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Core Sessions

 

In order to provide patients with effective cognitive-behavioral coping skills, therapists need to be sure to cover all eight core topics and to do so thoroughly. “Introduction” must be presented first, and the final session in the 12-week intervention must be “Termination.” The remaining core topics can be discussed in any order. We suggest the sequence in which they are presented here:

Session 1: Introduction to Coping Skills Training

Session 2: Coping With Cravings and Urges to Drink

Session 3: Managing Thoughts About Alcohol and Drinking

Session 4: Problem Solving

Session 5: Drink Refusal Skills

Session 6: Planning for Emergencies and Coping With a Lapse

Session 7: Seemingly Irrelevant Decisions

 

After the first seven core sessions have been completed, the therapist may move on to one or more elective topics.

Final Session: Termination.

 

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Session 1: Introduction to Coping Skills Training

 

This session has two major purposes: first, to establish rapport with the client, and second, to introduce the client to the reasoning behind coping skills training. By doing this, clients can have very clear expectations about how treatment will proceed and about what behaviors may be expected of them. The time shown for each topic area is only suggested, and some areas (e.g., building rapport) may take longer than the time shown, while others may require less.

Building Rapport (45 minutes)

 

This is an extremely important part of the treatment, where the therapist first gets to know the client. Therapists should begin by introducing themselves and by explaining who they are (e.g., a private practitioner in the area, a VA psychologist). The therapist should then explain the purpose of this first meeting: to get to know the client, to get an idea of the client’s drinking patterns and motivation, and to discuss the rationale for treatment and what the sessions will be like. The initial interview should be informal, but it is desirable to obtain some key information in the first session. Questions to be asked of the client include the following (not necessarily in this order):

  • Tell me a bit about yourself. What do you do for a living? Married? How do you spend your free time? What is your living situation like (lives alone, apartment, own house, children, extended family)?

  • How serious do you think your drinking problem is?

  • Why are you seeking treatment now?

  • Why did you seek treatment here? How did you hear about this treatment program?

  • Have you been treated before for alcoholism or drug abuse? (If yes: What were your experiences like?)

  • Have you ever tried to quit on your own? (If yes: How did you do?)

  • When you think about alcoholism treatment, what do you think about? That is, what is your idea of what treatment should be like?

  • What do you want out of treatment? How will you get it?

  • How confident are you that you can succeed, that is, remain abstinent?

Conceptualizing Treatment: What Is Alcoholism? (5 minutes)

 

Having begun to establish rapport with the client, therapists may begin to explain the rationale for coping-skills training. This begins with a social learning explanation of alcohol abuse. As therapists go through this explanation, they may illustrate the various points by drawing on what the client has already described. The explanation may run as follows:

In thinking about alcoholism, we view excessive drinking as harmful behavior. Once people start to drink alcohol a lot, they sometimes learn that it changes the way they feel. For example, some people use it like a tranquilizer to help them deal with stressful situations. Other people expect that it will make good times seem even better. Some people think it will make them more confident. Some people use it just to keep from thinking about things.

After a while, drinking can be triggered by things in the environment, sometimes without the person even realizing it. Often, things in the environment can trigger feelings of craving, but that does not happen with everyone. Things in the environment that often trigger drinking may include seeing alcoholic drinks, being in the presence of people who are drinking, or being in situations that are stressful.

Finally, people often develop beliefs about alcohol and about their own drinking (e.g., “Drinking is not a problem for me. I can stop whenever I want.” “I need to change, but it’s not worth the effort.” “Stopping drinking is not possible for me.”).

Alcohol can change the way a person feels, thinks, and acts. This can make substance abuse very easy to start and very difficult to stop. The purpose of this treatment is to help you avoid or cope better with those situations in which you tend to drink and to help you find behaviors that you can do instead of drinking.

 

The therapist should probe for understanding.

Assessing High-Risk Situations (15 minutes)

 

The therapist should give a brief explanation of how treatment works, again capitalizing on the client’s experiences to make points more clearly.

If drinking changes the way a person acts, thinks, and feels, we need to begin by finding out what situations you are most likely to drink in and what you are thinking and feeling in those situations. We call these high-risk situations. What we want to find out is what kinds of things are triggering or maintaining your drinking. Then we can try to develop other ways you can deal with high-risk situations without drinking. This involves learning specific skills and strategies to use.

The main point is that once we know about the situations and problems that contribute to your drinking, we can look for other ways to deal with those situations.

 

The therapist should again probe for understanding or resistance.

