2.6l. Ending Sessions. In addition to a standard opening for sessions (see 2.6i), there is also a normal
procedure for bringing sessions to a close. About five to ten minutes before your scheduled time is over, signal
that the session is coming to a close and offer a summary reflection, give an indication of what will happen
next, and then give the client an opportunity to ask for clarification or add something. Here is an example:
Let me go over what we’ve done today, and where we will go from here. We talked a lot today about
the reasons why you want to quit drinking, and also some of your concerns about quitting. I really
appreciate how honest you have been with me and with yourself in exploring this. You have really
enjoyed drinking, particularly up until a few years ago, and it has become a major part of your social
life. You can see, though, that in another way it has taken over your life, to the point that it is
compromising your health and your relationship. You started drinking in the morning, even though
you had promised yourself you wouldn’t ever do that, and some of the feedback we discussed worries
you. We’re getting to the end of the time we scheduled today, but I’d like to see you again soon
because you seem really eager to take a next step. What we’ll do next time, then, is to start sorting out
what you want to do about your drinking. There are some things we can do together to figure out what
might work best for you, and I will certainly want to hear your own ideas on what you want to do.
How does that sound? Did I miss anything important? . . . . . . Is there anything else you’d like to ask
or tell me before next time?
The content of the closing summary will vary, of course, depending on what happened in the session. The
point is to draw together in your summary:
what has been discussed during the session
self-motivational themes that have emerged during the session (and before)
honest affirmation of the client’s efforts, strengths, intentions, etc.
any tasks that the client is to do between now and the next session
anticipation of what you will be doing in the next session
scheduling of the next session
2.7 When the Supportive Significant Other (SSO) Attends the first CBI Treatment Session
2.7a. Overview. Typically, the first SSO-involved session occurs at the third session of CBI
treatment, but only after the feedback on the baseline measures has been provided to the client. The overall
purposes of the initial SSO-involved session are (1) to orient the SSO to his or her role/function in CBI
treatment (2) to obtain the SSO’s commitment in supporting the client’s efforts to change and (3) to enhance
the SSO’s skill in providing clear and meaningful support to the client. Efforts are made to find opportunities
for the SSO to increase his or her supportive behaviors. Other activities include helping the SSO determine
when to, and when not to, offer support. For example, there are certain circumstances where it may be
desirable for the SSO to "back off" rather than continuing to offer support. Such situations may involve a
client's failure to adhere to treatment goals such as not taking medications, not attending job training sessions,
and not willing to "sample" abstinence. Under these circumstances it may be valuable for the SSO to withdraw
her/his support to allow the client the opportunity to experience the costs/consequences of his choices/actions.
This process can help mobilize a client’s inner resources to deal with the drinking problems.
2.7 b. Orienting the SSO to CBI. SSO selection should occur by the second CBI session. If the client
agrees, the SSO is invited to the third CBI session, but only if assessment feedback has been completed. At
this initial SSO-involved session, welcome and thank the SSO for coming in support of the client’s treatment.
Ask the SSO whether he or she received the letter inviting him or her to participate in the client’s treatment (A
letter inviting the SSO to participate will be given to the client to bring to the SSO prior to the initial SSO-
involved session). Briefly review the contents of the letter for those who did not receive it. Ask the SSO
whether he or she has questions and concerns about the strategies and procedures covered in the letter.
Respond in a straightforward manner to any questions or concerns that the SSO may have about the
To prevent misunderstandings between you, your client, and the SSO, which could result in
compliance problems later on, review the goals and objectives of the client's treatment. Clarify what roles the
SSO might play in the sessions. Remind the SSO that she or he knows much more about the client than the
therapist and consequently could be helpful in a number of ways such as providing constructive feedback on
the plans which have been devised by the client and therapist to maintain abstinence. Explain that the SSO is
not expected in any way to be a co-therapist, and assure the SSO that you will not ask him or her to do
anything that he or she is not comfortable doing. If the SSO is a family member, explain that you will not be
doing marital or family therapy (in which the relationship is the focus of treatment). You may discuss issues
that have to do with communication in relationships, but the primary purpose of treatment is to help the client
get and stay sober. Explain also that the SSO’s role does not include any policing or enforcing, but rather the
main focus is to be supportive of change. Explain clearly that the SSO’s role is to provide support for sobriety
during treatment, both inside and outside of sessions. This will include:
offering helpful ideas and input
supporting and reinforcing the client’s efforts to stay sober, and
helping - in ways the client wishes- to carry out plans for staying sober.
