National Institute on Alcohol Abuse and Alcoholism

Project MATCH Monograph Series

Volume 6

Improving 

Compliance 

With Alcoholism 

Treatment

Edited by

Kathleen M. Carroll, Ph.D.

Yale University School of Medicine

Project MATCH Monograph Series: 

Margaret E. Mattson, Ph.D., Editor

Megan Columbus, Assistant Editor

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

National Institutes of Health

National Institute on Alcohol Abuse and Alcoholism 

6000 Executive Boulevard

Rockville, Maryland 20892-7003
Project MATCH is supported by grants under a cooperative agreement 

funded by the National Institute on Alcohol Abuse and Alcoholism 

(NIAAA) and implemented by nine clinical research units and a 

coordinating center. The project was initiated and is administered 

by the Treatment Research Branch, NIAAA.

The contents of this manual are solely the responsibility of the 

authors and do not necessarily represent the official views of NIAAA.

COPYRIGHT STATUS

The table appearing on page 62 is copyrighted and is 

reproduced herein with permission of the copyright holder. 

Further reproduction of this copyrighted material is prohibited 

without specific permission of the copyright holder. All other 

material contained in this volume is in the public domain 

and may be used or reproduced without permission from the 

Institute or the authors. Citation of the source is appreciated.

NIH Publication No. 97–4143

Printed 1997
iii

Acknowledgments

We gratefully acknowledge the invaluable contributions made to the 

development of this manual by members of the Project MATCH research 

group.

Project MATCH Research Group and

Other Contributors

William Miller, Ph.D.

J. Scott Tonigan, Ph.D.

Center on Alcoholism, Substance Abuse and Addictions

University of New Mexico

Albuquerque, NM

Gerard Connors, Ph.D.

Robert Rychtarik, Ph.D.

Research Institute on Alcoholism 

Buffalo, NY

Carrie Randall, Ph.D.

Raymond Anton, M.D.

Medical University of South Carolina and 

Veterans Affairs Medical Center

Charleston, SC

Ronald Kadden, Ph.D.

Mark Litt, Ph.D.

University of Connecticut School of Medicine 

Farmington, CT

Ned Cooney, Ph.D.

West Haven Veterans Affairs Medical Center and 

Yale University School of Medicine

New Haven, CT

Carlo DiClemente, Ph.D.

Joseph Carbonari, Ed.D.

University of Houston

Houston, TX

Principal and 

Coinvestigators 

at the Sites
iv

Improving Compliance With Alcoholism Treatment

Allen Zweben, D.S.W.

University of Wisconsin—Milwaukee

Milwaukee, WI

Richard Longabaugh, Ed.D. 

Robert Stout, Ph.D.

Brown University

Providence, RI

Dennis Donovan, Ph.D. 

University of Washington 

Seattle, WA

Coordinating 

Center

Principal and 

Coinvestigators

Thomas Babor, Ph.D.

Frances Del Boca, Ph.D.

University of Connecticut

Farmington, CT

Kathleen M. Carroll, Ph.D. 

Bruce Rounsaville, M.D. 

Yale University

New Haven, CT

NIAAA Staff John P. Allen, Ph.D.

Chief, Treatment Research Branch

Margaret E. Mattson, Ph.D.

Staff Collaborator for Project MATCH 

Treatment Research Branch

Megan Columbus

Program Specialist

Division of Clinical and Prevention Research

Consultants Philip Wirtz, Ph.D.

George Washington University

Washington, DC

Contractor Jane K. Myers

Janus Associates

Bethesda, MD
v

 Contents

Page

Acknowledgments .......................................................................iii

Introduction.......................................................................... 1

Compliance and Alcohol Treatment: An Overview.................. 5

Kathleen M. Carroll

Noncompliance and the Treatment of Alcohol 

Use Disorders.........................................................................6

Defining Compliance in Alcohol Treatment .............................8

Retention-Related Indicators..............................................9

Treatment-Specific Indicators ............................................9

Client Characteristics Associated With Noncompliance .........10

Treatment as a Partnership ..................................................11

Part 1—Strategies for Enhancing Client Compliance ........13

Practical Strategies for Improving Client Compliance 

With Treatment ................................................................... 15

Elise Kabela and Ronald Kadden

Before Treatment Begins................................................ 15

Initial Contact......................................................................16

Provide Rapid Response...................................................16

Describe Pretreatment Meetings ......................................16

Pretreatment Meetings .........................................................17

Assess Client Expectations ..............................................17

Describe the Treatment Program .....................................17

Clarify Expectations ........................................................20

Review Potential Barriers.................................................21

Physical Dependence ...................................................22

Comorbid Psychopathology ..........................................23

Introduce Group Therapy ................................................23

During Treatment .......................................................... 25

Engender Trust....................................................................25

Provide Support and Advocacy .............................................26

Encourage Clients to Share Concerns..............................26

Explore Ambivalence .......................................................27

Maintain Relevance to Clients’ Needs in 

Research Protocols.......................................................27

Involve Significant Others................................................28

Enlist Other Social Supports ...........................................28
vi

Improving Compliance With Alcoholism Treatment

Page

Increase Motivation to Change..............................................29

Give Feedback .................................................................31

Help Clients Set Goals .....................................................32

Individualize Client Goals.............................................32

Reassess Goals ............................................................32

Focus on Strengths......................................................33

Give Assignments.................................................................36

Provide a Rationale..........................................................36

Explore Resistance ..........................................................37

Identify Reminders and Reinforcers .................................37

Rehearse .........................................................................38

Monitor and Follow Through............................................38

Obtain Commitments To Comply .....................................38

Use Contracts ......................................................................39

Behavioral Contracts .......................................................39

Sobriety Contracts...........................................................40

Contracts for People With Dual Diagnoses .......................41

Be Aware of Safety Issues ................................................41

Reinforce Compliance...........................................................43

Use Incentives .................................................................44

Money Deposits ...............................................................45

Inpatient Incentives.........................................................45

Dealing With Absences .........................................................46

Use Reminders ................................................................46

Use a Contract ................................................................46

Follow Up ........................................................................46

Suggest Referrals.............................................................48

Termination .........................................................................49

Part 2—Strategies for Enhancing Therapist Compliance...51

The Use and Development of Treatment Manuals................. 53

Kathleen M. Carroll and Kathryn F. Nuro

Overview ..............................................................................53

Manuals and Treatment Compliance ....................................53

Therapist Compliance...........................................................54

Compliance Versus Competence...........................................55

Linkage of Client and Therapist Compliance .........................56

Manual Content ...................................................................56

Treatment Definition .......................................................60

Treatment Implementation ..............................................61

Therapist Training and Supervision.................................63

Manual Style........................................................................64

Anticipate Real-World Problems.......................................64

Include Troubleshooting Guidelines.................................65

Cover the Basics..............................................................65

Required Versus Optional Elements.................................66

Tailor the Treatment........................................................67

Summaries and Outlines .................................................67

Decision Points................................................................67
vii

Contents

Page

Criticism of Manuals ............................................................70

Form Versus Substance...................................................70

Mechanization of Therapy................................................70

Update Often........................................................................71

A Case Study in Clinical Supervision: Experience From 

Project MATCH.................................................................... 73

Georgeann Witte and Charles H. Wilber

Levels of Supervision............................................................73

Pilot Phase Therapist Training..............................................74

Main Study Supervision Procedures .....................................74

General Issues in Supervision ..............................................76

Treatment-Specific Issues in Supervision .............................80

Cognitive-Behavioral Therapy ..........................................80

Twelve-Step Facilitation...................................................80

Measures of Supervision ......................................................81

Relationship Between Supervision and Therapist

Compliance ..........................................................................85

Bibliography.........................................................................85

Appendix: Overview of Project Match................................... 87

Subjects...............................................................................87

Forms ..................................................................................88

Treatments...........................................................................88

Cognitive-Behavioral Therapy ..........................................88

Twelve-Step Facilitation...................................................92

Motivational Enhancement Therapy.................................92

Therapist Training, Supervision, and Monitoring.....................92

References........................................................................... 95

1

Introduction

The goal of this manual is to provide a compendium of strategies 

for enhancing client compliance to psychosocial treatments, as well 

as therapist compliance with treatment protocols, in treatment and 

research programs involving alcohol-using populations. The authors 

recognize multiple determinants of compliance and emphasize methods of enhancing treatment programs to meet the needs of a variety of 

clients, thereby improving compliance.

The volume consists of two parts. Part 1 is directed to both clinicians 

and clinical researchers, with points of particular interest to researchers shown in italics as research notes. In this section, Kabela and 

Kadden focus on strategies for enhancing client compliance throughout 

treatment. These are, for the most part, generic client compliance strategies that can be used across a range of treatment types and modules. 

