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Elective Sessions

 

Therapists may present up to four elective sessions after the first seven core sessions. The therapist and client should agree on which sessions to use. If the therapist feels that a particular session is especially relevant to a client, but the client disagrees, it is probably better to go along with the client’s choice.

 

The sessions listed here can be offered in any order.

Starting Conversations

Nonverbal Communication

Introduction to Assertiveness

Receiving Criticism

Awareness of Anger

Anger Management

Awareness of Negative Thinking

Managing Negative Thinking

Increasing Pleasant Activities

Managing Negative Moods and Depression

Enhancing Social Support Networks

Job-Seeking Skills

Couples/Family Involvement I

Couples/Family Involvement II

 

Elective Session: Starting Conversations

 

This session is exactly as presented in Monti et al., pages 28­–32. The only modification is elimination of the modeling section, which would require an interaction between cotherapists.

 

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Elective Session: Nonverbal Communication

 

This session has no changes from the corresponding session in Monti et al., pages 36–40 except for minor modifications in wording to accommodate individually administered treatment.

 

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Elective Session: Introduction to Assertiveness

 

The majority of this session is exactly as found in Monti et al., pages 46–49, with the few following changes.

Skill Guidelines

 

A 7th skill guideline is added:

  1. Some of the most difficult situations in which to respond assertively are those that may potentially end with negative consequences. These often involve anticipatory anxiety, which can have a disorganizing effect. Examine the cognitions that may be preventing you from acting assertively (e.g., “I’ll get fired if I tell my boss I can’t work overtime tonight because I have to get to my therapy session”). In examining these cognitions, apply many of the same skills discussed for managing thoughts about drinking. These include:

    1. Determine the thought or fear. What’s stopping me from asserting myself? What am I afraid will happen? What’s the worst that could happen if I stand up for myself? What’s so upsetting about that?

    2. Assess the probabilities. How likely is the negative consequence? (How likely is it that I get fired for not working overtime once?)

    3. Evaluate the catastrophe. What would happen if the dire consequence occurred? Would I be able to get another job? Would my life be over?

    4. Identify the rules. What assumptions and beliefs are governing my feelings in this situation? (Should I please everybody? Is it necessary that everyone like me?)

       

Behavior Reversal Role Play

 

Omit this exercise.

Modeling

 

Omit the Monti et al. modeling exercise and replace it with the following:

  1. Have the client role play a coworker who suggests that the therapist accompany him/her for a drink after work. The therapist will model passive, aggressive, passive-aggressive, and assertive responses, respectively. After each type of response, ask the client to identify the type of behavior that was demonstrated and how successful each of the approaches would be in avoiding drinking.

  2. Practicing assertive responses

Have the client generate a number of situations that were difficult in the past (not necessarily those involving drinking) and practice assertive responses in role plays. If the client has trouble supplying these readily, try some easy ones (e.g., returning an item bought in a store to the clerk, dismissing a pesky salesperson) and some difficult ones (e.g., asking a good friend to return a loan made several months ago or confronting a supervisor who took credit for an idea of the client’s).

Practice Exercise

 

If the response style in any of the three social situations specified in the Monti et al. exercise (p. 201) is not assertive, the client is asked to think of an assertive response and write it down.

 

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Elective Session: Receiving Criticism

 

This session represents a combination of the two sessions in Monti et al. on “Receiving Criticism,” pages 55–58, and ”Receiving Criticism About Drinking,” pages 58–61.

Rationale

 

Combine the two rationale sections from Monti et al. on pages 55–56 and 58–59.

Skill Guidelines

 

Combine the skill guidelines sections on pages 56–57 and 59.

Modeling

 

 
The modeling exercise from the “Receiving Criticism” session (p. 57) is utilized, with the client first playing the part of the critical store manager and the therapist modeling receipt of criticism in the role of clerk, followed by a role reversal.

Behavior Reversal Role Play

 

The behavior rehearsal role plays of both sessions are omitted in Project MATCH.

Practice Exercise

 

The practice exercises from both sessions are retained (pp. 203–204).

 

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Elective Session: Awareness of Anger

 

This session has no changes from the corresponding session in Monti et al., pages 103–105, except for minor modifications in wording to accommodate individually administered treatment.

 

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Elective Session: Anger Management

 

This session has no changes from the corresponding session in Monti et al., pages 106–108, except for minor modifications in wording to accommodate individually administered treatment.

 

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Elective Session: Awareness of Negative Thinking

 

This session has no changes from the corresponding session in Monti et al., pages 108–111, except for minor modifications in wording to accommodate individually administered treatment.

 

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Elective Session: Managing Negative Thinking

 

This session has no changes from the corresponding session in Monti et al., pages 111–116, except for minor modifications in wording to accommodate individually administered treatment.

 

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Elective Session: Increasing Pleasant Activities

 

The goal of this session is to encourage the client to participate in activities which are pleasurable in order to provide a constructive behavioral alternative to alcohol use and to help the client counter the feelings of boredom and loneliness many problem drinkers experience when they stop drinking.

 

Material for this session was taken from pages 87–89 of the Monti et al. book, with the following modifications.

Skill Guidelines

 

Add to skill guideline number 1:

Try to think of some activities you would enjoy doing by yourself and some you would enjoy with other people. A balanced life includes both private time and social time. Asking others to participate in pleasant activities with you is a good ice breaker and another way to enlarge your circle of friends and supporters.

