Behavioral Marital Therapy Couples Groups for Male Alcoholics and Their Wives

Transcription

1 Journal ofsubstance Abuse Treatment, Vol. I, pp Printed in the USA. All rights reserved. Copyright /84 $00 +.oo Q 1985 Pergamon Press Ltd ORIGINAL CONTRIBUTION Behavioral Marital Therapy Couples Groups for Male Alcoholics and Their Wives TIMOTHY J. O FARRELL, PhD VA Medical Center and Harvard Medical School HENRY S.G. CUTTER, POD VA Medical Center and Brandeis University Abstract- This article presents in detail the clinical procedures for a behavioral marital therapy (BMT) couples group for male alcoholics. Methods used to recruit and prepare couples for therapy are presented. In the BMT couples group, therapists use behavioral rehearsal and weekly homework assignments to help couples (a) decrease drinking and alcohol-related interactions by making an Antabuse Contract and discussing relapse prevention; (b) plan shared recreational activities; (c) notice, acknowledge, and initiate daily caring behaviors; (d) learn communication skills of listening, expressing feelings directly, and the use of planned communication sessions; and (e) negotiate desired changes using positive specific requests, compromise, and written agreements. Methods for deaiing with resistance and noncompliance in the group are also described. Finally, modtfications in the BMT treatment package presented here that may be helpful in other settings are described. Keywords-Marital therapy for alcoholics, couples groups for alcoholics, behavioral marital therapy, alcoholics marriages. INTRODUCTION MARITAL AND FAMILY THERAPY have been described as the most notable current advance in psychotherapy for alcoholism (Keller, 1974). Steinglass (1976) traced the development of marital and family treatment approaches to alcoholism. He indicated that the field started with the treatment of each spouse separately in either individual or group therapy and developed into the conjoint treatment of both spouses together. More recently, the marital treatment of alcoholics has progressed to the most popular current methodmultiple couples group therapy. This approach has received empirical support (Cadogan, 1973) and is considered the treatment of choice for married al- The clinical methods described in this paper were developed in a research project supported by the Veterans Administration and by Ayerst Laboratories. Requests for reprints should be sent to Timothy J. O Farrell, Alcohol and Family Studies Laboratory, VA Medical Center (151D), Brockton, MA coholics by some (Gallant, Rich, Bey, & Terranova, 1970). Although alcoholics frequently have extensive and serious marital problems, they very often do not receive up-to-date, state-of-the-art counseling for these problems. Two recent surveys of alcoholism treatment settings showed that despite the great interest and enthusiasm for marital and family therapy noted in alcoholism publications and conferences, the provision of marital and family treatment is not widespread (Regan, Connors, O Farrell, & Jones, 1983; Camacho-Salinas, O Farrell, Jones, & Cutter, 1984). One reason for this state of affairs is that many alcoholism treatment personnel have little or no training in marital and family therapy (Steinglass, 1976). In addition, as Orford (1975) has noted, until very recently the study of alcoholics marriages has occurred in isolation from the larger literature on marriage and the family, a field of study that has experienced a number of advances in the past lo-15 years. The goal of our ongoing clinical research program has been to apply the most promising marital therapy

2 192 T. J. G Farrell and H.S. G. Cutter methods available to the troubled relationships of male alcoholics and their spouses. Early suggestive findings with nonalcoholics (Jacobson 8~ Martin, 1976; Patterson, Weiss, & Hops, 1976; Stuart, 1%9) encouraged us to direct our research to the use of behavioral marital therapy (BMT) with alcoholics. This choice has been validated by the results of a number of later studies that converge to suggest that BMT deserves serious evaluation in the treatment of alcoholism. The behavioral nonmarital treatment of alcoholism currently shows promise (Miller & Hester, 1980), and among nonalcoholic populations behavioral approaches to marital therapy are equal or superior to nonbehavioral methods (Jacobson, 1978). Also, although methodologically adequate studies have yet to be accomplished, preliminary studies report very good results using BMT with alcoholics (O'Farrell & Cutter, 1977). The authors have been conducting a research project in the Alcoholism Clinic of the Veterans Administration (VA) Medical Center in Brockton, Massachusetts. The goals of this project were to develop and evaluate BMT couples groups as an adjunctive treatment to individual counseling for newly abstinent male alcoholics. This article describes the clinical procedures we have used in some detail in order to provide relevant, practical information about the conduct of these BMT couples groups with alcoholics. It is hoped that by making this behavioral format for a couples group available to alcoholism practitioners, the use of these promising BMT methods in alcohol treatment programs, many of which now use nonbehavioral couples groups, will be encouraged. RECR-T AND PREPARATION OF COUPLES FOR TREATMENT In a few cases where the couple had already separated or the wife was making serious threats of separation or divorce, the husband or the alcoholism counseling staff sought out the couples group project staff. However, in most cases both staff and patients saw the drinking as the major problem and were not likely to seek couples group therapy. Consequently, recruitment efforts were necessary. These initially consisted of group educational sessions with the alcoholics about alcoholism and marriage and personal interviews to invite each husband to talk with his wife about the project. A monthly Couples Information Night (GIN) was begun, an educational session in the alcoholism clinic for couples. Written invitations and confirming phone calls were made to each potential couple. A special effort was made to talk with the wife since the majority of wives at least recognized that alcoholism had damaged their marriage relationship. At the CIN a rationale for couples therapy when an alcoholic stops drinking, which Table 1 outlines, was presented and discussed. In this short lecture it was stressed that once the alcoholic has begun successfully to abstain, abusive drinking may be gone, but it is not forgotten. The wife s resentment about past drinking and fear and distrust about the possible return of drinking in the future, coupled with the alcoholic s guilt and desire for recognition of improved drinking behavior, often lead to an atmosphere of tension and unhappiness in the marital relationship. Few positive interactions or enjoyable activities occur, and both the alcoholic and wife may become aware of extensive relationship problems. First, there are drinkingcaused problems (e.g., bills, legal charges, embarrassing incidents) that still need to be dealt with. Second, a backlog of other unresolved marital and family problems that the drinking obscured or prevented resolution of often exists. These problems may be perceived as having gotten worse since the drinking improved, although generally this is simply a recognition of problems that have existed for a long time TABLE 1 What Happen8 in an Alcoholic s Momlogo When Drlnklng Stopa: A RatIonale for Couplr Therapy wlth Alcohollcs Status of the Alcohoilc Husband s Drinking Aspect of Marriage Active Drlnking Sobriety Alcohol Way too much Gone but not forgotten Tension, nagging, arguments, fear, distrust Love (Daily caring) Very little Still not enough Fun Very little Still not enough Problems Too many Still too many -Drinking-caused problems (bills, job loss, etc.) -Sometimes worse since marital problems recognized now -Everyday marital problems -Lack of good will or skills to and differences pile up (unresolved and often solve problems and dlfunrecognized) ferences

