (650) 321-3055 

Fax: (650) 321-3785 

Web site: http://www.mri.org 

E-mail: mri@mri.org 

Since 1959, the Mental Research Institute of Palo 

Alto, California, has been a source of new ideas 

in the area of interactional/systemic studies, 

psychotherapy, and family therapy. It offers a 

variety of workshops and trainings related to 

brief therapy, narrative therapy, and 

strategic/interactional therapies. 

Humanistic and 

Existential Therapies 

State University of West Georgia 

Department of Psychology 

1600 Maple Street 

Carrollton, GA 30118 

Phone: (770) 836-6510 

Fax: (770) 836-6717 

Web site: http://www.westga.edu/ 

~psydept/index.html 

E-mail: meast@westga.edu 

The State University of West Georgia 

Psychology Department is one of the only 

departments in the country whose theoretical 

roots are in the humanistic psychology and 

transpersonal psychology traditions. They offer 

courses that explore humanistic and 

transpersonal concerns in psychological theory 

and therapy. 

211 
Appendix B 

American Psychological Association 

(APA)—Division 32: Humanistic 

Psychology 

Will Wadlington, Ph.D. 

Center for Counseling & Psychological Services 

221 Ritenour 

University Park, PA 16802 

Phone: (814) 863-0395 

Fax: (814) 863-9610 

Web site: http://www.apa.org/about/division/ 

div32.html 

E-mail: wlw3@psu.edu 

Division 32 of the APA (see above), whose 

foundations include philosophical humanism, 

existentialism, and phenomenology, seeks to 

contribute to psychotherapy, education, 

theory/philosophy, research, organization and 

management, and social responsibility and 

change. 

Association for Humanistic 

Psychology (AHP) 

45 Franklin Street #315 

San Francisco, CA 94102 

Phone: (415) 864-8850 

Fax: (415) 864-8853 

Web site: http://www.ahpweb.org/ 

E-mail: ahpoffice@aol.com 

AHP was formed in 1962 by Abraham Maslow, 

Carl Rogers, Charlotte Buhler, Rollo May, 

Virginia Satir, and other founders of the 

personal growth movement. AHP is a forum for 

sharing ideas and inspiring community through 

a full calendar of conferences and events. 

Members also connect and pursue common 

interests through self-generated communities 

and projects called “Energy Centers,” which 

offer personal and professional support and 

carry out activities and projects on specific 

issues. 

Institute of Transpersonal 

Psychology (ITP) 

744 San Antonio Road 

Palo Alto, CA 94303 

Phone: (650) 493-4430 

Fax: (650) 493-6835 

Web site: http://www.itp.edu/ 

E-mail: itpinfo@itp.edu 

ITP is a private, nonsectarian graduate school 

accredited by the Western Association of 

Schools and Colleges. For more than 20 years, 

the Institute has remained at the forefront of 

psychological research and education, probing 

the mind–body–spirit connection. The Institute 

provides dynamic online/distance-learning 

opportunities using the personal mentor system, 

as well as an evening master’s program for 

working adults. 

Saybrook Graduate School and 

Research Center 

450 Pacific, 3rd Floor 

San Francisco, CA 94133-4640 

Phone: (800) 825-4480 

Fax: (415) 433-9271 

Web site: http://www.saybrook.edu 

E-mail: saybrook@saybrook.edu. 

The Saybrook Graduate School and Research 

Center provides master’s and doctoral 

programs, research, and communication in 

humanistic psychology and human science, 

focused on understanding and enhancing the 

human experience. 

212 
Information and Training Resources 

Psychodynamic Therapy The C.G. Jung Institutes 

The Inter-Regional Society of Jungian Analysts 

American Psychoanalytic 

Association (APSA) 

309 East 49th Street 

New York, NY 10017 

Phone: (212) 752-0450 

Fax: (212) 593-0571 

Web site: http://apsa.org 

E-mail: central.office@apsa.org 

APSA is a professional organization of 

psychoanalysts throughout the United States. 

The association comprises Affiliate Societies and 

Training Institutes in many cities (listed on their 

Web site at http://apsa.org/organiz/ 

society.htm) and has about 3,000 individual 

members. APSA is a Regional Association of the 

International Psychoanalytical Association. 

Alfred Adler Institute of 

San Francisco 

7 Cameo Way 

San Francisco, CA 94131 

Phone: (415) 282-1661 

Web site: 

http://www.adlerian.us/

E-mail: HTStein@worldnet.att.net 

The Alfred Adler Institute provides distance 

training, study-analysis, and case consultation to 

mental health professionals and students 

throughout the world via telephone, E-mail, and 

the Institute’s Web site documents. A unique 

mentor-based service offers self-paced programs 

through customized training, home study of 

audio-taped seminars, weekly discussions, and 

case consultations by telephone. 

Wilma H. Spice, Ph.D. 