 

Add to skill guideline number 3:

Try to schedule this time during high-risk periods (e.g., after work, after dinner, on weekends). This way, you can reward yourself with positive activities rather than with drinking. Keeping yourself active with pleasant activities when you might be likely to think about drinking can result in your not thinking about drinking at all.

 

Add skill guideline number 5:

    1. Also remember that getting involved with a pleasant activity is a great way to cope with cravings and urges.

 

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Elective Session: Managing Negative Moods and Depression

Rationale

  1. Negative moods and depression are common among alcoholics during the recovery process. Often, these moods are related to the actual depressant effects of alcohol or drugs or to the losses experienced in one’s life (e.g., family, job, finances) as a result of drinking. Depression and negative moods related to these factors often get better during the course of treatment without any specific attention, as one is sober longer and begins to deal more effectively with the remaining life problems. Some people, however, continue to experience problems with depression even after they have been clean and sober for fairly long periods of time. In such cases, it may be necessary to focus more directly on these negative moods.

  2. Depression is a problem in its own right. However, it is a particular problem for the recovering alcoholic, since negative mood states, particularly depression, are a major reason for relapse and, thus, represent high-risk situations.

  3. Returning to drinking is not an effective way to cope with depression and only serves to make the person more depressed in the long run.

  4. There are many different ways to cope with depression and negative moods. Given the focus of the present therapy approach, negative moods can be dealt with effectively by changing the ways one thinks and behaves. As such, many of the skills that have been learned to manage negative thoughts, to solve problems, and to increase pleasant activities can be used to deal with depression and its symptoms.

  5. The best way to beat depression is to consider each symptom as a separate problem to be solved. The symptoms of depression are interrelated; improvement in one area leads to improvement in other areas.

 

[NOTE: Adapted from Emery 1981. © Simon and Schuster. Used with permission.]

Skill Guidelines

 

Depression has a number of causes and symptoms. Several different cognitive-behavioral approaches have been found helpful in dealing with depression of mild to moderate proportions.

  1. Change your way of thinking about yourself and the world. One of the things that is most characteristic of depression is that the individual tends to view the world and the self through distorted and depressive perceptions. The way one thinks affects how one feels. As such, it is important to look at the way you think and see if this contributes to your feeling sad and depressed.

  2. The steps to changing your thinking, while not easy, are simple. First, become aware of your self-defeating thoughts; second, answer these with more realistic ones; and third, act on the new thoughts. If you use these three A’s, you can overcome the symptoms and causes of your depression.

  3. Awareness. The first step in the process is to recognize the symptoms of your depression. Depressed people often miss or misinterpret symptoms of depression. Below are some ways you can become more aware of your symptoms:

    1. Pay attention to your mood changes. When you start to feel sad, gloomy, ashamed, bored, lonely, or rejected, tune into what’s going on, to how you’re feeling. These are important clues to your thinking.

    2. Own your feelings. If you are having trouble recognizing your feelings, start talking about them. Tell people how you are honestly feeling at any given moment.

    3. Be alert to your body. This is a clue to your emotions. Notice your posture, your facial expression, how you are walking and moving.

    4. Label your avoidance. Keep a lookout for people, places, and activities that you once enjoyed but are now avoiding. Forget about the reasons why you are avoiding them, just see when you do.

    5. Watch for times when your confidence disappears. Are there times and places when you ask others for help? Ask yourself whether you were able to handle this on your own before. Remember, this loss of confidence can be a symptom of depression.

    6. Look for activities that require great effort. Do you have to force yourself to make or return phone calls? Do you have trouble completing tasks around the house?

    7. Become aware of trouble concentrating or making decisions. Do you vacillate over simple decisions or second guess yourself? These can be symptoms of depression.

  4. The second level of awareness is catching the thoughts that come before your symptoms. These are called automatic negative thoughts. During depression, these automatic negative thoughts become stronger and drown out more sensible thoughts. Thoughts are used to monitor feelings and behavior. They are used to initiate action and anticipate events. Your thoughts tell you what to do and how to feel. The chief characteristic of automatic negative thoughts is that they are generally wrong.

    Automatic thoughts make you depressed; the more depressed you become, the more negative thoughts you will have and the more likely you are to believe them. Below is a list of thinking errors or methods of distortion characteristic of depressed thoughts.

    Thinking Errors

    Type of error

    Examples

    Personalizing

    Thinking all situations and events revolve around you. “Everyone was looking at me and wondering why I was there.”

    Magnifying

    Blowing negative events out of proportion. “This is the worst thing that could happen to me.”

    Minimizing

    Glossing over the saving and positive factors. Overlooking the fact that “nothing really bad happened.”

    Either/or thinking

    “Either I’m a loser or a winner.” Not taking into account the full continuum.

    Taking events out of context

    After a successful interview, focusing on one or two tough questions. “I blew the interview.”

    Jumping to conclusions

    “I have a swollen gland. This must be cancer.”

    Overgeneralizing

    “I always fail—I fail at everything I ever try.”

    Self-blame

    “I’m no good.” Blaming total self rather than specific behaviors that can be changed.

    Magical thinking

    “Everything is bad because of my bad past deeds.”

    Mind reading

    “Everyone there thought I was fat and ugly.”

    Comparing

    Comparing self with someone else and ignoring all of the basic differences. “Cher has a better figure than mine.”