3 Marital Therapy for Alcoholics 193 and the loss of the myth that everything will be better once drinking stops. Often the couple does not have adequate communication skis, or the positive feeling for each other and good will necessary to resolve these problems by themselves. Given this analysis, it should come as no surprise that many marriages and families break up during the first one or two years of the alcoholic s recovery and that marital and family conflicts often trigger relapse and a return to abusive drinking by the alcoholic (Hore, 1971a, 1971b; Marlatt, 1978). Finally, it was stressed that many alcoholics need assistance to improve their marital and family relationships once changes in drinking have been started. At the end of the CIN, the couples groups were explained, interested couples enrolled, and uncertain couples were urged to complete a Couple Evaluation (part of our pretreatment assessment) to get to know us and more about your relationship with the possibility of joining a couples group after this evaluation. The pretreatment assessment consisted of (a) the husband and wife being interviewed separately about the alcoholic s drinking history and in detail about the drinking in the previous year (Time-line Drinking Interview - O Farrell, Cutter, Bayog, Dentch, & Fortgang, 1984), (b) each completing separately a series of questionnaires about their marital (Marital Adjustment Test -Locke & Wallace, 1959; Marital Status Inventory- Weiss & Cerretto, 1980; Areas of Change Questionnaire- Margolin, Talovic, & Weinstein, 1983) and sexual relationship (Sexual Adjustment Questionnaire- Q Farrell, Kleinke, & Cutter, 1984), and (c) a videotaped sample of communication while the couple discussed a current marital problem. During this two to three session assessment phase, it often became clear that the couple did not meet the criteria that had been set for inclusion in the couples group. To be candidates for the BMT group, the couple had to be currently living together and legally married for at least a year. In addition, the husband had to accept abstinence as a goal, the wife could not also be an alcoholic, and neither partner could suffer from a major mental illness. Couples who did not meet these criteria were judged unlikely to benefit from a short-term structured couples group and were seen in single couple conjoint sessions instead. After the pretreatment assessment and prior to the first group session, each couple met alone for one session with their therapists who emphasized the value of a group approach to marriage counseling and tried to promote favorable therapeutic expectations. Verbal commitments were obtained from the husband and the wife to live together for the 10 weeks of the group, not to threaten divorce or separation during this period, and to do their best to focus on the future and the present, but not the past in the sessions and at home. In addition, couples were asked to agree to do weekly homework assignments, and an attempt was made to specify a few areas or issues in the marriage to be addressed in the short-term group. BEHAVIORAL MARITAL THERAPY COUPLES GROUP INTERVENTIONS The goals of couples groups for alcoholics and their spouses are to decrease conflict about drinking and to increase positive interaction between spouses, effective communication, and resolution of conflicts and problems (about sex, finances, children, leisure time, etc.). To achieve these goals, couples who participate in nonbehavioral interactional couples group therapy, which has been described as a reality-oriented and goal-directed method (Blinder & Kirschenbaum, 1976; McCrady, Paolino, Longabaugh, & Rossi, 1979; Yalom, 1974), receive feedback on current negative interaction patterns and suggestions for specific changes in couple behavior. This type of couples group emphasizes catharsis, ventilation, sharing of feelings, problem solving through discussion, and providing verbal insight on each couple s relationship both from the therapists and from other group members. Behavioral marital therapy couples groups have the same goals as other types of couples groups with alcoholics but use different methods to achieve these goals. In-the BMT groups, therapists use extensive behavioral rehearsal of new communication skills, specific weekly homework assignments, written behavior change agreements, and other BMT techniques described below to help couples change specific behaviors during the group session and at home. In designing the present behavioral couples group for alcoholics, Miller s (1976) observations on changing the alcoholic s marriage were used to adapt marital therapy procedures developed for nonalcoholics by Liberman and colleagues (Liberman, Wheeler, devisser, Kuehnel, & Kuehnel, 1980). According to Miller, there are two basic objectives in modifying the alcoholic s marriage. The first goal is to change alcohol-related interactional patterns (e.g., nagging about past drinking but ignoring current sober behavior) presumed to maintain abusive drinking. Clinical experience suggests that one can get abstinent alcoholics and their spouses to engage in behaviors more pleasing to each other, but if the alcohol-related interactional patterns are not changed, they soon return to arguing about past or possible future drinking. Frequently such arguments lead to renewed drinking (Hore, 1971a, 1971b; Marlatt, 1978). They then feel more discouraged about their relationship and the drinking than before and are less likely to try pleasing each other again. The second goal involves altering general marital patterns to provide an atmosphere that is more conducive to sobriety. Table 2 lists the five major areas targeted in