 

Having given the client a rationale for treatment, the therapist should begin an informal assessment of high-risk situations. Among the questions the therapist might ask are—

  • In what kinds of situations do you drink? What are your triggers for drinking?

  • Can you give a specific example (e.g., a relapse story)?

  • Can you remember your thoughts and feelings at the time?

  • What were the positive consequences of drinking?

  • What were the negative consequences of drinking?

 

The therapist should show the client the self-monitoring record handout and demonstrate its use by recording the above responses on it. The therapist should summarize with the client the apparent determinants of drinking in this episode and follow up by asking for other examples.

Motivation (5 minutes)

 

At this point, if clients are sufficiently engaged, the therapist can try to boost motivation by expressing confidence in their ability to do well in treatment. The therapist may also help the client review reasons to stop drinking and may elicit examples of the client’s successes in the past (e.g., longest period of abstinence or controlled drinking to date). The therapist should commend the patient for making this effort now.

Contract and Ground Rules (10 minutes)

 

The therapist needs to stress at this point that treatment can help but that it will require certain commitments on the part of the client. The therapist will be there to help the client figure out how to deal with alcohol problems, but the client will have to work at it. That work will include certain ground rules:

  • Attendance. The client must attend without fail. Cancellations must be made in advance, and the client must have a good reason to cancel. The client may withdraw from treatment but must discuss this decision with the therapist first (i.e., not just fail to show up).

  • Promptness. The client must be on time for sessions. If for some reason clients cannot be on time on a given day, they must contact the therapist to that effect.

  • Alcohol and drug use. This treatment is intended for people who want to abstain from alcohol. Although clients may not want to have total abstinence as the goal, they must work on remaining abstinent for the program to be most effective.

  • Completion of homework. One of the ways in which this treatment works is that therapist and client decide the appropriate skills to learn and how best to learn them. This may include homework assignments, such as practicing specific skills, that clients must do if they are to benefit from treatment. The client, therefore, must agree to complete homework assignments.

 

These ground rules are set out in a contract that the therapist asks the client to read and sign. Included in the contract is a statement of the short-term goals that the client agrees to work on.

Homework (5 minutes)

 

The therapist sends the client home with the self-monitoring record, gives instructions in its use, and requests that the patient take time once a day to record episodes of craving or desire for alcohol. The therapist then sets the next appointment.

 

Treatment Contract

  1. I understand that this treatment will last 12 weeks, and I agree to participate for that length of time. If I want to withdraw from the program, I agree to discuss this decision with my therapist prior to taking this action.

  2. I agree to attend all sessions and to be prompt. If it is absolutely necessary that I cancel a session, I will call in advance to reschedule. I also agree to call in advance if I will be late to a session.

  3. I understand that this treatment is intended for people who want to abstain from drugs and alcohol. I understand that I must work on remaining abstinent for this program to be most effective.

  4. I agree that it is essential for me to come to the session drug and alcohol free. I understand that I will be asked to leave any session to which I come after using drugs or alcohol. I will be asked to arrange safe transportation home.

  5. I understand that I will be expected to practice and implement some of the skills I discuss in treatment. I agree to bring in the practice exercise sheet each week to discuss with my therapist.

  6. I agree to work on the following specific goals during the next 12 weeks.

1.     __________________________________________

2.     __________________________________________

3.     __________________________________________


 

I have reviewed the above statements with my therapist, and we both agree to abide by them.

 

_____________________________________________  Date ________________

 

_____________________________________________  Date ________________

 

Self-Monitoring Record

TRIGGER
(What sets me up to use?)

THOUGHTS AND FEELINGS
(What was I thinking? What was I feeling?)

BEHAVIOR
(What did I do then?)
POSITIVE CONSEQUENCES
(What positive thing happened?)
NEGATIVE CONSEQUENCES
(What negative thing happened?)
     
     

Reprinted with permission from Jaffe et al. 1988.

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Session 2: Coping With Cravings and Urges to Drink

Rationale

  1. Craving is most often experienced early in treatment, but episodes of craving may persist for weeks, months, and sometimes even years after some alcoholics stop drinking. Craving may be uncomfortable but is a very common experience and does not mean something is wrong. You should expect craving to occur from time to time and be prepared to cope with it if and when it occurs.

  2. Urges to drink, or cravings, can be triggered by things you see in the environment that remind you of using alcohol. Physical signs may include tightness in your stomach or feeling nervous through your body; psychological signs may include increased thoughts of how good you would like to feel from using alcohol or drugs, remembering times you used alcohol in the past, planning how you would go about getting a drink, or feeling you need alcohol.