In general, by becoming an ally for change the SSO can help to improve the effectiveness of treatment.
However, you may want to remind the client that no one else can make the ultimate decision about change, or
take responsibility for it.
Mention that the intention of CBI treatment is to have the SSO participate in all CBI sessions so that
the client will obtain maximum benefit of treatment. Explain that the number of CBI sessions (i.e., up to 20
sessions) is usually decided collaboratively among the parties involved (i.e., client, SSO, and therapist).
Typically, a client’s treatment is terminated when she or he (client) has achieved treatment goals or a
determination is made that she or he (client) has derived optimum benefit from such involvement. Here is an
example of how this opening statement might sound in ordinary language:
I appreciate your willingness to attend these sessions and to help David
(client) as he makes some major changes. Your support and encouragement
can be valuable in helping David overcome the drinking problem. Let me
start by asking - in what way have you tried to be helpful in the past?
SSO: I found that David didn’t drink at all when I kept him busy around the house, especially when
I asked him to care for the children. He loves his children and would never do
anything to hurt them. He never drank when he would take them out for food,
ball games, and swimming.
THERAPIST: So one thing you have tried is to keep him busy, especially with the children, to help
him not drink. (Turning to the client) Is that something that you found
I didn’t realize what was behind it, but I know I don’t drink when I’m taking care of
Good. (To SSO). How else have you tried to support David in not drinking? Give me another example.
It didn’t work very well, but I would kind of snoop around to see if he had a bottle - things like that.
You meant well in doing that, but it didn’t really work so well. I can see, though, that you have really been
looking for what you can do to support him in not drinking - whether or not it
was always the right thing to do. (Turning to client) Let me ask you this: Do
you have any concerns or anticipate any problems in having Martha (SSO)
come to the sessions with you?
I’m concerned that if Martha comes to these sessions, she will get obsessed with my
drinking. This was a problem in the past. Martha was furious with me when I
was drunk, and like she said, she acted like a detective. Sometimes when I
arrived home with a package I would get this suspicious look as if I was
hiding booze in the bag. This stopped once I entered this program, though.
THERAPIST: (To SSO). So you have been making an effort not to be too involved with his drinking
since he came here. I imagine it was something of a relief for you.
SSO: It certainly is. I feel like finally I don’t have to be the only one standing between him and his
You know, that’s really not so unusual. When somebody you love is in trouble, you’re concerned and just
want to do something, anything. It happens particularly when the level of
stress and conflict is high. Sometimes people do things that don’t make sense,
just trying to do something, anything to bring about a change. Now it feels
like the weight isn’t so much on your shoulders. I think you both understand
that even with Martha participating in these sessions, the real responsibility
for change lies with you, David. Nobody can do it for you, even if they really
want to. (Turning to the Martha) What I want you to do in these sessions is
to provide emotional support while David is making changes related to his
drinking. You could also provide constructive input and ideas along the way.
But there’s really nothing else right now that I need for you to do. Just your
being here is helpful. What do you both think about that? Are you willing to
help in that way, Martha?
Here are a few points to remember after you have given your introduction and described the SSO’s role.
1. Ask whether the SSO is willing to help in this way.
2. Ask whether the client is willing to have the SSO help in this way.
3. Ask whether the SSO has any questions that you could answer.
4. Ask whether the client has any questions about how the SSO will be involved.
Ask the SSO what steps has she/he found helpful to the client in achieving sobriety. If SSO is unable
to respond give her/him a few examples of what might be helpful to a client such as maintaining a sense of
optimism, praising the client for his or her efforts, spending time with the client in activities incompatible with
alcohol use, and celebrating the achievement of an important step - e.g., refusing to drink with a special friend.