Particular types of treatment approaches also have specific strategies 

for enhancing compliance. (Examples of treatment-specific compliance 

enhancing techniques can also be found in the Project MATCH treatment manuals—Vol. 1–3 of the Project MATCH Monograph Series.)

Part 2 focuses on strategies for enhancing therapist compliance in 

treatment delivery through the use of treatment manuals and careful supervision of the therapists delivering the intervention. Both are 

important ingredients in ensuring that the therapies are of high quality, evaluable, and consistent. Thus the concept of “compliance” is 

equally relevant to the behavior of the therapist and the client. Carroll 

and Nuro review the development and use of manuals as a clinical 

tool. By defining exactly what clients and therapists should be complying with, treatment manuals have revolutionized the field of treatment 

research and made it easier to define and therefore monitor compliance by both clients and therapists. Witte and Wilber draw upon the 

experience of Project MATCH and provide a range of strategies for promoting therapist compliance with treatment protocols through close 

therapist supervision.

Many of the strategies described in this manual were used in Project 

MATCH, a multisite collaborative study sponsored by the National 

Institute on Alcohol Abuse and Alcoholism (NIAAA). The primary goal 

of Project MATCH was the evaluation of client-treatment interaction, 

that is, whether treatment outcomes can be improved by matching 
2

Improving Compliance With Alcoholism Treatment

particular types of clients to particular types of treatments. Because 

of a number of special considerations regarding matching research, 

achieving adequate treatment compliance by both clients and therapists was particularly critical. The study also required that treatments 

be as distinct as possible in order to determine whether different clients will respond to different treatments; that treatments be delivered 

as described in the protocol and clients be exposed to a sufficient dose 

of their treatment; and that attrition remain low in order to maintain 

adequate power to detect matching effects.

Overall, treatment compliance was unusually good in Project MATCH, 

with clients completing approximately 75 percent of their scheduled 

treatment sessions (see table). Rates of compliance were fairly consistent across treatments, reflecting, among other factors, the careful 

efforts of the therapists to deliver high quality therapy that engaged the 

clients. It is important to recognize, however, that while the investigators 

emphasized compliance throughout the planning and implementation 

of Project MATCH, the project was not a study of compliance per se. 

While the strategies presented here are drawn from experience with 

Project MATCH and several other clinical trials, comparatively few have 

been evaluated empirically. Thus, it is not possible to state whether 

these strategies actually improved compliance, whether the high rates 

of compliance were related to other factors, or whether other strategies 

would have produced the same or better results. Moreover, it is not 

Treatment compliance in Project MATCH: Session attendance by treatment

Treatment weeks1 # Treatment sessions2

Outpatient study

Cognitive-Behavioral Treatment (n=300) 9.28 (4.02)3 8.28 (4.18)

Motivational Enhancement Therapy (n=312) 8.50 (4.24) 3.29 (1.18)

Twelve-Step Facilitation (n=334) 8.30 (4.35) 7.49 (4.08)

Aftercare study

Cognitive-Behavioral Treatment (n=258) 8.21 (4.62) 8.08 (4.51)

Motivational Enhancement Therapy (n=256) 7.99 (4.66) 3.11 (1.36)

Twelve-Step Facilitation (n=240) 7.81 (4.73) 7.31 (4.56)

1 Range is 0 to 12. 

2 Range is 0 to 12 for CBT and TSF, 0 to 4 for MET. 

3 Standard deviation in parentheses.
3

Introduction

certain which particular strategies may have enhanced or even diminished compliance. Experimental research in this area is needed and 

would be likely to have broad clinical utility, as strategies that enhance 

compliance are also likely to enhance outcomes.

We describe these strategies merely as suggestions to clinicians and 

as ideas for enhancing adherence to particular treatment regimens by 

therapists in research settings. We believe but do not guarantee that 

these strategies will actually improve compliance.

5

Compliance and Alcohol 

Treatment: An Overview

Kathleen M. Carroll, Ph.D.

Yale University School of Medicine

New Haven, Connecticut

One of the few universal problems in the delivery of health care is treatment compliance. Across a wide variety of disorders and treatment 

regimens, research consistently indicates that a substantial minority, 

and sometimes a majority, of clients do not adhere to their prescribed 

regimen (see reviews1–3). For example, rates of adherence to pharmacotherapy regimens in general medical practice have been estimated at 

only 50–55 percent.4

A recent meta-analysis of 164 studies evaluating methods of improving 

patient’s keeping medical appointments indicated that the average rate 

of compliance was 58 percent.5 Most individuals referred for psychotherapy do not follow through on that recommendation.6 As many as 

50 percent of hypertensive individuals in the United States drop out 

during the first year of treatment, and of those who remain in treatment, most do not comply adequately with their prescribed medication 

regimen.7,8

Noncompliance raises profound problems from both clinical and 

research perspectives. Clinically, compliant clients generally have better outcomes than noncompliant clients,9–12 although this relationship 

is not uniform and may be quite complex.13

Moreover, the strong relationship between compliance and outcome 

holds even when placebo treatments are being evaluated.10 This suggests that compliant behavior may tap important beneficial processes 

other than active ingredients of the treatment itself, such as the instillation of hope, self-efficacy, and enhanced health-promoting behaviors.

Noncompliance leads to need for additional services (clinic visits, hospital admissions, emergency room visits) and for increased provider 

time, thereby reducing access of other patients to needed services, and 
6

Improving Compliance With Alcoholism Treatment

increases health care costs and the risk of complications and even 

patient death.5,14,15

From a research perspective, noncompliance is problematic because 

it reduces statistical power to detect treatment effects, leads to the 

need for larger sample sizes, increases sample bias, undermines the 

internal validity of a study, and is associated with a host of other methodological and statistical concerns.16–19 In clinical trials, differential 

compliance across treatments leads to compliance bias,20 where differences in outcomes between treatments may be due to differences 

in the level of compliance across treatments rather than effects of the 

treatments themselves.

Noncompliance

and the

Treatment of

Alcohol Use

Disorders

Compliance is a prominent issue in the treatment of alcohol and substance abuse and dependence, where rates of treatment dropout range 

from 25 to 90 percent.21–22 That alcohol abuse poses special problems 

for compliance is illustrated by the frequency with which trials evaluating treatments for disorders other than substance abuse refuse to 

accept substance users into their protocols in order to improve compliance.23 Similarly, substance abuse is often cited as a correlate of 

noncompliance in other populations.24–28

Like the broader field of compliance with medical recommendations, 

compliance with alcohol treatment recommendations usually results 

in improved outcome. Compliance with psychotherapy (treatment 

attendance) and pharmacotherapy (medication compliance) has been 

associated with improved outcome in several studies.29–32

Table 1.1 presents rates of one type of noncompliance in alcohol 

treatment—dropout—defined broadly (and oversimply) here as the 

proportion of clients who do not complete treatment. The table summarizes attrition rates across several recent uncontrolled studies and 

randomized clinical trials which include a range of client populations, 

settings, treatment types, and length of prescribed treatment.

Review of the attrition rates among the uncontrolled studies is for 

the most part similar to that reported in 1973 by Baekeland and colleagues,56 where:

■ 17.5 percent were immediate dropouts (i.e., failed to return after 

the first visit).

■ 26 percent were rapid dropouts (after 1 to 4 weeks of treatment).

■ 30 percent were slow dropouts (leaving between 2 and 5 months of 

treatment).
7

Compliance and Alcohol Treatment: An Overview

Table 1.1. Rates of dropout from alcohol treatment: Selected recent studies

Study Treatment studied

Sample 

size Rates of dropout

Single-site studies

Allan 198733 Outpatient community 112 64% drop out by 4 weeks

93% by 6 months

Brizer et al. 199035 Outpatient 178 52% drop out before 9 visits

Castaneda et al. 199236 Inpatient & outpatient 109 54% don’t follow through on referral

Fink et al. 198437 Extended inpatient 258 41% noncompleters

Huselid et al. 199138 Female halfway house 30 47% drop out

Jones 198539 Residential 34 71% drop out

Leigh et al. 198440 Outpatient 172 72% drop out (15% don’t start)

Noel et al. 198741 Outpatient couples 105 35% don’t start

22% drop out

Pekarik & Zimmer 

199242

5 settings 3240 52.7% average across programs

Rees 198543 Outpatient 117 77% drop out by 6 months

Verinis 198644 Outpatient 121 38% don’t start

36% drop out

Randomized clinical trials

Chick et al. 198845 Advice vs treatment 152 45% of treatment group drop out by 

10 appts.

