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Four different therapeutic approaches and their usefulness

in client work.

BRIEF INTERVENTION

Brief Intervention (BI) is a clinically based cost effective time efficient approach
designed to counsel non-dependent problem drinkers and/or drug users about
strategies to reduce their alcohol and/or drug use. The main goal of BI is to prevent
future alcohol and/or drug related health problems and injury. Being both a focuses
and time limited, BI is designed for use by counsellors and other health care providers
in their daily practice. Counsellors are uniquely positioned to provide BI to clients
who have experienced alcohol and/or drug related problems and who have been
referred by self or others (for example significant, school, justice, medical) in a
variety of settings such as schools, hospitals, clinics and homes.

BI is a simple, quick and clinically effective strategic approach that motivates clients
to consider the consequences of their behaviour after an alcohol and/or drug related
incident and to move toward new behaviours. BI strategies are directed prevention
techniques that focus on reducing alcohol and/or drug use in the non-dependent user.
They are designed to increase the person’s motivation and enhance the probability
that the individual will examine his or her current drinking and/or drugging patterns.

Two particular areas of emphasis are to examine the low risk drinking limit and safe
limits of drugging and work toward reducing or abstaining from alcohol and/or drug
use. For example, in low risk drinking:

males no more than two standard drinks per day

females no more than one standard drink per day
over 65 no more than one standard drink per day

(A standard drink being 1 can of beer, 1 glass of wine or 1 shot of liquor.)

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With these strategies in place, the ultimate goal is for individuals to reduce their risk
for future injury and alcohol and/or drug related health problems and incidents.

The components of Brief Intervention are:

1. assessment and feedback concerning current drinking and or drugging patterns,

2. information on the health and social consequences of hazardous and harmful drink
and/or drugging,
3. advice on reducing alcohol and/or drug consumption,
4. negotiation of a plan of action to change drinking and/or drugging behaviour,
5. goal setting,
6. behavioural modification techniques.

Information booklets and/or a self help manual can be used during sessions which last
from 20-40 minutes depending on the type of strategies used.

In BI, six elements, when combined, act to motivate clients to consider changing their
alcohol and/or drug consumption patterns without raising their defences while
simultaneously allowing clients to maintain control over their choices. These six
components can be remembered by the acronym FRAMES:

Feedback provide personalised feedback based on assessment of current

alcohol and/or other drug (AOD) behaviour
Responsibility emphasise personal responsibility for change
Advice give clear advice about recommended change and consequences of
AOD use
Menu provide choices from a range alternative strategies for change

Empathy deliver messages with empathy and reflective listening

Self-efficacy support that the changes is possible and beneficial

The components of responsibility, empathy and self-efficacy constitute the

motivational aspects of the approach. Through these elements clients are motivated
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to assume responsibility for their choices to change. Empathy is used to support the
client in the change process while recognising that change is difficult. For many
clients, it is difficult at times to explore the consequences of drinking and drugging
behaviour, make a decision to change, and begin taking steps to change. Support,
coupled with the belief that change as possible and beneficial, empowers the client
and enhances the clients sense of self efficacy.

Enhancing the motivational elements to create a successful BI are the other three
elements: feedback, advice and menu. Feedback consists of cognitive aspects of
personalised feedback based on current assessment data. Brief screening methods
such as the cage, audit, and the audit adapt for cannabis use are used and feedback
based on the responses.
Using outcomes from the questionnaires, clients are given feedback as to whether
their current using patterns fall into the hazardous, harmful or dependent category.
Once it is determined whether the client is a sensible or low-risk, hazardous, harmful,
or dependent drinker/user, the appropriate intervention strategy is implemented, this
being simple advice or brief counselling.

Simple advice consists of a 5 minute intervention to review with the client the steps
of BI and provide a pamphlet or booklet detailing the steps for future reference and
review. Brief counselling generally lasts 20-40 minutes at one or two visits and
encompasses the steps of BI, with attention given to developing personalised coping
strategies to manage and change drinking/drugging behaviour.