4 194 w T. J. O Farrell and H.S. G. Cutter TABLE 2 Five MaJor Areas Targeted In Behavioral Couploa Qroup 1. Alcohol and Alcohol-Related Interactions A. Antabuse contract 6. Discussions about preventing/coping with relapse 2. Caring Behaviors A. Catch your spouse doing something nice 6. Caring days Shared Recreational Activities 4. Communication Skills Training A. Listening B. Expressing feelings directly C. Communication sessions 5. Making Agreements A. Positive specific requests 8. Negotiating and compromising C. Couple agreements the BMT group, roughly in order of their coverage in the group sessions. Alcohol-related feelings and interactions and daily caring behaviors are dealt with first to decrease tension about alcohol and to build good will, both of which a.re necessary for dealing with marital problems and desired relationship changes later using communication skills training and behavior change agreements. It should be noted that the division of the BMT group into the five content areas is for clarity of description and does not indicate a rigid sequence of nonoverlapping interventions; in fact, there is considerable overlap across the different areas from one session to the next. (The Appendix contains a session-by session outline of the ten BMT group sessions.) The BMT couples groups were provided only to alcoholics who had recently entered the VA Medical Center s Alcoholism Outpatient Clinic. The standard clinic program consisted of four weekly individual al- : coholism counseling sessions in the first nionth of clinic contact and monthly sessions thereafter for as long as the patient desired. The individual counseling was done by paraprofessional alcoholism counselors who provided supportive counseling that encouraged Antabuse, Alcoholics Anonymous, and abstinence. In addition to the husbands individual sessions, the alcoholics and their wives participated in BMT couples groups consisting of four couples, a male and female co-therapist team, and an observer who took process notes during each session. Therapists were doctorally trained clinical psychologists and predoctoral clinical psychology interns, and therapists served as observers as part of their training to conduct future groups. The therapists used a detailed treatment manual with a preplanned outline for each session and spent at least 30 minutes planning each session. Each couples group met for 10 weekly 2-hour sessions with a IO-minute mid-session refreshment break. Couples took turns providing refreshments, and the meeting room was open 30 minutes before and after the session both of which allowed for informal interaction among group members and helped build group cohesion. Finally, the observer phoned each couple mid-week to prompt homework completion, monitor progress, and confirm attendance at the next session. Alcohol and Alcohol-Related Interactions Antabuse@ (disulfiram), a drug which produces extreme nausea and sickness when the person taking it ingests alcohol, is widely used in alcoholism treatment as a deterrent to drinking. It was a routine part of the individual alcoholism counseling participated in by all the husbands in the BMT groups. Unfortunately, Antabuse often is not effective because the alcoholic prematurely discontinues the drug (Lundwall & Baekeland, 1971). In the BMT group we used an Antabuse contract (O Farrell & Bayog, 1984), a procedure adapted from the work of Miller and Hersen (1975) and Azrin (Azrin, 1976; Azrin, Sisson, Meyers, & Godley, 1982), to maintain Antabuse ingestion and abstinence from alcohol and to decrease alcohol-related arguments and interactions between the alcoholic and his wife. In the Antabuse contract the husband agreed to take Antabuse each day while the wife observed. The wife, in turn, agreed to record the observation on a calendar provided and not to mention past drinking or any fears about future drinking. It is extremely important that each spouse view the agreement as a cooperative method for rebuilding trust that has been lost and not as a coercive checking-up operation. More details on how to implement the Antabuse contract and how to deal with common resistances to this procedure will be contained in a manuscript currently being prepared (O Farrell & Bayog, 1984). Maintenance of abstinence was facilitated by monitoring compliance with the Antabuse agreement at the beginning of each session. In addition, the early warning system of the contract (by which spouses agree to call the therapists if Antabuse was not taken for 2 days in a row), the alcoholic s daily record of urges to drink which therapists reviewed at each session, and mid-week phone calls to prompt homework completion all served to inform the therapists of lapses in the Antabuse agreement and other precursors of a drinking episode. There were very few drinking episodes during the course of the BMT groups and none that got very far along without the therapists knowledge. Therapists goals once the alcoholic had taken a drink were to get the drinking stopped and the couple to the clinic for a conjoint conference to use the relapse as a learning experience. At the clinic session therapists were extremely active in assisting the couple to restart the Antabuse contract,

5 Marital Therapy for Alcoholics 195 identify what couple conflict (or other antecedent) had led up to the drinking, and generate alternative solutions other than drinking for similar future situations. The success of this approach, which minimized drinking during the BMT groups, seemed due to the fact that all the alcoholics had been abstinent at least 3 weeks prior to starting the group and that the methods we used effectively prevented drinking in nearly all cases and allowed early intervention very soon after drinking started when needed. The Antabuse agreement was a constructive way to deal with couples desires to talk about drinking (rather than non-drinking issues) early in treatment and avoid arguments about drinking until other treatment interventions had built marital satisfaction to compete with future drinking. With the exception of regular tracking of urges to drink, drinking was downplayed as a topic in the group after the Antabuse procedure had been negotiated. Drinking became a major topic again when the maintenance of therapeutic gains was planned just prior to the end of the group. Husbands and wives completed a worksheet for homework, adapted from a section of Marlatt s Drinking Profile (Marlatt, 1976), designed to help specify high-risk situations for relapse to drinking that might occur after treatment. Group discussions focused on possible coping strategies the alcoholics and wives could use to prevent or minimize relapse when confronted with these or similar situations. Caring Behaviors The goal of this part of the BMT group was to increase the frequency with which spouses noticed, acknowledged, and initiated caring behaviors on a daily basis. Caring behaviors were defined as behaviors showing that you care for the other person and illustrated by examples from the Spouse Observation Checklist (Weiss, 1975). Session one had homework called Catch Your Spouse Doing Something Nice (Turner, 1972) which required each spouse to write down one caring behavior performed by the partner each day (see Figure 1). This procedure was designed to compete with the spouses tendency to ignore positive and focus on negative behaviors. In session two, spouses read the caring behaviors recorded in the previous week. Next, a communication session to practice acknowledging caring behaviors was introduced as a way that spouses can reinforce what they want more of and start opening their hearts to each other. Group leaders modeled noting the importance of eye contact, smiling, sincere, pleasant tone of voice, and totally positive content. Then each spouse practiced acknowledging the two best caring behaviors from the daily list. Although often difficult for many couples, repeated role-playing with extensive prompting, coaching, and modeling (especially by other group members) usually succeeded in instigating the desired behavior. A 2-5 minute daily communication session was assigned for further practice at home. Finally, each partner was asked to give the other a Caring Day by doing some special caring behaviors in the coming week. Couples who engaged wholeheartedly in this assignment often influenced the more negative group members to begin acting more positively toward each other. Discussion often centered on the need (a) to take a risk and act in a loving way toward one s spouse rather than wait for the other to make the first move and (b) to act differently first and then have the feelings change. Shared Recreational Activities (Shared Rewarding Activities) For homework after session two, spouses separately listed Shared Recreational Activities (SRA) they might like to do with each other, either alone, with their children, or with other adults. When couples reported their SRA lists in session three, therapists often pointed out that a number of activities appeared on both partners lists even when a couple had serious conflicts about SRAs. Planning an SRA was the next assignment, and SRA plans were finalized in the next group session with help from the therapists and group members as needed. Similar SRA assignments were given weekly thereafter with one spouse responsible for planning an activity and the other spouse having one veto. The planning role was alternated weekly to show that taking turns is one simple way to resolve conflicts about recreation and also about many other issues. Currently we have relabelled this module as Shared Rewarding Activities to include a date at home and not just activities outside the home. Many couples had stopped doing fun activities together because in the past the alcoholic had so frequently sought enjoyment only in alcoholinvolved situations and embarrassed his wife when he drank too much. A recent study found family participation in SR4s to be one of the few family characteristics associated with positive alcoholism treatment outcomes (Moos, Bromet, Tsu, & Moos, 1979). Communication Skills Training Therapists used instructions, modeling, prompting, behavioral rehearsal, and feedback in teaching communication skills of listening, expressing feelings directly and the use of Communication Sessions. The training started with nonproblem areas that were positive or neutral and moved to problem areas and charged issues only after each skill had been practiced on less problematic topics.

