The treatment approach specified in this manual is based upon a cognitive-behavioral model, with a focus on the training of interpersonal and self-management skills. Research has provided some evidence for the efficacy of cognitive-behavioral approaches with alcoholic patients, but considerably more detailed information is needed. The present manual provides a basis for advancing that work by presenting a clearly specified treatment that can be reliably delivered, monitored, and evaluated.
Outpatient treatment offers considerable opportunity for interaction between the treatment program and the realities of each client’s daily existence. The events of clients’ daily lives can be described in treatment sessions and used as the basis for problem-solving exercises, role plays, and homework assignments. Outpatients have the advantage of being able to practice new skills in a variety of problem situations. This greatly enhances generalization of new behaviors to various aspects of a client’s natural environment. In addition, the outpatient therapist can provide session-by-session monitoring of progress in applying new skills and supervised problem solving to deal with difficulties as they arise.
The primary goal of this treatment is to master skills that will help to maintain abstinence from alcohol and other drugs. In order to develop these skills, clients must identify high-risk situations that may increase the likelihood of renewed drinking. These high-risk situations include precipitants of drinking that are external to the individual as well as internal events such as cognitions and emotions.
Having identified situations that represent a high risk for relapse to drinking, clients must develop skills to cope with them. In this program, all clients are first taught basic skill elements for dealing with common high-risk problem areas; they are encouraged to engage in problem solving, role playing, and homework practice exercises that will enable participants to apply the new skills to meet their own particular needs.
[NOTE: This overview makes extensive use of material from chapter 4, “Treatment Considerations for Inpatient and Outpatient Settings” (Monti et al.1989). © Guilford Press. Used with permission.]
Cognitive behavioral treatment for alcohol abuse requires active participation by individual clients as well as their assumption of responsibility for learning the necessary self-control skills to prevent future abuse. Through active participation in a training program in which new skills and cognitive strategies are acquired, an individual’s maladaptive habits can be replaced with healthy behaviors regulated by cognitive processes involving awareness and responsible planning.
Patients must get a chance to build their actual skills during role plays and to receive constructive feedback using relevant (client-centered) problems rather than simply discussing or reflecting on material. Active participation, modeling, and practice with positive, corrective feedback are the most effective ways to modify self-efficacy expectations and create long-lasting behavior change.
Since behavioral approaches to treatment are sometimes misunderstood as “cookbooks” to be applied without careful consideration of the unique needs of the individual receiving treatment, it is important that therapists be experienced in psychotherapy skills as well as behavioral principles. In addition, they must have good interpersonal skills and be familiar with the materials so as to impart skills successfully and serve as credible models. They must be willing to play a very active role in this type of directive therapy.
Despite this behavioral approach, many of the basic rules for conducting psychotherapy apply. Therapists must use many traditional therapy skills (e.g., establishing rapport, limit setting, empathy), while functioning as active teachers and role models.
Prior to each treatment session, therapists are encouraged to reread relevant sections of the manual. To ensure that the main points of each session are covered, we recommend outlining them or highlighting them in the text. In presenting the didactic material, we suggest briefly paraphrasing the main points and listing them on a chalkboard or flipchart.
Although standardization is essential when conducting a clinical trial, and covering all important points is desirable, it is essential that the desire to comply with the treatment protocol not lead to reading to clients from the text. As long as the major points are covered, a natural, free-flowing presentation style is preferred. It is crucial that clients not get the message that the therapist’s agenda of adhering strictly to the manual is more important than the issues and concerns that constitute the client’s personal agenda.
Indeed, if clients are not routinely involved and encouraged to provide their own material as examples, we have found that treatment becomes boring and the energy level for learning drops off dramatically. Therapists may experience burnout as a result. Effective reinforcement of clients for their active participation can help prevent burnout on the part of both clients and therapists.
The “Rationale” and “Skill Guidelines” sections of each session are intended to provide therapists with adequate background information to guide discussion of the topic. Although the topics covered usually generate discussion that is meaningful, the discussion must be shaped by the therapist to prevent it from shifting focus onto other clinical issues. Since the treatment session can pass very quickly, it is important that the therapist keep the presentation of the rationale and skill guidelines brief, to allow adequate time for role playing, feedback, and discussion.
One self-disclosure issue likely to come up at the beginning of therapy is the drinking practice of the therapist.l Therapists differ as to whether or not to answer this question directly; however, we agree with Vannicelli that the real concern that is usually being expressed is “Will you, therapist, be able to understand me, and can I get the kind of help here that I need?” (p. 21). Thus, although we leave the specific answer to this question up to the therapists’ judgment and individual therapeutic styles, we do encourage them to acknowledge to the client asking the question that they hear the underlying message. Acknowledgment of the clients’ underlying concern, coupled with an invitation to clients to judge the value of this program for themselves, usually is adequate.