4135 Brownsville Road 

Pittsburgh, PA 15227 

Phone: (412) 882-7010 

Web site: http://www.irsja.org

E-mail: wspice@ccac.edu 

There are a number of independent C.G. Jung 

Institutes in the United States, all of whom are 

members of the International Association for 

Analytical Psychology. In addition to the one 

listed above, other institutes exist in 

Washington, D.C., Philadelphia, San Francisco, 

Los Angeles, Chicago, Dallas, Boston, Santa Fe, 

New York, Seattle, and Eugene, Oregon. All of 

these institutes offer training programs, lectures, 

and workshops. 

Family Therapy 

American Association for Marriage 

And Family Therapy (AAMFT) 

1133 15th Street, NW, Suite 300 

Washington, DC 20005-2710 

Phone: (202) 452-0109 

Fax: (202) 223-2329 

Web site: http://www.aamft.org/ 

E-mail: Central@aamft.org 

AAMFT is the professional association for the 

field of marriage and family therapy, 

representing the professional interests of more 

than 23,000 marriage and family therapists 

throughout the United States, Canada, and 

213 
Appendix B 

abroad. The association facilitates research, 

theory development, and education. AAMFT 

hosts an annual national training conference 

each fall as well as a week-long series of 

continuing education workshops in the summer. 

Group Therapy 

American Psychological Association 

(APA)—Division 49: Group 

Psychology and Group 

Psychotherapy 

Alan M. Orenstein, Ph.D. 

9712 DePaul Drive 

Bethesda, MD 20817 

Phone: (202) 373-7083 

Web site: http://www.apa.org/about/division/

div49.aspx

E-mail: alano@erols.com 

Division 49 of the APA (see above) provides a 

forum for psychologists interested in research, 

teaching, and practice in group psychology and 

group psychotherapy. Current projects include 

developing national guidelines for doctoral and 

postdoctoral training in group psychotherapy. 

Association for Specialists in Group 

Work (ASGW) 

Jeremiah Donigian, President 

Department of Counselor Education 

SUNY College at Brockport 

Brockport, NY 14420 

Phone: (800) 347-6647 

Web site: http://www.asgw.org/

E-mail: jdonigia@po.brockport.edu 

ASGW was founded to promote quality in 

group work training, practice, and research, 

both nationally and internationally. A division 

of the American Counseling Association (ACA), 

ASGW numbers among its members more than 

5,800 group workers and group work educators. 

The ASGW Web site provides a resource base 

for teachers, students, and practitioners of group 

work and includes both organizational 

information and professional resources. 

214 
Appendix C

Glossary 

Attribution(s): An individual’s explanation of 

why an event occurred. Some researchers 

believe that individuals develop attributional 

styles (i.e., particular ways of explaining 

events in their lives that can play a role in the 

development of emotional problems and 

dysfunctional behaviors). The basic 

attributional dimensions are internal/ 

external, stable/unstable, and 

global/specific. For instance, clinically 

depressed persons tend to blame themselves 

for adverse life events (internal), believe that 

the causes of negative situations will last 

indefinitely (stable), and overgeneralize the 

causes of discrete occurrences (global). 

Healthier individuals, on the other hand, 

view negative events as due to external 

forces (fate, luck, environment), as having 

isolated meaning (limited only to specific 

events), and as being transient or changeable 

(lasting only a short time). 

Authenticity: In existential therapy, this concept 

refers to the conscious feelings, perceptions, 

and thoughts that one expresses and 

communicates honestly. An individual 

achieves authenticity through courage and is 

thus able to define and discover his own 

meaning. 

Classical conditioning: According to this 

theory, an originally neutral stimulus 

becomes a conditioned stimulus when paired 

with an unconditioned stimulus (an event 

that elicits a response without any prior 

learning history) or with a conditioned 

stimulus. This is also referred to as stimulus 

substitution. As applied to substance abuse, 

repeated pairings between the emotional, 

environmental, and subjective cues 

associated with use of substances and the 

actual physiological effects produced by 

certain substances lead to the development of 

a classically conditioned response. 

Subsequently, when the substance abuser is 

in the presence of such cues, a classically 

conditioned withdrawal state or craving is 

elicited. 

Cognitive restructuring: The general term 

applied to the process of changing the 

client’s thought patterns. Using this process, 

the therapist identifies distorted “addictive” 

thoughts in the client and encourages her to 

search for more rational ways of seeing the 

same event. The client develops and 

practices these alternative ways of thinking 

over the course of cognitive restructuring. 

Contact: A term used in Gestalt therapy that 

refers to meeting oneself and what is other 

than oneself. Without appropriate contact 

and contact boundaries, there is no real 

meeting of the world. Instead, one remains 

either engulfed by the world or distant from 

the world and people. The Gestalt therapist 

tries to help the client make contact with the 

215 
Appendix C 

present moment rather than seeking detailed 

intellectual analysis. 

Contingency management: A contingency 

management approach attempts to change 

those environmental contingencies that may 

influence substance abuse behavior. The 

goal is to increase behaviors that are 

incompatible with use. In particular, 

contingencies that are found through a 

functional analysis to prompt as well as 

reinforce substance use are weakened by 

associating evidence of substance abuse (e.g., 

a drug-positive urine screen) with some form 

of negative consequence or punishment. 