6 196 T. J. o% arreil and H. S. G. Cutter CATCH YOUR SPOUSE DOING SOMETHING NICE NAME: NAME OF SPOUSE: John DAY MON DATE TUES. 10/9 Brought home a rosa for me. PLEASING BEHAVIOR He emptied dlahwasher and folded clothes after I went to bed early because I didn t feel good. WED. lo/to John cleaned up after supper so I could get an early start on food shopping. THURS. lo/11 Gave me extra money for myself. FRI Called me during the day and told me how much he loved me. SAT He watched the kids in the morning so I could get my hair done. SUN John told me I looked nice when I got dressed to go to church. NAME: John NAME OF SPOUSE: Mary MON. TUES. WED. DAY DATE PLEASING BEHAVIOR THURS. FRI. SAT. SUN IgIg lo/ to Mary made my favorlte supper. She put the storm windows on the wlndows and doors so I would have more time on Sat. Told me she loved me. Got up and fixed brgakfart for me even though she was up late the night before. After I came home from work she fllled the tub and we jumped in together, etc. (The klds were at her mother%.) Mary came out and looked at the work I had done in the yard and told me how nice it looked. Made coffee and talked with me for an hour. FIGURE 1.. Sample record shoots of daily caring behavlon completed by couples in BMT group.. COUPLE AGREEMENT RECORD Name: John & Mary Doe Week Beglnning: lw12/s3 (Wed.) John s RESPONSlBlLlTfES ( Mary checks when performed) 1. Go to look at refrigerator on Frlday night. 2 Take Mat-y to movie of her choice on Saturday.,WedIThursI y / S; (Sun IMonITue5j Mary s RESPONSIBILITIES ( John checks when performed) 1. Serve dinner in kitchen three nights this week. 2. Sit down for 15-mlnute communication session after supper each night.,wtirityi ; / Sat 1 Sun IM;ITues, SIGNED: John Doe and Mary Doe DATE: 10/l 1183 FIGURE 2 Sample couple agmement.

7 Marital Therapy for Alcoholics I97 Communication Sessions. A communication session was defined to the couples as a planned structured discussion in which spouses talk privately, face-toface, without distractions, taking turns expressing their point of view without interruptions. From session two on, communication sessions were assigned for homework and the length of session and topic changed with the skill being taught. The time and place at which couples planned to have their assigned communication practice sessions was discussed in the group. The success of this plan was assessed at the next session at which time any needed changes were suggested. In addition to being a vehicle to cue communication practice, a communication session was a method couples could use to exercise stimulus control over their problem solving discussion during and after therapy. Couples were encouraged to ask each other for a communication session when they wanted to discuss an issue or problem and to keep in mind the ground rules of behavior that characterize such a session. Listening. This communication skill helps each spouse feel understood and supported, slows down couple interactions preventing quick escalation of aversive exchanges, and is a prerequisite for couple problem solving and agreements. Therapists began by defining effective communication as message intended (by speaker) equals message received (by listener) (Gottman, Notarius, Gonso, & Markman, 1976). Spouses were instructed when in the listener role to repeat both the words and the feelings of the speaker s message and to check to see if the message they received was the message intended by their partner ( What I heard you saying was... Is that right? ). When the listener had understood the speaker s message, roles changed and the former listener then spoke. Teaching partners in an alcoholic marriage to communicate support and understanding by rephrasing the partner s message before stating one s own position was a major accomplishment that had to be carefully shaped. Such learning often was impeded by a partner s failure to separate understanding the spouse s position from agreement with it. Both how the couples do the listening skill and how they view it were important. In terms of doing the skill, couples were instructed to keep each message to a reasonable length that the listener could digest and to use the exact words of the listening response until they had mastered the skill. Couples needed repeated practice with feedback stressing both the verbal and nonverbal (eye contact, voice, tone, facial expression, posture) components of the behavior. Spouses had to be taught specifically how to respond when the listener did not receive the message intended by the speaker. The speaker first had to indicate what part of the message was correctly repeated by the listener and then state what ad- ditional information he was trying to convey; the interchange was complete when speaker s intended message had been understood by the listener. Some couples viewed this exercise in terms of credit and blame; when a message sent was not received accurately, one partner was to blame-either one spouse was a bad listener or the other was an inadequate speaker who had not made his/her message clear. Therapists taught couples that the exercise is a cooperative, task-oriented effort, that it is equally likely over the long run that unclear reception of messages will arise from unclear sendings as often as from inaccurate hearing, and that the technique is most useful when initial communication is somewhat unclear. Expressing Feelings Directly. Many alcoholic marriages are characterized by the husband s nonassertive, indirect, responsibility-avoiding style of communication and the wife s hostile, blaming, attacking behavior (Becker & Miller, 1976; Cutler, 1976; Drewrey & Rae, 1969; DuHamel, 1971; Gorad, 1971; Gynther & Brilliant, 1967; Mitchell, 1959). This skill was taught as an alternative to these faulty communication patterns. Couples were instructed that when the speaker expresses feelings directly, there is a greater chance of being heard because the speaker says these are his feelings, his point of view, not some objective fact about the other person. This reduces listener defensiveness and makes it easier to receive the intended message. The use of statements beginning with I rather than you was emphasized. Differences between direct expressions of feelings vs. indirect and ineffective or hurtful ways were presented along with examples such as the following: Direct I like you. I feel uneasy in this situation. I m mad at you for being late. I really liked that dinner. I feel uneasy when you drive fast. Spontaneously and immediately telling partner that not helping with chores makes self feel abandoned or over-burdened, etc. Owning up to feeling hurt by partner s forgetting anniversary. Indirect You re a very likeable person. This is the kind of situation that makes a person feel uneasy. Why can t you be on time? That was a nice dinner. You shouldn t drive so fast-it s dangerous. Storing up antagonisms and letting them come out later in a burst of pent-up rage. Beating around the bush and hinting indirectly that feelings are hurt.