  3. Craving and urges are time-limited, that is, they usually last only a few minutes and at most a few hours. Rather than increasing steadily until they become unbearable, they usually peak after a few minutes and then die down, like a wave. Urges will become less frequent and less intense as you learn how to cope with them.

Skill Guidelines

  1. Learn how to recognize urge “triggers” so you can reduce your exposure to them.

    1. Common triggers include—

      • Exposure to alcohol itself.

      • Seeing other people drinking.

      • Contact with people, places, times of day, and situations commonly associated with drinking (such as drinking buddies, parties and bars, getting home from work, weekends).

      • Particular types of emotions (such as frustration, fatigue, feeling stressed out). Even positive emotions (elation, excitement, feelings of accomplishment) can be triggers.

      • Physical feelings (feeling sick, shaky, tense).

    2. Some triggers are hard to recognize, and self-monitoring, which will be assigned as the practice exercise this week, can help you recognize them.

    3. The easiest way to deal with cravings and urges is to try to avoid them in the first place. This can be done by reducing your exposure to craving triggers (getting rid of alcohol in the house, not going to parties or bars, reducing contact with friends who drink, and so on).

  2. Sometimes craving cannot be avoided, and it is necessary to find a way to cope with it. There are many different strategies for coping with craving:

    1. Get involved in some distracting activity. Reading, a hobby, going to a movie, exercising (jogging, biking) are good examples of distracting activities. Once you get interested in something else, you’ll find the urges go away. Another effective response to craving is eating, as most people do not feel like drinking after eating a big meal or something very sweet.

    2. Talk it through. Talk to friends or family members about craving when it occurs. Talking about cravings and urges can be very helpful in pinpointing the source of the craving. Also, talking about craving often helps to discharge and relieve the feeling and will help restore honesty in your relationship. Craving is nothing to feel bad about.

    3. Urge surf. Many people try to cope with their urges by gritting their teeth and toughing it out. Some urges, especially when you first return to your old drinking environment, are just too strong to ignore. When this happens, it can be useful to stay with your urge to drink until it passes. This technique is called urge surfing.

      Urges are a lot like ocean waves. They are small when they start, grow in size, and then break up and dissipate. You can imagine yourself as a surfer who will ride the wave, staying on top of it until it crests, breaks, and turns into less powerful, foamy surf. The idea behind urge surfing is similar to the idea behind many martial arts. In judo, one overpowers an opponent by first going with the force of the attack. By joining with the opponent’s force, one can take control of it and redirect it to one’s advantage. This technique of gaining control by first going with the opponent also allows one to take control while expending minimal energy. Urge surfing is similar. You can initially join with an urge (as opposed to meeting it with a strong opposing force) as a way of taking control of it. After you have practiced urge surfing several times and become familiar with it, you may find it a useful technique when you have a strong urge to drink.

      There are three basic steps in urge surfing:

      1. Take an inventory of how you experience the craving. Do this by sitting in a comfortable chair with your feet flat on the floor and your hands in a comfortable position. Take a few deep breaths and focus your attention inward. Allow your attention to wander through your body. Notice where in your body you experience the craving and what the sensations are like. Notice each area where you experience the urge, and tell yourself what you are experiencing. For example, “Let me see . . . My craving is in my mouth and nose and in my stomach.”

      2. Focus on one area where you are experiencing the urge. Notice the exact sensations in that area. For example, do you feel hot, cold, tingly, or numb? Are your muscles tense or relaxed? How large an area is involved? Notice the sensations and describe them to yourself. Notice the changes that occur in the sensation. “Well, my mouth feels dry and parched. There is tension in my lips and tongue. I keep swallowing. As I exhale, I can imagine the smell and tingle of booze.”

      3. Repeat the focusing with each part of your body that experiences the craving. Pay attention to and describe to yourself the changes that occur in the sensations. Notice how the urge comes and goes. Many people, when they urge surf, notice that after a few minutes the craving has vanished. The purpose of this exercise, however, is not to make the craving go away but to experience the craving in a new way. If you practice urge surfing, you will become familiar with your cravings and learn how to ride them out until they go away naturally.

    4. Challenge and change your thoughts. When experiencing a craving, many people have a tendency to remember only the positive effects of alcohol and often forget the negative consequences of drinking. Therefore, when experiencing craving, many people find it helpful to remind themselves of the benefits of not drinking and the negative consequences of drinking. This way, you can remind yourself that you really won’t “feel better if you just have one drink,” and that you stand to lose a lot by drinking. Sometimes it is helpful to have these benefits and consequences listed on a small card that you can keep with you.

