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

Rationale

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

As drinking increases in severity over time, there appears to be a “funneling” effect or narrowing of social relationships: individuals begin to eliminate sober friends, and their peer group becomes populated with others who support and reinforce continued drinking.

Being with such individuals and former drinking buddies increases the risk of relapse through multiple avenues: (1) overt and covert pressure to drink; (2) conditioned craving associated with people, places, activities, and emotional states related to past drinking; (3) increased positive outcome expectancies about the effects of drinking; and (4) increased access/availability of substances.

Two forms of social/peer pressure are often experienced by individuals in recovery: direct and indirect social pressure.

The former occurs when someone offers the individual a drink directly and up front. This is most likely to happen in high-risk situations. Indirect social pressure involves returning to the same old settings (e.g., taverns, lounges, parties), with the same people, doing the same things, and experiencing the same feelings previously associated with drinking.

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

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

Skill Guidelines

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

If unable to avoid high-risk situations and people, the next level of response is being able to refuse requests to drink. The more rapidly a person is able to say “no” to such requests, the less likely he/she is to relapse.

Why is this so? The old notion of “he who hesitates is lost”; that is, being unsure and hesitant allows you to begin rationalizing (e.g., “One beer wouldn’t be so bad.”). The goal then is to learn to say “no” in a convincing manner and to have your response at the tip of your tongue.

In-Session Practice

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

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

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

Next, provide the clients with the “Social Situations” cards from the “Comprehensive Drinker Profile.”

Have them sort the cards from the most to the least frequent drinking situation. Have the clients indicate which of the people identified in their social network they anticipate contacting during the next 90 days.

Ask them to indicate which of these individuals are likely to support sobriety and which are likely to tempt/pressure them to drink.

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

Modeling

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

Behavioral Rehearsal Role Play

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

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

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

Reminder Sheets and Practice Exercises
These are retained as in Monti et al., page 205.

Source page:
http://pubs.niaaa.nih.gov/publications/MATCHSeries3/core.htm