Fuller et al. 198330 Disulfiram 128 78% keep less than 85% of 

scheduled appointments

Ito et al. 198846 Aftercare psychotherapy 39 25% don’t start, 20% drop out at 

6 months

Kadden et al. 198947 Aftercare psychotherapy 96 19% drop out after 2 sessions

Kranzler et al. 199448 Outpatient, buspirone 61 18% don’t start, 31% drop out by 

3 months

Kranzler et al. 199549 Outpatient, fluoxetine 101 22% don’t start, 6% drop out by 

3 months

Mason et al. 199450 Outpatient, nalmefene 21 76% drop out by 3 months

Murphy et al. 198651 Lifestyle modification 60 20% don’t start, 35% drop out by 

4 months

Monti et al. 199352 Cue exposure + coping 40 21% drop out by 3 months

Naranjo et al. 199553 Outpatient, citalopram 62 37% noncompleters

O’Farrell et al. 199354 Outpatient couples 59 19% drop out

O’Malley et al. 199255 Naltrexone/

psychotherapy

97 26% don’t start

35% drop out

Powell et al. 198631 Outpatient 100 30% drop out by 6 months
8

Improving Compliance With Alcoholism Treatment

■ 26.6 percent persisted in treatment longer than 6 months.

Rates of dropout tend to be somewhat lower in the recent randomized trials than the uncontrolled studies, but this may in part reflect 

inclusion of more select samples in clinical trials, research procedures 

which may have enhanced retention, or the treatments evaluated. 

Similarly, rates of alcohol clients’ compliance with aspects of treatment 

other than retention, such as medication compliance, have also been 

poor in many studies.57

High rates of dropout and noncompliance suggest that no matter how 

effective a treatment is, its success will be constrained by its ability to 

retain clients. In other words, compliance may be a necessary, but not 

sufficient, component of treatment effectiveness. Furthermore, available treatments for substance abuse are often considered effective to 

the extent that they demonstrate the ability to retain clients.23

For example, methadone maintenance, despite its drawbacks, is the 

most successful pharmacologic strategy for opioid dependence, in 

large part due to its power to retain clients over extended periods. On 

the other hand, naltrexone, which is an elegant, safe, long-acting, and 

theoretically perfect antagonist treatment for opioid dependence, is 

infrequently used and often perceived as ineffective largely because 

of its historically poor record of retention.58 Similarly, the combined 

voucher and CRA approach described by Higgins and colleagues59–60

has generated a great deal of excitement because several trials evaluating this approach have shown unusually high retention and abstinence 

rates among cocaine abusers. In part, the failure of many alcohol and 

drug abuse treatments to retain clients beyond a few weeks has led 

to increased emphasis on developing and evaluating brief treatments, 

such as motivational approaches.61–62 These treatments, which typically involve only a session or two, have been found to have durable 

effects on alcohol use as well as low rates of attrition.63–64

Defining

Compliance in

Alcohol

Treatment

The broad definition of compliance is “the extent to which a person’s 

behavior (in terms of taking medications, following diets, or executing 

lifestyle changes) coincides with medical or health advice.”65 However, 

specific definitions of compliance vary with the treatment prescribed 

and research questions asked in particular studies.

In treatments involving the administration of medications, compliance 

is usually defined as the person’s taking the prescribed dose of medication, at the prescribed schedule, for the prescribed duration of therapy, 

and also refraining from using other medications or substances that 

may interact negatively with the medication prescribed. Here, compliance can be measured by a variety of mechanisms, including 

monitoring medication plasma levels, pill counts, markers introduced 
9

Compliance and Alcohol Treatment: An Overview

into the medication, MEMS caps and other monitoring devices, client 

self-reports, and so on.14,57,66,67

The bulk of alcohol treatment consists of psychosocial treatments, 

principally group, family, or individual counseling or therapy, with 

pharmacotherapies such as disulfiram or naltrexone typically delivered 

as adjuncts to a primarily psychosocial approach. Thus, compliance 

is defined and measured differently in psychosocial treatments for 

alcohol abuse, usually falling into one of two broad categories: retention-related and treatment-specific (table 1.2).

Table 1.2. Indicators of compliance in psychosocial treatments

 Retention-related indicators

— Number of prescribed sessions attended

— Number of sessions missed

— Lateness to sessions

— Repeated rescheduling of sessions

— Failure to call to cancel sessions

— Attending sessions while intoxicated

— Use of other psychoactive substances

 Treatment-specific indicators

— Failure to complete homework assignments

— Incomplete homework assignments

— Failure to attend AA meetings

— Involvement in non-study treatments

— Failure or refusal to bring in spouse or family for family therapy

— Overt resistance (e.g., silence, hostility) 

— Failure to provide breath/urine/blood samples

RetentionRelated 

Indicators

In psychosocial treatments, the most important indicator of compliance is treatment attendance; that is, whether or not the client attends 

the sessions prescribed. Retention is particularly important because it 

is often closely related to outcome in alcohol treatment.67 In addition, a 

variety of secondary indicators are related to retention, including lateness to sessions, missed sessions, and rescheduling of sessions.

TreatmentSpecific 

Indicators

Psychosocial treatments for alcohol abuse typically include a number 

of specific recommendations or tasks for clients, and the degree to 

which clients adhere to these prescribed activities is another indicator of compliance. Depending on the specific treatment, these might 

include completion of homework assignments (e.g., practicing a skill 

taught during therapy), attending self-help meetings or getting a sponsor, practicing skills learned during therapy, or bringing in one’s 

spouse or family members for recommended family meetings.
10

Improving Compliance With Alcoholism Treatment

It is important to note that different indicators of compliance may not 

converge; for example, high attendance does not always imply that clients have fully complied with treatment. Thus, multiple indicators of 

compliance may be needed to fully assess compliance and its effects on 

process and outcome in a clinical trial. Some aspects of treatment compliance, particularly treatment attendance, are frequently monitored 

and reported on in clinical trials and reports on treatment outcome. 

However, other aspects of compliance are less frequently evaluated. 

For example, client compliance with key aspects of therapy, such as 

homework completion, is rarely monitored.68

Client

Characteristics

Associated

With

Noncompliance

Traditionally and persistently, the causes of noncompliance and attrition have been conceived as client driven. That is, investigators have 

focused their efforts on searching for client characteristics associated 

with poor compliance, such as demographic characteristics, social 

instability, and low motivation.33,34,36,39,41,44,56,69–71

The search for universal client characteristics associated with compliance has met with mixed success, in large part because findings of 

client characteristics associated with dropout in one treatment setting 

are frequently not replicated in other settings with differing treatment 

approaches.42

Although there is little consistency across studies and treatment settings in terms of characteristics of clients who comply with or drop 

out of treatment, there is a good deal of consistency across studies 

suggesting that the bulk of attrition occurs early, with the majority of 

dropouts usually occurring during the first month of treatment.21–72

Furthermore, in both clinical and research settings, client heterogeneity has often been met with treatment homogeneity. That is, regardless 

of clients’ backgrounds and preferences, the nature or severity of their 

alcohol abuse and related problems, or the factors that precipitated 

treatment-seeking, many treatment programs offer only a single type 

of treatment. With this “one size fits all” model, variations in compliance and outcome have traditionally been ascribed to client factors 

and characteristics.73 Thus, clients who are a good “fit” for a given 

approach are more likely to remain in treatment, and those who are 

less well suited to the treatment may be more likely to drop out.

Again, in treatment settings that offer only a single approach, it may 

not make sense to ask clients what they need, desire, or expect out of 

treatment. If clients want something other than the services the center 

provides, very often staff can do little to accommodate them. In addition, clients often have only an uncertain idea of what treatment will 

entail until it begins. Thus, early attrition may reflect self-selection, 

where clients may find themselves in the wrong treatment setting, 
11

Compliance and Alcohol Treatment: An Overview

wrong group, with the wrong therapist, or participating in a treatment 

geared to a stage other than the one they are in. It is thus not surprising that dropouts usually seek treatment again elsewhere.74

Treatment as 

a Partnership

The emphasis on identifying client correlates of noncompliance is shifting, and current efforts to reduce attrition and enhance compliance 

reflect increasing awareness that compliance is related to a combination of conditions and efforts contributed by therapists, investigators, 

and research staff, as well as clients.23,32,75–77 Thus, in this manual, 

compliance is conceived as a partnership relationship among client, 

therapist, treatment, and setting. In other words, compliance may have 

more to do with what investigators and treatment providers do than 

who their clients are.