(1 Vannicelli, M. Group therapy with alcoholics: Special techniques. Journal of Studies on Alcohol 43:17–37,1982.)
When using this manual in a controlled research project, it is crucial that the guidelines in the manual be strictly followed. Deviations will add “noise” to the study, and supervision will therefore focus on adherence to the manual. If the concept of manual-based treatment is troublesome, or if any of the demands made by this particular manual seem difficult to follow or are incompatible with a therapist’s style or beliefs, this should be discussed in supervision as soon as possible.
A word is needed about the sequence in which clients are exposed to the various topics. An ambulatory program presents an inherent conflict regarding the order in which skills are taught and rehearsed.
Good teaching practice demands that skills be taught in a logical sequence, in which more basic topics are covered first and serve as the foundation for subsequent presentation of higher order skills. However, there is a conflicting need to help clients deal with immediate threats to their sobriety, which may lead them to an early relapse and undermine their continuation in the program. Therefore, sessions such as “Managing Thoughts About Alcohol” and “Drink Refusal Skills,” which might otherwise have come late in the program after more fundamental skills have been acquired, are instead presented early to give clients the tools to cope with situations that may overwhelm them and lead them to relapse or drop out of treatment. Another session, “Problem Solving,” consists of a complex set of cognitive skills that would be more appropriately taught late in the program but is instead also presented early to provide clients and therapists with a common language and framework for dealing with problems and crises in clients’ lives that can lead to early relapse. Following these sessions, other topics may be selected based on their potential for helping clients cope with high-risk situations that they may face or based on the client’s apparent skills deficits.
This cognitive-behavioral treatment program is composed of eight core elements to which all the clients will be exposed. There is also a menu of additional sessions that may be selected based on the therapist’s assessment of a client’s problems or on needs or desires expressed by the client. Although it may be obvious to the therapist which of the elective topics should be included, it is advised that clients be allowed to participate as much as possible in making the selection. If a difference of opinion on the choice of sessions arises between clients and therapist, it is probably advisable to defer to the patients, in the interest of maximizing their involvement in treatment.
The overall treatment goals and methods are the same for those sites doing outpatient or aftercare treatment. At the outpatient treatment sites, however, the focus is more on achieving abstinence and managing some of the problems of early recovery. The choice among which optional sessions to include may be determined in part by problems that are likely to pose an imminent threat to the client’s sobriety.
At the aftercare sites, the focus is more on maintenance of sobriety. Clients have already been exposed to an intensive treatment program and may have received training in some of the skills offered here. They nevertheless should be given all the core elements of this program, but the choice among the optional sessions may be guided by a client’s need for additional skill building or by topics that may not have been covered during the prior treatment.
Clients experience numerous problems, cravings, and actual slips as they struggle with sobriety. Although the focus of the sessions must be on the structured program, ignoring clients’ real life problems entails the risk that they will view treatment as peripheral or irrelevant to their current needs. As a compromise between the demands of the protocol and the clients’ perceived needs, it is suggested that 15–20 minutes be spent at the outset of each session discussing current problems.
Efforts should be made to structure these discussions along lines that are consistent with a skills-training approach. This can be accomplished most easily using the problem-solving format presented in session 3. In subsequent sessions, this format should be used whenever possible in discussing clients’ problems. However, problem solving will not be appropriate for all situations that are brought up. In such instances, a functional analysis may be helpful, focusing on identification of the ABC’s (antecedents, behavior, consequences) and on ways that the patient can try to change them. The general rule is that these opening discussions should be structured along behavioral lines to keep them consistent with the approach of this manual.
There is frequently conflict between the desire of clients to get help with their immediate problems and the desire of the therapist to get on with the day’s agenda. As a result, the first phase of a session often lasts longer than the therapist would like but shorter than the client desires. Clients must be reminded that this time-limited therapy cannot always explore problems to the point of complete resolution. In Project MATCH, if serious problems arise repeatedly, the project coordinator is consulted. Criteria have been developed to determine if additional treatment is needed or if participation in the program is in the patient’s best interest.