    People constantly appraise and think about things that happen to them and the things that they do. The way that you feel and act can be highly influenced by these subjective facts or appraisals as well as objective facts. What you tell yourself about your urges to drink will affect how you experience and handle them. Your self-talk can be put to use to strengthen or weaken your urges. The process of making self-statements becomes so automatic by the time you are an adult, you may not notice that you do this; it simply does not require any attention now. A self-statement that has become automatic for you is, “The big hand is on the 7, so it is 35 minutes after. The little hand is between the 2 and 3, so it is 2 o’clock. That means that the time is 2:35.” Instead, you automatically read the clock to tell time. Hidden or automatic self-statements about urges can make them harder to handle (“Now I want a drink. I won’t be able to stand this. The urge is going to keep getting stronger and stronger until I blow up or drink.”). Other types of self-statements can make the urge easier to handle (“Even though my mind is made up to stay sober, my body will take a while to learn this too. This urge is uncomfortable, but in 15 minutes or so, I’ll be feeling like myself again.”).

    There are two basic steps in using self-talk constructively:

    1. Pinpoint what you tell yourself about an urge that makes it harder to cope with the urge. One way to tell if you are on the right track is when you hit upon a self-statement that increases your discomfort. That discomfort-raising self-statement is a leading suspect for challenge, since it pushes your buttons.

    2. Use self-talk constructively to challenge that statement. An effective challenge will make you feel better (less tense, anxious, panicky) even though it may not make the feelings disappear entirely. The most effective challenges are ones that are tailored to your specific upsetting self-statements. Listed below are some stock challenges that people find useful:

    What is the evidence? What is the evidence that if you don’t have a drink in the next 10 minutes, you will die? Has anyone (who has been detoxed) ever died from not drinking? What’s the evidence that people who are recovering from an alcohol problem don’t experience the feelings that you have? What is the evidence that there is something the matter with you, that you will never improve?

    What is so awful about that? What’s so awful about feeling bad? Of course you can survive it. Who said that sobriety would be easy? What’s so terrible about experiencing an urge? If you hang in there, you will feel fine. These urges are not like being hungry or thirsty or needing to relieve yourself—they are more like a craving for food or an urge to talk to a particular person—they pass, in time.

    You are a regular human being and have a right to make mistakes. Maybe you worry about being irritable, preoccupied, or hard to get along with. What’s so bad about that? We all make mistakes, and in a situation that is complicated, there is no right or perfect way to get along. Our most memorable lessons, invariably, are learned in the school of hard knocks. It’s a school that every single one of us attends throughout life.

Some of the substitute thoughts or self-statements will only be necessary or helpful initially, as ways of distracting yourself from persistent urges; you’ll have an easier time if you replace the uncomfortable thoughts with other activities. After a while, sobriety will feel less unnatural; many of the urges will diminish and drop out, and you won’t need constant replacements.

In-Session Exercises

  1. Make a list of craving triggers. Circle the triggers that you can avoid or to which you can reduce your exposure (like not having alcohol in your home).

  2. Make up a craving plan. Pick two or three of the general strategies that were discussed and make up a plan about how you would put them into practice if you experience an urge. Remember—cravings can come when you least expect them! For example, if you think getting involved in a distracting activity would be helpful, which activities would you pick? Are these available to you now? Which may take some preparation? If you were feeling craving, who would be best for you to call? If you have not tried urge surfing before, it might be very helpful to practice with your therapist before trying it when facing an urge.

 

Coping with Cravings and Urges

Reminder Sheet

  • Urges are common in the recovery process. They are not a sign of failure. Instead, try to learn from them about what your craving triggers are.

  • Urges are like ocean waves. They get stronger only to a point, then they start to go away.

  • You win every time you defeat an urge by not using. Urges only get stronger if you give in and feed them. An urge will eventually weaken and die if you do not feed it.

Practice Exercises

For next week, make a daily record of urges to use drugs or drink, the intensity of those urges, and the coping behaviors you used.

  1. Fill out the DAILY RECORD OF URGES TO DRINK

    1. Date

    2. Situation: Include anything about the situation or your thoughts or feelings that seemed to trigger the urge to drink.

    3. Intensity of thirst: Rate your thirst, where 1 = none at all, 100 = worst ever.

    4. Coping behavior. Use this column to note how you attempted to cope with the urge to drink. If it seems like it would help, note the effectiveness of your coping.