The next step is to review with the client future health, medical, social, psychological
consequences that may occur if alcohol and/or drug use continues in the current
pattern. Information is also provided about any physical medical or psychological
consequence that may already be experienced.

Choices of whether to cut down or stop altogether are then explored with the client.
Appropriate goals are set and if no follow up visit is required, written information
given out, for example a workbook, pamphlet or diary to keep off drinking/drugging
use.
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Brief counselling provides an opportunity to discuss specific reasons why the client
may wish to cut down and to explore the situations in which alcohol/drugs are used in
excess. After reviewing these situations, coping strategies can be developed for each
relevant situation. At the end of a brief counselling session, clients are encouraged
not to give up because changing a balance is difficult and is often accompanied by
some lapses. Follow up interactions, for example, by phone, can reinforce and
support the difficulty of behaviour change.

COGNITIVE BEHAVIOUR THERAPEUTIC APPROACH

A cognitive behaviour therapeutic approach utilises cognitive and behavioural

methods including formal and informal coping modelling, affective education,
practice and role playing, and reinforcement via tangible and social reward
contingencies to help the drug dependent individual learn the self guided problem
solving skills necessary to gain control over the drug using behaviours and their lives.
This approach views drug dependence as a learned behaviour pattern maintained by
conditioning factors. Drug dependence is viewed as a behavioural pattern which is
acquired socially through modelling the behaviour of others and which is reinforced
by a wide variety of positive consequences. Essentially, the purpose of cognitive-
behavioural therapy is to help the individual stop and think before acting.

A cognitive-behavioural approach for teaching self control consists of six main

components - a problem solving approach, self instructional training, coping
modelling, affective education, role playing exercises and behavioural contingencies,
each of which are described (when applied with the drug dependent individual).

Problem solving
Central to the cognitive-behavioural approach, problem solving is a strategy to teach
clients to engage and utilise adaptive planning strategies when encountering a vast
array of problematic situations related not only to the drug use but also every day
situations. The role of the therapist being to emphasise continually that difficult
situations are merely problems that may often be solved by stopping and thinking
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rather than being outside of the clients control. Awareness of the clients cognitive
style is essential to assess their ability to reason through problems, when problem
solving, for example, trying too hard to convey an understanding of the client’s
thoughts and feelings may be counterproductive. It may be more productive for the
therapist to allow the client more autonomy by acknowledging that the therapist may
not fully understand or have the answers that the client is the only one who can decide
what is right.

Self instructional training

This is a step by step thinking strategy taught to guide the client through the problem
solving process. Self instructions are discrete steps that the client may ? to diverse
problematic situations. With self instruction procedure there is a move from the
identification of a problem to be solved to approaching the problem in a systematic
way, focusing on attentions and generating alternatives, and choosing an answer,
followed by either self reinforcement for correct responses or a coping response
following a wrong answer. This is designed to encourage clients to reflect critically -
to stop and think - about the problem that needs to be analysed, how to initiate a
cognitive strategy, how to consider alternatives and the behavioural and emotional
consequences of each, and how to make a choice of a possible solution and follow
through on a thoughtful plan. Self reinforcement is designed to strengthen the use of
the stop and think process by reminding the client that appropriate choices may often
have positive self rewarding consequences. Coping strategies are included to help
reduce the possibility of “blowups” resulting from becoming overly frustrated
following a mistake. It can also be helpful to acknowledge that everyone
occasionally makes mistakes and that using an appropriate coping self statement can
help get the client back on track to more effective problem solving. It is also crucial
to individualise the self statements for the specific client - the purpose being to make
this the “personal property” of the client this allowing the client to use these
statements in the outside world. The cognitive /developmental level of each client
also needs to be taken into consideration so that instructions can be understood.