8 198 T. J. O Farrell and H. S. G. Cutter After rationale and instructions had been presented, the therapists modeled correct and incorrect ways of expressing positive and negative feelings and elicited group member s reactions to these modeled scenes. Then couples role played a communication session in which spouses took turns being speaker and listener with the speaker expressing feelings directly and the listener using the listening response. Similar communication sessions, minutes each, three to four times weekly, were assigned after sessions four to six, and more role-playing practice was done in the group when this homework was discussed. Making Agreements When the focus of the later group sessions turned to making agreements, some changes desired by spouses already had been achieved. What remained often were the deeply conflictual issues that each partner felt strongly about and that had been the focus of considerable hostility and coercive interaction over the years. Learning to make positive specific requests (PSR) and to negotiate and compromise are prerequisites for making sound behavior change agreements to resolve such issues. Positive specific requests. Initially it was explained that couples often complain about what is wrong and what they are not getting, are vague and unclear about what they want, and try to coerce, browbeat, and force the partner to change. Couples were told that in order to negotiate or contract for desired relationship changes each partner has to learn to state his/her desires in the form of: positive-what you want, not what you don t want; specific- what, where, and when; requests-not demands which use force and threats but rather requests which show possibility for negotiation and compromise. To illustrate this notion, therapists presented the following eleven sample requests (adapted from Weiss & Ford, 1975): I d like my partner to: a Kiss me when I come home from work. Help out more around the liouse. Tell me more about his work day at dinnertime. Stop bugging me so much. Do the dishes on nights that I go to class. Appreciate me more. Have sex with me more often. Hold my hand while we watch TV. Put his dirty clothes in the hamper. Spend more time with our kids. Stop acting like a prude when I want sex. Couples were asked to indicate which of these requests met the PSR criteria and, after feedback from the therapists, to rewrite the incorrect requests (nos. 2, 6, 7, IO-not specific; nos. 4 and 11-neither positive or specific) making each into a PSR. For homework each partner listed at least five of their own PSRs for use in the next session. Negotiation and Compromise. Spouses shared their lists of requests starting with the most specific and positive items, and the therapists gave feedback on the requests presented and helped rewrite items as needed. Then the therapist explained that negotiating and compromising can help couples reach an agreement in which each partner agrees to do one thing requested by the other. To help couples compromise and agree on the granting of a stated request, they were instructed to translate each request into a continuum of possible activities in terms of frequency, duration, intensity or situation, rather than present the request in all-or-none terms. For example, if a husband stated his desire for more independence and time to work on his hobbies, this general, vague goal might be translated into explicit dimensions of activity such as when, how often, how long, and where. The couple can negotiate these dimensions. Perhaps he and his wife could agree to his spending an hour three times weekly after supper in the basement or garage. After giving instructions and examples, the therapists coached one couple while they had a communication session in which requests were made in PSR form, heard by each partner, and translated into a mutually satisfactory, do-able agreement for the upcoming week. The therapists tried to be sure that the couple used all the communication skills taught previously to help them reach a reasonable compromise. Agreed-to requests had to be realistic, reasonable and commensurate with previously demonstrated skill levels of the spouses, since fanciful and overly optimistic promises generally make for a weak agreement with little chance of success. After this demonstration, each therapist worked with a pair of couples to help each couple negotiate an agreement that each partner would fulfill one request in the next week. Couple Agreements. Specific written agreements were the focus of much of the later group sessions beginning with a review of the first agreement made in the previous session. Figure 2 is a typical example of a couple agreement negotiated in these sessions. After completing agreements in the group under therapists supervision, couples reviewed a handout on the steps involved in making agreements and were asked to have a communication session at home to negotiate an agreement on their own and bring it to the following session for review by therapists and group members. Agreements were of the good faith type (Weiss, Birchler, & Vincent, 1974) in which each partner agrees to make his/her change independent of whether or not the spouse keeps the agreement; ex-

9 Marital Therapy for Alcoholics 199 ternal monetary or other reward contingencies were not used. DEALING WITH RESISTANCE AND NONCOMPLIANCE IN THE BMT COUPLES GROUPS Resistance to Rationale and Structure of the Groups Frequently, spouses each wanted the other to change first, loving feelings to precede loving action, and to solve their most difficult problems first before committing themselves further to therapy or the relationship. We indicated that their attitudes and feelings were understandable given their history together, but that they had neither the skill nor the good will and positive feeling needed for the negotiation and compromise that could help them resolve their major problems and differences. The authors pointed out that their approach had not been working and that they must take an opposite method if they really wanted to see if their relationship could improve. It was also acknowledged that really giving their relationship a good chance to improve by changing how they act with each other requires risk and vulnerability but that there was no other way. Presentation and repetition of this mtionale often helped spouses decide initially to engage fully in the therapy and later to recommit themselves to the effort after backsliding or noncompliance. Couple and Therapist Resistance to Role Playing Couples initial resistance to engaging in behavioral rehearsal usually was overcome fairly easily if the therapists (a) gave clear instructions and rationale for the role-playing so group members knew what they were supposed to do and why it was important and (b) modeled the desired behavior to give couples a picture of how to perform the specific behaviors. Starting the first role-playing in the group was facilitated by practicing acknowledging caring behaviors which spouses could read from their record sheets and by therapists prompting a spouse s response by providing the first words if necessary. To encourage further practice, therapists gave positive feedback first, followed by suggestions for improvement. Once one couple had role-played, the others were less reluctant. Although reluctance to role-play decreased in later sessions, some resistance remained and required skillful effort of the type just described to overcome it. It was discovered during initial groups that although therapists and couples were talking a lot about the new skills and about the small amount of role playing that was being done, very little time was being devoted to behavioral rehearsal. Hersen (1981) has labeled this problem, which consists of therapists wandering from an approach that emphasizes active participation and modeling to one reflecting a more cognitive and passive attitude, therapist drift. The most effective procedure to deal with this problem was having the group observer record and give feedback on the amount of time spent role-playing to the therapists at mid-session break and at the end of the session. This increased time spent on rehearsal during the sessions. Gaining Compliance with Homework Assignments Weekly homework assignments, which were designed to transfer new behaviors learned in the group to the couple s day-to-day life at home, required specific procedures to gain compliance. In the pre-therapy orientation session, therapists explained the reasons for and the types of weekly assignments and that therapists and other group members would take a verbal commitment to do the homework as a serious pledge. The mid-week phone calls between sessions to prompt and reinforce performance of the assignments were also explained and therapists determined the best time to call the couple. How the homework was assigned in the group was also very important. We used a detailed homework assignment sheet, discussed each part at the end of the group session, and asked each couple to make a verbal commitment to complete the assignments. Therapists started each session by asking for a couple who had completed the previous week s assignment and gotten something positive out of it. Couples who completed homework assignments had approximately 10 to 15 minutes to report on their progress and any problems; those not completing an assignment had only 5 minutes. Throughout the group, the leaders refrained from giving negative attention to noncomplying couples, but rather used the 5-minute contingency and a matter-of-fact request for better effort in the future. The greater success of other couples frequently served as a model for the more resistant couples through vicarious learning. Although therapists sometimes felt reluctant to exert such strong control over the couples reporting at the beginning of each session, the authors became extremely impressed with the importance of doing this. Often noncomplying spouses were angry with each other when the session started and each wanted to present their side of the story first to gain group support for their position and to coerce the partner into changing. If allowed to go unchecked, this frequently led other couples, including those who were making some positive progress, to present the negative side of their situation. The session would take on a depressing, hopeless air and most of the couples would leave feeling worse than when they came and