Furthermore, the implications of seeking client characteristics associated with noncompliance or dropout are quite different, depending 

upon whether one sees noncompliance as solely client driven or as 

the product of a partnership. If seen as client driven, identification of 

client characteristics associated with dropout or noncompliance could 

be used to identify a profile of clients who are less likely to continue or 

have good outcomes in the treatment program. This strategy could be 

used to direct costly treatment resources primarily to those clients who 

are most likely to benefit from the program and not ‘waste’ resources 

on those who will derive little benefit. However, characteristics usually 

associated with dropout and noncompliance are frequently those associated with the greatest need for treatment (e.g., low socioeconomic 

status, more psychiatric impairment, and fewer social supports). 

Treatment programs using this strategy might thus be faced with the 

unpleasant prospect of refusing treatment to those who need it most. 

Moreover, given the inconsistent findings linking client characteristics 

to outcome and the heterogeneity in alcohol outcomes, some clients, 

who might in fact do well in the treatment program, could be turned 

away merely because they have the wrong “profile”.

Conversely, if one sees compliance and retention as the product of a 

partnership, information about client characteristics associated with 

noncompliance or dropout can, and should, be used to make treatment programs more responsive to the special needs of these clients, 

broaden the scope of services offered to meet heterogeneous needs of 

clients, and identify treatment practices or therapists which discourage compliance.

This manual is organized to reflect this latter strategy, which recognizes multiple determinants of compliance and emphasizes methods 

of enhancing treatment programs to meet the needs of heterogeneous 

clients, thereby improving compliance.

13

Part 1

Strategies for Enhancing

Client Compliance

15

Practical Strategies for Improving 

Client Compliance With Treatment

Elise Kabela, Ph.D.

Ronald Kadden, Ph.D.

University of Connecticut School of Medicine 

Farmington, Connecticut

Erratic attendance, premature termination, and inadequate participation in treatment have been pervasive problems in the alcohol treatment 

field. Attrition rates for substance abuse treatment range up to 90 percent, and those clients who remain in treatment and participate more 

fully generally fare better than those who terminate prematurely.

This section presents several compliance-enhancement procedures 

that have proven effective from the first contact with the program 

through termination of treatment and, for research projects, through 

the followup phase. Some strategies do not apply to all settings—some 

may even change the nature of the treatment itself—and may therefore 

be impractical in certain programs. Using those that do apply, however, should enhance treatment for both the client and the therapist.

Note that the focus of this manual is on compliance with psychosocial 

treatments for alcohol problems; compliance issues with pharmacologic 

treatments for alcohol problems have been addressed elsewhere.57,78,79

Before Treatment Begins

Prospective clients may find a treatment program on their own or they 

may be referred by a clinical program, health-care professional (e.g., 

social worker, psychologist, psychiatrist, physician, nurse, employeeassistance counselor), social service agency, probation department, 

telephone hot line, or case manager of a health-maintenance organization. Often, an advertisement is seen by a concerned spouse, family 

member, friend, or health-care professional who encourages the prospective client to call and learn more about the program.
16

Improving Compliance With Alcoholism Treatment

Pretreatment contacts with clients and concerned others may involve 

various program personnel, and may or may not involve a therapist. 

Thus, all relevant staff should be prepared to conduct pretreatment 

activities in a manner consistent with the treatment model.

Initial Contact The initial contact with the treatment site is often over the telephone. 

A staff member usually conducts a brief screening to identify those 

who may be appropriate for the treatment offered and give alternative 

treatment referrals to those who are not appropriate candidates for the 

specific treatment being offered.

Provide Rapid 

Response

To enhance compliance and the likelihood of the client’s actually entering treatment, schedule the initial appointment as soon as possible 

after the call and provide adequate information about the program and 

the application procedures.

Since some clients may be most motivated for treatment when they 

first call the program, attempt to complete all steps necessary for entry 

into treatment promptly. Decreasing the time between application for 

treatment and the first appointment has been shown to significantly 

improve retention in treatment.21,40,80,81 Timely scheduling of client 

evaluation is facilitated by having several staff members available to 

do interviews and by providing evening hours for appointments to 

increase flexibility.

Describe 

Pretreatment 

Meetings

When the first appointment is made, fully inform clients about the 

reason for the meeting and what they can expect. This should include 

who they will see, how long the meeting will last, and what kinds of 

information they are expected to provide (e.g., demographics, recent 

alcohol and drug use, psychiatric status, legal status) and why it is 

needed (e.g., administrative purposes, initial diagnosis, identification 

of areas of concern to the client).

Research Note: In some situations, especially research programs or others where the program itself is being evaluated, interviews may be taped 

(e.g., videotaped or audiotaped). Clients should be informed in advance 

and told why this is important to the program. If clients are also to be 

breathalyzed, this should be explained and the consequences of elevated blood alcohol level readings during treatment should be reviewed.
17

Practical Strategies for Improving Client Compliance With Treatment

Pretreatment Meetings

Assess Client 

Expectations

Many clients have not experienced previous alcohol treatment and 

express some anxiety (and relief) at finally getting help for their drinking. It is important to assess their reactions to the prospect of treatment 

and any expectations they might have. The interviewer should listen 

attentively to the client and periodically reflect back and summarize 

what is heard in order to help the client feel understood without feeling 

judged.

A structured clinical interview or self-report can help clients identify their problems with alcohol. Then interviewers can indicate how 

treatment may help address those problems (e.g., treatment may help 

identify alternative ways to relax after work or suggest ways to cope with 

relationship issues related to drinking). This discussion may elicit any 

uncomfortable feelings or negative reactions to treatment. Reassure 

the client that expressing such feelings will positively affect treatment 

outcome. Eliciting reflection on treatment has been described as one 

strategy to help prevent premature withdrawal from treatment.82

Describe the 

Treatment 

Program

Treatment compliance is enhanced when the client’s expectations 

match what the program can actually provide. Clients are more likely 

to drop out of treatment prematurely if misunderstandings occur 

between the practitioner and client regarding treatment.83 Therefore, 

be sure to carefully describe details of the treatment program and the 

client’s obligations.

During the first inperson assessment, give the client a brief overview 

of the treatment being offered and general ways in which it may be 

helpful. If the program offers more than one treatment approach (e.g., 

one-on-one, group, 12-step, behavior modification), explain the potential benefits and risks involved in each. Bring up other issues, such 

as whether family members will be involved and expectations regarding simultaneous attendance at Alcoholics Anonymous (AA) meetings. 

Table 2.1 suggests issues to review when preparing research clients for 

treatment.

Be sure that clients understand the different roles of the people they 

encounter in the program. Also provide them with names and telephone numbers of staff to contact about scheduling problems and 

other such concerns.

Clients may also be given an individually customized handout that 

describes the treatment, the therapist’s name(s), the starting dates of 

treatment, the time of the first session, rules regarding attendance, 

and other matters of importance (see table 2.2). Material in writing 
18

Improving Compliance With Alcoholism Treatment

Table 2.1. Preparing clients for treatment in an alcohol research setting

 Review differences between research (pretreatment, followup) and treatment 

phases of study, and give clients a project timeline sheet which provides an overview of the different phases over time.

 Review staff roles during all study phases. Indicate project staff to call in case of 

emergency (e.g., project coordinator, principal investigator).

 Review differences between study treatment and other nonresearch treatments 

potentially available:

— client will likely have no choice regarding treatment assignment, and cannot 

“switch” to a more preferred treatment group.

— study treatment will be manualized and protocol-driven, and may be less 

eclectic.

— review protocol requirements regarding family involvement or noninvolvement 

in treatment.

— attitudes towards involvement in AA or other self-help groups may differ from 

other treatment programs. For example, in MATCH III, we adopt a neutral 

stance towards self-help group attendance. 

— interviews and treatment sessions will be audio- or videotaped. Explain why 

this is important, and who will be allowed to listen to these tapes.

— study treatment may be free to client because of research funding, but will 

require client’s accurate completion of interviews and questionnaires, which 

can be lengthy.

— unlike some other treatment programs, clients who prematurely leave treatment will not be able to reenroll in study treatment at a later date.

 Review informed consent procedures, and give client a copy of form. Include 

review of:

— confidentiality.

— a description of procedures for assessment (e.g., interviews, questionnaires, 

breathalyzer readings, urinalyses), detoxification, and treatment (e.g., scheduling, assignment to treatment, brief description of possible treatments).

— client obligations during treatment. Describe possible problems which may 

emerge (e.g., arriving to treatment intoxicated, need for more intensive treatment) and how the project handles them. Review referral procedures for 

additional alcohol and nonalcohol treatment.

— payments for followup assessments. Remind clients that even if they choose 

to withdraw from treatment prematurely, we will still contact them to complete 

followup assessments.