After the initial period of supportive therapy, the structured portion of the session is initiated with a review of the skills taught in the preceding session and of the homework assignment. New material is then introduced, beginning with the rationale, which emphasizes the relationship of the new skills both to maintaining sobriety and to dealing with problems that are commonly faced by recovering alcoholics. The skill guidelines are presented verbally, listed on a chalkboard or poster board, and printed in handouts for the client to take home. It is critically important that therapists not spend large amounts of time lecturing to clients. It is essential that the therapist solicit input and reactions from the clients during the presentation of the rationale and skill guidelines sections to engage their interest and prevent them from tuning out. Therapists model the performance of the skills, and clients are then encouraged to generate role-play scenes based on their daily experience.
Role playing is viewed as a critical part of the experience, and at least one-third of each session should be allocated to it. Nevertheless, it is sometimes a struggle to engage clients in role plays. Therapists may have to provide considerable structure and encouragement to get the process underway.
There is a danger that, with such a full agenda and such highly structured sessions, the clients may come to feel that the therapist’s agenda is more important than their own needs. Therefore, it is essential that the therapist not read from written material or be too rigid in following the set agenda and strive as much as possible to provide examples from material that the client has previously brought up. Usually this is not difficult, because the skills-training sessions cover commonly encountered problems that are likely to have been raised already by the client. Occasionally, it is necessary to sharply curtail a session’s agenda in order to deal with some individual crisis. However, this should be a rare event and avoided as much as possible.
Behavior rehearsal plays a central part in this skills-training program and is the main strategy by which clients acquire new skills. Each session provides a safe haven where clients can practice and improve their skills prior to trying them in the real world. Although some amount of discussion during the introduction to each new skill is useful, therapists should discourage lengthy discussion about problem situations and instead should focus on setting up and processing role plays.
Clients normally feel a bit uncomfortable or embarrassed at first about role playing. Therapists should acknowledge that this is a normal reaction and that behavior rehearsal becomes easier after a few experiences with it. After a while, participants are able to get into a scene more realistically and to focus on their role in it. Resistance can take subtle forms, such as focusing on other issues or asking many questions. Therapists can acknowledge that they also feel uncomfortable role playing. They may have to take the lead and demonstrate the first role plays.
Therapists should encourage clients initially to generate and describe personally relevant scenes that are of only moderate difficulty. As clients demonstrate ability to handle these situations effectively, they should be encouraged to generate and practice more difficult ones. An adequate description of a scene will include specifying where it takes place, what the primary problems are, whom the role play partner should portray (boss, stranger, child, spouse, date), relevant behaviors of the person portrayed so that the partner can act accordingly, and specification of the client’s goal in the interaction.
The following strategies are useful in helping clients to generate scenes:
Ask clients to recall a situation in the recent past where use of the new skill being taught would have been desirable (e.g., a client wanted to start a conversation but could not; another yelled at a neighbor about an unleashed dog tearing up the garden; another wanted to express positive feelings toward his spouse but could not without drinking first).
Ask clients to anticipate a difficult situation that may arise in the near future and that calls for use of the skill (e.g., a client’s apartment has been cold this winter and she wants to ask the building owner to raise the setting on the thermostat; another client is going to a retirement party this weekend and will be offered alcoholic drinks).
Therapists can suggest appropriate situations based on their knowledge of a client’s recent circumstances.
It is essential that every role play be effectively processed. It is an opportunity for clients to receive praise/recognition for practice and improvement as well as constructive criticism about the less effective elements of their behavior. During this portion of the session, the therapist’s primary goals are to identify specific problem areas and to shape and reinforce successive approximations to more effective communication skills.
Immediately after every role play, the therapist should reinforce the client for participating. Next, the therapist and the client should both give their reactions to the performance (e.g., How does the protagonist feel about the way he handled the situation? What effect did the interaction have on the partner?).
The therapist then offers comments about the role play. These comments should be both supportive/reinforcing and constructively critical. If a role play performance has several deficiencies, the therapist should choose only one or two to work on at a time. All positive and negative feedback should focus on specific aspects of the person’s behavior, since global evaluations do not pinpoint what was particularly effective or ineffective. Finally, the praise/reinforcement provided should always be sincere. The therapist should refrain from being unnecessarily effusive so that the value of the positive feedback is not undermined. Therapists may repeat a scene to give clients an opportunity to try out the feedback they received the first time around.
Role reversal” is a role-play strategy in which the therapist models use of a new skill, with the client playing the role of the target person (e.g., spouse, employer, neighbor). This strategy is particularly useful if clients are having difficulty using a skill or are pessimistic about the effectiveness of a suggested communication approach. By playing the “other,” they have an opportunity to observe and to experience firsthand the effects of the suggested skill.
