With those who are married or involved in a romantic relationship, CRA + Vouchers focuses on reciprocity relationship counseling. Therapists train couples in the use of general communication skills and the application of those skills to developing behavioral contracts to improve the quality of their relationship. These procedures are based on those outlined by Azrin et al. (1973) and Sisson and Azrin (1989). Interested readers should see those sources and Meyers and Smith (1995) for more information on this approach.
The schedule generally consists of one session each week for 4 weeks and then one session every 2 - 4 weeks for the remainder of treatment, for a total of eight sessions. Each session is about 1 hour long, and many of the major problems in the couple's relationship may be discussed.
The couples sessions replace individual sessions. Therefore, discussion of urinalysis results should be the first topic addressed. If disulfiram is being used, the Disulfiram Assurance Procedure should also be followed in the office.
Introduce Relationship Counseling
During the first relationship counseling session, therapists should provide an overview of this therapy and explain that the primary objective is to make both individuals more satisfied with their relationship.
"As you well know, an important area of your life that is negatively affected by cocaine problems is your relationship with your partner. Those close to the person with the problem are typically most affected by the problem. Many partners of cocaine abusers have tried many times to help their mate stop using. Strategies for trying to help vary. Anger and frustration usually build up, and feelings of hopelessness and helplessness sometimes arise. Sometimes attempts to help are met with resentment and anger from the partner with the problem."
"In this part of treatment, we focus on how cocaine use has affected your relationship and how we can work to increase the positive aspects of your relationship. We also discuss ways that your partner can assist you in achieving and maintaining abstinence. We hope to be able to help you both deal more effectively with this cocaine problem."
"We have found that, where there are drug abuse problems, there are usually communication problems. Usually, we see communication that is filled with anger, silence, apathy, or resentment, and many times partners try to get their needs met outside the relationship. By the time patients come to see us, there is little, if any, enjoyment left in their relationship."
At this point, therapists should ask if any of this sounds relevant to their situation and then discuss any issues that arise. After checking for questions and comments, therapists can continue as follows.
"Another major reason we find it important to include partners is that they can provide a source of support that is important for successful treatment. It is essential, as a person begins to stop using cocaine and starts to engage in 'good' behaviors, that they be acknowledged for doing so. It is sometimes hard for others close to the user to do that because most of what they have experienced during the last months or years is negative emotion and disappointment as far as their partner is concerned. Therefore, if we include the partners in treatment, they can perhaps empathize with and understand more about what the patient is going through and the effort being given toward treatment. This understanding may make it easier for the partner to provide the support that will be helpful for increasing the chances of recovery."
"Our goals are to help you -
- Achieve and maintain cocaine abstinence.
- Change your current lifestyle.
- Increase enjoyment in your relationship.
- Learn better ways to solve problems.
- Develop effective communication skills."
"Achieving these goals will not be easy. However, if we all work hard on making changes, the outcome will likely be positive, that is, you will learn how to stop using cocaine and alcohol or other drugs. Our role will be to help you make positive changes in your relationship so that it becomes more meaningful and enjoyable. Like the other areas of change, making changes in your relationship will require much work. You will have to learn and practice new ways of communicating and problem solving. With such practice, we expect that you will learn how to use your new skills to increase the satisfaction you get from your relationship."
"Before beginning relationship counseling, it is important to note that blaming one another will not be helpful. Each of you is always responsible for your own behavior. Cocaine use is your (the patient's) problem, and you are responsible for your choice to use or not. You (the partner) are responsible for your behavior as well and whether or not you do things that make it easier or harder for your partner to stop."
"There are many causes of cocaine abuse, so it does not help to blame one thing or event. Genetics probably play a role, as do family and societal stressors. Whether you consider your problem a disease or a bad habit does not matter when you are trying to stop using. Once your problem exists, the things that cause you to keep using in the here and now must be dealt with to help you stop using. That will be our focus in this program."
After giving this introduction, therapists should ask both patients and partners how they feel about what has been said. Questions about the process, rationale, causes, blame, responsibility, and so forth should be expected and be answered in an empathic manner to reassure couples that counseling can help them.
Next, to break the ice and create a more positive atmosphere, couples can be asked to recount to each other what it was like when they first met and began to spend time together. The rationale for this is to remind them why they chose to be together and what they might like to regain in their relationship. This exercise may provide good ideas for the types of goals to set in counseling to increase satisfaction in the relationship.