 When clients are assigned to treatment, provide a handout which identifies the 

treatment to which they have been assigned, the therapist(s), session location, 

starting and ending dates and times, and expectations regarding attendance, 

completion of research forms during treatment, and followup assessments.

reinforces the information provided in the initial contact and allows 

the client to review that information at home. However, this handout 

should never be used as a substitute for the personal, one-on-one 

discussion.
19

Practical Strategies for Improving Client Compliance With Treatment

Table 2.2. Sample treatment handout to client

Interactional Therapy

Wednesdays

7:30 to 9 pm

8/20/97 – 2/4/98

(26 weekly sessions)

 For first session only (8/20), please arrive at waiting area by 7:15 pm 

for pregroup interview with therapists. Therapists: (name); (name).

 If you have any questions or concerns between group sessions, 

please contact (name), at (phone #), Monday through Friday, 9:30 to 

5:30.

Additional sample items for research programs:

 Anticipate that 1 or 2 questionnaires will need completion at the end 

of sessions 3, 12, and 14.

 Remember the 4/8 rules: If you miss 4 consecutive treatment 

sessions, or 8 or more sessions, we will consider dropping you from 

treatment, but not from the followup phase.

 Followups with your research assistant, (name), will begin in 

February 1998.

Research Note: Giving clients a project timeline (see figure 2.1) that provides an overview of their scheduled involvement in both the treatment 

and research aspects of the study over time is also helpful in preventing 

scheduling conflicts and missed appointments.

Figure 2.1. Sample timeline

Welcome! Your participation in this study is divided into three phases: evaluation, treatment, and followup. 

The research team will conduct the evaluation and followup phase; the treatment team conducts the 

treatment phase.

EVALUATION PHASE

Assignment 

to treatment TREATMENT PHASE

Diagnostic 

Evaluation →

Detox if 

needed →

Pretreatment 

evaluation → Week 1 → → Week 26 →

FOLLOWUP PHASE

Posttreatment 

assessment → 3-month followup → 6-month followup → 9-month followup → 12-month followup

In person 

$50 payment

Telephone 

$20 payment

In person 

$50 payment

Telephone 

$20 payment

In person 

$50 payment
20

Improving Compliance With Alcoholism Treatment

Clarify 

Expectations

In research studies, the informed consent form (see sample in appendix) has been valuable in clarifying treatment parameters and thereby 

improving compliance. A similar form or contract in a nonresearch setting may serve the same compliance-enhancing role. Careful attention 

to this procedure can avoid misperceptions about treatment and thus 

prevent many potential problems.

To ensure that clients understand the form, read it aloud to the client 

or paraphrase its major points and answer any questions that arise. 

Key issues to cover include:

■ Confidentiality. Assure clients at the beginning of the interview that 

confidentiality will be maintained at all times. Discuss your policies 

for ensuring this, such as not using last names in group meetings. 

Explain any potential exceptions to confidentiality (e.g., statemandated reporting of child abuse); provide a handout describing 

confidentiality and these limitations if not covered in the informed 

consent.

Where programs are required to report on their caseloads or provide aggregate client data, explain the procedures for protecting 

client identity. These could include identifying all client information 

by client number and storing information linking client numbers to 

names in a locked file cabinet. If relevant, inform clients that any 

taped interviews will not include their complete names and that 

personnel who listen to these tapes (e.g., for supervision purposes) 

will not know their names. In some cases, confidentiality of the 

videotapes may be further ensured by aiming the camera at the 

therapist so that the client cannot be seen.

■ Client obligations during treatment. Clarity regarding the clients’ 

obligations will help foster compliance. Explain all the program’s 

rules and expectations and answer any questions that arise. Such 

obligations could include the following:

— Clients are expected to attend all scheduled sessions. Spell out 

the consequences of irregular attendance.

— Cancellations should be made at least 24 hours in advance.

— Clients should arrive for all appointments on time.

— Clients should inform staff of relapses involving alcohol or 

drugs and make a good faith effort to maintain abstinence during treatment.

— Clients should always arrive sober for sessions. Consequences 

of showing up intoxicated might include not being allowed to 
21

Practical Strategies for Improving Client Compliance With Treatment

participate in the session and car keys being held by staff until 

the breathalyzer reading drops to a safe level or alternative 

transportation is arranged.

— Any plans to prematurely leave treatment should be discussed 

with the staff; clients should not drop out without explanation.

■ Involvement of significant others. This will vary with the type of program. Some programs do not involve significant others. Some may 

depend on significant others for support, information, or involvement in treatment.

Research Note: Two specific types of outside contacts may be required 

for tracking clients:

— Locator. Clients may be asked to identify at least one person 

(who does not live with them) whom the program can contact 

if it loses touch with the client. If called, this person will be 

asked to help contact the client but will not be told about the 

nature of the program.

— Collateral. Clients may be asked to provide the name of 

someone whom staff may call at various times during treatment to obtain additional information regarding the client’s 

functioning. Any information obtained through these interviews will be confidential and will not be shared with client.

Review Potential 

Barriers

Discuss potential barriers to full compliance, such as transportation 

and childcare problems, work or school schedules, court involvements, 

and planned vacations (table 2.3) in detail before starting treatment. 

For example, the provision of childcare while attending treatment 

appointments may be critical for women clients. For less socially stable 

clients, it may be necessary to provide bus tokens, bus schedules, and 

perhaps taxi service. Clients who drive to the clinic should be given 

specific directions to safe and convenient parking.

Research Note: In a research study, the protocol may require random 

assignment to treatments that meet at fixed times (e.g., groups). If it 

appears that scheduling conflicts will prohibit clients from attending the 

particular treatment to which they are assigned, determine the flexibility 

of their schedules and explore strategies that would support attendance 

(e.g., obtain consent to talk to the client’s employer or family). Research 

subjects should be reminded during the pretreatment phase that they 

cannot switch their treatment assignment to another study treatment 

or group time because of a change in schedule or desire for alternative 

treatment. Clients should not be accepted if they are unwilling to attend 

any treatment to which they may be assigned or if they are strongly 

opposed to the goals of the program (e.g., abstinence). Ignoring these 

rules can lead to premature dropout, sometimes even before treatment 

begins.
22

Improving Compliance With Alcoholism Treatment

Table 2.3. Potential barriers to treatment

 Traveling distance to treatment facility. Clients are more likely to leave treatment prematurely if their 

drive is lengthy.

 Reliability of transportation. This is particularly important for clients who live in more rural areas not 

accessible by a local bus line. Clients who have no driver’s license or who are awaiting sentencing 

regarding a DWI charge need to brainstorm alternative, feasible ways to get to treatment.

 Legal difficulties that may interfere with choice of treatment.

 Flexibility of schedule and absences due to upcoming vacations from work or school.

 Family support for client involvement in treatment. Clients who live with substance-abusing or 

physically abusive partners may require additional referrals and support during treatment.

 Childcare arrangements. If the program cannot provide childcare, consider arranging appointments 

in the evenings or on weekends when other caretakers may be available.

 Psychiatric or medical problems that would significantly interfere with participation.

Additional issues for research programs:

 Access to client by phone, or access to someone who can reliably contact the client.

 Alcohol treatment history. Limitations regarding recent prior treatment or concurrent treatment.

 Adequate cognitive ability to understand assessment questionnaires.

 Client willingness to accept assignment to any of the treatments offered in the study.

 Client willingness to be audiotaped or videotaped during treatment sessions.

Physical 

Dependence

Significant withdrawal symptoms can present a number of barriers to outpatient treatment and hence lead to compliance problems. 

Therefore, screen potential clients regarding the need for medically 

supervised detoxification. Have complex cases reviewed by a medical 

team (nurse, physician’s assistant, internist). Provide referrals to clients who cannot safely self-taper gradually from alcohol or who are not 

appropriate for outpatient detoxification. Unfortunately, clients who 

require inpatient detoxification before treatment (because of serious 

medical or psychiatric problems or a history of seizures or DTs) often 

do not complete it. On the other hand, clients who can safely undergo 

outpatient detoxification tend to progress more quickly toward treatment assignment.

Ask clients who can safely self-taper from alcohol to negotiate a realistic target date for sobriety so they will be medically stable and no 

longer experiencing withdrawal symptoms when treatment starts. The 

target date helps clients progress through the pretreatment phase so 

they may more quickly be assigned to treatment. A sample contract for 

outpatient detoxification is included in the appendix.
23

Practical Strategies for Improving Client Compliance With Treatment

Comorbid 

Psychopathology

Indications of psychopathology, such as significant depression or anxiety, should be assessed and addressed before beginning treatment to 

maximize retention. Although some clients’ symptoms may improve 

after several weeks of sobriety, others may require medication or referral for psychotherapy. These clients often require more contacts with 

the program for referrals and support.