Homework is a powerful adjunct to treatment, because real life situations can be utilized for practice, enhancing the likelihood that these behaviors will be repeated in similar situations (generalization). A preplanned homework exercise has been designed for every session of this program. Most require that the clients try in a real life situation what they have already role played in the session. The homework assignment also requires that the clients record facts concerning the setting, their behavior, the response they evoked, and an evaluation of the adequacy of their performance. Homework exercises can be modified to fit the specific details of individual situations more closely, and extra homework assignments are sometimes given to help clients cope with problem situations they have encountered.
Compliance with homework is often a problem in behavior therapy. A number of steps are taken to foster compliance:
The assignments may be referred to as “practice exercises” to avoid the negative connotations often associated with the term “homework.”
When giving each assignment, the therapist should provide a careful rationale and description of the assignment.
Ask the client what problems can be foreseen in completing the assignment, and discuss ways to overcome these obstacles.
Ask clients to identify a specific time that can be set aside to work on the assignment.
- The therapist should review the preceding session’s exercises at the beginning of each session, making an effort to praise all approximations to compliance with the assignment.
Although problems that clients have with the exercises should certainly be discussed and understood, the main emphasis is on reinforcing the positive aspects of performance. For those who did not do an assignment, discuss what could be done to ensure compliance with the next assignment. No contingencies other than social praise or disapproval are imposed by the therapists to enhance compliance with homework assignments.
Clients are strongly urged to bring in their spouse, someone they live with, or a close supportive friend for two of the sessions. The emphasis in these sessions should be placed on interpersonal skills-training topics, saving the more individually focused cognitive and intrapersonal exercises for individual therapy sessions. Communication skills training can be beneficial to clients and significant others for reducing dysfunctional interactions.
As an illustration, a spouse may challenge/criticize an alcoholic in a suspicious manner that, while intended to prevent drinking, may actually exacerbate the situation and increase the likelihood of drinking. The client and spouse can be taught directly, in role plays with each other, how to give and receive criticism in a more adaptive fashion. If the role play and feedback reduce misunderstanding and improve communication, then maintenance of sobriety is more likely.
Occasionally, the relationship between a significant other and the alcoholic is so conflicted that effective role playing cannot take place. In these circumstances, it is helpful to first have the therapist model the skills in question. Following this, the significant other is paired with the therapist and the scenario is repeated. Next, the alcoholic role plays with the therapist. Finally, the alcoholic is paired with the significant other. By this time, after receiving feedback on several role plays, the pair may be better equipped to engage in effective role playing together.
In couples with a great deal of marital distress, it is best not to try to deal with all of the complex marital, and perhaps sexual dysfunction, issues. Limit the skills-training focus to more basic, safe skills (e.g., giving and receiving compliments, criticism, assertiveness, nonverbal behavior).
Although it is essential to explore communication concerning drinking behaviors and triggers of drinking, such exploration may lead to more deep-seated marital conflicts over trust, anger, intimacy, abandonment, dependency, and narcissistic needs. Sometimes these issues can be dealt with briefly, but they tend to require large amounts of time, and consequently the didactic skills materials may not get covered. The therapist needs to bring the focus back to the specific observable behaviors that appear to be functionally related to drinking or poor communication skills.
In the first session, it is important to anticipate potential obstacles to successful treatment, especially factors that may lead to early attrition. Therefore, the therapist should explore any instances in which clients previously dropped out of treatment and advise clients that they should discuss any thoughts of quitting treatment. Such thoughts are not uncommon, and open discussion can resolve problems before clients drop out. Progress in treatment is not steady—there are ups and downs. Most clients experience hopelessness, anger, frustration, and other negative feelings at times. Clients should be advised to discuss such feelings, even if they fear that it might be embarrassing to the therapist.
It is useful for the therapist to point out that terminating treatment may be one of a series of “seemingly irrelevant decisions” that eventually lead to a client’s later drinking. For this reason, any hint that a client is considering dropping out should be taken very seriously and fully discussed.
Many clients quit treatment after their first drinking episode. Clients should be warned that, even with efforts to maintain abstinence, some of them may slip and begin drinking. At the first session, they should be told not to come to treatment intoxicated, but they should be strongly encouraged to continue to attend after a drinking episode so that they can receive help in regaining sobriety, coping with their reaction to the slip, and avoiding future lapses.
There is a delicate balance between setting the stage for clients’ feeling that it is permissible to return after a lapse and actually giving them permission to drink. Therapists should take care that clients understand this distinction.
Clients are asked to accept the goal of total abstinence from alcohol and all nonprescribed psychoactive drugs, at least for the duration of treatment. They are also asked to talk about any drinking or drug use that occurs and about any cravings or fears of relapse that they experience. They are told that it is common to have some ambivalent feelings about accepting abstinence as a goal, and they are encouraged to discuss these feelings as well as any actual slips that might occur. Clients are allowed to continue even after an episode of alcohol or other drug use, as long as they make the commitment to work toward renewed abstinence. However, they are asked not to come to a session under the influence of alcohol and other drugs because they would not be able to concentrate on or recall the topics covered.