Therapists can then begin by asking patients what they liked about their partners, what sort of fun things they did together, and what attracted them in the first place. Therapists should direct couples to speak directly to each other. If either one tries to recount this to the therapist, redirect the person toward the partner. Also, therapists should remind them that this is a positive exercise; no negative or critical comments are allowed at this point. This exercise can be embarrassing for some patients and partners, so it is important for therapists to make them feel as comfortable as possible. The exercise is meant to be light and fun. If couples have difficulty participating and cannot think of things to say, therapists should prompt, model, and gently coax them to continue.
After both have taken turns with this exercise, therapists should ask them to do the same thing again, but this time to tell their partners what they like about one another now. The same "rules" should be followed for this exercise, that is, only positive things should be shared, and each one should talk directly to the partner. This exercise may highlight how the relationship has changed and may indicate specific, positive aspects that have faded and need to be recaptured.
After this exercise is completed, it is important for therapists to explain that, because of the impact of drug use on their lives, they may not be communicating with each other the way they did in the past, and that many of the things they liked about their partners may not be apparent now. However, this does not mean that those positives cannot be recaptured with hard work.
Relationship Happiness Scale
At this point, therapists can introduce the Relationship Happiness Scale (exhibit 21). This scale is used to assess how happy couples are currently with various areas of their lives. Each partner should complete the form independently. Therapists should emphasize that they are to evaluate the problems in terms of current, not past, satisfaction. A list of examples (exhibit 22) is given to couples to provide them with types of events relevant to each area.
Once completed, therapists should collect the forms and initiate a brief discussion of their responses. Therapists should explain that this happiness scale will be completed at the start of each session to assess changes that occur during treatment.
Daily Reminder To Be Nice
Therapists should next give patients and their partners each a copy of the Daily Reminder To Be Nice Form (exhibit 23) and explain the rationale for its use.
"Many times in relationships, partners begin to take each other for granted. If you think about it, sometimes they treat strangers with more courtesy, respect, or appreciation than they do their own partners. This situation can be even worse in relationships that are stressed by drug use. Thus, we have created an exercise that can help to reverse the negative behavior that may have become habitual in your household. Even if your situation is not as bad as I described, you both could probably still benefit from this exercise. What I will be asking you to do is simply be nice to your partner. This form lists seven ways to do that. The form is supposed to serve as a reminder for you to do more of these nice things and to record how well you are doing with actually engaging in these nice behaviors."
Therapists should then review the form with the couples, answer any questions they may have, and ask them to complete a sample form by reflecting back on last week's behavior. Once this is completed and discussed, therapists can ask how the patients would feel if their partners performed these behaviors every day. Again, couples should be instructed to respond directly to one another and to tell each other specifically what they would like the other to do. The mood during this exercise should be light and fun.
Therapists should instruct patients to record on the sheet each day whether they performed each of the positive behaviors. A discussion should be initiated concerning where the forms should be kept and how they will remember to fill them out. A good place to keep them is on the refrigerator or on top of the television set, any place where they can be seen frequently to remind them to do the nice behaviors and to record them.
To make the partners even more aware of ongoing reciprocal behavior, therapists should have them list at least 10 satisfactions their partners are providing to them as well as 10 they provide to their partners. They should be encouraged to refer to specific events rather than general attitudes. For example, "I do laundry each week," "I clean the house,"I provide advice when asked,"I provide moral support,"I went food shopping." After the lists are completed, they should be discussed so agreement is reached and the amount of existing reciprocity is assessed.
After this session, the couple should be given Daily Reminder forms to complete at home before the next session. In addition, they should be instructed to mention each day any novel, unusual, unanticipated, or unscheduled satisfaction they receive from their partners.
Each session thereafter, therapists should review the completed Daily Reminder forms and discuss how the expression of appreciation or satisfaction is going.
When couples come in for their next session (and all subsequent sessions), therapists should have them complete the Relationship Happiness Scale and briefly discuss any changes from the last session.
Next, therapists should review and discuss the Daily Reminder forms completed during the days between sessions. Both partners should be encouraged to state specifically what behaviors they engaged in and how they were affected by the other partner's nice behaviors. In this way, the session begins on a positive note. The patients should then be given additional forms and instructed to continue to complete them daily.
If patients and partners did not bring in their forms, or if they did not fully comply with the procedures, a discussion and plan for how to increase compliance should be initiated. Therapists can emphasize the importance of following through with these assignments by reviewing the rationale. problem solving techniques and appropriate behavioral procedures should be used to address any compliance-related problems.
Perfect Relationship Form
Next, therapists should give patients and partners the Perfect Relationship form (exhibit 24) and provide the rationale for its use.