For clients who already have a relationship with a therapist, consider 

recommending that they schedule more frequent sessions (e.g., see 

their psychiatrist every other week rather than once per month) if there 

appear to be significant concurrent psychiatric problems. This gives 

clients the clear message that their clinical needs are of primary importance. Clients should also be encouraged to contact program staff if 

their existing symptoms begin to worsen or if new symptoms develop.

Introduce Group 

Therapy

An induction interview that prepares clients for group therapy can help 

reduce premature dropout.82 Have clients in group treatment meet 

with their therapists individually before their first group session for a 

role induction interview. This should supplement information already 

provided by the staff regarding the treatment. A sample guideline for 

meeting with new members of a coping skills group is provided in 

table 2.4.

The role induction interview may be conducted by the group’s therapist 

or a cotherapist, with one or more clients who are beginning group at 

the same time. After introductions, provide some general information 

about the group’s composition and meeting schedule. Elicit some of 

the client’s more salient problems at this time to identify them as part 

of the agenda for working with the clients and to impart the message 

that this therapy will be relevant to their particular needs. Material 

elicited during the role induction can later be used in therapy sessions. 

One approach is to give clients a list of typical problems and ask them 

to check off those they have experienced in each area.

Discuss the general philosophy of the treatment approach that will be 

used, making specific reference to the client problems that were just 

identified. For example, in the case of a coping skills training approach, 

explain the process of identifying trigger situations that may lead to 

relapse, the benefit of developing skills for avoiding or managing these 

triggers, and the need to practice the new coping skills to become proficient in them.

Next describe the roles of the therapists and clients. For example, therapists provide information and support without making decisions for 

clients or telling them what to do. Clients are expected to participate 

actively in the group, attempt to abstain from drinking, and complete 
24

Improving Compliance With Alcoholism Treatment

Table 2.4. Guidelines for role induction interview for cognitive-behavioral group therapy

 General information

— Number of other clients in the group

— Name of cotherapist

— Weekly meetings for ______ weeks

 Identify current problem areas

— Usual drinking situations

— Social pressure to drink

— Marital/family problems

— Negative moods: depression, anxiety, anger, loneliness, boredom

— Other problems

 Coping-Skills Training approach

— Difficulty handling problems can lead to a relapse.

— To stay sober, you will learn new ways to cope with problems.

— Opportunities will be provided to practice what you learn, so that the new skills will become 

easier and more natural to perform.

— Practice exercises will be distributed each week, to help you practice new skills at home.

— Do not abandon a skill until you have tried it several times.

 Therapist and client roles

— Therapists’ job is to assist you, but not tell you what to do.

— Client’s role is to participate actively in group and complete homework exercises.

 Stumbling blocks

— Explore instances when client previously dropped out of treatment. If client is considering 

dropping out, discuss it with the group—unlikely to be the only one who feels this way.

— Most clients experience hopelessness, anger, frustration, and other negative feelings about 

group at times. Client should come to group and discuss these feelings, even if they may be 

embarrassing to the therapists.

— In spite of efforts to maintain abstinence, some clients will slip. Client should come sober to 

group and let the group support efforts to get back on the wagon.

 Group members’ contract

— Review and obtain client’s concurrence.

assignments between sessions. Explore potential obstacles to compliance, and encourage clients to come to group to discuss the problems 

they are encountering, rather than allowing them to interfere with their 

recovery or serve as a pretext for dropping out of treatment.
25

Practical Strategies for Improving Client Compliance With Treatment

During Treatment

A number of compliance issues arise when treating clients with drinking problems, but the major focus is often on preventing dropouts. 

Even when valiant attempts are made to persuade clients to stay in 

treatment, they may still withdraw prematurely for various reasons 

(e.g., a change in their priorities or schedule, feeling cured and in no 

further need of treatment, dislike of the treatment or setting, need 

for more intensive alcohol or non-alcohol treatment, embarrassment 

about relapse, desire for a group with a greater number of abstinent 

members). Moreover, clients may leave treatment without ever disclosing their reasons.

When the reason can be determined, sometimes clients can be persuaded to return if they appear ambivalent and client concerns are 

listened to and addressed. For example, when clients complained of 

the heat and lack of space in a group meeting room, adding a fan and 

removing a table solved the problem. Clients who are more emphatic 

about dropping out may be less amenable to staff persuasion to attend 

another treatment session and may complain that they feel they have 

been pressured too much. Staff need to use clinical judgment when 

deciding the best approach to take with a particular client.

The following suggestions come from a variety of treatment approaches 

and settings. All have worked in their particular programs and may be 

equally effective in other circumstances.

Engender Trust Successful implementation of compliance-enhancement strategies is 

facilitated if the client learns to trust the therapist and other program 

staff. Developing the necessary degree of trust requires a satisfactory working relationship with the client. Only then may the client 

be willing to divulge personal material in therapy and cooperate with 

assignments.

A number of steps can help to improve the therapeutic relationship. 

The primary goal is to foster a sense of active partnership and shared 

responsibility between therapist and client. Specific techniques include 

probing for the client’s worries and concerns, attending to and reflecting what the client is saying, discussing all diagnoses and treatment 

alternatives, exploring the client’s expectations about treatment, and 

discussing potential adherence problems openly with the client.

Therapists should use a friendly, empathic, nontechnical communication style and encourage the clients to express any doubts or 

misgivings they may have. Deemphasizing use of the term “alcoholic” 

may enhance the therapeutic relationship, especially among clients 
26

Improving Compliance With Alcoholism Treatment

who acknowledge an alcohol problem but ascribe the alcoholic label 

primarily to others who appear less socially stable or more physically 

dependent than themselves.

Provide 

Support and 

Advocacy

Sometimes clients are more likely to continue attending treatment if 

they can contact the staff to share uncomfortable feelings about the 

treatment or to discuss a troublesome slip. Clients who are dissatisfied 

with the treatment can be encouraged to bring it up with their individual therapist or group. For example, one client who had just begun 

interactional group therapy told the staff that she thought the type of 

therapy was wrong for her, in part because she was concerned that in 

her current group she would care more for others than herself. At the 

staff’s suggestion, she agreed to give her group another try and discuss 

her concerns there. As a result, she continued to attend her original 

group and was able to request more support for herself.

Encourage Clients 

to Share Concerns

Concerns that clients may want to discuss with staff during treatment 

(and which may affect treatment attendance) include difficulties with 

the therapists, difficulties with other group members, need for letters 

of participation for court, and requests for additional treatment referrals for alcohol or nonalcohol disorders. Sometimes a client can be 

persuaded to discuss interpersonal concerns with the therapists or 

other group members, but at other times, the distressed client’s concerns may require contact with more senior staff (e.g., a supervisor or 

project coordinator).

For example, one group member almost dropped out of treatment after 

one session because of a great fear of becoming infected with HIV by 

another group member. After speaking to the project coordinator several times and gathering additional information from trusted friends 

regarding HIV transmission, she was able to manage her fear well 

enough to attend group consistently but did not discuss her fear with 

the group nor with this particular member. Her therapist was informed 

of this situation and helped the client feel more comfortable with the 

other group member by engaging them in role plays together.

Sometimes a staff member (e.g., nurse, project coordinator) can assist 

a client without involving the therapists or other group members. For 

example, when one client with bipolar disorder noticed an increase in 

manic behavior but had difficulty reaching her psychiatrist to request 

more medication, she phoned the program for help. After some reassurance and problem solving, she was able to reach her psychiatrist 

and obtain the medication she had previously found helpful, thereby 

preventing further deterioration. This client also reported concerns 

about spending sprees, for which she received additional treatment 

referrals. She continued to attend regularly and do well in the study 

treatment and updated the staff periodically about her progress.
27

Practical Strategies for Improving Client Compliance With Treatment

Explore 

Ambivalence

Clients may be more inclined to reconsider their resistance to change 

if they believe that the therapist understands their reasons for being 

hesitant to change (e.g., lifestyle changes can be difficult, it may be 

unpleasant to give up old drinking buddies, it may seem easier to 

handle various feelings and problems by using alcohol). Therapeutic 

collaboration may be facilitated when therapists empathically examine 

resistance and are willing to look at the disadvantages and difficulties 

of change.

Maintain 

Relevance to 

Clients’ Needs in 

Research Protocols

Research Note: During the course of treatment, clients experience numerous problems, as well as cravings and actual slips, as they struggle to 

achieve sobriety. It is crucial that clients perceive the treatment they are 

receiving as relevant to the major issues they are confronting. The therapy manuals employed in clinical research studies often require that the 

focus of sessions be limited to prescribed topics. However, if therapists 

ignore the real-life problems that clients are experiencing and probably 

want to talk about, they risk having the clients view the treatment as 

peripheral or even irrelevant to their current needs.