Contingencies that prompt and reinforce 

behaviors that are incompatible with 

substance abuse and that promote abstinence 

are strengthened by associating them with 

positive reinforcers. 

Core conflictual relationship theme (CCRT): 

Used in Supportive-Expressive (SE) Therapy, 

this concept refers to the way in which the 

client interacts with others and with herself. 

The CCRT is considered to be the center of a 

client’s problems. It develops from early 

childhood experiences, but the client is 

unaware of it and of how it developed. SE 

therapy posits that the client will have better 

control over behavior if she knows more 

about what she is doing on an unconscious 

level. 

Core response from others (RO): A term used 

in SE therapy to explain one way in which 

the core conflictual relationship theme is 

unconsciously developed. The RO 

represents an individual’s predominant 

expectations or experiences of others’ 

internal and external reactions to himself. 

Core response of the self (RS): A term used in 

SE therapy that helps to develop an 

individual’s core conflictual relationship 

theme. The RS refers to a more or less 

coherent combination of somatic experiences, 

affects, actions, cognitive style, self-esteem, 

and self-representations. 

Counterconditioning: A method that uses 

classical conditioning principles to make 

behaviors previously associated with 

positive outcomes less appealing by more 

closely associating them with negative 

consequences. By repeatedly pairing those 

cues that formerly elicited a particular 

behavior with negative rather than positive 

outcomes, the cues lose their ability to elicit 

the original classically conditioned response; 

instead, they elicit a negative outcome. This 

is also called an aversive or counterconditioning 

treatment approach. 

Countertransference: The phenomenon in 

which the therapist transfers his emotional 

needs and feelings onto his client. This can 

occur to a degree of personal involvement 

that seriously harms the therapeutic 

relationship. 

Covert sensitization: A technique used in 

counterconditioning therapy that pairs 

negative consequences with substancerelated cues through visual imagery. 

Cue exposure: This principle of classical 

conditioning holds that if a behavior occurs 

repeatedly across time but is not reinforced, 

the strength of both the cue for the behavior 

and the behavior itself will diminish, and the 

behavior will eventually vanish. Using cue 

exposure, a client is presented with physical, 

environmental, social, or emotional cues 

associated with past substance abuse (e.g., by 

accompanying her into an often-frequented 

bar). The client then is prevented from 

drinking or taking drugs. This process, over 

time, leads to decreased reactivity to such 

cues. 

Defense mechanisms: The measures taken by 

an individual’s ego to relieve excessive 

anxiety. When the environment causes 

excessive stress, the client’s ego will operate 

216 
Glossary 

unconsciously to deny, distort, or falsify 

reality. Defense mechanisms include denial, 

displacement, grandiosity, introjection, 

isolation, projection, repression, regression, 

undoing, and identification with the 

aggressor. 

Deliberate exception: A situation in which a 

client has intentionally maintained a period 

of sobriety or reduced use for any reason. 

For example, a client who did not use 

substances for a month in order to pass a 

drug test for a new job has made a deliberate 

exception to his typical pattern of daily 

substance use. If he is reminded that he did 

this in the past, it will demonstrate that he 

can do so in the future. 

Directive approach: This form of group therapy 

offers structured goals and therapist-directed 

interventions to enable individuals to change 

in desired ways. It is a contrast to the 

process-sensitive approach. The directive 

approach addresses specific agenda items in 

a logical order with greater emphasis on 

content as the primary source of effective 

change. 

Effect expectancies: A set of cognitive 

expectancies that the client develops 

concerning anticipated effects on her feelings 

and behavior as drinking and drug use are 

reinforced by the positive effects of the 

substance being taken. These represent the 

expectation she holds that certain effects will 

predictably result from drinking or using 

specific drugs. 

Family sculpting: A technique used in family 

therapy. The therapist “sculpts” family 

members in typical roles and presents 

significant situations related to substance 

abuse patterns. In this process, family 

members enact a scene to graphically depict 

the problem. The physical arrangement of 

the family members can illustrate emotional 

relationships and conflicts within the family. 

For example, a family may naturally break 

up into a triad of the mother, sister, and 

brother, and a dyad of the father and another 

sibling. In that case, the therapist might 

highlight the fact that the mother and father 

communicate through one of their children 

and never talk to each other directly. 

Functional analysis: A process used in 

behavioral and cognitive– behavioral therapy 

that probes the situations surrounding the 

client’s substance abuse. A functional 

analysis examines the relationships among 

stimuli that trigger use and the consequences 

that follow. This can provide important 

clues regarding the meaning of the substance 

use behavior to the client, as well as possible 

motivators and barriers to change. In these 

forms of therapy, this is a first step in 

providing the client with tools to manage or 

avoid situations that trigger substance use. 

Functional analysis yields a roadmap of a 

client’s interpersonal, intrapersonal, and 

environmental catalysts and reactions to 

substance use, thereby identifying likely 

precursors to substance use. 

Insight: A particular kind of self-realization or 

self-knowledge, usually regarding the 

connections of experiences and conflicts in 

the past with present perceptions and 

behavior, and the recognition of feelings or 

motivations that have been repressed. 

