This manual for therapists is provided to the public to permit replication of the treatment procedures employed in Project MATCH, a multisite clinical trial of patient-treatment matching sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). It describes Cognitive-Behavioral Coping Skills Therapy (CBT), one of three treatment approaches studied in Project MATCH. Therapist manuals for the other treatments—Twelve-Step Facilitation Therapy (TSF) and Motivational Enhancement Therapy (MET)—are available in volumes 1 and 2 of this series, respectively.
for Patient-Treatment Matching
Although a number of therapies have had varying degrees of success, no single treatment has been shown to be effective for all individuals diagnosed with alcohol abuse or dependence. In recent years, interest in the field has increasingly focused on patient-treatment matching to improve outcome. The hypothesis is that more beneficial results can be obtained if treatment is prescribed on the basis of individual patient needs and characteristics as opposed to treating all patients with the same diagnosis in the same manner.
Many investigators have turned their attention from main effects evaluations (i.e., studies that ask whether one intervention is more effective than another) to studies specifically designed to identify interactions between particular treatments and patient variables. While treatments may not appear to differ in effectiveness when applied to a heterogeneous client population, specific treatments may indeed be more or less effective for specific, clinically meaningful subgroups.
This reasoning has led to a new generation of alcoholism treatment research studies whose design is driven by the objective of finding effective “matches.” Ultimately, the goal of this line of research is to provide the clinician with valid and practical rules applicable across a variety of treatment settings to assign patients to those treatment regimens particularly suited to them.
MATCH: An Overview
Project MATCH, a 5-year study, was initiated by the Treatment Research Branch of NIAAA in 1989. The details of the design and implementation of Project MATCH will be described in full in forthcoming publications. This section outlines the major features of the study.
The objective of Project MATCH is to determine if varying subgroups of alcohol abusing or dependent patients respond differentially to three treatments: (1) Twelve-Step Facilitation Therapy, (2) Cognitive-Behavioral Coping Skills Therapy, and (3) Motivational Enhancement Therapy. Each treatment is delivered during a 12-week period by trained therapists following a standardized protocol.
The project consists of two independent treatment-matching studies, one with clients recruited at five outpatient settings, the second with patients receiving aftercare treatment at four sites following an episode of standard inpatient treatment. Patients are randomly assigned to one of the three treatment approaches. Each study evaluates the interaction effects between selected patient characteristics and the three treatments.
Each of the nine study sites is recruiting approximately 150-200 clients. Clients are evaluated at intake and again at 3, 6, 9, 12, and 15 months. Outcome measures for the trial include drinking behavior, psychological and social function, and consequences of drinking. Analyses of a priori hypotheses, as well as exploratory analyses, will show whether different patient characteristics are associated with differential treatment outcomes in each of the three therapeutic interventions.
This therapy is based on the principles of social learning theory and views drinking behavior as functionally related to major problems in the person’s life. It posits that addressing this broad spectrum of problems will prove more effective than focusing on drinking alone. Emphasis is placed on overcoming skill deficits and increasing the person’s ability to cope with high-risk situations that commonly precipitate relapse, including both interpersonal difficulties and intrapersonal discomfort, such as anger or depression. The program consists of 12 sessions with the goal of training the individual to use active behavioral or cognitive coping methods to deal with problems, rather than relying on alcohol as a maladaptive coping strategy. The skills also provide a means of obtaining social support critical to the maintenance of sobriety.
Twelve-Step Facilitation Approach.
This therapy is grounded in the concept of alcoholism as a spiritual and medical disease. The content of this intervention is consistent with the 12 Steps of Alcoholics Anonymous (AA), with primary emphasis given to Steps 1 though 5. In addition to abstinence from alcohol, a major goal of the treatment is to foster the patient’s commitment to participation in AA. During the course of the program’s 12 sessions, patients are actively encouraged to attend AA meetings and to maintain journals of their AA attendance and participation. Therapy sessions are highly structured, following a similar format each week that includes symptoms inquiry, review and reinforcement for AA participation, introduction and explication of the week’s theme, and setting goals for AA participation for the next week. Material introduced during treatment sessions is complemented by reading assignments from AA literature. M
Motivational Enhancement Therapy.