In this program, anyone found to be under the influence of alcohol or other drugs is asked to leave the session. This is done in such a way that clients do not view it as a punishment; anyone asked to leave is encouraged to return to the next session sober and to continue in treatment.
Clients asked to leave are not allowed to drive themselves home. Their car keys are taken away, and they are asked to arrange safe transportation with a family member, a friend, or public transportation.
When discussing episodes of drinking or drug use, emphasize that these are common occurrences. An atmosphere of openness about this topic should be fostered. Clients are encouraged to conduct a functional analysis of their alcohol use and of urges to drink, identifying specific people, places, events, thoughts, emotions, and behaviors that preceded and followed the drinking or urges.
Clients are given specific guidelines for dealing with the immediate aftermath of a drinking episode. They are advised to get rid of the alcohol, remove themselves from the setting in which the drinking occurred, and call someone for help (a friend or spouse). They are cautioned about feelings of guilt and self-blame that often accompany a slip and are warned not to allow such reactions to prompt further drinking.
Guidelines are also given for dealing with the longer term impact of drinking episodes. Clients are urged to examine a slip with someone, not to sweep it under the rug. They are advised to analyze possible triggers, including the who, when, and where of the situation and anticipatory thoughts. Did they expect substance use to change something or meet some need? Reactions to the drinking episode should also be analyzed, including behavior, thoughts, and feelings, with special attention to feelings of guilt, depression, and self-blame. Clients are warned about catastrophizing thoughts, such as “Here I go again; I guess I’ll never change” or “I’ll quit again after I finish this bottle.” If allowed to proceed unchecked, these common reactions can contribute to further drinking. The value of reminder cards, listing the troubles that addictive behavior has caused and the benefits that sobriety has brought, is stressed.
If a client does not come for a scheduled therapy session, the therapist should immediately attempt to contact the client by telephone to ascertain why the session was missed and to reschedule if possible. If the therapist is unable to contact the client within 2 days by telephone, a brief letter should be sent to the client. (In Project MATCH, the project coordinator is in charge of sending the letter.) It is important that all reasonable efforts be made to keep clients in treatment. These efforts are continued until clients miss two sessions or clearly state that they wish to quit. When clients return after an absence, they are urged to make future attendance a priority and to make whatever arrangements are necessary to avoid further absences.
Therapists should convey the attitude that sessions are too important to waste time by being late and should make reasonable efforts to help clients solve whatever problems may be causing them to be late.
If a client is less than 15–20 minutes late, the session should take place and end at the regularly scheduled time. If a client is more than 25 minutes late, the therapist should attempt to reschedule within the next few days.
Some patients will request extra sessions with the therapist, particularly in the early weeks of treatment. The need for extra sessions should be determined by the clinical judgment of the therapist, based on the seriousness of the situation. The maximum number of permissible extra sessions in the Project MATCH protocol is two (making the maximum number of sessions 14). If a patient requires more than two additional sessions with the therapist, the possibility of clinical deterioration and/or withdrawal from the study is considered.
In Project MATCH, certain limitations are placed on participation in other forms of therapy during the 12-week intervention period. Since 12-step treatment is another modality in this clinical trial, therapists in the cognitive-behavioral modality are instructed to assume a neutral stance toward clients’ participation in 12-step fellowship activities. Attendance at Alcoholics Anonymous (AA) is neither encouraged nor discouraged. If therapists have difficulty with this requirement, they discuss their concerns at once with their project coordinator, supervisor, or training staff.
In addition, Project MATCH clients may not be seen by other mental health professionals for more than a total of 6 contact hours during their 12 weeks of treatment in the study. If clients express interest in other forms of treatment, they are urged to postpone them, if possible, until after this treatment is completed.
Criteria have been developed to define clinical deterioration. All instances must be reviewed with the project coordinator. These include development of acute psychosis, suicidal or homicidal ideation, onset of cognitive impairment, deterioration of physical health, and extensive drinking or drug use. Project MATCH has developed procedures for responding to these developments, and therapists are instructed to review them with the project coordinator at the first indication of a problem.
Termination can be problematic for many clients, and can lead to clinical deterioration or acting out prior to the end of treatment. About 4–5 weeks before the end of treatment, therapists should review the session on termination to sensitize themselves to the issues involved and to ensure that they respond to them in a manner consistent with this manual.