Miracle question: A solution-focused 

interviewing strategy in which the therapist 

asks the client the question, “If a miracle 

happened and your condition were suddenly 

not a problem for you, how would your life 

be different?” This forces the client to 

consider a life without substance use and to 

imagine himself enjoying that life. 

Operant learning: Operant learning refers to the 

process by which behaviors that are 

reinforced increase in frequency. Behaviors 

that result in positive outcomes or that allow 

the client to avoid negative consequences are 

likely to increase in frequency. Substance 

217 
Appendix C 

use in the presence of classically conditioned 

cues is instrumental in reducing or 

eliminating the arousal associated with a 

state of craving, thus serving to reinforce the 

substance abuse behavior. That is, the 

behavior serves a basic rewarding function 

for the individual. For example, an alcohol 

abuser who drinks to feel more social and 

less anxious is using substances in an 

instrumental way. To the extent that she 

experiences the effects she seeks, the greater 

the likelihood she will use alcohol under 

similar circumstances in the future. 

Process-sensitive approach: This term consists 

of two, somewhat different, contrasting types 

of group psychotherapy. The processsensitive group approach examines the 

unconscious processes of the group as a 

whole, using these energies to help 

individuals see themselves more clearly and 

therefore open up the opportunity for 

change. The first type of process-sensitive 

approach may be termed the “group-as-awhole” approach and sees healing as an 

extension of the individuals within the group 

as the group comes to terms with a 

commonly shared anxiety. The second type 

of process-sensitive approach uses an 

interactional group process model. By 

attending to the relationships within the 

group and helping individuals understand 

themselves within the relational framework, 

an interactional group process provides 

individuals with significant information 

about how their behavior affects others and 

how they are in turn affected by other 

members. 

Psychodrama: A method of psychotherapy in 

which clients act out their personal problems 

by spontaneously enacting specific roles in 

dramatic performances performed before 

fellow clients. 

Random exception: An occasion upon which a 

client reduces substance use or abstains 

because of circumstances that are apparently 

beyond his control. The client may say, for 

example, that he was just “feeling good” and 

did not feel the urge to use at a particular 

time but cannot point to any intentional 

behaviors on his part that enabled him to 

stay sober. In such instances, the therapist 

can ask the client to try to predict when such 

a period of “feeling good” might occur again, 

which will force him to begin thinking about 

the behaviors that may have had an effect on 

creating the random exception. 

Selfobject: A term used in self psychology that 

refers to something or someone else that is 

experienced and used as if it were part of 

one’s own self. For example, a child is 

dependent on her parent’s love and praise in 

order to develop a sense of self-worth and 

self-esteem. In that way, the child 

internalizes a part of the parent as the 

selfobject. 

Therapeutic alliance: The relationship between 

the therapist and client. In all 

psychodynamic therapies, the first goal is to 

establish a “therapeutic alliance” between 

therapist and client, because this association 

functions as the vehicle through which 

change occurs. A therapeutic alliance 

requires intimate self-disclosure on the part 

of the client and an empathic and 

appropriate response on the part of the 

therapist. In brief psychodynamic therapy, 

this alliance must be established as soon as 

possible, and the therapist must be able to 

establish a trusting relationship with his 

client in a short time. 

Transference: The process, basic to all 

psychodynamic therapies, of the client’s 

transference of salient characteristics of 

unresolved conflicted relationships with 

significant others onto the therapist. For 

example, a client whose relationship with her 

father is deeply conflicted may find herself 

reacting to the therapist as if he were her 

218 
Glossary 

father. An initial goal of brief 

psychodynamic therapy is to foster 

transference by building the therapeutic 

relationship. Only then can the therapist 

help the client begin to understand her 

reasons for using substances and to consider 

alternative, more positive behavior. 

Transpersonal awakening: The process of 

awakening from a lesser to a greater identity 

in transpersonal psychotherapy. This form 

of therapy uses the healing nature of 

subjective awareness and intuition in the 

process of awakening and employs the 

therapeutic relationship as a vehicle for this 

awakening in both client and therapist. 

219 

Appendix D

Health Promotion Workbook 

Reprinted with permission from Barry, K.L., and Blow, F.C., 1998. 

Part 1: Summary of Health Habits 

Let’s review some of the information about your health, behavior, and health habits that we discussed in 

the clinic. 

