Brief Treatment of Substance Use Disorders: Why Neither Brief Nor Long is the Right Question

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Brief Treatment of Substance Use DisordersWhy
Neither Brief NorLong is the Right Question
Milton Erickson Foundation Brief Therapy
Conference December 7, 2006
Michele Packard, Ph.D.
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Why neither brief nor longis the right question

• 1. 34 clinical trials confirm that brief can be
  as effective as longer-term treatment with
  certain populations
• 2. What populations are likely to benefit most
  from brief interventions and which are more
  likely to require longer-term treatment?

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• Research efforts currently focusing on
• treatment processes that impact outcome
• engagement
• retention
• compliance
• better outcomes
• A B C D

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• Search for mediating and moderating variables
• that influence outcomes, eg
• Client variables
• self-efficacy
• coping skills
• untreated co-occurring issues
• Therapist variables

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• 5. Best Practices in the treatment of ABs
• have been identified
• CBT
• Motivational Interviewing
• Relapse Prevention
• Community Reinforcement Approach
• Contingency Management

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• ? Brief Intervention ?
• A strategy or set of strategies designed
• to motivate or help a person get to the
• next step
• 1-4 sessions
• ? Brief Therapy ?
• Involves a series of steps designed to
• help a person solve a problem
• 6-20 sessions
• focus is on present
• downplays psychodynamic factors
• focus is on changing behavior

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What Works ??8 Basic Principles

• Rethinking substance abuse What science tells
  us and what we should do about it.
• Principles of Therapeutic
• Change that Work.

Miller Carroll, 2006
Castonguay Beutler, 2006
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• 1. Addictive behavior (AB) is reinforcing
  behavior, subject to expansions and
• behavior, subject to expansions
• contractions
• neurochemical
• behavioral
• cognitive

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• AB emerge gradually and occur along
• a continuum
• Once well-established, ABs tend to
• be self-perpetuating

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Consumption alcohol related problems
None
Mild
Moderate
Substantial
Severe
Severe
Substantial
Moderate
Mild
None
Alcohol Problems
IOM, 1990
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Spectrum of intervention response
Brief intervention
Specialized treatment
Threshold for action
Severe
Substantial
Moderate
Mild
None
Alcohol Problems
IOM, 1990
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Populations likely to benefitfrom brief
interventions

• 1. Patients being seen in non-specialist
• settings
• primary care settings
• private practice
• ERs
• criminal justice
• EAP
• schools

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6 Active ingredients inbrief interventions

• F feedback
• R responsibility
• A advice
• M menu of options
• E empathy
• S self-efficacy

F feedback R responsibility A
advice M menu of options E empathy S
self-efficacy
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5 Steps of Brief Interventionin Substance Use
Disorders

• 1. Introduce issues in context of clients
• health, life circumstances,
  consequences experienced, etc.
• 2. Screening, evaluating and assessing
• 3. Providing feedback
• 4. Talking about change and setting goals
• 5. Summarizing getting an agreement
• for the next step.

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• Examples of Brief Interventions
• 1. Brief Drinkers Check-Up
• www.drinkerscheckup.com
• Kaiser Permanente Oregon
• Miller Berg
• Working with the Problem Drinker.
• Emergency Room Settings

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4. Motivation is central to intervention
The Nature and the Dynamics of Ambivalence
Benefits of Change
Consequences of Change
Individualized treatment plan matched to
Stage-of-Readiness
Carrots (Incentives) for Change
Obstacles (Disincentives) for Change
Miller Rollnick Motivational Interviewing
(2003)
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The Stages of Change
Prochaska DiClemente
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The Social Context of ChangeFactors Outside of
TreatmentThat Influence Outcomes

• 5. AB are affected by a larger social context
  and respond to social reinforcement
• Family
• Friends and social networks
• Workplace
• Rudolph Moos, Ph.D.
• Stanford University

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6. AB does not occur in isolation but is part of
a cluster
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• The biopsychosocial model is built on the
• foundation of Alfred Banduras
• Social Learning Theory which asks
• What are the factors that shape,
• perpetuate and maintain
• ( problem behavior) ?

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Biopsychosocial Domains

• Cognitive factors
• Behavioral factors
• Motivational factors
• Biological factors
• Environmental factors
• Spiritual factors

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• 7. There are identified risk and protective
• factors
• Search Institute Peter Benson, Ph.D.
• 40 developmental assets in youth
• www.searchinstitute.com

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• 8. AB occurs within a family context
• psychoeducational interventions are limited
• interventions need to be within context of
• family system and structure
• Peter Steinglass, MD
• The Alcoholic Family
• Maintaining the rituals of normal family
• life

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The therapeutic alliancematters (a lot!)

• ability to recognize change talk
• able to elicit change talk
• able to reinforce change talk
• Desire
• Ability
• Reasons
• Need Commitment

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• Identify ABs and intervene early
• Enhance personal motivation and commitment to
  change
• Make sobriety worthwhile
• improve access to non-drug positive reinforcement
• Enhance social support for abstinence
• For well-established AB a period of ensured
  abstinence is ideal
• Use Motivational Interviewing principles
• Involve family or social system to reinforce
  abstinence
• Address other social and behavioral problems
• Encourage AA or other support groups or drug-free
  activities
• Promote meaningful employment
• Remove/reduce reinforcement for using
• Expect gradual progress
• Think outside the skin
• Use Evidence-Based Treatments

SUMMARY
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For Michele Packards Training Schedule

• Visit our website at
• www.sagetraining.com
• 303.443-3920

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