  2. Below is an example of how to fill out the record form.

Daily Record of Urges to Drink

DateSituation (include your thoughts and feelings) Intensity of cravings
(1–100)
Coping behaviors used
5/16/91Was feeling stressed. Had a disagreement with my boss. 75Shut myself in office and relaxed. Felt better after 20 minutes.
5/17/91Antsy at bed time. Trouble getting ready to go to bed. 60Took hot shower, listened to the relaxation tape. Shower better than tape.
5/18/91Went to Andy's Diner for lunch, where I always used to order something to drink. 80Ordered a tonic with lime. It was a close call. Should have prepared in advance.
5/19/91Pay day. Bob wanted to party after work. 68Suggested we go for coffee. Bob agreed. Boy—was I surprised!

Daily Record of Urges to Drink

DateSituation (include your thoughts and feelings) Intensity of cravings
(1–100)
Coping behaviors used
    
    
    
    
    
    
    

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Session 3: Managing Thoughts About Alcohol and Drinking

Rationale

The following paragraph is inserted between the first and second elements of the Monti et al. rationale:

Recovering alcoholics need to be aware of a state of mind that can predispose them to a relapse—a state of mind characterized by certain dangerous attitudes and thought processes. This state of mind is often described as “negative tapes.” These thought processes and attitudes are dangerous because they induce alcoholics to relax their guard (decrease vigilance). Stinking thinking, as the saying goes, leads to drinking thinking, and then, usually, to drinking without thinking. It is not the thinking itself that creates the problem, but how people deal with it. If alcoholics can learn to dismiss this thinking from their minds whenever it appears, recognize it for what it is, or counter it with contrary thoughts, it need not lead to a relapse.

The following items are added to the list of situations that may lead clients to have thoughts about resuming drinking:

  1. Escape. Individuals wish to avoid the discomfort aroused by unpleasant situations, conflicts, or memories. Failure, rejection, disappointment, hurt, humiliation, embarrassment, discontent, or sadness all tend to demand relief. People get tired of feeling hassled, lousy, and upset. They just want to get away from it all and, more to the point, from themselves. It is not necessarily intoxication that is sought; rather it is numbness, the absence of problems, and peace.

  2. Relaxation. Thoughts of wanting to unwind are perfectly normal, but they go awry when they are coupled with the expectations of this happening immediately, without the benefit of doing something relaxing. Rather than engaging in a wide variety of possibly enjoyable and relaxing activities, the individual may choose the more immediate route induced through alcohol.

  3. Socialization. This overlaps with relaxation but is confined to social situations. Many individuals, shy or uncomfortable in social settings, may feel a need for a social lubricant to feel more at ease and decrease the awkwardness and inhibitions they feel around others.

  4. Improved self-image. This situation typically involves a relatively pervasive negative and low self-esteem. When individuals start becoming unhappy with themselves, when they are feeling inferior to others, when they regard themselves as lacking in essential qualities, when they feel unattractive or deficient, they often begin to think again of alcohol, through which they may have previously achieved immediate and temporary relief.

  5. Romance. Individuals often indulge in adolescent fantasies. When bored or unhappy with their lives, they yearn for excitement, romance, the joy of flirtation, and the thrill of being in love. This is usually the kind of thought that, when engaged in too seriously, requires a drug like alcohol to sustain it and make it more vivid and real.

  6. To hell with it. Some individuals seem to have lost all incentive for pursuing any worthwhile goals. Their thoughts express disillusionment; nothing really matters. There is no reason to try. Why should they give a damn? Such an attitudinal set leads these individuals to be less vigilant and not care whether they remain sober.

  7. No control. This represents the other side of the coin from the “Testing Control” script. Just as believing in one’s ability to handle alcohol is usually a setup for relapse, the opposite attitude of not being able to control one’s cravings virtually insures it. Individuals give up the fight, conceding defeat even before they have made any effort to resist. Alcohol is seen as one of the few viable options available. This differs from the “hell with it” attitude. In that situation, individuals do not necessarily feel powerless; they just do not want to exert the effort to continue what they have been doing.

[NOTE: The major portion of this session is based on the corresponding session in Monti et al. (pp. 79–83). A number of additions made to the original materials are derived from Ludwig (1988). © Oxford University Press. Used with permission.]