Coping modelling
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Modelling of cognitive and behavioural problem solving by the therapist is designed

to facilitate the clients acquisition of these strategies. The therapist alternates
performing tasks with the client and in doing so, models the self instructional
problem solving sequence. The therapist does not tell the client what to do or how to
do it, rather, the client solves problems themselves using the strategies that are being
taught to them. The therapist, as a problem solving model, actually demonstrates to
the client that stopping and thinking about problematic situations - seeking alternative
solutions, evaluating these probabilities, and anticipating likely consequences, can be
a valuable means by which to not only resolve difficult situations but also to reach
desired goals.
The therapist can also act as an informal model to solve real life problem situation
that arise during the course of counselling. Through doing so, the client observes that
mistakes and frustration may be dealt with adaptively rather than being a catalyst for
more frustration. It also demonstrates the capacity to cope with difficult situations
even in the face of failure.

Affective education
This component is designed to help the client accurately label their emotional states
as well as those of others. The rationale being that the ability to identify feeling states
will improve personal and interpersonal problem solving effectiveness. The crucial
aspect of affective education is to generate a discussion of emotions, how emotions
are related to thoughts and behaviours, and the role of self talk in mediating
emotional arousal. Discussion can be generated through a variety of means, for
example, use of pictures showing people with various expressions and postures in
problematic situations.

Role play exercises

The purpose of role play is to promote the generalisation of self instruction to
emotionally charged real life situations. Role play sessions can reflect both typical
concerns and those relevant to the problematic themes in the client’s life. Situations
to be role played can be hypothetical or real. Whatever situation used alternative
solutions are generated. After a number of alternatives have been suggested, the
emotional and behavioural consequences are chained to each alternative from both the
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client’s and the therapist’s perspectives. Each alternative and it’s outcome is the
performed after which a discussion of the client’s and the therapist’s thoughts and
feelings about each situation follows. The client then picks the response that they
view as the best. Role plays are usually brief (2 - 4 minutes) with a more extended
discussion following each role play. In role play exercised it is important to create an
environment in which the client feels safe enough to act out potentially embarrassing
thoughts, feelings, behaviours, etc.

Behavioural contingencies
These are designed to motivate clients to learn and apply problem solving self
instructions. Specific contingencies used include social reward, response cost, and
self reward. Concrete rewards can also be used, particularly within a therapeutic
setting, for demonstrating self evaluating behaviour and problem solving skills.
Significant others can be encouraged to also provide behavioural contingencies.
Social approval in the form of appropriate messages, for example, comments such as
“good job”, “excellent”, “keep it up”, smiles, and nods, are used liberally to create an
environment in which the client feels secure and motivated to learn and use the
strategies being taught. Self reward is encouraged, the important point being that the
client acknowledges and self reinforces after successful use of problem solving
strategies. To promote self awareness skills necessary for self monitoring and
intrinsic reward capacity, self evaluation is included where the client rates their
behaviour on an agreed scale.

These cognitive, behavioural, and affective components are interwoven within an

entire treatment programme rather than separately. The therapist and client
collaborate to arrange tasks, set rules, and use self instructions applicable to tasks.
Working together involves the therapist consulting with the client, helping the client
think through each problem, and while the stop and think process is encouraged and
emphasised, the specific answer chosen is up to the client.

Generally, the efficacy of this type of therapeutic approach is favourable in helping

the client deal with real life problems that arise as a consequence of their drug
dependent behaviour. As a consequence of a cognitive behavioural approach, the
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client may experience reduction of anxiety, increased social recognition and peer
approval, along with a reduction in drug use.