    Catastrophizing

    Putting the worst possible construction on events. “I know something terrible happened.”

    In addition to becoming aware of the typical thoughts associated with depression noted above, it is important for you to become aware of your characteristic automatic negative thoughts. A number of steps can be taken to help you do this.

    1. One way to become more aware of your thoughts is simply to count them. This will help you realize that they just appear—they are automatic and not a reflection of reality.

    2. Give yourself a goal of collecting 50 negative thoughts. It seems like an impossible task, but it will prompt you to think hard and you are likely to come up with 5 to 10 such thoughts, even if you don’t make it to 50!

    3. Use an instant replay technique. If you have some negative feelings and cannot quite catch the thoughts, replay the feelings over and over until you catch the thoughts. If you can remember what happened, imagine the event as if it were happening right now.

    4. Look for the meaning of the situation. Ask yourself, “What is the significance of the situation… what are the consequences?” By doing this you can usually become aware of your thoughts.

    5. Set aside a specific time to collect negative thoughts. You may find that setting aside a regular time may be helpful. During a half hour period, for example, write out some of the negative thoughts you had during the day. You might want to limit the thoughts to specific problems or situations.

    6. Write out your thoughts. Putting your thoughts down on paper is one of the best ways to become aware of them. When writing them out, force yourself to go beyond the obvious thoughts that first come to mind.

    7. Use the excuses you come up with to avoid collecting negative thoughts as cues to swing into action. This way the excuse can become an early warning signal.

  5. Answering. Once you begin catching negative thoughts, you can begin answering them. The secret to answering negative thoughts is to realize there are different interpretations of any event and some are closer to reality than others. When answering your thoughts, try to consider a wide range of possible interpretations, not just the negative ones. If you are depressed, it is important to separate thoughts from facts, since you will have distorted thoughts, and when you believe and act on distorted thoughts, you become more depressed. You must begin to question the assumptions involved in the thoughts. A good way to do this is to ask some serious questions of yourself and your automatic thoughts.

    Here are 20 questions that you can use to generate answers to your negative thoughts:

    1. What’s the evidence? Ask yourself, “Would this thought hold up in a court of law or is it circumstantial?” Just because the newspaper is late one day doesn’t mean you can’t count on anything. Give yourself a fair trial before you convict yourself.

    2. Am I making a mistake in assuming what causes what? Determining causes is rarely simple. Example: Many women think they’re fat because they have no willpower. Scientists have been studying obesity for years and they don’t know what causes it. They know the determinants are partly biological, social, cultural, psychological, familial, and economic. Saying lack of willpower causes obesity is an oversimplification. Specifics are difficult to pinpoint.

    3. Am I confusing a thought with a fact? This can lead to trouble—especially if you call yourself names and then believe them as gospel. There is an old story that makes this point: “How many legs would a dog have if you called the tail a leg? Five? Wrong. The answer is four. Calling a tail a leg doesn’t make it so.” Don’t be dogmatic about your thoughts—look for the facts.

    4. Am I close enough to the situation to really know what’s happening? One woman said, “The bosses upstairs don’t like our department’s work and want to get rid of us.” Who knows what they’re thinking upstairs? You’re not up there with them. You have to rely on what you know as fact. The woman’s worry turned out to be a false rumor.

    5. Am I thinking in all-or-none terms? Do you see the world in either/or terms (“I’m ugly and everyone else is beautiful”)? Just about everything is in degrees and on a continuum. Even a person’s gender is not always clear cut; some people’s hormonal makeup is such that it’s a tossup whether they’re male or female.

    6. Am I using ultimatum words in my thinking? (“I always should be nice or no one will like me.”) You place unfair ultimatums on yourself with these words. This isn’t “just semantics,” but relates directly to how you feel and act.

    7. Am I taking examples out of context? One student believed she’d been given a bad letter of recommendation. She thought the teacher said in the letter that she was narrow and rigid. When she reread the letter, she saw the teacher had written, “She has high principles.” It was really a positive letter, and she had taken this part out of context.

    8. Am I being honest with myself? Am I trying to fool myself—denying the truth, making excuses, and misplacing the blame? One depressed woman, speeding on the freeway, thought, “I hope they catch me and put me in jail.” When she thought about it for a moment, she realized she didn’t really mean this.

    9. What is the source of my information? Consider your sources. People have their own reasons for what they tell you. “Am I depending on unreliable sources and spreaders of gloom to tell me how it is? Why let them define reality for me?”

    10. Am I confusing a low probability (a rare occurrence) with a high probability? A mailman thought, “They’ll probably fire me for missing 3 days of work.” But after he reflected on it, he asked himself, “When was the last time they fired anyone at the post office?”

    11. Am I assuming every situation is the same? Are you taking into consideration time, location, and subtle differences? “Just because I dropped out of school 20 years ago doesn’t mean I’ll fail this time.”

    12. Am I focusing on irrelevant factors? Patients attempting to build a case for their depression have asked me, “What about Uganda, starving children, and Hitler?” It’s highly unfortunate that there is misery and evil in the world. But it’s irrelevant to being depressed. Do what you can to alleviate the suffering of others, but getting depressed over it won’t help.

    13. Am I overlooking my strengths? When people become depressed, they overlook the problems they have solved in the past. I am continually amazed at people’s ability to handle adversity once they turn their thinking around. Ask yourself how you handled situations like these in the past.