Skill Guidelines

The following introductory paragraph is added:

All recovering people have thoughts about drinking at one time or another. The thinking itself does not create the problem, but how people deal with it. If alcoholics can learn to dismiss this thinking from their minds whenever it appears, recognize it for what it is, or counter it with contrary thoughts, it need not lead to a relapse. There are three general and overriding prerequisites for an individual to cope effectively with thoughts about drinking: (1) one needs to be firmly committed to recovery in order to choose to remain abstinent and not give in to persistent thoughts; (2) one must be aware of the persistent aspects of thinking that would allow the individual to rationalize and justify (and provide guilt free) drinking; (3) one must maintain a high level of vigilance, always anticipating potential risks to relapse and never assuming that one is immune from the prospect of giving in to urges, cravings, or thoughts of drinking.

Add the following paragraph after the first skill guideline:

An important aspect of challenging possible thoughts about drinking (as well as forms of thought distraction and substitute behaviors incompatible with drinking) is not to visualize what one is not going to do but to picture a substitute or opposing behavior that one is going to do. To begin a new habit, individuals should have a behavioral image of themselves engaging in the new behavior, not just on occasion but every time the unwanted habit pops into mind.

The following paragraph is added after the third skill guideline:

The individual is asked to think beyond the more immediate pleasure associated with alcohol, to play out the mental image of the possible drinking episode to the end, and to include all the detrimental consequences that could arise if drinking occurs.

In skill guideline number 8, the reference to calling one’s AA sponsor is eliminated in Project MATCH to reduce overlap with the 12-Step facilitation treatment.

Introducing the Practice Exercise

The practice exercise in Monti et al. has been modified somewhat. The following paragraph replaces the one on page 83 in Monti et al.:

Ask clients to write out lists of (1) the 5 to 10 most anticipated positive consequences of sobriety and not drinking, (2) the 5 to 10 most negative personal consequences associated with drinking, and (3) the 5 to 10 greatest stumbling blocks or high-risk situations that will make it difficult to achieve or maintain sobriety. Then, ask clients to use this information (the positive benefits of sobriety and the negative consequences of drinking) to rate how committed they are to stop using and to stay sober. The rating of the person’s perceived level of commitment ranges from 1 (no commitment) to 10 (extremely high level of commitment).

 

Practice Exercise

The following composite Practice Exercise incorporates the modifications to the one in Monti et al.:

One way to cope with thoughts about using alcohol is to remind yourself of the benefits of not using, the unpleasant consequences of using, and the stumbling blocks or high-risk situations that may make it hard to keep your commitment to abstinence. Use this sheet to make a list of the 5 to 10 reminders in each category, then transfer this list onto a pocket-sized index card. Read this card whenever you start to have thoughts about drinking.

Positive benefits of not using:




Unpleasant effects or negative consequences of using:




Stumbling blocks, or high-risk situations, to keeping commitment to abstinence:




Overall level of personal commitment to remain abstinent:

None   1   2   3   4   5   6   7   8   9   10   Extremely high

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Session 4: Problem Solving

This session is based on the similar one in Monti et al., pages 83–87, with the following modifications.

Rationale

Item 2 of the Monti et al. rationale section is replaced with the following:

  1. Alcohol and drug abusers are likely to encounter the following general types of problems:

    1. Situations where drinking and drug use has occurred in the past

    2. Situations that arise only after you have stopped drinking or using drugs (i.e., social pressure, cravings, and slips)

    3. Difficulty in developing activities that may be useful to maintain sobriety (e.g., new recreational habits)

What sort of problems have you encountered so far?

Skill Guidelines

Items 3b and 3c are dropped and replaced with the following:

    1. Consider both behavioral and cognitive coping strategies (Sanchez-Craig 1983). When a problem involves conflict with other people, it is often better to employ behavioral coping and speak up (in an assertive way) so as to change the situation for the better. Negative emotional reactions to uncontrollable events may be best handled with cognitive coping, changing the way you think about the situation. In this manner, you may reduce your negative emotional reaction without changing a situation that may be beyond your control. In some situations, both cognitive and behavioral coping strategies are necessary to deal with a problem.

Behavior Rehearsal Role Plays

Retain the first paragraph in Monti et al., but omit the subsequent group exercises.

Reminder Sheet and Practice Exercise

These are retained as in Monti et al., page 212.

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Session 5: Drink Refusal Skills

The majority of this session is based on the corresponding session in Monti et al., pages 61–63. The following changes have been made.

