In Cognitive–Behavioral Relapse Prevention for Addictions, Dr. G. Alan Marlatt demonstrates his approach to working with clients dealing with addictions or compulsive habits such as substance abuse, gambling, or sexual addiction. Cognitive–behavioral relapse prevention helps clients through the process of relapse recovery by focusing on cognitive, behavioral, and lifestyle choices that might be changed or reinforced to help the client prevent relapse. Central to this approach is the work of identifying relapse triggers and developing coping strategies. In this session, Dr. Marlatt works with a 41-year-old woman who has been abusing alcohol for a number of years and seeks help with quitting.
This DVD features a client portrayed by an actor on the basis of actual case material.
Two months prior to seeking treatment, Carol's children were away on an overnight school trip, and she decided to visit a friend in the evening. She had been drinking since late afternoon and continued drinking at the friend's house. On the way home, barely able to see the road, she pulled over on a side street and passed out. When she didn't arrive at home by midnight, her husband Ken called the town police. They found her in the car, and she was arrested for driving while intoxicated (DWI). Subsequently, her license was revoked, and a notice of her arraignment appeared in the town paper.
There had been other "public" incidents when Carol was drunk over the past few years. Usually, Ken was able to get her home without too much notice, but last year at a wedding Carol had been "falling down drunk" and had humiliated them both. However, this degree of public drinking was fairly unusual.
Carol's private drinking has been more consistent. Increasingly over the past 4 or 5 years, Carol rarely feels happy or lively unless she has had something to drink, which she does on a daily basis, usually when she is alone. She typically has her first drink of the day—a quick shot of vodka or a few glasses of wine—between the time that she has eaten with the children and before Ken arrives home from work.
After the children are asleep, Carol tends to get quietly drunk. She stays in her "den," listens to music, and sometimes she tries on different outfits and dances around the room. Early in her nightly drinking, she feels flirtatious and lively, and in this mood she would like to interact with Ken. But he is so critical and accusing, she avoids him most evenings. Instead, when she is in these moods she chats on the phone with friends or her sister. As she gets progressively more drunk, she cries, thinks about what is wrong in her life, and struggles to figure out how she can change it.
Once or twice a week—when Ken is in his study engrossed in TV or some work—she drinks, unnoticed, until she falls asleep (or passes out) in a chair. On these occasions, she awakens in the middle of the night and quietly sneaks into bed, hoping not to wake Ken.
Ken rarely drinks. He has been insisting for the past 2 years that Carol enter inpatient treatment. He does not feel that psychotherapy is "enough." Ken's best friend died about 3 years ago of cardiac arrest. Ken's friend was an alcoholic and had convinced Ken that his alcoholism was purely biological–genetic and that it had little psychological cause.
There is a history of alcohol problems in Carol's family of origin. Her father is an active alcoholic whose drinking is "accepted" by the family. Both her older and her younger brothers are alcoholics. The younger brother is sober and has been going to AA for 18 months. The oldest brother is actively drinking. Her sister is single. She drinks socially, but she never drinks to excess. Carol's mother never drinks at all.
After the DWI incident, Ken became more insistent that Carol enter the hospital. In lieu of this, Carol made an appointment to see Dr. Marlatt, who had been on a list of referrals given to her during her court-ordered assessment for drug and alcohol problems.
- What is your impression of Carol?
- How typical or atypical are her life experiences and her current behavior?
- What do you believe are the core issues for Carol?
- What is the utility of these initial formulations?
- Before you read the next section, what topics and issues do you think will be addressed in the initial sessions?
Notes on Previous Sessions
Initial telephone contact: In the process of making the first appointment, Carol asked Dr. Marlatt about the treatment and what would happen in the first session. He explained that they would talk about what was going on in her life and what problems she was experiencing and that he would ask her about her individual and family history. He said that he would describe his treatment approach in detail and that after the first session, she should be in a better position to decide if she would want to work with him.
Carol then asked him how long she would be in treatment, and Dr. Marlatt explained that he could not gauge that without meeting with her. He went on to say that he usually saw people once a week for about 90 days. After 90 days, they usually set up a maintenance schedule (unless there was still a high risk for relapse). Carol asked him whether she had to quit drinking before she saw him, and he told her that she did not. He did inform her that she must keep track of her drinking if she continues to drink and record when she drank, how much she drank, and what her mood was before and after she drank.
Session 1: Dr. Marlatt began the session by introducing himself, reiterating the purpose of this first session, and asking Carol to "tell me in your own words, how you view your problems and why you are here."