"We are going to use this form to target areas in which each of you would like to see some changes from your partner. These changes should be things that you feel would increase the satisfaction or happiness you get from your relationship. The exercise is designed to help you identify specific behaviors for change so it will be easier for your partner to know and then respond to your needs. If you don't identify specific behaviors for change, it is difficult for your partner to meet your needs or make you happier. Thus, this exercise will begin by identifying needs and then will move on to exploring ways to ask for these changes that will increase the chance that your partner actually will make those changes."
Each partner then fills out the first section of the form, "Household Responsibilities." They should list things in this category they would like their partner to do or to do more often. Therapists should repeat the instructions to be specific and to word their requests in a positive manner. Encourage them to be as selfish as possible in stating their wishes and give them an example.
"You would like your partner to help out more with the laundry and vacuuming. Write down: On Saturday mornings after breakfast, I would like it if you would vacuum the living room and our bedroom. Also, on Saturday morning, I would appreciate it if you would gather the laundry from all the rooms and place it in the laundry room."
Next, therapists can work with couples to create specific lists of things each would like the other to do. After completing one or two categories, couples should take the form home, complete it, and bring it back to the next session.
After patients and partners have completed one or two sections of the Perfect Relationship form, therapists should introduce the notion of positive requests. This component is designed to teach couples how to request things from each other in a way that will increase their chances of getting what they want. The rationale for this component is provided as follows.
"Learning or relearning to communicate positively is important for many couples who come to our clinic, because many times they have stopped communicating as drug use has become prevalent in their lives. Even when there is no drug abuse, it is common for couples to stop using positive types of communication in ongoing relationships. However, if you or your partner want the other to make changes, the most effective way to do this is by using positive communication rather than demanding, nagging, or ordering the other to change."
"We would like to teach you how to use a particular method for making requests that will increase the probability that your partner will make the effort to change. This type of communication is a skill and, like any skill, requires practice to be able to do it effectively. Thus, it is important that you both agree to make an effort to learn and practice these skills. Trying to use this type of communication may be difficult at first and may seem forced or unnatural but, over time, you will begin to feel more comfortable."
Therapists then explain that some ways of making a request are more pleasant than others, which, in turn, make it more likely that a request will be acted upon (exhibit 25).
- Try to take the other person's point of view and understand how it feels. The other person may not recognize your needs or realize that you are unhappy.
- Try to take partial responsibility. For example, if you want your partner to take more initiative in helping the kids with their homework, but have never told your partner how important that is to you and why, then you could preface your request by saying, "I know I have never told you how important it is to me for the kids to do well in school, but because of how I failed and how it made me feel so stupid, I really don't want them to have to feel that way their whole lives. I know it's partly my fault that we don't spend a lot of time with them on schoolwork, but I would like us to begin to do that as much as possible."
- Offer assistance to make it easier for your partner to fulfill your request. In the example I just gave, you could remind your partner, if it is the partner's turn to help with homework, that you could arrange or schedule the times for this to happen. In making the request, you could say something like, " Would it be helpful if I..."Would it make it easier for you to do this, if I..."
After reviewing these steps, another one or two examples of a positive request should be provided by therapists, and couples should be encouraged to review these steps before they make a request.
Next, therapists can have each partner take out a Perfect Relationship form and practice making positive requests. Each partner can pick one request to practice. The components of an effective request are reviewed, and therapists help the partners choose words that are specific and positive. Each one then practices making these requests to the other partner.
Couples should be encouraged to try to fulfill each other's desires, at least in part, and to adopt the attitude that any desire can be fulfilled and "If you want it, you can get it."
Techniques for working out compromises should be discussed next. Specifically, couples should be taught to turn a particular request into a continuum rather than an all-or-none request. For example, if one partner wants the other to initiate sexual activity and the other refuses to accept that responsibility, a discussion of exactly how often the partner wants the other to initiate sex can lead to an agreed-upon compromise.
Any time a request is made by one partner, the other should be asked whether it will be done. If the answer is no, a compromise should be worked out. The partners are encouraged not to refuse requests from one another. Rather than saying no to a request, a partner might suggest an alternative. When proposing an alternative solution, the partners are instructed to follow the same steps used for making a new request.
After compromises are practiced, therapists should ask each partner to pick one request that will be the target for change in the next week. These requests are then directly stated to the partner in the session. The requests can be practiced repeatedly, if necessary, with therapists providing feedback to help shape effective, positive requests. Once the requests are agreed upon, they should be written down in contract form on the request forms shown in exhibit 26.