Rationale

Item 2 in Monti et al. is added to item 4. The following two elements are inserted in place of the relocated item 2:

As drinking increases in severity over time, there appears to be a “funneling” effect or narrowing of social relationships: individuals begin to eliminate sober friends, and their peer group becomes populated with others who support and reinforce continued drinking. Being with such individuals and former drinking buddies increases the risk of relapse through multiple avenues: (1) overt and covert pressure to drink; (2) conditioned craving associated with people, places, activities, and emotional states related to past drinking; (3) increased positive outcome expectancies about the effects of drinking; and (4) increased access/availability of substances.

Two forms of social/peer pressure are often experienced by individuals in recovery: direct and indirect social pressure. The former occurs when someone offers the individual a drink directly and up front. This is most likely to happen in high-risk situations. Indirect social pressure involves returning to the same old settings (e.g., taverns, lounges, parties), with the same people, doing the same things, and experiencing the same feelings previously associated with drinking.

The following is added at the beginning of item 3 in the Monti et al. rationale:

Given the increased risk associated with social pressure, the first action that should be considered is behavioral avoidance. However, avoidance is not always possible or practical.

Skill Guidelines

The following paragraph is added at the beginning of the skill guidelines section:

If unable to avoid high-risk situations and people, the next level of response is being able to refuse requests to drink. The more rapidly a person is able to say “no” to such requests, the less likely he/she is to relapse. Why is this so? The old notion of “he who hesitates is lost”; that is, being unsure and hesitant allows you to begin rationalizing (e.g., “One beer wouldn’t be so bad.”). The goal then is to learn to say “no” in a convincing manner and to have your response at the tip of your tongue.

In-Session Practice

The following material is added prior to the Modeling exercise. It requires having available the “Drinking Locations” and the “Social Situations” cards from the “Comprehensive Drinker Profile” (Miller and Marlatt 1984).2

(2 Miller, W.R., and Marlatt, G.A. Comprehensive Drinker Profile. Odessa, FL: Psychological Assessment Resources, Inc., 1984.)

Provide the clients with the “Drinking Locations” cards from the “Comprehensive Drinker Profile.” Have them sort the cards from the most to the least frequent drinking setting. This listing of drinking settings will enable the client to anticipate settings having high risk for drinking and social pressure to drink.

Next, provide the clients with the “Social Situations” cards from the “Comprehensive Drinker Profile.” Have them sort the cards from the most to the least frequent drinking situation. Have the clients indicate which of the people identified in their social network they anticipate contacting during the next 90 days. Ask them to indicate which of these individuals are likely to support sobriety and which are likely to tempt/pressure them to drink.

This exercise will help clients identify people and situations to avoid because they represent a high risk to their sobriety. It will also help the therapist identify specific individuals and situations to include in the behavioral rehearsal role play.

Modeling

The therapist plays the role of the person being pressured to drink (by the client) and demonstrates an effective and assertive way to handle the situation.

Behavioral Rehearsal Role Play

This is conducted essentially the same way as described in Monti et al. An additional source of ideas for role plays derives from the in-session practice exercise: those locations and situations that were identified as high frequency represent considerable risk and would therefore provide good scenarios for role playing. The following suggestions are added at the end of the Role Play section:

  • The therapist should encourage the client to try to visualize scenarios involving a group of people, even though the individual therapy situation does not provide an opportunity for the use of multiple role-play partners.

  • In many cases, it may be useful for the therapist to elicit the client’s fantasies about how the target person will react to the client’s refusal to drink.

Reminder Sheets and Practice Exercises

These are retained as in Monti et al., page 205.

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Session 6: Planning for Emergencies and Coping With a Lapse

This session is based almost entirely on the similar session in Monti et al. entitled “Planning for Emergencies” (pp. 120–121). The Project MATCH manual included a few modifications, as follows.

Rationale

The fifth item in the Monti et al. rationale section is replaced by the following two items:

  1. If a lapse or slip back to drinking does occur, it is likely to be accompanied by feelings of guilt and shame. These must be dealt with at once, before they lead to further drinking. After a slip, one should try to learn, from the events that preceded it, to reduce the likelihood of a repetition.

  2. Ask the client to describe one or more life events or life changes that might lead to craving for alcohol or to a lapse. The therapist should list these on the chalkboard and ask clients to consider how they might affect their behavior and interactions with others.

Skill Guidelines

Two additional skill guidelines items have been added. These are taken from page 157 of Monti et al., the paragraphs on dealing with the immediate aftermath and the longer term impact of a drinking episode.

Practice Exercise

The practice exercise remains as specified in Monti et al.

Reminder Sheet

Two reminder sheets from Jaffe et al. (1988) have been added. These are reproduced below.