In the case illustration below, the therapist discusses with Janet (client's wife - SSO) and Bob (client) how to
employ support effectively with the client:
Based on my previous discussions with Bob you appear to be his strongest
supporter. You seem really committed to helping him overcome the drinking
problem and I really applaud your coming to the sessions with him. Maybe
you can start by saying something about the steps you have taken that have
been helpful to him.
Well, I am just so proud that he has been sober for the past three weeks and I
told him so. I have encouraged him to open up to me about how hard it is to
How did you do this?
I don't know. I just thought it was important for Bob to know how badly I felt
about the drinking. Telling him this seemed to help him open up more to me.
(To Bob) How has this helped?
Janet’s support and encouragement has meant a lot to me. I find it easier to
handle my urges when I know Janet is behind me.
He (Bob) appreciates my efforts. In the past, when I tried to help he would
often tell me to leave him alone. This no longer happens.
These are important ways to help Bob avoid drinking. I am impressed that
you both recognize the importance of Janet’s support in addressing the
Comment: Here the therapist discusses the importance of the reinforcing behavior with Janet. At the
same time, he (therapist) helps to build confidence of the SSO by linking Janet's change efforts to client
Continue the discussion on the importance of these reinforcing activities. Explore other ways that the
SSO could be helpful to sustain sobriety. Examine how the presence of the SSO could lead to an improvement
in the drinking. Below is another case illustration demonstrating how reinforcing behavior impacts positively
on the treatment process.
(To Bob) What are other ways Janet can be helpful to you?
I am not sure Janet realizes this but last week when she went to the ball game
with me I was tempted to order a beer from the vendor but I didn't. I knew
she (Janet) would be upset if I started to drink.
Janet, how did you feel?
I was glad Bob asked me along. Going to ball games and bowling can be bad
for him. I was pleased that Bob had me in mind when he decided not to drink.
The fact that I do not drink at these events probably helps a little bit.
(To Bob) What did you learn from the situation?
Having her (Janet) there really helped. I was able to control my desire to
drink because I did not want to disappoint her. Also, it helped to talk to her
beforehand about the difficulties of attending a ball game on a hot summer
afternoon without having a beer.
Having Janet there was really good for you. What do you suppose would
have happened if she wasn't there?
I'm sure that I would have come home drunk.
(To Bob) There will be times when you are in problem situations (high risk)
like bowling when Janet will not be there. What do you need to do to help
yourself to stay sober?
I could telephone her but this is not always possible. I probably should
always keep Janet in mind if I am to get through the situation (high risk)
Comment: The therapist helps Bob understand how Janet’s presence enabled him to refrain from
alcohol use. He helps Bob identify the coping mechanism used in this situation to forestall alcohol use. Bob
learns that just "keeping Janet in mind" may be an effective coping mechanism in dealing with future alcohol
2.7c. When Differences Occur Between the SSO and Client. It is not uncommon to find that the
SSO is more committed to changing the drinking practices than the client him/herself. As a result,
discrepancies often occur between SSO and client concerning what needs to be done to overcome the drinking.
Such differences need to be normalized and resolved. In the excerpt below, Janet’s proposed action steps are
in conflict with Bob’s.
I want to raise a concern about an event occurring at our house next week. We are
planning a surprise birthday party for Bob's father. I do not think we should serve
alcohol at the party. Bob disagrees. He sees no problem in having alcohol available
for relatives and friends. I tell him he is just looking for trouble if he serves alcohol.
THERAPIST: I am impressed that you both recognize this as a potential problem and are willing to
talk about it. These issues are not uncommon in families where one of the partners is
struggling to stay sober. What may be helpful here is to discuss what might happen if
alcohol is served or not. Let's start with not serving alcohol at the party. What do you
suppose would happen?