    14. What do I want? What are my goals? Do I want to be happy and get the most out of life? Is this thinking (“Everything’s bad”) getting me what I want? Is it doing me any good?

    15. How would I look at this if I weren’t depressed? Would I think a cold sore is the worst thing that could happen? How would others (nonpartisan viewers) interpret this situation? Imagine how you will react to it once you are over your depression.

    16. What can I do to solve the problem? Are my thoughts leading to problem solving (generating solutions) or to problem blockage? If your kids are fighting and the plumbing is stopped up, thinking about the “unfairness of it all” doesn’t lead to any solutions.

    17. Am I asking myself questions that have no answers? (“How can I redo the past?” “How can I be someone different?” “How can a relationship that’s ended not be over?”) Questions like these often can only be answered with questions. “Why should this happen to me?” Answer: “Why shouldn’t it?” “What if something terrible happens?” Answer: “So what if it does?” Asking yourself unanswerable questions is another way of demanding that the world be different than it is.

    18. What are the distortions in my thinking? Once you pinpoint the errors, you can correct them. Are you jumping to conclusions? Painting everything black? Are you confusing your behavior with your worth?

    19. What are the advantages and disadvantages of thinking this way? Ask if there are advantages in thinking, “I hate this house, I hate this neighborhood, and I hate this city and everything in it.” Probably few. The disadvantage is that this type of thinking can stop you from getting your share of pleasure.

    20. What difference will this make in a week, a year, or 10 years? Will anyone remember (let alone care) in 10 years that I made a stupid remark at a party or had dandruff on my sweater? People often believe that their mistakes will be frozen forever in others’ minds.

  6. Action. Just answering your thoughts won’t be enough to get you over your depression. You must act on your new thoughts and beliefs. By acting differently, you can change old thinking habits and strengthen the new ones. You have to do something to challenge your automatic thoughts. Listed below are a number of approaches that have been effective for many people in changing their behavior and overcoming depression.

    1. Problem solving. As individuals’ drinking problems become more severe, a number of problems often develop in other areas of their lives. These may be in relationships with spouse, significant other, or family members; loss of job or a lack of vocational direction; financial difficulties; legal problems. Many times, the person feels overwhelmed by these problems, worries about them, begins to feel helpless over their outcomes, and starts to feel depressed.

 

NOTE: The following information is provided only as a review of general problem-solving strategies and may not be necessary
to go over in detail, if at all, depending on the client’s level of demonstrated skill in this area from previous sessions.

 

One way to try to deal with this form of depression is to use the general problem-solving strategies outlined in a previous session:

  1. Recognize the problem. Does a problem exist? What are some of the clues that one does exist?

  2. Identify the problem. What is the problem? Define it as specifically and concretely as possible, including its smaller parts.

  3. Consider various approaches. What can I do to possibly solve this problem? Try brainstorming, changing your point of view or frame of reference, or adapting a solution that has worked before as ways to generate alternative solutions.

  4. Select the most promising approach. The solution that maximizes positive outcomes and minimizes negative ones is the one to implement first.

  5. Assess the effectiveness of the selected approach. How well did it work? Do I need to try a different approach?

 

Using a systematic problem-solving approach lets people feel that they have an impact on and control over problems in their lives. As the problems are put in a different perspective and hopefully solved, depression begins to fade and they begin to feel better about themselves.

    1. Change your activity level. One of the ways shown to improve mood and depression is to increase involvement in positive activities and reduce involvement in negative ones. (A more detailed focus of increasing positive activities is found in another session of this manual.)

    Why focus on increasing positive activities? First, increasing your activity is a major way to change your thinking. When you are depressed, you do less, blame yourself for doing less, and become more depressed and apathetic; doing more challenges these stances. Second, studies show that even very depressed persons feel better when they become more active; activity improves mood. Third, activity counteracts the fatigue found in depression; you have to do more to get more energy. Fourth, activity increases one’s motivation; you have to do what you don’t feel like doing before you feel like doing it. Fifth, activity improves your mental ability; you not only change your situation by action, but you stimulate yourself to think. Solutions to what seem like unsolvable problems come to mind as you begin moving. Sixth, once you become more active, people will get off your back. Usually others will respond positively to your attempts to become more active, providing a secondary source of reinforcement for continued change.

 

NOTE: The following information is provided only as a review of strategies involved in increasing pleasant activities and may not be necessary to go over in detail, if at all, depending on the client’s level of demonstrated skill in this area from previous sessions.

 

Increasing Pleasant Activities: Positive Steps.
People who are depressed often do not want to be involved in any activities and instead are inert. Developing a schedule of daily activities and following through with them is one way to help overcome depression. A number of steps have been found to help depressed individuals get going again:

  1. Develop a schedule of activities that is flexible and allows for alternatives or contingencies if the activities you planned cannot be accomplished.

  2. Stick with the general plan. If for some reason you cannot do the activity that you had planned, don’t try to go back and make it up; just go on with the schedule.

  3. Schedule activities in one hour and half hour intervals. Do not plan activities that are too specific or too general.

  4. Plan for quantity, not quality. When you are depressed, anything worth doing is even worth doing poorly!

  5. Be task oriented. Remember that your primary goal is to follow the schedule you have established for yourself. The focus is on becoming more active; lessening of depression will follow.

  6. After completing a planned day of activities, write down how you have done. Look at what you did right and where you can improve. Again, do not expect to follow the schedule perfectly.