Exercise 

Days per week you participated in vigorous activity 









none 

seldom 

1–2 days per week 

3–5 days per week 

6–7 days per week 

Minutes of exercise per day  not applicable 

 fewer than 15 minutes 

 15–30 minutes 

 more than 30 minutes 

Nutrition 

Weight change in last 6 months  no change in weight 

 gained more than 10 pounds 

 lost more than 10 pounds 

 don’t know 

221 
Appendix D 

Tobacco Use 

Tobacco used in last 6 months  no 

 yes 

If yes, which ones? 

 cigarettes 

 chewing tobacco 

 pipe 

Average cigarettes smoked per day in last 6 months  not applicable 

 1–9 

 10–19 

 20–29 

 30+ 

Alcohol Use 

Drinking days per week  1–2 days per week 

 3–4 days per week 

 5–6 days per week 

 7 days per week 

Drinks per day  1–2 drinks 

 3–4 drinks 

 5–6 drinks 

 7 or more 

Binge drinking within last month (5 or more drinks per  none 

occasion for women; 6 or more drinks per occasion for  1–2 binges 

men)  3–5 binges 

 6–7 binges 

 8 or more 

Are there any of these health behaviors (exercise,  no 

nutrition, tobacco use, alcohol use) with which you  yes 

would like some help? If yes, which ones? 

 exercise 

 nutrition 

 tobacco use 

 alcohol use 

Part 2: Types of Drinkers in the U.S. Population 

It is helpful to think about the amount of alcohol consumed by adults in the United States and by you. 

There are different types of drinkers among the adult population, and these types can be explained by 

different patterns of alcohol consumption. These include: 

222 
Health Promotion Workbook 

Types Patterns of Alcohol Consumption 

Abstainers and light  Drink no alcohol or fewer than 3 drinks per month 

drinkers  Alcohol use does not affect health or result in negative consequences 

 Pregnant and breastfeeding women are advised to drink NO alcohol 

Moderate drinkers  Drink 3 or fewer times per week 

 Drink 1–3 standard drinks per occasion 

 Alcohol use does not affect health or result in negative consequences 

 At times moderate drinkers consume NO alcohol, such as before 

driving, while operating machinery, while pregnant, etc. 

At-risk drinkers  Drink over 12 (women) and 15 (men) standard drinks per week 

 At risk for negative health and social consequences 

Alcoholics  Heavy drinking has led to physical need for alcohol and to other 

problems 

At-Risk Drinkers (10%)

Alcoholics (10%)

Moderate Drinkers (40%)

Abstainers and Light Drinkers (40%)

Part 3: Consequences of Heavy Drinking 

Drinking alcohol can affect your physical health, emotional and social well-being, and your 

relationships with others. The following are some of the positive effects that people sometimes describe 

as a result of drinking alcohol. 

 Temporary high  Social ease  Temporarily reduced stress 

 Forget one’s problems  Relaxation levels 

 Enjoy the taste  Sense of confidence and daring  Avoid uncomfortable feelings 

 Ease in speaking one’s mind 

223 
Appendix D 

The following are some of the negative consequences that may result from drinking. 

 Difficulty coping with  Sleep problems  Accidents/injuries 

stressful situations  Arrests for driving under  Relationship problems 

 Depression the influence of alcohol  Increased risk of sexual assault 

 Blackouts  Sexually transmitted  Financial problems 

 Problems at work or school diseases  Stomach pain 

 Liver problems  Car crashes 

 Sexual performance problems  High blood pressure 

Part 4: Reasons To Quit or Cut Down on Your Drinking 

The purpose of this step is to think about the best reason for you to quit or cut down on your drinking. 

The reasons will be different for different people. 

The following list identifies some of the reasons why people decide to cut down or quit drinking. Check 

each box by the three most important reasons why YOU want to quit or cut down on your drinking. 

Perhaps you can think of other reasons that are not on this list. 

 To consume fewer empty calories (alcoholic drinks contain many calories) 

 To sleep better 

 To live longer—probably between 5 and 10 years longer 

 To look younger 

 To be less likely to die of heart disease or cancer 

 To save lots of money 

 To be happier 

 To reduce the possibility that I will die of liver disease 

 To reduce the possibility that I will die in a car crash 

 To achieve more in my life 

 To do better at my job 

 To be a better father/mother to my children 

 Other: ____________________________ 

Write down the three most important reasons you chose to cut down or quit drinking. 

1. _______________________________________________________________ 

2. _______________________________________________________________ 

3. _______________________________________________________________ 

224 
_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

Health Promotion Workbook 

Think about the consequences of continuing to drink heavily. Now think about how your life might 

improve if you change your drinking habits by cutting down or quitting. What improvements do you 

anticipate? 

Physical health: 

Mental health: 

Family:

Other relationships: 

Work/school: 

Financial:

Legal: 

Part 5: Drinking Agreement 

The purpose of this step is to decide on a drinking limit for yourself for a particular period of time.

Negotiate with your health care provider so you can both agree on a reasonable goal. A reasonable goal

for some people is abstinence––not drinking any alcohol. 

As you develop this agreement, answer the following questions: 

 How many standard drinks (see below)?

 How frequently? 

 For what period of time? 

DRINKING AGREEMENT 

Date: ________________________ 

Patient signature: ______________________________________________ 

Physician signature: ____________________________________________ 

225 
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Day Beer Wine Liquor Number

Sunday 

Monday 

Tuesday 

Wednesday 

Thursday 

Friday 

Saturday 

WEEK’S TOTAL: 

Appendix D 

The drinks shown below in normal measure contain roughly the same amount of pure alcohol. You can 

think of each one as a standard drink. 