MOTIVATIONAL INTERVIEWING
The way in which therapists broach clients’ problematic drinking and/or drug use can
influence their acceptance of the problem and the need for change. Motivational
interviewing (MI) is a practical counselling approach that shows promise as a way of
promoting behavioural change in clients in the alcohol and drug field. MI is based on
two premises, the first is that offering direct advice or labelling the client’s drinking
and/or drug use as a problem leads to increased resistance and defensiveness
preventing behavioural change and that labels with strong negative connotations such
as junkie and alcoholic are especially likely to be counterproductive. The second
premise is that drinkers and drug users are in varying stages of readiness to change
and therapists must begin at the stage client’s have reached and gently attempt to
move them to the next stage. Starting the interview from the wrong stage or pushing
clients too quickly can lead to increased resistance.
A useful way of describing the stages of change is the “stages of change model”
which describes how people change, whether by themselves or with professional help
(Prochaska & DiClemente, 1982). Change is viewed as a cyclical phenomenon in
which, for example, smokers may move around the cycle more than once before
stopping smoking permanently. Relapse is seen as a natural component of the
process, rather than as a total failure; after relapse, the cycle may be re-entered. In
the first stage, precontemplation, clients do not recognise that they may have a
problem. Clients in this stage should be asked neutral and non threatening questions
such as, how do drugs and/or alcohol fit into their lives or how do they affect their
health. These questions can lead clients to begin thinking about the adverse effects of
alcohol and/or drugs on their lives. In the second stage, contemplation, clients
recognise a problem but are ambivalent about the need for change; however, towards
the end of this stage, they characteristically determine to make the change which
leads them on to the next stage. In the third stage, action, clients have resolved their
ambivalence and are committed to change. Therapists should discuss treatment
options while emphasising that clients have personal control over treatment decisions.
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In the next stage, maintenance, support from the therapist or other health care workers
during follow-up helps to sustain the change.

The overall goal is to leave the cycle permanently but when relapse occurs the goal is
to move the client around the cycle once more by contemplating change again. By
identifying the client’s stage of readiness, the therapist is able to make a more suitable
approach to achieving change. For clients who are in the ambivalent stage who are in
conflict with their behaviour, motivational interviewing is helpful.

MI attempts to resole the ambivalence and move people through the stages of change
toward action. MI has a persuasive, supportive, and non authoritarian style. the
therapist needs to remember that the responsibility of change lies with the client at all
times and that the therapist’s role involves respect for the client’s views and concerns.
Flexibility, patience, and a gentle empathetic approach are also essential. Reflective
listening skills should be used to demonstrate that the therapist understands and
appreciates the client’s perspective. In order to move a client on the therapist needs
to create a discrepancy or dissonance between what the client does and what the client
wants to do. Clients believe what they hear themselves saying rather than what they
hear others telling them. Hearing themselves stating out loud what is wrong and why
change is needed helps them become aware of their discontent. Throughout the
process of MI the therapist is building up the client’s sense of self efficacy. As a
therapeutic approach MI can provide meaningful helpful change for the client and
therapeutic satisfaction for the therapist.

A NARRATIVE THERAPEUTIC APPROACH

To understand and make sense of the world people tend to structure the stream of
time and events into a story with a beginning, middle and end. History represents not
only the desire for a true and reliable report of events but also a way to understand the
present as an outcome of the past. Every client has a personal and family life story.
The story is already an interpretation based on what clients perceive to be true, even
when they have knowingly told different life stories at different stages of their lives.
The story telling approach differs from conventional psychotherapy in that it involves
the construction of subjective narratives rather than of logical arguments. As an
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approach for treating alcohol and/or drug dependence, the story telling or narrative
approach has been described by many therapists, among them, Bruner (1986), White
& Epston (1990), and Hunter (1991) who stated that by talking about our lives, we
become the biographic narrators through whom we “tell of our lives”. Our stories
selectively include or omit information, omissions being no less important than
inclusions. In his book, Doctor’s Stories, hunter likened patients to texts to be
examined, studied and understood by physicians. In analysing narratives, the
therapist must understand the levels of explanations found in the stories (personal,
family, social, and cultural) and their emotional aspects. Clients know, a priori, the
conventions of presenting their alcohol and/or drug problems to therapists. They
usually come prepared for deep disclosure of innermost conflicts and problems.