In the next session, therapists should express interest in hearing from couples about how things went. Couples should be informed that therapists will be tracking progress with these requests each week. Lastly, patients are asked to complete the rest of the Perfect Relationship form and bring it to the next session. Therapists can again emphasize that these are to be thought of as "perfect" relationship requests, not demands that they are forcing on their partner. Thus, they can be encouraged to be selfish when writing down those things they would like their partner to do.
At the beginning of the third session, therapists should review the Daily Reminder forms and have the couple complete the Relationship Happiness Scale. Next, the Perfect Relationship forms should be reviewed. If couples did not complete these forms, they should take a few minutes during the session to do so; at least a significant portion of the form should be completed. Progress on the reciprocal-request contract is then reviewed. If progress was good, therapists should provide social reinforcement. If little or no progress was made, a problem solving discussion should follow, focused on developing a plan for the coming week that will increase the likelihood of compliance with the request.
Next, therapists and couples target another set of requests for change. The Relationship Happiness Scale is used to prioritize areas for change. For example, areas that patients or partners rate as low in satisfaction are likely to be areas in which therapists encourage them to make changes. Once an area is agreed upon, each partner can pick one request from the Perfect Relationship form. Therapists then have couples practice making positive requests using the steps reviewed in the last session. Then another reciprocal contract for behavior change is completed and signed.
Usually only one new request for change is recommended each week and, if no progress is made during the week, new requests are placed on hold until couples successfully comply with the first request.
Next, couples are given the Communications Skills Training #1 handout (exhibit 27). The components of positive communication training are reviewed and discussed. These procedures for teaching positive communication skills are based on the approach of Gottman et al. (1976) and McCrady (1986). The Perfect Relationship form is then used to identify areas of their relationship the couple would like to improve. They then pick an area to discuss in session. The rationale for this exercise could be explained as follows.
"Like any other skill, developing communication skills takes practice. What I would like you to try to do now is to have a discussion about [name subject area], and while doing so, try to keep in mind the communication skills we just reviewed. During your discussion, I will be interrupting you to point out particular strengths and weaknesses of your interaction in terms of the communication skills. I may show you some other ways to get across your points. I may ask you to try again and practice another way of phrasing something, or practice omitting parts of your comments that are not effective. You may find this exercise a little strange or embarrassing; it may also be quite frustrating. However, I would like you to try to stick with it and even try to enjoy yourself. Learning new ways to communicate is not easy, but the only way to improve and to change old habits is to practice."
The rest of the session should be used to practice these communication skills. Before leaving, the couple should pick two problem areas they will discuss during the next week, using the communication skills learned. Therapists should encourage them to select a specific day and time to have the discussions and to write down their impressions of these encounters and how they felt they did. Finally, therapists should remind them to continue to complete the Daily Reminder sheets.
At the beginning of this session, therapists should -
- Review the Daily Reminder To Be Nice completed in the past week.
- Have the couple fill out the Relationship Happiness Scale.
- Review progress on the reciprocal contract requests.
- Review how the couple fared in the scheduled discussion of the two problem areas.
If there were problems, these should be dealt with. It is important to spend as much time as needed to review, problemsolve, and discuss any relevant issues. If the couple complied well with the reciprocal requests, an additional request should be considered. If it is decided that the couple is going to add another request, the same procedures as in Session 2 should be followed to target and practice this request.
Next, therapists should give the couple Communications Skills Training #2 (exhibit 28). The communications skills are reviewed with the couple and the procedures used in Session 3 are used to teach and practice these skills. Again, therapists should provide as much positive feedback as possible as they try to shape effective, positive communication between the couple. With some couples this will be painstakingly slow, so it is important to be flexible and to use a reflective and empathic counseling style and behavioral skills to help the couple comply and progress in this area of change.
At the end of the session, the couple should be asked to repeat the same assignments given in the last session (i.e., discuss two problem areas and practice using the communications skills and complete the Daily Reminder sheet).
Sessions 5 - 8
Throughout the remainder of the relationship counseling sessions, the couple should continue to complete the Relationship Happiness Scale, the Daily Reminder sheets, make reciprocal contract requests, and practice communication skills. Many times, the first few weeks or so of this counseling go very smoothly. Because patients are making an effort that can readily be seen by their partners, many positive changes usually occur. It is important to recognize that this may not last. The old, habitual patterns of communication will most likely surface as stressors occur or if the patient uses cocaine. Therapists should persist in teaching the communication and relationship skills. These are the skills that will help couples get through the difficult times.
The last few sessions should be scheduled further apart (biweekly, then monthly) prior to ending relationship counseling. Therapists should ensure the patients' partners that they are still involved, even if not attending regularly, and that they can contact the therapist any time they feel the need.