 

Increasing Positive Activities: Blocks to Action.
Despite good intentions, depressed people are often able to come up with a number of reasons (rationalizations?) that keep them from engaging in positive activities:

  1. “I can’t think of any activities to schedule.” Is it that you cannot or just that you are having trouble? In general, you can schedule three types of activities: (1) things that you must do daily (eat, dress); (2) things that bring you pleasure (going to a movie, reading, shopping), and (3) things that bring a sense of satisfaction or mastery (answering letters, finishing projects).

  2. “Practical problems stop me from carrying out activities.” Life is a series of practical problems that are more difficult to solve when exaggerated by depression; solving them often sets the stage for getting better. Use the general problem-solving approach to overcome these problems.

  3. “I’m not a recordkeeper—I can’t keep a schedule.” While this may be a hassle, recordkeeping is not impossible! The key is to write down your activities in some form.

  4. “I get distracted and sidetracked and don’t follow through on my schedule.” If this is a problem, see it as a challenge you can beat. Get rid of distractions; don’t lie down during the day if you’re depressed; use aids to help follow through on the schedule; reward yourself for following your schedule; plan activities for specific times, and make sure you follow through on time; develop cues to switch into your activity; start your plan with a success experience.

  5. “I’m so overwhelmed with problems that I can’t get started.” Believing your problems are too much for you is part of depression; don’t be overwhelmed by this sense of being overwhelmed. The sense of being overwhelmed is nearly always worse than the reality of the situation.

  6. Pace yourself. As you start to become more active, you may try to do too much, especially if you’ve been depressed for a while. The drawback to becoming overly ambitious is that it can backfire, especially if you run into difficulty; it is easy to become discouraged. So stick to your plan and increase your activities gradually.

 

Decreasing Unpleasant Activities.
Another way to combat feelings of sadness and depression is to decrease unpleasant activities. The following are some methods you can use to decrease unpleasant activities:

  1. Avoid the situation. Engaging in the opposite action often solves the problem. Many unpleasant activities can simply be avoided.

  2. Change the situation. Do some “engineering” that modifies the situation to make it more manageable or less aversive.

  3. Plan. Good planning can prevent many unpleasant activities.

  4. Say “no.” Learn to say “no” to things that you do not want to do. This is probably the best way to ward off an unpleasant event.

  5. Master the problem. Move toward an unpleasant activity instead of avoiding it. Embrace the activity and see if you can master it.

  6. Limit the activity. If you just do not like some activity, “build a fence” around it. Give yourself a specific amount of time to work on it and no more.

  7. Be careful of your thoughts. If you’re bothered by thoughts of certain activities, separate the reality from what you imagine.

  8. Use the three A’s. Become aware of thoughts and images that are making events more unpleasant, answer them, then act on the new ones.

In-Session Exercise

 

Have clients describe their depression or an event that seems to contribute to their depression. Have them focus on the three A’s involved in overcoming depression. What cues are they aware of in mood, thought, and behavior. Explore with clients the automatic negative thoughts about self and the world that underlie the depression or are manifested in the situation. Have clients answer these thoughts. Have them ask questions of the thoughts or perceptions of self or situation that are outlined in the skill guidelines. Have clients outline the actions that they will use to help challenge their thoughts and behave in a more positive way. This may include active problem solving or modifying positive or negative behaviors.

 

Managing Negative Moods and Depression

Reminder Sheet

 

Use the Three A’s to help overcome your depression

  • Be AWARE of the symptoms of depression.
    • Be aware of your moods and the situations that influence them.
    • Be aware of your automatic negative thoughts.
  • ANSWER these thoughts.
    • Ask questions, challenge the assumptions behind these thoughts.
    • Replace the negative thoughts with positive ones.
  • ACT differently.
    • Use your problem-solving skills to deal with issues that give you worries and concerns.
    • Increase your positive activities.
    • Decrease your involvement in unpleasant activities.
    • Reward yourself for the positive steps you are making.

Practice Exercise

 

Use this worksheet to help you become more aware of the issues involved in your depression and the active steps you can take to change your moods.

  1. What are the ways that I show my depression in my moods, attitudes, and actions? What are my symptoms?


  2. What are the automatic negative thoughts that go along with my depression? What do I think about myself, my current situation, and my world in general?


  3. What questions can I ask myself to challenge these automatic negative thoughts?


  4. What steps am I going to take to act differently? What problem-solving strategies have I come up with to deal with my problems? What pleasant activities might I increase? What unpleasant activities might I avoid or minimize?


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Elective Session: Enhancing Social Support Networks

 

This session was taken from pages 72–76 of the Monti et al. book, with the following modifications.

Rationale

 

Add to rationale item 1:

It is important for abstinent drinkers to work on building social support systems. Often, in the course of a drinking career, drinkers’ social circles narrow to include only other people who drink and who therefore will not be of much support in efforts to quit. Also, many drinkers find it hard to ask for help from family and friends because they feel they’ve disappointed those who have offered support many times in the past. If so, this might be a good time to hold a couples or family session, to go over how the family member can help you cope with situations that may be difficult for you.

Skill Guidelines

 

Add the following after item 2e:

  1. Help with not drinking. Asking your spouse to talk with you or participate in a distracting activity when you are craving; asking a friend or coworker not to offer you drinks or talk about drinking when you are around; asking a parent to handle your money or paychecks for a few months so you don’t have a lot of money lying around; asking a roommate who drinks not to drink around you (have you considered that you might need to get a new roommate?).