A compromise is therefore necessary between the demands of the protocol and being responsive to clients’ perceived needs. A limited amount of 

time can usually be allocated at the outset of each session for discussing current problems. The general rule is that these opening discussions 

should be structured in a way that is consistent with the therapeutic 

protocol being employed in the study.84

For example, at the beginning of a coping skills group, a male client may 

describe difficulty with a high-risk situation such as a recent conflict 

with his wife. Although the topic scheduled for discussion in this session may be “increasing pleasant activities,” the therapists would still 

attempt to identify cognitive and behavioral antecedents of the conflict. 

If the conflict relates to his having difficulty expressing anger with his 

wife, therapists and clients might suggest principles from past groups 

(e.g., anger management, feeling talk and listening skills, giving and 

receiving criticism), if he has already been exposed to these topics.

If not yet exposed, the group could still problem-solve options, such as 

asking the client to more often discuss his concerns with his wife as 

they emerge rather than stuffing his feelings and becoming increasingly 

angry. Examples of ways to frame his concerns nondefensively might be 

given or role played. If the client agrees to try the suggestions, his progress would be assessed at the beginning of the next group. Engaging 

in pleasant activities also might be used as a possible way to manage 

moods and deal with future conflicts with his wife.

Some problems, however, may only receive relatively brief attention at 

the beginning of a session. It may become necessary to inform clients 

with special needs that, given the limitations imposed by the research 

protocol, not all problems can be dealt with fully. Clients with issues 
28

Improving Compliance With Alcoholism Treatment

that require interventions beyond the study treatment can be given referrals for additional therapy. For example, if despite group suggestions, 

the client described above continues to report relapses related to ongoing conflicts with his wife, he might be given referrals for individual or 

couples therapy.

Another potential relevance issue that can affect compliance relates to the 

presentation of didactic material. If therapists present new information 

by reading from a manual, they may give the appearance of being more 

concerned with following a predetermined protocol than with the needs 

of their clients. Therefore, when presenting new material, therapists 

should not read verbatim from a treatment manual but rather should 

paraphrase the major points in their own words and include illustrative examples derived from what they have learned about their clients’ 

particular problems or needs. In addition, only relatively small amounts 

of information should be imparted at anyone time to prevent overloading the clients. The information should be presented simply, using short 

sentences and nontechnical language. Therapists should check for client 

understanding during the course of any presentations they make.

Involve 

Significant 

Others

Significant others can provide information and encouragement and can 

help the client to secure material aid, develop realistic goals, identify 

and express feelings, find meaning, and develop a sense of belonging.3

Socially stable problem drinkers are more likely to remain in treatment 

if their spouses are involved in the sessions.85,86 Moreover, favorable 

treatment outcomes are more likely if positive ties existed between 

spouses before treatment.82,87

Inviting spouses or partners to one or two treatment sessions allows 

the significant other to learn more about the clients’ treatment and 

followup, ask questions, express concerns, and participate in future 

treatment planning. This involvement may help the significant other 

become an ally and prevent sabotaging of treatment.23 Significant 

others can be encouraged to help motivate the client for change and 

identify possible obstacles to such change. They can also give the client 

feedback regarding drinking-related consequences and support their 

positive efforts.

Depending on the treatment approach, it may also be useful to discuss ways to decrease significant others’ enabling behaviors, increase 

appropriate detachment and Al-Anon attendance, use problem solving 

during high-risk situations, and enhance communication skills. For 

some clients, couples counseling may be recommended.

Enlist Other 

Social Supports

Regardless of whether a spouse or significant other participates in 

treatment, clients should routinely be encouraged to consider how 

their friends and possibly other people could support their efforts to 
29

Practical Strategies for Improving Client Compliance With Treatment

maintain sobriety. This may be particularly important for those clients with unsupportive spouses or families. The availability of social 

supports helps assure treatment compliance, decreases client denial, 

mitigates against the occurrence of slips, and supports reintegration 

into treatment when relapses occur.

Clients can be specifically taught how to use AA to develop a social 

support network and other ways to enhance social supports (e.g., by 

joining a church or club or by generally engaging in more mutually 

beneficial relationships). Specific training in interpersonal skills can 

help clients enhance their social supports by improving their ability 

to interact effectively with others (e.g., through training in starting 

conversations, assertiveness, drink refusal skills, and dealing with 

criticism). Social support research suggests that it is not the number 

of social contacts per se but rather the quality of the relationships that 

influences the individual’s ability to cope with distress and adhere to 

treatment.3

Clients in group therapy often give one another support, as well as 

suggestions for maintaining sobriety. Group therapy clients can occasionally call each other between group sessions to obtain additional 

support, or provide it to a fellow group member who appears particularly distressed. This contact between members outside of the formal 

group sessions can help maintain their involvement in treatment and 

is acceptable providing this is agreed upon in formulating the group 

rules, members discuss this contact during the next group, and subgroups do not form.

Increase 

Motivation to 

Change

Eliciting statements that indicate client recognition of an alcoholrelated problem and a commitment to deal with the problem may help 

retain ambivalent clients in treatment. Motivational enhancement 

therapy was designed around this concept. It is based on elements 

that appear to be the common and active ingredients in effective brief 

interventions, and its principles could be applied with other types of 

therapy.61 Several specific strategies for implementing this approach 

have proven helpful:

■ Give clients personalized, objective feedback of drinking-related 

consequences.

■ Emphasize that the responsibility for change rests with the client.

■ Clearly advise clients to make a change in their drinking.

■ Provide a menu of alternative strategies from which a course of 

action can be selected.
30

Improving Compliance With Alcoholism Treatment

■ Employ an empathic rather than a confrontational approach.

■ Reinforce clients’ self-efficacy to enhance their belief that they can 

successfully make changes.

■ Use reflective listening, summarizing, and reframing.

■ Explore discrepancies between client goals and current problem 

behaviors.

■ Avoid argumentation and direct opposition of client resistance.

Other strategies for enhancing client cooperation and motivation 

include the use of open-ended questions (e.g., What concerns you 

about your drinking? How has your drinking changed over time?), periodic questioning about drinking-related problems, and reviewing the 

pros and cons of changing versus not changing. A decisional balance 

worksheet (table 2.5) designed for clients examines the benefits and 

the costs of continuing to drink at pretreatment levels as well as the 

benefits and costs of changing drinking habits.88

Case History: Resistance to Assigned Treatment

This separated female in her early 40s participated 

in a 12-step treatment. She was encouraged to 

maintain her sobriety by attending AA meetings; 

enlisting support from AA members (e.g., obtaining 

phone numbers and using them when experiencing urges); keeping a journal of experiences with 

AA, treatment, and sobriety; reading recovery 

literature; and beginning to work steps 1 through 5 

of the AA program.

The client reported no previous alcohol treatment 

or any drug problems and no significant problems 

with anxiety or depression. Before starting treatment, she drank about a half pint of vodka, 5 or 6 

days per week. She agreed to a treatment goal of 

abstinence.

The client was hesitant to become involved in the 

AA program, in part because her difficulties with its 

spiritual aspects. The therapist first praised the client when she tried suggestions in the book "Living 

Sober" and when she wrote in her journal.

The client was then reinforced for successive 

approximations to AA attendance, since she was 

anxious about actually sitting in a meeting. Initially, 

the client was praised for driving to an AA meeting 

several times, even though she stayed in the car. 

In later weeks, she was praised for actually sitting 

in on a meeting. Obstacles to meeting attendance 

and ways in which other AA members might help 

her remain sober were repeatedly discussed. The 

therapist obtained commitments to comply with 

further meeting attendance. The client reported 

few slips during treatment.

During the second half of treatment, the client 

canceled her 7th session because of personal 

business out of town. She spoke with her therapist 

and a staff member and was reminded of her treatment end date. Her therapist supported her plan to 

attend AA meetings at her destination, and it was 

agreed that the client would call the therapist upon 

her return. When this did not occur, the therapist 

mailed her a letter inviting her to reschedule before 

her treatment end date. However, the client did not 

call to reschedule.

Although this client withdrew from treatment 

prematurely despite staff outreach by phone and 

letter, she did not appear to respond to her therapist’s praise for completing successively more 

difficult recovery tasks, despite her initial resistance to the AA approach.
31

Practical Strategies for Improving Client Compliance With Treatment

Give Feedback Objective feedback about the negative consequences of drinking that 

the client is personally experiencing right now is an effective way to 

clarify the problem and motivate clients to change. This information 

can come from a variety of sources:

■ Data obtained from intake assessments (e.g., DRINC questionnaire, 

Alcohol Use Inventory). A percentile measure can be computed 

comparing the client’s drinking to American adults in general (controlled for gender).

