Homework

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.

Coping Skills Training With Significant Others

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.

Preventing Attrition

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.

Alcohol and Other Drug Use

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.

Absences

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.

Lateness

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.

Extra Sessions

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.

Concurrent Treatment

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.

Clinical Deterioration

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

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.