After giving Dr. Marlatt a factual account of her DWI, Carol explained that her husband was very concerned about her drinking. She herself is not sure what her problem is—her drinking or her depression.
Dr. Marlatt proceeded to ask Carol some questions about her family background, and she conveyed that there was a history of alcohol problems in the family. Dr. Marlatt asked her, "Once you realized that others in your family had problems with drinking, did you ever try to stop drinking yourself?" Carol replied that she had stopped drinking for about 3 months last year but that she couldn't maintain the abstinence, and she started to drink again.
Dr. Marlatt asked her what motivated her initially to stop drinking last year, and what motivated her on a daily basis to maintain her abstinence. She told him that she stopped drinking because she was feeling very confused during the day, and she was forgetting things, misplacing things, and felt in a "fog." She was motivated to maintain her abstinence by the increasingly clearheaded feeling she was getting and by the satisfaction she felt from the amount of work she could accomplish and the energy she had. Dr. Marlatt emphasized that her 3-month period of abstinence was a significant accomplishment on which she could build.
Dr. Marlatt then explained his view that alcoholism involves multiple risk factors—biological, social, and psychological—and that the treatment would involve consideration of all three factors. He explained that he would ask her to think about her patterns of drinking, to keep a record of any drinking that occurred and of any close-calls, and to fill out "monitoring cards" each day that she drank or had a near-slip. The card listed the day of the week, the time of day, the amount she drank, the mood before she drank, and the mood after she drank. Dr. Marlatt then asked Carol to describe what she saw as her goals for treatment. She stated that she wanted to quit drinking forever.
Dr. Marlatt explained to Carol that he would help her reach her goal of not drinking by teaching her how to help herself when she is at risk for taking a drink. He would show her ways to handle the things that trigger her drinking and offer her new ways to think about her problem, to change her behavior, and to help her cope.
At the end of the session, Dr. Marlatt asked Carol whether she thought this treatment would work for her and whether she wished to continue working with him. Carol said that she thought the treatment would help her stop drinking, but she still wasn't sure what could be done for her depression. Before she left she asked Dr. Marlatt for some recommended reading, and he suggested she try When AA Doesn't Work, by Albert Ellis.
Session 2: Carol gave Dr. Marlatt her monitoring cards as soon as she entered his office. She was very pleased that she had neither had a drink nor had a near-slip all week and reported that her spirits had been high. She and Ken had gotten along all week.
Dr. Marlatt again talked with Carol about her motivation to stop drinking, this time developing together a "decision matrix" to focus Carol on the choice of drinking or not drinking. Dr. Marlatt made a chart on the blackboard: "What Happens if I Stop Drinking?" "What Happens if I Continue Drinking?"
Dr. Marlatt asked her what course of action she thinks is best. Carol responds that it will be "best" not to drink, clearly the list tells her that, but part of her feels hopeless at the prospect of never drinking again, never "feeling loose and drifting slowly and sweetly out of my life."
Dr. Marlatt probed Carol's commitment to stop drinking, and she told him that she knows she must stop drinking. Dr. Marlatt asked Carol further questions: What would it take to stop drinking? What are the ways she can change her thinking so that she can cope without drinking? What can she do to ensure that she will not relapse? He asked her to think about all of these things during the coming week.
Session 3: As soon as Carol settled in Dr. Marlatt's office, she handed him her monitoring cards, this time with an air of defiance and embarrassment. Before reading the card, Dr. Marlatt asked her what had happened in the past week, and Carol told him that she "slipped" on Tuesday, but "I don't feel bad about it." He asked her what time of the day she drank, how much she drank, what her mood was before she drank, and how she felt after she drank. Carol told him, "It's all on the card."
Dr. Marlatt read the card and then probed for more information about the chain of events on Tuesday that led her to take a drink. Carol explained that she was feeling sad and hopeless on Tuesday.
Dr. Marlatt continued to ask her questions about the slip: "Were you alone when you drank? How have your friends and family reacted to your decision to stop drinking? Has anyone pressured you to have a drink? What started the chain of bad feelings? How did you feel right after you had the first drink? How did you feel the next day?" Dr. Marlatt talked about the negative affect and social pressures that usually lead one to relapse. They explored how she might have handled her feelings of resignation and hopelessness in other ways.