10 200 T. J. O Farreii and H.S. G. Cutter less committed to behavior change at home in the coming week - an unfortunate occurrence in a shortterm group. CONCLUDING COMMENTS Preliminary Results on BMT Group Effectiveness Evidence for the effectiveness of these treatment procedures comes from our outcome investigation (O Farrell, Cutter, & Floyd, 1984, 1985) evaluating BMT couples group treatment as an adjunct to individual alcoholism counseling. Relative to alcoholics and their wives who received no marital therapy, couples who completed the BMT couples group reported higher levels of relationship satisfaction, demonstrated greater marital stability, displayed more positive communication skills while discussing marital issues, and reported fewer symptoms of emotional distress following treatment. Couple members also reported being quite satisfied with the BMT treatment they had received, especially communication skills Farrell & Cutter, 1984). At present, evaluation of the long-term impact of the BMT groups for a period of 2 years following treatment is in process. An important emphasis of the long-term follow-up is to assess the status of patients alcohol problems. It is hoped our major goal will be realized; that is, by assisting alcoholics and their wives to improve their troubled relationships, we provide them with skills and strengths to help them in the process of recovery. Applications in Other Settings In closing, it should be noted that the BMT couples group treatment package presented here may require modifications for use in other settings. We limited ourselves to male alcoholics because very few women alcoholics are seen in our VA setting. However, it is suggested that the methods described here should be quite applicable to female alcoholics and their husbands as long as the couples meet the same criteria we have used for selecting suitable participants. The Antabuse contract procedure, although extremely helpful, is not a necessary component of the format described. It is only one way to reduce alcohol-related interaction patterns (such as arguments and nagging about past drinking) and to prevent unwanted future drinking. However, it is essential to deal with alcohol-related interaction patterns by means of a clear agreement between spouses about the goal for the drinking and the role of each spouse in achieving and maintaining that goal. Other methods to achieve these goals have been described elsewhere (O Farrell, in press). The BMT group presented here requires an alcoholic who ad- mits he has a problem and wants to stop drinking. In many cases the alcoholic is still actively drinking and the therapeutic task is to mobilize the nonalcoholic spouse to confront the alcoholic and help him decide to change the drinking. After this decision is made, the marital therapy methods presented here often can be quite helpful. Others may find, as we have in some cases, that ten sessions is insufficient time to deal with all the problems that couples have. In addition, the group format at times may make it difficult to individualize the treatment to the desired extent and to deal with sensitive issues a couple is unwilling to reveal to a group. Structuring the treatment to last longer, while still maintaining a time-limited ap preach by contracting with group members for a specific number of additional sessions, is an option that has been found useful. Single couple conjoint BMT sessions have proven quite useful for individualizing treatment and for dealing with sensitive, complex, or highly charged issues. In fact, the treatment package described here can be adapted to single couple conjoint sessions quite readily. However, it has been found that in addition to the obvious economic benefits of couples groups, the structure and social support offered by the group can be powerful forces for producing short-term behavior change that are lost if only conjoint sessions are used. Quite possibly the optimal approach would include a short-term BMT couples group to teach communication skills and start behavior change followed by conjoint sessions to help couples apply their new skills to their most difficult problems and work on issues of long-term recovery. REFERENCES Azrin. N.H. (1976). Improvements in the community-reinforcement approach to alcoholism. Behaviour Research and Therapy, 14, Aarin, N.H., Siison. R.W., Meyers, R.. & Godley, M. (1982). Alcoholism treatment by Disulfm and community reinforcement therapy. Journal of Behavior Therapy and Experimental Psychiatry, l3, 105-l 12. Becker, J.V., 8c Miller, P.M. (1973). Verbal and nonverbal marital interaction patterns of alcoholics and nonalcoholics. Journal of Studies on Alcohol, 34, Blinder, M.G., & Kirschenbaum, M. (1967). The technique of married couple group therapy. Archives of GeneralPsychiatty, 17, Cadogan. D. (1973). Marital group therapy in the treatment of alcoholism. Quarterly Journal of Studies on Alcohol, 34, Camacho-Salinas, R.L., O Farrell, T.J., Jones, W.C., & Cutter, H.S.G. (1984). Services for the families of alcoholics: A national survey of Veterans Admit&ration alcoholism treatment programs. Manuscript in preparation. Cutler, C.M. (1976). Relational communication in the marriage of the alcoholic. Unpublished doctoral dissertation, Purdue University. Drewery, J., Kc Rae, J.B. (1969). A group comparison of al-