Drinking Diary Card 

One way to keep track of how much you drink is the use of drinking diary cards. One card is used for 

each week. Every day record the number of drinks you have. At the end of the week add up the total 

number of drinks you had during the week. 

Diary Card 

KEEP TRACK OF WHAT YOU DRINK OVER THE NEXT 7 DAYS 

STARTING DATE _______________ 

226 
Health Promotion Workbook 

Part 6: Handling Risky Situations 

Your desire to drink may change according to your mood, the people you are with, and the availability of 

alcohol. Think about your last periods of drinking. 

Here are examples of risky situations. The following list may help you remember situations that can 

result in at-risk drinking. 

 Parties  Sleeplessness  Anger 

 Boredom  Family  Watching television

 Tension  Friends  Other people drinking

 Feeling lonely  Criticism  Certain places

 Feelings of failure  Dinner parties  After work

 Frustration  Children  Weekends

 Use of tobacco  TV or magazine Ads  Arguments

What are some situations that make you want to drink at a risky level? Please write them down. 

1. ____________________________________________________________________________ 

2. ____________________________________________________________________________ 

Ways To Cope With Risky Situations 

It is important to figure out how you can make sure you will not go over drinking limits when you are 

tempted. Here are examples: 

 Telephone a  Call on a neighbor  Read a book 

friend

 Go for a walk  Watch a movie  Participate in a sport

Some of these ideas may not work for you, but other methods of dealing with risky situations may work. 

Identify ways in which you could cope with the specific risky situations you listed above. 

1. For the first risky situation or feeling, write down different ways of coping. 

 ________________________________________________________________________ 

 ________________________________________________________________________ 

227 
Appendix D 

2. For the second risky situation or feeling, write down different ways of coping. 

 ________________________________________________________________________ 

 ________________________________________________________________________ 

Think about other situations and ways in which you could cope without using alcohol. 

Visit Summary 

We have covered a great deal of information today. Changing one’s behavior, especially drinking 

patterns, can be a difficult challenge. The following pointers may help you stick with your new behavior 

and maintain the drinking limit agreement, especially during the first few weeks when it is most difficult. 

 Remember that you are changing a habit and that it can be hard work. It becomes easier with time. 

 Remember your drinking limit goal: __________________________________ 

 Read this workbook frequently. 

 Every time you are tempted to drink above limits and are able to resist, congratulate yourself because 

you are breaking an old habit. 

 Whenever you feel very uncomfortable, tell yourself that the feeling will pass. 

 At the end of each week, think about how many days you have been abstinent (have consumed no 

alcohol) or have been a light or moderate drinker. 

 Some people have days during which they drink too much. If that happens to you, DON’T GIVE UP. 

Just start again the next day. 

228 
Appendix E

Resource Panel 

Gregory Barranco 

Assistant Vice President 

Government Relations 

National Council for Community Behavioral

 Healthcare

Rockville, Maryland 

Peggy Clark, M.S.W., M.P.A. 

Behavioral Health/Medicaid Managed Care 

Health Care Financing Administration 

Baltimore, Maryland 

Peter J. Cohen, M.D., J.D. 

Associate Professor of Law 

Georgetown University Law Center 

Washington, D.C. 

N. Ross Deck 

Deputy Director 

Office of Programs, Budget, Research, and 

Evaluation 

Office of National Drug Control Policy 

Washington, D.C. 

Col. Kenneth J. Hoffman, M.D., M.P.H., M.C.F.S. 

Drug and Alcohol Consultant 

Headquarters, 18th Medical Command 

Office of Army Surgeon General 

Yong San, Seoul, Korea 

Richard T. Suchinsky, M.D. 

Associate Chief for Addictive Disorders and 

Psychiatric Rehabilitation 

Mental Health and Behavioral Sciences 

Services

Department of Veterans Affairs 

Washington, D.C. 

Michael F. Weaver, M.D. 

Assistant Professor of Internal Medicine and 

Psychiatry 

Division of Substance Abuse Medicine 

Medical College of Virginia 

Virginia Commonwealth University 

Richmond, Virginia

229 

Appendix F

Field Reviewers 

Henrietta Robin Barnes, M.D. 

Assistant Professor of Medicine 

Cambridge Health Alliance 

Cambridge Family Health 

Harvard Medical School 

Cambridge, Massachusetts 

Jerome R. Barry, M.S., L.M.H.D., C.P.C., 

 C.A.D.A.C.

Director 

St. Francis Medical Center 

Grand Island, Nebraska

Insoo Kim Berg, Ph.D., M.S.W. 

Director 

The Brief Family Therapy Center 

Brookfield, Wisconsin 

JudyAnn Bigby, M.D. 

Medical Director 

Community Health Services 

Brigham and Women’s Hospital 

Boston, Massachusetts 

Susan B. Blacksher, M.S.W. 

Executive Director 

California Association of Addiction Recovery 

Resources 

Sacramento, California 

Patricia Bradford, L.I.S.W., L.M.F.T., C.T.S. 

Clinical Social Worker/Coordinator 

WJB Dunn Medical Center 

Department of Veterans Affairs 

Columbia, South Carolina 

Milton Earl Burglass, M.D. 