In-Session Exercise

 

The following exercise is added:

Make a diagram of your circle of social support. Put yourself in the center, the people who are already important in your life closest to you, people who are currently neutral a little farther away, and people you have not seen for a while or who are negative even farther away. Write in their roles (family, coworker, friend) and what kind of support they do (or could) offer. Circle the people who will be of most help in your efforts to not drink. What kind of support or help could you (or do you) provide them?

 

NOTE: In practice, one of the more convenient methods for enhancing a drinker’s social support network is through involvement in self-help groups. However, in Project MATCH, a self-help, 12-Step facilitation approach is being contrasted with this cognitive-behavioral approach, so it is not permissible for a therapist to suggest or strongly encourage involvement in AA. If the patient suggests AA as a way of enhancing social supports, the therapist should not say anything more compelling than “That sounds like a good idea.” Let it go at that, and go on to help the patient develop some other, non-AA strategies for enhancing social supports.

 

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Elective Session: Job-Seeking Skills

Rationale
    

 

The Job Club is a disciplined approach to assist clients in obtaining satisfying employment. This approach to job finding uses behavioral principles.

 

A major premise of the Job Club is that finding a job is a full-time job, and all job seekers need to treat the problem as such. It must be emphasized that it is as important as therapy. The key elements to job finding are—

  • Development of a resume.

  • Instructions on how to fill out a job application.

  • Using relatives, friends, and the phone book to generate job leads.

  • Telephone techniques to secure interviews.

  • Rehearsal of the interview process.

  • Information on appropriate employment.

Skill Guidelines

The Resume  

 

Developing a positive resume is one of the first tasks. A resume should not leave large gaps between jobs, even if the client was not working due to drinking. These gaps can be handled by stating that the client was self-employed or rethinking his career goals during that period. The resume should be professionally typed and a good cover letter should be developed with counselor assistance. There are forms in the Job Club Counselor’s Manual (Azrin and Besalel l980) to help clients develop resumes.

The Job Application

 

Filling out a job application correctly needs to be taught to many clients. They should learn how to emphasize positive persona1 attributes along with good job skills. Counselors need to work with the patients to make sure they understand how to correctly answer difficult questions.

Generating Job Leads

 

Job finding needs to be done in a matter of fact yet supportive manner. Clients will often take the easy way out and not comply with this critical aspect unless they are given a structure (e.g., the “Job Leads Log”) and are monitored.

 

After completing the resume and learning how to fill out a job application, the patient needs to generate possible job leads. One way is to ask family and friends if they know of any possible employment opportunities. Another is to ask former employers and coworkers. If this fails to generates sufficient leads, advise the client to use the yellow pages of the phone book. For instance, if the client is looking for employment as a salesperson in a lumber yard, look in the yellow pages under lumber yards.

 

To document leads, have the client use the “Job Leads Log” included at the end of this section. It has a place for date, name of company and address, phone number, and space to jot down details during and after the phone call. There is also a place on this form for call backs if necessary. A minimum of 10 job leads are generated before the patient begins to make any phone calls. This list is checked by the counselor to assure that all leads are appropriate.

Telephone Skills Training

 

The next step is to rehearse telephone skills to make sure the client can use the telephone in a positive way. The following is a suggested outline:

  • Introduce yourself by giving your name and then asking for the person who does the hiring.

  • If you get this person on the line, again introduce yourself and make a statement like “I heard that ABC Lumber company is a good place to work, and I would like to come down and discuss with you my qualifications as a lumber yard worker. When can I meet with you?”

  • If you do not get the person that does the hiring, ask for his or her name so you have it when you call back.

 

Other scenarios will occur, and each one has to be discussed and rehearsed so mastery is achieved. Try to get the name of the person who does the hiring beforehand, if possible, so you can ask directly for that person. This may be possible if you get the name from a friend or former coworker.

Rehearsal of Interview Process

 

After job leads are generated and phone calls have secured interviews, train the client, using behavioral rehearsal, in the interviewing process. Reinforce the client at each step of the process. Once clients are ready for the interview, make sure they have proper transportation. Clients must also be prepared to be rejected for employment.

Goal Setting

 

Each day, the client must get 10 new leads, make appropriate telephone calls, write necessary letters, and attend interviews. Success comes from making enough calls to secure enough interviews so the chances of getting a job increase to 100 percent.

Job-Seeking Skills

Reminder Sheet

  1. Finding a job is a full-time job in itself and you need to treat it as such.

  2. The key elements include:

    1. developing a resume,

    2. knowing how to fill out a job application,

    3. using relatives, friends, and the phone book to generate job leads,

    4. using telephone techniques to secure interviews,

    5. rehearsing the interview process, and

    6. deciding what is appropriate employment.

Exercises

 

After this session, job finding should become a daily routine until you are successful in getting a job. Here is a suggested schedule:

  1. Each evening, develop 10 job leads either through friends or with the Yellow Pages.

  2. Get up at the same time each morning and begin making phone contacts at 8:00 a.m. Continue with this through the morning until the first scheduled job interview appointment in the afternoon. If unsuccessful in getting a job interview for the afternoon, spend the afternoon either making followup calls to companies contacted before or develop additional leads rather than waiting until the evening.

  3. If you have the time, try to practice answering possible job interview questions with a friend or family member before going to an interview.