MET is based on principles of motivational psychology and is designed to produce rapid, internally motivated change. This treatment strategy does not attempt to guide and train the client, step by step, through recovery, but instead employs motivational strategies to mobilize the client’s own resources. MET consists of four carefully planned and individualized treatment sessions. The first two sessions focus on structured feedback from the initial assessment, future plans, and motivation for change. The final two sessions at the midpoint and end of treatment provide opportunities for the therapist to reinforce progress, encourage reassessment, and provide an objective perspective on the process of change.
and Critical Considerations
Although all three manuals were developed for a randomized clinical trial focusing on patient-treatment matching hypotheses, the substance of the interventions is equally suitable for other research questions and designs. However, the reader needs to be aware of the parameters of Project MATCH.
Therapy is delivered in a structured research situation. All three treatments are manual guided and administered by experienced therapists who receive specialized training in one of the three project interventions. Therapists closely follow the procedures outlined in their manual, with regular supervision (by observation of videotapes) from both local and projectwide clinical supervisors.
This manual is written for therapists with similar intensive training and supervision. A summary of the procedures used to select, train, and supervise therapists in Project MATCH is provided in appendix B.
There is an important difference between a therapy textbook and a therapy manual. A therapy textbook is a comprehensive presentation of a particular therapeutic approach, usually describing a conceptual model, general principles, and a broad range of applications and examples. It is typically meant to facilitate broad utilization of a therapeutic approach by a wide range of practitioners in a variety of settings. A therapy manual, on the other hand, is intended to operationalize and standardize a treatment approach to be used in a particular context, usually a specific clinical trial. In writing a therapy manual, the authors must make a number of specific decisions (e.g., the number and timing of sessions, the content of each session) that are ordinarily left to clinical judgment in a therapy textbook.
This manual is designed to standardize CBT as a 12-session treatment modality within the particular context of Project MATCH. All treatments are preceded by the same extensive assessment battery, requiring approximately 7–8 hours. Abstinence is the expressed goal of all treatments, and except in unusual situations, all sessions are videotaped. Each treatment session is preceded by a breath test to ensure sobriety, and a positive breath alcohol reading results in rescheduling the session. Therapists are prohibited from mixing CBT with other treatment approaches, and the purity of approach is maintained by local and national supervisors who review videotapes. All therapy has to be completed within 90 days. A significant other can be invited to participate in up to two sessions.
Other design requirements of clinical trials are likewise standardized across all sites, including features such as defined patient eligibility criteria, randomized assignment of treatment, and guidelines for dealing with patients who are late or absent for treatment sessions or who show significant clinical deterioration during the course of the intervention. Guidelines regulate and document the amount and type of therapy over and above that provided by Project MATCH that a client receives during the study. Data collection and delivery of treatment are kept strictly separate, with the former being handled by research assistants under the supervision of the project coordinators. The three manuals refer to these Project MATCH-specific procedures with the knowledge that some readers may wish to follow similar guidelines, while others may choose to devise new guidelines more appropriate to the requirements of their own project.
The therapeutic approach that underlies this manual is described in the references cited in the bibliography. The specific session-by-session instructions to the therapists were drawn from a number of sources. Chief among these was a previously published therapists’ manual, Treating Alcohol Dependence: A Coping Skills Training Guide by Monti, Abrams, Kadden, and Cooney (1989). The integration of material from the Monti text and other source material as well as the modifications introduced to address the requirements of Project MATCH are described in detail in the introduction.
The general therapeutic principles underlying CBT can be applied in many other ways than those delineated here. Under ordinary circumstances, the number, duration, and distribution of sessions could be flexible. Significant others might be involved in all sessions or none at all. The goals of therapy might be more flexible, and cognitive-behavioral procedures could be intermixed with other therapeutic strategies. The specific prescriptions outlined in this manual are imposed for purposes of standardization and separation of treatments in Project MATCH.
The staff of Project MATCH and NIAAA make no claims or guarantees regarding the effectiveness of the treatment procedures described in this manual. Although the principles of CBT are well-grounded in clinical and experimental research, the specific efficacy of CBT as outlined in this manual remains to be tested. The final reports of Project MATCH will provide clearer information on the efficacy of this approach relative to others and on the types of clients for whom it may be optimal. In the interim, this manual offers a detailed description of CBT procedures as constructed by consensus among the investigators and implemented by the therapists of Project MATCH. All manuals of this kind should be regarded as under development and subject to ongoing improvement based on subsequent research and experience.
The planning and operation of Project MATCH and the products now resulting from it, including this series of manuals, reflect the efforts of many individuals over a period of several years. Their dedication and collegial collaboration have been remarkable and will enrich the field of alcoholism treatment research for years to come.
Margaret E. Mattson, Ph.D.
Project MATCH Staff Collaborator
Project MATCH Monograph Series Editor
Division of Clinical and Prevention Research
National Institute on Alcohol Abuse and Alcoholism