Professor and Theologian 

Addiction Medicine 

Neuropsychiatric, Family, and Legal 

Medicine 

Homestead, Florida 

Anthony J. Cellucci, Ph.D. 

Associate Professor of Psychology 

Director, Idaho State University Clinic 

Idaho State University 

Pocatello, Idaho 

Larry Halverson, M.D. 

Springfield, Missouri 

Thomas J. Harvey, M.S.W. 

Senior Vice President for Member Services 

The Alliance for Children and Famlies 

Milwaukee, Wisconsin 

James N. Heckler, M.S., M.B.A., C.A.S.A.C. 

Managed Care Liaison 

New York State Office of Alcoholism and 

Substance Abuse Services 

Albany, New York 

231 
Appendix F 

Pablo Hernandez, M.D. 

Administrator 

Division of Behavioral Health 

Department of Health, State of Wyoming 

Cheyenne, Wyoming 

John Higgins-Biddle, Ph.D. 

Assistant Professor/Project Director 

Cutting BackTM 

Department of Community Medicine and 

Health Care 

University of Connecticut Health Center 

Farmington, Connecticut 

Jeff A. Hoffman, Ph.D. 

President 

Danya International, Inc. 

Silver Spring, Maryland 

Robert Holden, M.A. 

Program Director 

Partners in Drug Abuse Rehabilitation 

Counseling (PIDARC)

Washington, D.C. 

Vaughn J. Howland, M.S.W., M.A.C. 

Director 

The Intervention Center 

Kensington, Maryland 

Darin Kawazoe, M.A., C.S.A.C. 

Director 

Hawaii Drug Court Program 

Honolulu, Hawaii

Carol L. Kuprevich, M.A.

 Training Administrator 

Division of Alcoholism, Drug Abuse, and 

Mental Health 

Delaware Health and Social Services 

New Castle, Delaware 

Linda Lantrip, D.O. 

Medical Director/Dual Diagnosis 

Psychiatrist 

Little Rock Community Mental Health 

Center 

Mid-ARK Substance Abuse Series 

Little Rock, Arkansas 

Bruce R. Lorenz, B.S., C.A.D.C., N.C.A.C. II 

Director 

Thresholds, Inc. 

Georgetown, Delaware 

Russell P. MacPherson, Ph.D., C.A.P., C.A.P.P.,

 C.C.P., D.A.C., D.V.C. 

President 

RPM Addiction Prevention Training 

Deland, Florida 

Douglas B. Marlowe, Ph.D., J.D. 

Senior Scientist 

Treatment Research Institute at the 

University of Pennsylvania 

Philadelphia, Pennsylvania 

Ruby H. Martinez, R.N., Ph.D., C.S. 

Assistant Professor 

Acute and Long Term Care School of 

Nursing 

University of Colorado Health Sciences 

Center 

Denver, Colorado 

Susan McCrane, Ph.D. 

Associate Professor 

School of Nursing 

University of Maryland 

Baltimore, Maryland 

Lisa A. Melchior, Ph.D. 

Vice President 

The Measurement Group 

Culver City, California 

232 
Field Reviewers 

Scott D. Miller, Ph.D. 

Co-Founder 

Brief Therapy Training Consortium 

Institute for the Study of Therapeutic Change 

Chicago, Illinois 

Thomas Nicholson, Ph.D, M.P.H., M.A.Ed. 

Professor 

Department of Public Health 

Western Kentucky University 

Bowling Green, Kentucky 

Michele A. Packard, Ph.D. 

Executive Director 

Training and Consulting 

SAGE Institute 

Boulder, Colorado 

Michael Pantalon, Ph.D. 

Assistant Professor of Psychology 

Substance Abuse Center 

Department of Psychiatry 

Yale University School of Medicine 

New Haven, Connecticut 

Gilbert R. Parks, M.D. 

Board of Directors 

National Medical Association 

Topeka, Kansas 

Joe R. Pereira, L.I.C.S.W., C.A.S. 

Clinician/Trainer 

Recovery Strategies 

Belmont, Massachusetts 

Anthony M. Rizzo, Ph.D. 

Clinical Psychologist/Coordinator 

Chemical Dependency Programs 

Division of Mental Health 

SCRIPPS Clinic 

San Diego, California 

Maurilia Rodriquez, Ph.D., R.N., C.D.E. 

Health and Medical Services 

Houston Independent School District 

Houston, Texas 

Robert J. Schneider, Ed.D. 

Psychologist 

Harvard Vanguard Medical Associates 

Braintree, Massachusetts 

Anne H. Skinstad, Psy.D. 

Assistant Professor 

Division of Counseling, Rehabilitation, and 

Student Development 

Iowa Addiction Technology Training Center 

University of Iowa 

Iowa City, Iowa 

Richard E. Steinberg, M.S. 

President/CEO 

WestCare Foundation 

Las Vegas, Nevada 

Richard T. Suchinsky, M.D. 

Associate Chief for Addictive Disorders and 

Psychiatric Rehabilitation 

Mental Health and Behavioral Sciences 

Services

Department of Veterans Affairs 

Washington, D.C. 