  4. Spend the afternoon attending the job interview you scheduled that morning.

 

Continue with this daily schedule until you are successful. Remember that sticking with it is often the most important thing you can do to get a job.

 

Job Leads Log

DateCompanyPerson's name Telephone number AddressResult of call Second call Third call
DateResultDateResult
          
          
          
          
          
          
          
          
          
          
          
          
          
          
          
          
          
          

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Elective Session: Couples/Family Involvement I

This session is directed toward couples. Appropriate adjustments can be made for use with other family members or significant others.

Rationale

  1. We have asked you to come as a couple. This is because, as you know, drinking affects other areas of your life, including marriage and the family. Spouses usually have some feelings and reactions to their partner’s drinking. Sometimes spouses try over and over to help their partners stop. Sometimes they give up or get angry. Sometimes their well-intentioned attempts to help are resented or make things worse in the long run. (Ask clients if any of these observations rings a bell in their lives and how they feel about the above.)

  2. We have also found that, in many couples, when one person has a drinking problem, there are also marital problems. For one reason or another, couples no longer get the positive rewards out of marriage and each other that they used to. Usually communication between partners is poor, nonexistent, or filled with negative emotions such as anger, withdrawal, heavy silence, or getting needs met outside the relationship (e.g., going out alone).

  3. Another common marital difficulty is that small problems begin to get one down. It becomes harder to make even easy decisions. Eventually, they pile up so that essential tasks do not get done (shopping, paying bills, cleaning house, filling the car with gas). Couples begin to lose their ability to make decisions or solve problems. (Ask client if any of the above is relevant.)

  4. Our goals are to—

    1. Help you work together to achieve sobriety of the drinking partner.

    2. Increase the positive rewards in your marriage.

    3. Learn how to solve problems when they come up.

    4. Develop good communication skills.

[NOTE: Adapted from Abrams et al. 1979, developed with support of NIAAA grant AA–07070, Barbara McCrady, Principal Investigator. The rationale section is taken directly from Session 1, pages 3–4. The Skill Guidelines #l and the first two paragraphs of #2 are directly from Session 4, pages 31–32. Used with permission.]

Skill Guidelines

  1. Stimulus Control. One type of situation that spouses are often concerned about is having alcohol in the house. Many times, a wife will feel that the stocked liquor cabinet, or beer in the refrigerator, is just too much of a trigger for drinking. Some problem drinkers feel similarly, while others find that alcohol in the house does not make much difference. (Ask couple: have the two of you thought about this? Have you discussed it with each other at all?)

  2. Have the couple discuss this topic with each other for a few minutes, trying to come to a decision about how they will handle alcohol in the house. As the therapist, help them follow good listening and communication skills. Encourage both of them to express their own feelings about whether or not to keep alcohol in the house. You may have to get them to paraphrase what the other person is saying to assure that they understand each other. Work toward an initial agreement that they both can live with, and have them implement it during the week.

  3. Reinforcing Sobriety. Besides the one plan already discussed, there are some other ways to view spouse involvement in sobriety. Explain to the spouse that sober behavior can be made more likely by looking at the short-term consequences of staying sober. If people are specifically complimented (rewarded) for staying sober, not just taken for granted, then these pleasant short-term consequences can help them stay sober in the future.

    Have the couple come up with some desirable verbal statements that the spouse and drinker would like to hear, contingent on sobriety. Elicit from them an agreement on three or four verbal rewards that they would like to implement. Suggest that these be implemented for homework, at least one verbal reward per day contingent on sobriety.

    In addition to rewarding sobriety, the couple should also make plans to reward each other for some of the favors they do. Too often, alcohol-involved marriages slip into a cycle of mutual criticism and recriminations. This can be reversed by having each spouse make an effort to praise the other daily for some satisfaction or favor provided. To paraphrase a slogan from Parent Effectiveness Training, they should “catch each other being good.” Have the spouses role play appropriate ways of giving verbal praise.

  4. Problem Solving. The process by which problems are dealt with in a close relationship is a very important aspect of that relationship. Problem-solving skills have already been presented to the identified patient in an earlier session. The steps of that process should be reviewed at this time: (1) recognize that there is a problem, (2) identify the problem, (3) consider various approaches, (4) select the most promising approach, and (5) assess the effectiveness of the selected approach. Discuss each step in some detail with the couple to verify their understanding.

In-Session Exercise

Have the couple identify a problem situation they are presently coping with, or one they can anticipate in the near future. Have them work through each of the first four steps of the problem-solving process together. The therapist may serve as a resource to answer questions, provide suggestions if they get stuck, or keep them on track, but otherwise should let the couple work it through by themselves as much as possible. For the fifth step of the process, the couple should specify acceptable outcomes as well as outcomes that would necessitate a reworking of their approach.

Introducing the Practice Exercise

The assignment has several elements. Go over each one with the couple to make sure they understand what is to be done and how their behavior is to be recorded. Suggest that they continue practicing each element of the assignment regularly until the next conjoint session.

Schedule the next couples session in several weeks.

 

Couples/Family Involvement I

Reminder Sheet

  1. The nonusing spouse should provide at least one verbal reward (praise) each day to the recovering drinker for continuing to be sober.