11 Marital Therapy for Alcoholics 201 coholic and nonalcoholic marriages using the interpersonal perception technique. British Journal of Psychiatry. 115, DuHamel, T.R. (1971). The interpersonal perceptions, interactions, and marital adjustment of hospitalized alcoholic males and their wives. Dissertation Abstracts International, 3 (10-B), Gallant, D.M., Rich, A., Bey, E., & Terranova, L. (1970). Group psychotherapy with married couples: A successful technique in New Orleans Alcoholism Clinic patients. Journal of the Louisiana Medical Society, 122, Gorad, S.L. (1971). Communication styles and interaction of alcoholics and their wives. Family Process, 10, Gottman, J., Notarius, C., Gonso, J., & Markman, H. (1976). A couples guide to communication. Champaign, IL: Research Press. Gynther, M.D., & Brilliant, P.J. (1967). Marital status, readmission to hospital and intrapersonal perceptions of alcoholics. Quarterly Journal of Studies on Alcohol, 28, Hersen, M. (1981). Complex problems require complex solutions. Behavior Therapy, 12, Hore, B.D. (1971a). Life events and alcoholic relapse. British Journal of Addiction, 66, Hore, B.D. (1971b). Factors in alcoholic relapse. British Journal of Addiction, 66, Jacobson, N.S. (1978). A review of the research on the effectiveness of marital therapy. In T.J. Paolino & B.S. McCrady (Eds.), Marriage and marital therapy: Psychoanalytic, behavioral and systems theory perspectives. New York: Brunner/ Mazel. Jacobson, N.S., & Martin, B. (1976). Behavioral marriage therapy. Psychological Bulletin, 83, Keller, M. (Ed.). (1974). Trends in treatment of alcoholism. In Second special report to the U.S. Congress on Alcohol and Health. Washington, DC: Department of Health, Education, & Welfare. Liberman, R.P., Wheeler, E.G., devisser, L.A., Kuehnel, J., & Kuehnel, T. (1980). Handbook of marital therapy: A positive approach to helping troubled relationships. New York: Plenum. Locke, H.J., & Wallace, K.M. (1959). Short marital-adjustment and prediction tests: Their reliability and validity. Journal of Marriage and Family Living, 21, 25 l-255. Lundwall, L., & Baekeland, F. (1971). Disulfiram treatment of alcoholism. Journal of Nervous and Mental Disease, 153, Margolin, G., Talovic, S., & Weinstein, CD. (1983). Areas of Change Questionnaire: A practical approach to marital assessment. Journal of Consulting and Clinical Psychology, 51, Marlatt, G.A. (1976). The drinking profile: A questionnaire for the behavioral assessment of alcoholism. In E.J. Mash & L.G. Terdal (Eds.), Behavior therapy assessment: Diagnosis and evaluation. New York: Springer. Marlatt, G.A. (1978). Craving for alcohol, loss of control, and relapse: A cognitive-behavioral analysis. In P.E. Nathan, G.A. Marlatt, & T. Loberg (Eds.), Alcoholism: New directions in behavioral research and treatment. New York: Plenum. McCrady, B.S., Paolino, T.J., Longabaugh, R., & Rossi, J. (1979). Effects of joint hospital admission and couples treatment for hospitalized alcoholics: A pilot study. Addictive Behaviors, 4, Miller, P.M. (1976). Behavioral treatment of alcoholism. New York: Pergamon. Miller, P.M., & Hersen, M. (1975). ModtJYcation of marital interaction patterns between an alcoholic and his wife. (Available from Peter Miller, Weight Control Center, Hilton Head Hospital, Hilton Head Island, SC.) Miller, W.R., & Hester, R.K. (1980). Treating the problem drinker: Modern approaches. In W.R. Miller (Ed.), The addictive behaviors: Treatment of alcoholkm, drug abuse, smoking, and obesity. New York: Pergamon. Mitchell, H.E. (1959). Interpersonal perception theory applied to conflicted marriages in which alcoholism is,and is not a problem. American Journal of Orthopsychiatry, 29, Moos, R.H., Bromet, E., Tsu, V., & Moos, B. (1979). Family characteristics and the outcome of treatment for alcoholism. Journal of Studies on Alcohol, 40, O Farrell, T.J. (In press.) Marital and family therapy for alcohol problems. In W.M. Cox (Ed.), Treatment and prevention of alcohol problems: A resource manual. New York: Academic Press. O Farrell, T.J., & Bayog, R.D. (1984). Antabuse contracts for married alcoholics and their spouses: A method to insure Antabuse taking and decrease conflict about alcohol. Manuscript in preparation, Veterans Administration Medical Center, Brockton, Massachusetts. O Farrell, T.J., & Cutter, H.S.G. (1977, August). Behavioral Marital Therapy (BMT) for alcoholics and wives: Review of literature and a proposed research program. Paper presented at the NATO International Conference on Experimental and Behavioral Approaches to Alcoholism, Bergen, Norway. (ERIC Document Reproduction Service No. ED ). O Farrell, T.J., & Cutter, H.S.G. (1984). Behavioral marital therapy for male alcoholics: Clinical procedures from a treatment outcome study in progress. American Journal of Family Therapy, 12, O Farrell, T.J., Cutter, H.S.G., Bayog, R.D., Dentch, G., & Fortgang, J. (1984.) Correspondence between one-year retrospective reports of pretreatment drinking by alcoholics and their wives. Behavioral Assessment. 6, O Farrell, T.J., Cutter H.S.G., & Floyd, F.J. (1985). Evaluating behavioral marital therapy for male alcoholics: Effects on marital adjustment and communication from before to after therapy. Behavior Therapy, 16, O Farrell, T.J., Cutter, H.S.G., % Floyd, F. (1984). Effects of adding a behavioral or an interactional couples group to individual outpatient alcoholism counseling: Results at one and two years follow-up. Manuscript in preparation. O Farrell, T.J., Kleinke, C.L., & Cutter, H.S.G. (1984). Sexual adjustment of male alcoholics: Changes from before to after receiving alcoholism counseling with and without marital therapy. Manuscript submitted for publication. Orford, J. (1975). Alcoholism and marriage: The argument against specialism. Journal of Studies on Alcohol, 36, Patterson, G.R., Weiss, R.L., & Hops, H. (1976). Training of marital skills: Some problems and concepts. In H. Leitenberg (Ed.), Handbook of behavior modtficotion and behavior therapy. Englewood Cliffs, NJ: Prentice-Hall. Regan, J.M., Connors, G.J., O Farrell, T.J., & Jones, W.C. (1983). Services to the families of alcoholics: A survey of treatment agencies in Massachusetts. Journal of Studies on Alcohol, 44, Steinglass, P. (1976). Experimenting with family treatment ap proaches to alcoholism, : A review. Family Process, 15, Stuart, R.B. (1969). Operant-interpersonal treatment for marital discord. Journal of Consulting and Clinical Psychology, 33, Turner, J. (1972, October). Couple and group treatment of marital discord. Paper presented at the Sixth Annual Meeting of the Association for Advancement of Behavior Therapy, New York. Weiss, R.L. (1975). Spouse Observation Checklist. Unpublished questionnaire, University of Oregon, Marital Studies Program, Eugene, OR. Weiss, R.L., Birchler, G.R., & Vincent, J.P. (1974.) Contrac-

12 202 T. J. O Farrell and H.S. G. Cutter tual models for negotiation training in marital dyads. Journal of Mamage and the Family, 36, Weiss, R.L.. & Ccrreto, M.C. (1980). Themarital status inventory: Development of a measure of dissolution potential. American Journal of Family Therapy, 8, Weiss, R.L., & Ford, L. (1975). A social learning view of marriage. Unpublished manuscript, University of Oregon, Marital Studies Program, Eugene, OR. Yalom. I.D. (1974). Group therapy and alcoholism. Annals of the New York Aca&my of Sciences, 233, Shared Recreational Activities (SRA) a. Explain briefly b. Assign for homework 8. Reiterate Homework Assignments a. Antabuse Contract b. Catch Your Spouse Doing Something Nice c. List possible SRA s for next week APPENDIX SESSION 3 Outline of Ten Session BMT Coapks Groop SESSION 1 1. Welcome and orientation 2. Introduction Brief lecture on the Alcoholic Marriage with overview of group 4. Targeting problems and goals 5. Antabuse Contract a. Explain b. Model c. Role-play d. Assign for homework 6. Catch Your Spouse Doing Something Nice a. Explain briefly b. Assign for homework 7. Reiterate homework assignments a. Antabuse Contract b. Catch Your Spouse Doing Something Nice c. Closing Procedure (1) Answer any questions about homework (2) Get explicit verbal commitment from each person to do homework (3) Mention phone reminder about next meeting and homework SESSION 2 Opening Procedure- Reiterate homework contingency and start with compliant couple Review Antabuse contract homework Negotiate continued Antabuse contract for at least to end of class Short lecture on reciprocity in marriage Review Catch Your Spouse Doing Something Nice homework 6. Communication Skills Training a. Importance of communicating feelings b. Initiating and acknowledging Pleasing Behaviors (1) Explain (2) Model (3) Role-play (4) Assign for homework 1. Review Antabuse Contract homework 2. Review Catch Your Spouse and Tell Him/Her Review lists of SRA s Planning Shared Recreational Activities (SRA) a. Explain b. Model and/or give verbal instructions c. Each couple plan for coming week d. Assign for homework Symbol of Special Meaning a. Explain b. Couples share Caring Day a. Explain b. Assign for homework Reiterate Homework Antabuse Contract Catch Your Spouse Caring Day SRA Assignments SESSION 4 Review Antabuse Contract homework Review Catch Your Spouse and Tell Him/Her Review Caring Day Homework Review SRA done for homework and SR4 planned for upcoming week 5. Use a blackboard to review and preview 6. Communication Skills Training: Listening and Validating a. Explain b. Model c. Role play 7. Communication Session a. Explain b. Each couple schedule for the coming week to practice Listening and Validating three times 8. Reiterate Homework Assignments a. Antabuse Contract b. Catch Your Spouse and Tell Him/Her c. Do planned SRA and plan SRA for next week d. Communication Session - to practice three times Listening and Validating