Michael J. Taleff, Ph.D., C.A.C., M.A.C., 

N.C.A.C. II 

Assistant Professor and Coordinator 

Graduate Programs in Chemical Dependency 

Counselor Education 

Department of Counselor Education, 

Counseling Psychology, and Rehabilitation 

Services 

Pennsylvania State University 

University Park, Pennsylvania 

Anthony Tusler 

Coordinator 

High Tech Center 

Santa Rosa Junior College 

Santa Rosa, California 

233 
Appendix F 

Nola C. Veazie, Ph.D., L.P.C., C.A.D.A.C. 

Superintendent 

Medical Services Department 

United States Air Force 

Santa Maria, California 

Robert Walker, M.S.W., L.C.S.W., B.C.D. 

Assistant Professor 

Center on Drug and Alcohol Research 

University of Kentucky 

Lexington, Kentucky 

Michael F. Weaver, M.D. 

Assistant Professor of Internal Medicine and 

Psychiatry 

Division of Substance Abuse Medicine 

Medical College of Virginia 

Virginia Commonwealth University 

Richmond, Virginia 

Ken C. Winters, Ph.D. 

Associate Professor 

Department of Psychiatry 

University of Minnesota 

Minneapolis, Minnesota 

David K. Yamakawa, Jr. 

Attorney at Law 

San Francisco, California 

234 
The TIPs Series

TIP 2 Pregnant, Substance‐Using Women BKD107

TIP 5 Improving Treatment for Drug‐Exposed Infants BKD110

TIP 6 Screening for Infectious Diseases Among Substance Abusers BKD131

TIP 11 Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases BKD143

TIP 13 The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders BKD161

TIP 14 Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment BKD162

TIP 16 Alcohol and Other Drug Screening of Hospitalized Trauma Patients BKD164

TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues for Alcohol and Other Drug Abuse Treatment Providers BKD173

TIP 21 Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the Justice System SMA 08‐4073

TIP 23 Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal Case Processing SMA 12‐3917

TIP 24 A Guide to Substance Abuse Services for Primary Care Clinicians SMA 08‐4075

TIP 25 Substance Abuse Treatment and Domestic Violence SMA 12‐4076

TIP 26 Substance Abuse Among Older Adults SMA 12‐3918

TIP 27 Comprehensive Case Management for Substance Abuse Treatment SMA 12‐4215

TIP 29 Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities SMA 12‐4078

TIP 30 Continuity of Offender Treatment for Substance Use Disorders From Institution to Community SMA 08‐3920

TIP 31 Screening and Assessing Adolescents for Substance Use Disorders SMA 12‐4079

TIP 32 Treatment of Adolescents With Substance Use Disorders SMA 12‐4080

TIP 33 Treatment for Stimulant Use Disorders SMA 09‐4209

TIP 34 Brief Interventions and Brief Therapies for Substance Abuse SMA 12‐3952

TIP 35 Enhancing Motivation for Change in Substance Abuse Treatment SMA 12‐4212

TIP 36 Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues SMA 08‐3923

TIP 37 Substance Abuse Treatment for Persons With HIV/AIDS SMA 12‐4137

TIP 38 Integrating Substance Abuse Treatment and Vocational Services SMA 12‐4216

TIP 39 Substance Abuse Treatment and Family Therapy SMA 12-4219

TIP 40 Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction SMA 07‐3939

TIP 41 Substance Abuse Treatment: Group Therapy SMA 09‐3991

TIP 42 Substance Abuse Treatment for Persons With Co‐Occurring Disorders SMA 08‐3992

TIP 43 Medication‐Assisted Treatment for Opioid Addiction in Opioid Treatment Programs SMA 08‐4214

TIP 44 Substance Abuse Treatment for Adults in the Criminal Justice System SMA 05‐4056

TIP 45 Detoxification and Substance Abuse Treatment SMA 08‐4131

TIP 46 Substance Abuse: Administrative Issues in Outpatient Treatment SMA 06‐4151

TIP 47 Substance Abuse: Clinical Issues in Outpatient Treatment SMA 06‐4182

TIP 48 Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery SMA 12‐4353

TIP 49 Incorporating Alcohol Pharmacotherapies Into Medical Practice SMA 09‐4380

TIP 50 Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment SMA 09‐4381

TIP 51 Substance Abuse Treatment: Addressing the Specific Needs of Women SMA 09‐4426

TIP 52 Supervision and the Professional Development of the Substance Abuse Counselor SMA 09‐4435

TIP 53 Addressing Viral Hepatitis in People With Substance Use Disorders SMA 11‐4656

TIP 54 Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders SMA 11‐4661

Other TIPs may be ordered by calling 1‐877‐SAMHSA‐7 (1‐877‐726‐4727) (English and Español)

or visiting http://store.samhsa.gov.

HHS Publication No. (SMA) 12-3952

Substance Abuse and Mental Health Services Administration

First Printed 1999

Revised 2002, 2003, 2004, 2007, 2009, 2011, and 2012