  2. Both partners should praise each other at least once daily for satisfactions given to each other.

  3. As problems are encountered, they should be dealt with by both spouses together, using the five-step problem-solving process:

    1. Recognize that a problem exists.

    2. Identify the problem as accurately as you can.

    3. Consider various approaches to solving the problem.

    4. Select the most promising approach.

    5. Assess the effectiveness of the selected approach.

Practice Exercises

  1. Implement the plan you came up with during the treatment session regarding alcohol in the home.

  2. The nonusing spouse should reward abstinent behavior verbally at least once each day.

  3. Use the problem-solving process together at least once every week. Write a brief summary of what you did and how it worked. Bring these summaries to the next couples session.

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Elective Session: Couples/Family Involvement II

Review of Practice Exercises

Review the couple’s progress on their plans regarding alcohol in the house, the praise given for sobriety, and their summaries of problem-solving efforts, as assigned at the previous couples session. Provide as much praise as possible for their efforts and accomplishments. Trouble-shoot problem areas or reasons for noncompliance.

Rationale1

(1 The rationale and skill guidelines are taken directly from selected sections of the Monti et al. session on “Close and Intimate Relationships,” pages 68–70.)

  1. There are any number of possible barriers to closeness or intimacy in relationships. Can you generate some examples? These might include distrust, anger, poor self-esteem, fear of failure, withdrawal/isolation, or sex role typing.

  2. Effective communication within close intimate relationships is important for several reasons. Among them are the following:

    1. It helps you and your partner to feel closer to each other.

    2. It promotes better understanding of each other’s point of view and increases your ability to solve difficulties and conflicts.

    3. It decreases the likelihood that resentment and bad feelings over something will build up and affect other areas of your life (e.g., daily bickering over finances or the in-laws may lead to more pervasive negative feelings).

    4. Drinking and relapse are less likely to occur when you have an effective way to respond to difficulties in a relationship.

Skill Guidelines2

(2 The last two paragraphs of the skill guidelines (4 and 5) are taken directly from Abrams et al. 1979, page 58.)

  1. Do not expect your partner to read your mind. That is, don’t expect his/her to know what you think, want, or feel without your expressing it.

  2. Do not let things build up. Frequent contact with a person increases the chance that some of his/her behaviors may bother you. Since the cumulative negative impact of saying nothing about a repeated annoyance can be great, it is important to give constructive criticism at an early point.

    When giving constructive criticism, calmly state the criticism in terms of your own feelings, focusing on the impact that the situation has on you. Criticize specific behavior (e.g., “I feel angry when you leave dirty dishes all over the kitchen”) not the person, and request a change in that behavior (e.g., “I’d appreciate it if you’d remember to rinse your dishes off and put them in the sink when you’re done with them”). Finally, offer to compromise, so that both of you can come away from the discussion feeling that you have gained something (e.g., “I’ll wash the dishes if you leave them rinsed and in the sink”).

    No matter how adept you are at giving criticism appropriately, you must be selective. Stop and think before commenting on irritations. Do not bring them up unless they seem important to you. Bringing up every minor annoyance can put your partner permanently on the defensive.

  3. Express your positive feelings. Many couples have difficulty expressing positive feelings within their relationship, particularly if the level of criticism has been increasing. When criticism occurs in the absence of any expression of positive affect, good feelings get overlooked, and negative feelings become more salient.

    One reason people become reluctant to express positive feelings is the fear that doing so would contradict the criticisms they have made. For example, one partner may refrain from saying that a dinner is good if he/she has criticized the other partner for serving it an hour later than expected. However, it is not inconsistent to verbalize both of these aspects of our reactions to another person’s behavior. A problem arises when we assume that positive verbalizations are not important because “he knows how I feel even if I don’t say it.”

  4. Couples may negotiate fun activities by using quid pro quos. (“I’ll do what you want today in exchange for you doing what I want over the weekend.”)

  5. Go out of your way to offer to do necessary but irksome tasks around the house. Offer to do tasks that one’s partner usually does or complains about. Give to the other without expecting anything back and without saying, I’ll do it only if you do something for me.

Behavioral Rehearsal Role Plays

Ask the couple to identify some situations that are problematic for them. Select one for role playing now and one for the practice exercise. Have the couple discuss how the application of some of the communications skills discussed could help them cope more effectively with the situation selected for role playing. Then have the couple role play the situation, trying to employ those skills. The therapist should provide feedback regarding both the verbal and nonverbal aspects of the role play.

Wrap-Up

Ask the couple to summarize what was most salient and useful from these two couples sessions. What do they plan to practice/apply in the future?

Introducing the Practice Exercise

Although the couple will not have an opportunity to turn in the completed exercise, they should be urged to complete it as a way of continuing the practice they began in the role playing. They should also be urged to make an effort to apply these principles in their relationship on an ongoing basis.

 

Couples/Family Involvement3

(3 The Reminder Sheet is adapted from Monti et al., page 207.)

Reminder Sheet

The following points can be of assistance to you within a close relationship:

  • Do not expect your partner to read your mind.

  • Do not let things build up: Give constructive criticism.

  • Calm down.

  • Stop and think before expressing irritation.

  • State the criticism in terms of your own feelings.

  • Criticize specific behavior, not the person.

  • Request specific behavior change.

  • Offer to compromise.

  • Express your positive feelings.

  • Offer to go along with a fun activity in exchange for doing one that you choose at a later time.

  • Offer to do necessary but irksome tasks around the house.

Practice Exercise

Use the practice exercise in Monti et al., pages 207–208.

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