I'm afraid that it will cause trouble with my friends. I do not want to be made the fool.
Bob' friends may find out he has a drinking problem if no booze is served. I say, "so
what". It might help if his friends know.
THERAPIST: You (Janet) feel that letting his friends know about the drinking problem would be a
clear indication of Bob's commitment to change and perhaps not serving drinks would
give a clear message to the friends about Bob's desire to remain sober.
THERAPIST: What about the alternative, that is, serving drinks to your friends and family? What do
you think would happen?
This is the situation we have faced before and it has never worked. Bob tries to have
one or two drinks just to be social but after a while just loses it.
This time it will be different because you (to Janet) will be there.
I am not so sure. You still drank last time I went to the bar with you and your friends.
I get very nervous about saying 'no' to my friends and usually end up drinking too
You can handle your friends. You're not afraid to tell them off about other things like
when they owe you money. When you feel right about something you can be really
I just want to say one thing: If you want to serve liquor I can't stop you. But I won't be
there watching you 'boozing'.
You're not coming to the party?
Not if you serve drinks. I can't stand watching what you do to yourself. The
arguments about trying to get you to stop. The blaming of yourself the next day
followed by the apologies. This is just too much. It really upsets me (Janet begins to
THERAPIST: (To Janet) You really do not want to continue hovering over Bob about the drinking,
I need to let go for my own sanity. I can't stand by and watch Bob destroy himself.
Maybe my not being at the party would help. Bob would finally learn that he really
THERAPIST: Let me summarize the situation. If you serve drinks, there is a high probability that
you (Bob) will resume drinking and upset your family. If you don't, then you might
be pressured to drink again by your friends. Any other alternatives?
A third possibility is that the friends might actually understand and be sympathetic
toward Bob about the drinking. They might even become supportive of his desire to
change. This is what he should expect if they were real friends.
Comment: In the excerpt above the SSO demonstrates her support for and confidence in Bob's ability
to handle the pressure of his friends to drink. Janet recognizes that not attending the party may not only be
important for herself but for Bob as well. It might lead to Bob’s understanding that he cannot drink
moderately, at least when socializing with friends.
2.7d. What Does the SSO Do If the Client Resumes Drinking? There may be times during the course
of treatment that the client will resume drinking which in turn could pose problems for the SSO. Some SSOs
might become angry, frustrated, or disappointed with the client and leave treatment abruptly, an act which
conceivably could impact negatively on the therapeutic process (e.g., undermine the self-efficacy of the client
in dealing with the drinking). Alternatively, some SSOs might intervene to protect the client from the costs or
consequences of the drinking. Examples of such behavior include making excuses for the client to his or her
employer, friends, or family for the alcohol use, cleaning up after him/her after a drinking episode, and in
general, continuing to play a supportive role despite the client’s using. These activities on the part of the SSO
have been termed “enabling behavior”(Meyers, Smith and Miller, 1998). Such behavior allows the client to
shift responsibility for the drinking away from himself and on to the SSO. Not allowing the client the
opportunity to experience the negative consequences of the drinking (i.e., enabling behavior) can undermine
his or her commitment to change (Meyer, Smith, and Miller, 1998). Thus, it may be useful to have a
discussion about alcohol use while the client is still sober or before heavy drinking occurs. At the same time,
efforts should be made to have the SSO and client devise a constructive plan to deal with the drinking when or
if it occurs (See #’s 1-4 below). Otherwise, there is a risk that the SSO may inadvertently diminish the
effectiveness of the treatment. In short, taking a proactive stance with the SSO and client can better prepare
them for dealing with the drinking episodes. Therefore, you might consider doing the following:
Explain that a return to alcohol use is not uncommon in alcoholism treatment especially in the
early months of treatment. However, the longer the client is able to abstain, the better the
chances are for continued sobriety.
Indicate that the client him/herself is responsible for addressing the problem.