Carol continued to talk about how she feels light-headed and positive for the first few hours when she is drinking. Dr. Marlatt suggested that she might try meditating to achieve the same effect, and he described in detail various meditation techniques. Carol promised to try these techniques at home when she is feeling depressed or agitated.
Session 4: To be viewed.
- Were the initial sessions as you expected?
- As you read the summary of the preceding sessions, were there any areas or topics that you thought should be covered but were not?
- What other information would you seek to assess the patient?
- Before viewing the tape, what do you think will unfold in the taped session?
- What issues will be discussed?
- What will the relationship between Dr. Marlatt and Carol be like?
Stimulus Questions About the Session
The session begins with Dr. Marlatt welcoming Carol back and collecting her monitoring cards from the previous week. Using the cards, he asks Carol to focus on her drinking "slip" on Wednesday evening.
- What expectations and responses does this structured opening appear to evoke from Carol?
- How might other clients with addictive problems respond?
About 10 minutes into the session, Dr. Marlatt begins to systematically examine the response chain of precipitants involved in Carol's slip.
- What is your understanding of the purpose of this assessment?
- How do the results of this assessment guide the therapeutic interventions?
In the first 15 minutes of the session, Dr. Marlatt elicits the antecedents and consequences of Carol's slip on Wednesday evening. In doing so, he elicits rich information about Carol's marital relationship, self-identity, affect, genetic vulnerability, and gender socialization.
- How do you think he decides which of these relevant areas to pursue in the session?
- How would you decide which area(s) to pursue?
About 21 minutes into the session: Dr. Marlatt invites Carol to review Wednesday's slip in the context of generating alternative or incompatible responses to drinking.
- What other treatments use this approach in helping patients change?
- What are alternative ways of eliciting coping techniques?
On three occasions, Carol states that it will be quite difficult for her to invite her husband to a conjoint session. Dr. Marlatt empathizes with her about the difficulties involved but encourages her to pursue the session.
- What are some alternative ways of facilitating Carol's husband coming to the session?
The patient describes her use of alcohol as a solace and a refuge and expresses her fear that abstinence would represent a loss. Dr. Marlatt then asks her whether she has done any of the things they talked about in previous sessions over the past 2 weeks (e.g., yoga, meditation).
- How do you react to his segue from her fear of loss to questions about positive alternatives to drinking?
- What role might these adjunctive activities potentially play in reaching therapeutic goals?
About 30 minutes into the session, Dr. Marlatt reviews with Carol her experience with meditation and the imagery of the "wave." He complements Carol on her periods of abstinence and her honesty in discussing her slip. He also encourages her to continue practicing meditation and imagery daily and to use centered breathing to cope with her negative emotions and drinking urges.
- Have you had any personal experience with using meditation and imagery?
- As a client, how might you respond to the use of meditation and imagery as part of psychotherapy?
- What technical procedures or interpersonal behaviors on the part of the therapist do you think contribute to Carol's willingness to comply with these homework assignments?
About 37 minutes into the session, Dr. Marlatt raises the prospect, as he did in the previous session, of Carol attending a self-help group such as AA or Rational Recovery to help her counter her feelings of shame and isolation. Carol expresses her reluctance to attend such meetings because she would have to reveal her behavior to strangers. Dr. Marlatt attempts to tailor his recommendation to address this concern. He suggests that she might try a women's self-help group in which members might have life experiences similar to hers.
- Do you believe that self-help groups are compatible with individual psychotherapy?
- In your view, is the cognitive–behavioral model of addictive behaviors compatible with a 12-step disease model of addictions?
Carol's drinking urges and behaviors are discussed as frequently interwoven with her marital relationship and its discontents. For example, in discussing her slip, Carol says of the relationship, "We can't talk. We never talk."
- On what basis would you, as a therapist, determine the frequency and timing of conjoint sessions with a spouse in this situation?
- Under what circumstances would you switch from relapse prevention therapy with an individual focus to marital therapy with the couple?
- Did the session progress as you anticipated?
- Was Carol as you expected? Was Dr. Marlatt?
- What are your general reactions to the session?
- What did you feel was effective in the therapy?
- What do you think were the strengths and the weaknesses of this approach?
- If you were not informed that this is "cognitive–behavioral relapse prevention," what would you have called it? What do you think makes this distinctly "cognitive–behavioral"?
- Now, after reading about the patient and viewing this session, what are your diagnostic impressions or characterizations of her problem?
- How would you proceed with Carol's therapy?
- What goals would you set?
- How many sessions do you think it would take to achieve these goals?