13 Marital Therapy for Alcoholics SESSION 5 Review Antabuse Contract homework Review Catch Your Spouse and Tell Him/Her, with acknowledging practice on best Pleasing Behavior Review SRA done for homework and SRA planned for upcoming week Review Communication Session a. Review how practicing Listening and Validating went at home b. More practice in couple pairs on non-charged topics 5. Use blackboard 6. Communication Request (PSR) a. Explain b. Assign for homework to review and preview Skills Training: Positive Specific Communication Skills Training: Expressing Feelings Directly and Listening Explain ;: C. Model Expressing Feelings Directly Role-play Expressing Feelings Directly d. Model Listening in response to directly expressed feelings e. Role-play in couple pairs Listening in response to directly expressed feelings Reiterate Homework Assignments in couple pairs a. Antabuse Contract b. Catch Your Spouse and Tell Him/Her c. Do planned SRA and plan SRA for next week d. Complete PSR to prepare for negotiating agreements e. Schedule three Communication Sessions to practice Expressing Feelings Directly and Listening/Validating SESSION 6 1. Review Antabuse Contract homework 2. Review Catch Your Spouse and Tell Him/Her, with acknowledging practice on best Pleasing Behavior Review SR4 done for homework and SRA planned for upcoming week 4. Review Communication Session a. Review how practicing Expressing Feelings Directly and Listening/Validating went at home b. More practice in couple pairs on noncharged topics 5. Communication Skills Training: More practice Expressing Feelings Directly and Listening a. Role-play in couple pairs b. Assign Communication Session for homework for further practice and use on everyday problems Negotiate Agreements to fulfill one PSR in coming week a. Review and give leader and group feedback on PSR lists from homework b. Explain how negotiating/compromise leads to agreements c. Model a negotiation for whole group d. In couple pairs, negotiate one request each partner will fulfill Reiterate Homework Assignments in couple pairs it: C. d. e. Antabuse Contract Catch Your Spouse and Tell Him/Her Do planned SRA and plan SRA for next week Complete PSR Agreements Schedule three Communication Sessions to practice Expressing Feelings Directly and Listening/Validating on everyday problems SESSION 7 1. Review Antabuse Contract homework 2. Review Catch Your Spouse and Tell Him/Her, with acknowledging practice on best Pleasing Behavior Review SRA done for homework and SRA planned for upcoming week 4. Review Communication Session a. Review how practicing Expressing Feelings Directly and Listening/Validating went at home b. More practice in couple pairs on charged topics 5. Communication Skills Training: Review and more practice 6. Review Negotiated Agreement homework a. Elicit positive responses first with focus on positive feelings caused by keeping agreement b. Troubleshoot unkept agreements 7. Negotiate Agreement to fulfill one PSR in coming week a. Review how negotiation/compromise leads to agreements b. Model a negotiation for the whole group c. In couple pairs, negotiate one request each partner will fulfill 8. Reiterate Homework Assignment in couple pairs a. b. :. e. Antabuse Contract _ Catch Your Spouse and Tell Him/Her Do planned SRA and plan SRA for next week Complete Negotiated Agreement Schedule three Communication Sessions to practice Expressing Feelings Directly and Listening/Validating on everyday problems

14 204 T. J. O%arreN and H.S. G. Cutter SESSION 8 Review Antabuse Contract homework Review Catch Your Spouse and Tell Him/Her with acknowledging practice on best Pleasing Behavior Review SR4 done for homework and SRA planned for upcoming week 4. Review Communication Session homework a. Review how practicing Expressing Feelings Directly and Listening/Validating went at home b. More practice in couple pairs on charged topics 5. Review Negotiated Agreement homework a. Elicit positive responses first with focus on positive feelings caused by keeping agreement b. Trouble-shoot unkept agreements 6. Negotiate Additional Couple Agreements a. Negotiate two responsibilities each spouse will agree to for coming week b. Use PSR lists and pre-treatment data in selecting responsibilities c. Write agreement and keep copy 7. Reiterate Homework Assignments in couple pairs Antabuse Contract it Caring Day and optional Catch Your Spouse and Tell Him/Her Do planned SRA and plan SRA for next week i. Complete Negotiated Agreements e. Use scheduled Communication Sessions to deal with everyday problems and events f. Complete worksheet about possible High Risk Situations for return to drinking SESSION 9 1. Very brief review of homework- they are on their own after next week a. Antabuse Contract b. Caring Day and option Catch Your Spouse and Tell Him/Her c. Planned SRA d. Communication Sessions to deal with everyday problems and events 2. Review Negotiated Agreement homework a. Elicit positive responses first with focus on positive feelings caused by keeping agreement b. Troubleshoot unkept agreements Negotiate Additional Couple Agreements a. Negotiate two responsibilities each spouse will agree to for coming week b. Use PSR lists and pre-treatment assessment to help select responsibilities C. Write agreement and keep copy 4. Coping with High Risk Situations for return to drinking a. Show chart about relapse process on board b. Go around group regarding high risk situations for them taken from their worksheets completed for homework c. Consider coping responses (1) Before a slip- stay on Antabuse Contract, communicate about the situation and how to change it, use a non-drinking pressure valve, return to counseling (2) After a slip-stop drinking ASAP, return to clinic, expect a tough period, bounce back using all the tools you have 5. Reiterate Homework Assignments in couple pairs a. Antabuse Contract- negotiate contract for after the class b. Complete Negotiated Agreements C. Homework(s) of choice- Communication Session, SRA, Catch Your Spouse, etc. d. Complete satisfaction questionnaire SESSION 10 Review Antabuse Contract renegotiation homework and sign completed contracts in class Review other homework a. Agreements (tell them this is something they can do on their own) b. Homework of choice (if couple didn t do one, ask what might be a good one for use after group) Get feedback on group sessions a. Share satisfaction questionnaire answers with group b. General group discussion re feedback on group Good-byes Mention possibility of informal group meetings t. Encourage clinic attendance by husbands (with wives, if desired) NOTES TO APPENDIX This Closing Procedure was used in Sessions Two through Nine. This Opening Procedure was used in Sessions Two through Nine.