In the initial therapeutic consultation, the narrative approach is explained if the client
has been assessed as suitable for this approach. The client is then asked to define
their goals and it is then suggested that they write a novel with themselves as the main
character/hero. Usually, the client will project all their own life experiences onto the
hero, define the sort of person they wish the hero to be, and set out ways of achieving
this, whilst consulting with the therapist occasionally. The therapist is the architect of
the story but the client themselves the independent builder of the plot. Gradually, the
client merges their own life into the story.

Further sessions consist of presentation of a new chapter setting out specific goals and
their attainment or discussion of the previous chapter. Homework is encouraged, and
under the therapist’s guidance, goals are continually being redefined and different
solutions proposed and discussed. Through being first the author and then the hero,
the client can dictate the scenario and act it out, yet stand aside and view it
objectively.

As a therapeutic approach storytelling is appropriate for many clients who are

problematic alcohol and/or drug users. Often this client group find conventional
therapy repetitive and irksome, are usually reluctant to co-operate, and comply half-
heartedly with the therapist’s instructions. Often clients seem to respond better to a
more short term, time limited approach, one that is active and creative, such as the
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story telling approach, an approach which requires unorthodox behaviour on both

sides. Narrative therapy takes into account the subjective element, the client’s life
story. Client’s problems become not merely personal, but can be separated from the
person. Clients can become detached from the problem and later slowly make
themselves part of the story they are building. Attention is paid to the other
subjective elements such as choosing, discussing, and planning the course of therapy.
The narrative approach is effective because clients are continually correcting their
lives under the therapist’s guidance rather than being led blindly. The therapist’s role
is passive-active rather than conventionally active and the urge to intervene actively
must constantly be resisted.

The narrative approach is not always appropriate. It is most effective for educated
people who can think abstractly and creatively. Despite this limitation the approach
is successful where clients feel the need to take greater control of treatment and want
to share their lives and fantasies with the therapist. Active involvement gives them a
greater stake in their lives. Therapists who listen to their clients’ stories carefully and
begin to understand what is being said can plot paths for the future. Only then can
they choose the right moment to intervene actively and objectively, leaving it to
clients to use their own imagination and initiative to help them take control of their
lives and behave independently.

Alcohol and/or drug problems and the individuals who manifest them are diverse and
effective treatment is likely to require not one but a whole range of effective models.
There is no single superior approach to treatment for all individuals and different
types of individuals respond best to different treatment approaches. A person who
responds very well to narrative therapy might do poorly with motivational
interviewing, whereas for another person motivational interviewing may be a superior
treatment to narrative therapy. Even when treatment approaches appear to be
equivalent in their overall effects within a heterogeneous population, they may be
very different in their appropriateness and effectiveness for a given sub-population
or individual. The appropriate question then is, which types of individuals are most
appropriate for a given therapeutic approach?, or, for this individual, which approach
is most likely to succeed?, rather than, which therapeutic approaches are best?
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It is inappropriate to offer or use the same therapeutic approaches for all individuals.
Using the right therapeutic approach through matching individuals to optional
approaches can increase treatment efficacy, and avoid unnecessary or ineffective
treatment, and even improve therapist morale.

Because of the prevalence of drug dependence and abuse in general clinical

populations it is important for psychologists to have knowledge and skill in many
therapeutic approaches thereby increasing treatment effectiveness and efficiency.
Matching therapeutic approaches is one of the most challenging and important tasks
of the psychologist. Inappropriate therapeutic approaches can result in wasted
money, time, even lost families and lives.

References
Bruner, J.S. (1986). Actual minds, possible worlds. Cambridge, Mass.:Harvard
University Press.

Hunter, K.H. (1991). Doctor’s stories: The narrative structure of medical knowledge.
New Jersey: Princeton University Press.

Prochaska, J. & DiClemente, C. (1982). Transtheoretical Therapy: Toward a more

integrative model of change. Psychotherapy: Theory, Research and Practice, 19, 276
- 288.

White, M. & Epston, P. (1990). Narrative means to therapeutic ends. New York:
Norton.