Introduction

The interventions to be tested in Project MATCH were selected by the trial’s Steering Committee, a group composed of the principal investigators of the participating sites and a representative of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). It was agreed that a cognitive-behavior therapy (CBT) approach would be among the treatments offered and that a recently published book, Treating Alcohol Dependence: A Coping Skills Training Guide by Monti, Abrams, Kadden, and Cooney (1989), would be the basic manual for this approach. This manual had been used in several treatment matching studies (Kadden et al. 1989; Monti et al. 1990; Rohsenow et al. 1991; Cooney et al. 1991) and seemed generally well suited for the requirements of Project MATCH.

This manual contains material for 22 sessions—8 core or required sessions that are implemented with all subjects and 14 elective sessions, of which 4 are selected for each subject. Thus, each subject receives a total of 12 sessions composed of a fixed set of core sessions and several elective sessions chosen for the individual patient.

Sixteen sessions are taken from the Monti et al. text. Rather than reproduce entire sessions from Monti et al. here, the present manual makes extensive reference to treatment sessions in the Monti et al. book and describes departures from them. Thus, this publication is not the exact document that the Project MATCH CBT therapists worked from, but it contains sufficient material and references so that anyone could replicate the protocol employed in Project MATCH by using this manual and the Monti et al. book conjointly.

The six sessions that were not drawn from Monti et al. are reprinted in full. Numerous other sources (see appendix A) contributed to these sessions, and they are gratefully acknowledged.

Given the extensive overlap between this manual and Monti et al., it is reasonable to ask why this version merits separate publication. There have been numerous requests for the Project MATCH treatment manuals for use in other research studies. It was felt that the exact protocols that were employed should be furnished to the community at large for those desiring to replicate the Project MATCH treatments.

This accounts for the format of the present volume, with new material being printed in full but without reprinting published material that is generally available. The only exception to this is the introductory chapter where, for reasons of comprehensibility, all of the text is presented, including the material taken directly from Monti et al.

Modifications to Monti et al.

The modifications made to the basic Monti et al. book to accommodate Project MATCH and the decisionmaking processes that led to them are summarized below.

Additions

The Project MATCH Steering Committee decided to include some additional elements of the Community Reinforcement Approach (Sisson and Azrin 1989) because of its demonstrated success in several clinical trials. The added elements were marital counseling, training in job seeking and interviewing skills, and expanded material on coping with cravings and urges to drink. Another session focusing specifically on negative moods was added to the four on negative thinking and anger already present, because depression is a widespread problem among recovering alcoholics.

Group Versus Individual Therapy

The Monti et al. book is built around a group therapy approach to treatment, although it does contain a section discussing adaptation to the individual treatment setting. The Steering Committee considered the advantages and disadvantages of both group and individual approaches for the Project MATCH trial.

The advantages of group therapy include its widespread use in alcoholism rehabilitation; the potential facilitative effect of a group’s social environment on cognitive, affective, and behavioral changes; the support system that groups provide for newly recovering clients; and the potential for cost savings with group compared to individual treatment. However, group therapy presented a number of problems from the research perspective. Clients might have to wait weeks before beginning treatment while groups were being assembled; it is more difficult to assess the therapist factor in outcome, and some argue that the groups (as opposed to individual clients) should be considered as the unit of analysis (e.g., Kaul and Bednar 1986). To properly evaluate the treatment, an individual therapy format was selected. This meant that some of the wording in Monti et al. had to be edited to reflect the dyadic therapeutic relationship, and some of the group-oriented role playing exercises had to be restructured. In the present manual, minor modifications of role-plays are described in terms of the changes made to the Monti et al. book. When the changes were substantial, the modified exercises are presented verbatim.

Whenever reference is made to material in the Monti et al. book, it is left to the reader to insert needed transpositions in the text from group to individual therapy.

Length of Treatment

The Monti et al. book presents 27 treatment sessions. With increasing pressures on clinicians to reduce the length of treatment, a clinical trial involving a 6-month treatment protocol would have been excessively long. The Project MATCH Steering Committee decided upon a 12-week duration for each study treatment. To best use the breadth of material in Monti et al. to meet clients’ needs, while at the same time assuring that all clients received certain essential sessions, the choice was made to have eight core sessions (introductory, termination, and six additional sessions) and to allow the therapist and client to jointly select the four most appropriate from among 14 elective sessions.

Supporting Data

The final chapter in Monti et al. describes empirical findings that have been obtained using its treatment materials. What follows is a summary of studies using the Monti et al. book that have appeared since its publication.

The treatment sessions in the Monti et al. book were designed to address both interpersonal and intrapersonal coping skills. The final chapter described a treatment study in which these two types of sessions were compared: alcoholics were randomly assigned to a “standard treatment” combined with (1) cognitive-behavioral mood management, (2) individual communication skills training, or (3) communication training with a significant other present. Recently published results indicate that while all treatment groups improved significantly in a role-play assessment of coping skills and showed reduced anxiety in both general and alcohol-specific role-play situations (Monti et al. 1990), patients who received either of the communications skills training packages improved the most in the alcohol-specific role-play assessment. Followup results at 6 months after treatment showed that alcoholics who received communication skills training, with or without family involvement, consumed significantly less alcohol than alcoholics who received cognitive-behavioral mood management training. Rohsenow et al. (1991) found that individual or family communication skills training benefited a broader spectrum of patients, regardless of initial level of education, alcohol dependence, skill, anxiety, or beliefs, when compared to mood management training.