Mention that procedures have been developed (see section 4.4. on Resumed Drinking) for
helping the client deal with these episodes. Discuss the methods used for helping clients who
have resumed drinking.
Examine the pros and cons of the various options the SSO might have in dealing with the
drinking. One option is to withdraw support from the client while she or he is drinking. This
might mean not participating in drinking-related events such as bowling, attending ball games,
and parties. If the SSO is a spouse, this might mean having separate sleeping arrangements,
not sharing the evening meal, and in general spending more time apart from each other while
the client is still drinking. Mention that such an approach has been shown to be effective in
facilitating positive change. Another option might be for the SSO to stop attending the
sessions and seek help elsewhere (e.g., attendance at Al-Anon) while the client is still
drinking. This may be useful for SSOs who are having a great deal of difficulty in coping with
the negative feelings resulting from the client’s alcohol use.
At the end of the session give the SSO a list of available phone numbers and hours in the event that he
or she needs to contact the therapist. Also, give the SSO an appointment card so that he or she may feel like an
integral part of the treatment process.
2.7e. Audiotaping. When a SSO arrives for the first time, before turning on the tape recorder, explain
that in this program, treatment sessions are routinely audiotaped for purposes of research and supervision.
Explain that what is said during sessions remains confidential, and that tapes are carefully protected and are
heard only by a supervisor and project research staff. Also explain that the tape recorder can be turned off
during a session, when either the client or SSO wishes, if particularly sensitive material is being discussed.
If the SSO is willing to be audiotaped, have the SSO sign the consent form for this purpose, and
proceed. If the SSO prefers not to be taped during the first session attended, proceed, but explain that future
sessions would have to be audiotaped if the SSO chooses to attend. If the SSO is unwilling to be audiotaped,
which would prevent the taping of all future sessions, identify another SSO.
2.7f. SSO Consent. Because the SSO will be participating in treatment sessions and will be tape
recorded, the SSO should review and sign a consent to be treated, acknowledging that session recordings will
be reviewed by supervisors and will be used to obtain data about treatment processes. This consent form must
be approved by the local IRB, and should be signed before the second session in which the SSO is involved.
2.7g. The Basic CBI Approach. While having a SSO involved in treatment can be very helpful, it
does not fundamentally alter the nature of CBI. Maintain the same motivational and problem-focused style,
staying within the procedures prescribed in each module. Some modules contain specific guidelines for how
to involve a SSO. Keep your focus on the client. Do not shift into a marital/family therapy strategy, where
you focus on changing the relationship. The primary focus is on the client.
Examples of appropriate therapeutic responses involving the SSO
Discussing how the SSO responds to client drinking
Reflecting SSO statements
Encouraging the SSO to provide positive reinforcement for sobriety
Material contained in the Communication Skills module
Examples of inappropriate therapeutic responses involving the SSO
Discussing family of origin issues
Constructing a genogram
Giving advice on parenting strategies
2.7h. The Problematic SSO. If the presence of the SSO poses a temporary problem, it is permissible
to gently excuse the SSO from part or all of a session. There are circumstances, however, where the SSO’s
involvement poses more persistent problems.
Identifying the problematic SSO. With proper screening, SSOs who interact negatively with the client
will be screened out prior to their involvement in treatment. Nevertheless, there may be cases where the
presence of a SSO can pose serious problems in the sessions. Therefore, it is important to detect problematic
SSOs before they undermine the treatment process. The following circumstances are examples of SSO-related
problems in sessions:
The SSO undermines the client's efforts to change the drinking behavior. The client's
optimistic comments about change are met with skepticism or derision by the SSO. The client
is repeatedly reminded of previous failures in implementing a change plan. Overall, the SSO
displays a negative attitude toward the change process.
The SSO evidences an unwillingness or inability to participate in activities that might lead to a
change in the drinking pattern such as attending alcohol-free events with the client. In
developing a change plan the SSO provides few constructive remarks unless prompted by the
Documents you may be interested
Documents you may be interested