 

Personal Emergency Plan: High-Risk Situation

Reminder Sheet

If I encounter a life event that puts me in a high-risk situation:

  1. I will leave or change the situation or environment.

  2. I will put off the decision to drink for 15 minutes. I will remember that most cravings are time-limited and I can wait it out—not drink.

  3. I will challenge my thoughts about drinking. Do I really need a drink? I will remind myself that my only true needs are for air, water, food, and shelter.

  4. I will think of something unrelated to drinking.

  5. I will remind myself of my successes to this point.

  6. I will call my list of emergency numbers:

NAME

  1. __________________________________ PHONE NUMBER ____________________

  2. __________________________________ PHONE NUMBER ____________________

  3. __________________________________ PHONE NUMBER ____________________

  4. __________________________________ PHONE NUMBER ____________________

  5. __________________________________ PHONE NUMBER ____________________

  6. __________________________________ PHONE NUMBER ____________________

GOOD LUCK!
REMEMBER: RIDING OUT THIS CRISIS WILL STRENGTHEN YOUR RECOVERY

 

Personal Emergency Plan: Lapse

Reminder Sheet

A slip is a major crisis in recovery. Returning to abstinence will require an all-out effort. Here are some things that can be done.

If I experience a lapse:

  1. I will get rid of the alcohol and get away from the setting where I lapsed.

  2. I will realize that one drink or even one day of drinking/drug use does not have to result in a full blown relapse. I will not give in to feelings of guilt or blame because I know these feelings will pass in time.

  3. I will call for help from someone else.

  4. At my next session, I will examine this lapse with my therapist, discuss the events prior to my lapse, and identify triggers and my reaction to them. I will explore with my therapist what I expected alcohol to change or provide. I will work with my therapist to set up a plan so that I will be able to cope with a similar situation in the future.

REMEMBER: THIS LAPSE IS ONLY A TEMPORARY DETOUR ON THE ROAD TO ABSTINENCE

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Session 7: Seemingly Irrelevant Decisions

The goals of this session are to (1) convey to the client the kinds of seemingly irrelevant thoughts, behaviors, and decisions that may culminate in a high-risk situation and (2) encourage the client to articulate and think through all decisions, no matter how small, in order to avoid rationalizations or minimizations of risk (e.g., “I need to keep a few beers in the refrigerator in case my brother-in-law comes over.”).

Material for this session was taken from Monti et al., pages 116–120, with a few modifications.

Rationale

Marlatt and Gordon’s (1985, p. 273) “George the Drinker” story is substituted for the “Sam the Gambler” story on pages 117–118 because of its more direct link to drinking.

The following is added to point 3 on page 117:

By paying more attention to the decisionmaking process, you will have a greater chance to interrupt the chain of decisions that could lead to a relapse. This is important because it is much easier to stop the process early, before you wind up in a high-risk situation, than later when you are in a situation that is harder to handle and may expose you to a number of triggers.

Also, by paying attention to your decisionmaking process, you will be able to recognize certain kinds of thoughts that can lead to making risky decisions, such as George’s thought that he “had to” have a cigarette in the story (“George the Drinker”). Thoughts like “I have to” go to a party, “should” see a certain drinking buddy, or “have to” drive by a particular place, often occur at the beginning of a Seemingly Irrelevant Decision and should be treated as a warning or red flag. Other red-flag thoughts often start with “It doesn’t matter if I . . . ,” “I can handle . . . ,” and so on.

Group Discussion

This exercise is easily accomplished in the individual therapy setting. The item referring to AA or Narcotics Anonymous meetings is omitted in Project MATCH.

Exercise in Group

This too is easily adapted to individual therapy. The following exercises are added:

  • Think about the most recent time you drank. Trace back through the decisionmaking chain. What was the starting point (exposure to a trigger, certain thoughts)? Can you recognize the choice points where you made risky decisions?

  • What plans have you made for this weekend? If none, why? Is this a seemingly irrelevant decision? Sometimes not planning means planning to drink. What plans could you make for this weekend that would reduce the risk of winding up in a risky situation?

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Final Core Session: Termination

This session is based on materials from two sections in Monti et al. It begins with material from chapter 4, pages 160–161, the subheadings entitled “Termination,” “Considering the Need for More Treatment,” and “Planning for Emergencies,” with material on taking Antabuse and attending AA deleted. The session description then picks up two subheadings from the session “Wrap-up and Goodbyes,” page 124: “Feedback to the Therapists” and “Goodbyes.” The session description concludes with “Coping With Persistent Problems,” pages 161–162.

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