The Monti et al. book described another patient-treatment matching study by Kadden et al. (1989) in which inpatients were randomly assigned to aftercare consisting of either interactional group therapy or CBT groups using Monti et al. as the treatment manual. Survival analyses provided evidence for the durability of matching interactions over a 2-year outcome assessment period (Cooney et al. 1991). Relapse occurred more slowly when clients having more psychopathology or sociopathy received CBT rather than interactional therapy. For those clients evidencing little psychopathology or sociopathy, relapse occurred more slowly when they received interactional therapy rather than CBT. Clients who were “matched” according to these results had 2-year abstinence rates of about 45 percent, whereas those who were mismatched sustained only a 25-percent abstinent rate. Clients classified as cognitively impaired had better outcomes in interactional therapy and worse outcomes in the CBT groups.

In other analyses on the same data set, trained raters analyzed audiotape recordings of treatment sessions to assess the discriminability of the two treatments (Getter et al. 1992). They found that CBT sessions were characterized by significantly more educational and skill-training activities, application of problem-solving techniques, role playing, and identification of high-risk situations. Interactional sessions produced significantly more expression of feelings, interpersonal learning, and here-and-now focus.

Another analysis was based on two clusters of variables that characterized the clients at intake to the study (Litt et al. 1992). Clients in the less severe cluster fared better in interactional treatment, whereas those classified in the more severe cluster had better outcomes in CBT.

Role-play assessments (Abrams et al. 1991; Monti et al. 1990, 1992) were used to examine the relationship between clients’ coping skills and the two treatments offered. CBT resulted in better treatment outcomes for those with poorer observer-rated coping skills, greater observer-rated anxiety, or greater self-reported urge to drink in the role-play assessments. Interactional therapy was better for those with greater skill, less anxiety, or fewer urges to drink in the role plays (Kadden et al. in press).

These findings indicate the usefulness of this version of CBT for clinical research studies of patient-treatment matching and begin to delineate some of the parameters that define the clients for whom it will be the most appropriate treatment.

Ronald Kadden
Ned Cooney
Peter Monti
David Abrams
Authors of Treating Alcohol Dependence: A Coping Skills Training Guide

References

Abrams, D.B.; Binkoff, J.A.; Zwick, W.R.; Liepman, M.R.; Nirenberg, T.D.; Munroe, S.M.; and Monti, P.M. Alcohol abusers’ and social drinkers’ responses to alcohol-relevant and general situations. Journal of Studies on Alcohol 52:409–414,1991.

Cooney, N.L.; Kadden, R.M.; Litt, M.D.; and Getter, H. Matching alcoholics to coping skills or interactional therapies: Two-year followup results. Journal of Consulting and Clinical Psychology 59:598–601,1991.

Getter, H.; Litt, M.D.; Kadden, R.M.; and Cooney, N.L. Measuring treatment process in coping skills and interactional group therapies for alcoholism. International Journal of Group Psychotherapy 42:419–430,1992.

Kadden, R.M.; Cooney, N.L.; Getter, H.; and Litt, M.D. Matching alcoholics to coping skills or interactional therapies: Posttreatment results. Journal of Consulting and Clinical Psychology 57:698–704,1989.

Kadden, R.M.; Litt, M.D.; Cooney, N.L.; and Busher, D.A. Relationship between role-play measures of coping skills and alcoholism treatment outcome. Addictive Behaviors, in press.

Kaul, T.J., and Bednar, R.L. Experiential group research: Results, questions and suggestions. In: Garfield, S.L., and Bergin, A.E., eds. Handbook of Psychotherapy and Behavior Change. 3rd edition. New York: Wiley, 1986. pp. 671–714.

Litt, M.D.; Babor, T.F.; DelBoca, F.K.; Kadden, R.M.; and Cooney, N.L. Types of alcoholics: II. Application of an empirically-derived typology to treatment matching. Archives of General Psychiatry 49:609–614,1992.

Monti, P.M.; Abrams, D.B.; Binkoff, J.A.; Zwick, W.R.; Liepman, M.R.; Nirenberg, T.D.; and Rohsenow, D.J. Communication skills training, communication skills training with family and cognitive-behavioral mood management training for alcoholics. Journal of Studies on Alcohol 51:263–270, 1990.

Monti, P.M.; Abrams, D.B.; Kadden, R.M.; and Cooney, N.L. Treating Alcohol Dependence: A Coping Skills Training Guide. New York: Guilford, 1989.

Monti, P.M.; Rohsenow, D.R.; Abrams, D.B.; Zwick, W.R.; Binkoff, J.A.; Munroe, S.M.; Fingeret, A.L.; Nirenberg, T.D.; Liepman, M.R.; Pedraza, M.; Kadden, R.M.; and Cooney, N.L. Development of a behavior analytically derived alcohol specific role play assessment instrument. Manuscript in submission, 1992.

Rohsenow, D.R.; Monti, P.M.; Binkoff, J.A.; Liepman, M.R.; Nirenberg, T.D.; and Abrams, D.B. Patient-treatment matching for alcoholic men in communication skills versus cognitive-behavioral mood management training. Addictive Behaviors 16:63–69,1991.

Sisson, R.W., and Azrin, N.H. The community reinforcement approach. In: Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives. New York: Pergamon, 1989.