■ Estimates of blood alcohol peaks during a typical week of drinking and on a heavy day of drinking, based on their own reports of 

amounts consumed.

■ The results of liver function tests. These can be provided at various times (e.g., pretreatment, midway through treatment, and at 

followup) to inform clients of how their drinking has affected their 

bodies.

■ The outcome of cognitive assessments.

Following this feedback, ask clients to comment on whether they perceive themselves as having alcohol-related problems and how formal 

treatment could help deal with these difficulties. The motivationenhancing effect of this strategy may prepare the client for compliance 

with a change plan.

Table 2.5. Decisional balance worksheet

CONTINUING TO DRINK AS BEFORE MAKING A CHANGE IN MY DRINKING

Benefits Costs Benefits Costs

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________
32

Improving Compliance With Alcoholism Treatment

Help Clients 

Set Goals

Engaging clients’ active participation in setting goals for change and 

selecting treatment components is likely to facilitate treatment compliance.89 One structured process for training clients in goal-setting90 

emphasizes that goals be clearly formulated and described in terms 

that are measurable so there will be no question as to when they have 

been met. If goals are framed in terms of abstract concepts or cannot 

be objectively assessed, it will be impossible to ascertain how successful one has been in achieving them.

Specify the steps required to reach a goal in terms of behaviors that the 

client is likely to perform, and determine a timeframe within which the 

various steps are to be completed. If goals entail some risk, clients are 

more likely to experience a sense of accomplishment if they are successful, but they should not be so risky, unrealistic, or difficult that 

failure is a certainty.

Individualize 

Client Goals

In cognitive-behavioral treatment, some treatment contracts outlining the rules for therapy participation include specific behavioral goals 

identified by the client. Such goals might involve learning to relax, 

dealing with depression without drinking, changing nighttime routine 

to improve sleep habits, and developing more friendships.

In some programs, clients also help determine which elective topics are 

covered after a number of core topics are completed.

For example, some clients choose to focus more on assertiveness and 

anger management, while others choose to focus on managing negative 

thoughts or moods and enhancing social support. The topics chosen 

are influenced by client goals. For example, a client interested in developing more friendships would be exposed to topics such as enhancing 

social supports and increasing pleasant activities.

Therapists and clients should actively collaborate on establishing 

goals. A change plan worksheet (table 2.6) helps to identify steps that 

could be employed outside of the therapy sessions to reach these goals. 

Clients can keep a copy of this change plan, which also provides a way 

to assess their progress.

Reassess Goals Midway through any treatment, reassess goals that were set at the 

beginning. Clients’ perspective or outlook may undergo changes during 

the course of treatment; certain problems that appeared overwhelming initially may assume more realistic proportions over time. Values 

may shift, perhaps returning to those that were more prominent before 

drinking became a serious problem. These changes can be identified 

and incorporated into the overall goals of treatment.
33

Practical Strategies for Improving Client Compliance With Treatment

Some clients who commit to abstinence during the pretreatment phase 

become ambivalent about it during the course of treatment. Remind 

clients that the goal of abstinence applies to the treatment period and 

that later they can decide whether to maintain it. Always remember the 

importance of nonjudgmentally discussing client ambivalence toward 

treatment or the goal of making changes. Some clients may need to 

first agree to reach intermediate goals, to make their task seem less 

overwhelming.

Focus on 

Strengths

Emphasize the client’s strengths to increase client involvement in goal 

setting and resource utilization.91 Ask clients, “What is healthy about 

you and how can you use your strengths to get what you need?” Help 

clients identify their strengths (e.g., intelligence, competence, and 

problem-solving abilities) and ask for their collaboration in setting 

goals, planning strategies to accomplish them, and identifying supports such as self-help groups, neighbors, and friends that can provide 

assistance to them in achieving their goals. Act as a consultant to 

clients and assist them in the processes of identifying their personal 

strengths; formulating broad goals, specific objectives, and strategies 

to accomplish them; and developing the behaviors needed to carry out 

the various aspects of their plan.
34

Improving Compliance With Alcoholism Treatment

Case History: Enhancing Motivation

At pretreatment, this alcohol-dependent, married professional man in his mid 30s reported drinking 

from a pint to a fifth of vodka 2 or 3 times per week, and noted that his drinking first became 

problematic when he was a teenager. His drinking led him to receive several charges of driving 

while intoxicated and contributed to marital difficulties. This was his second outpatient treatment for 

alcohol problems. He also reported significant problems with anxiety and depression, but denied 

drug use.

The client participated in all four motivational enhancement therapy sessions. To increase his 

motivation for change, he received feedback during his first session that he had a high level of 

negative consequences related to drinking and that he regularly consumed more alcohol than 95 

percent of other American males. His Alcohol Use Inventory scores also suggested that, relative to 

other adults seeking treatment for alcohol problems, he reported significantly more marital problems 

and a lack of control over drinking. He also was informed that his pretreatment liver function tests 

were within the normal range, and his brief neuropsychological tests suggested no drinkinginduced cognitive impairments. The client received this information well and reported motivation for 

continued sobriety.

Social support for maintaining positive change was enlisted by having the client’s wife attend the 

next two sessions. During both appointments, the client reported a drinking episode, and the client’s 

ambivalence toward complete sobriety was discussed. The therapist also examined the effects of 

the client’s use of alcohol on his marital relationship, and specific ways for the client and wife to 

support one another were discussed. The client’s ambivalence about making further changes in his 

drinking also was examined by having the client complete a decisional balance sheet.

A detailed change plan also was developed to help the client further specify behavioral goals, build 

motivation to achieve these goals, and specify steps needed to achieve them. For example, the 

client wanted to learn how to better manage his anxiety without alcohol, improve his relationship 

with his wife, get in better physical shape, and begin, to see himself as a nondrinker. He was well 

able to identify reasons for these changes and elucidated steps he planned to take to make these 

changes (e.g., reinforce his decision to continue sobriety, seek specific help from family and from 

professionals). He planned to continue receiving biofeedback treatment to help reduce his anxiety 

and to take time off from work to get more rest.

During the development of his change plan, the client reported feeling better able to make positive 

changes and more ready to accept help from others. The client and therapist reviewed specific 

obstacles that could interfere with his attainment of goals and how he might surmount these 

obstacles. When the client was asked to identify ways to assess how well his plan was working, he 

reported that he would have more sober days, be more optimistic, less negative toward himself, 

and more in control of his anxiety.

To increase the client’s commitment, he was given a copy of the change plan, and the therapist 

asked for a commitment to comply within the next 6 weeks. The therapist was warm, empathic, and 

nonjudgmental, communicated respect for the client, and expressed some understanding for his 

ambivalence about change. She also gently and persistently focused on the discrepancies between 

his behavior and stated goals.

During his last session about 6 weeks later, the client reported another drinking episode, but also 

reported his longest period of sobriety. His therapist noted that, relative to earlier sessions, he 

seemed more motivated for positive change and displayed less discrepancy between his behavior 

and stated goals.
35

Practical Strategies for Improving Client Compliance With Treatment

Table 2.6. Change plan worksheet

The changes I want to make are:

The most important reasons why I want to make these changes are:

The steps I plan to take in changing are:

The ways other people can help me are: 

Person Possible ways to help

I will know that my plan is working if:

Some things that could interfere with my plan are:

Source: Miller et al. 61
36

Improving Compliance With Alcoholism Treatment

Give 

Assignments

All therapies expect clients to make some efforts to change outside 

of the sessions. Many provide homework assignments, which present 

an ongoing compliance challenge throughout the course of treatment. 

Although the nature of the assignments may vary widely across different types of therapy, nevertheless certain general approaches to the 

assigning of homework may serve to enhance compliance across various situations. These are summarized in table 2.7.

Table 2.7. Checklist for giving homework assignments

 Provide a rationale and a clear description of the assignment.

 Give clients an active role in developing, or selecting aspects of, the 

assignment.

 Explore any fears about, or attitudes toward, the assignment.

 Model and/or practice the assignment during the session.

 Ask clients to try something once, rather than setting an expectation 

that they do it “from now on.”

 Encourage clients to make an appointment with themselves to do 

the assignment and to consider what cues may help remind them to 

do it.

 Anticipate what sorts of things might get in the way of completing the 

assignment.

 Find out how the clients motivate themselves to do things.

 Help clients anticipate the possibility of failure and how to react to it.

 Self-reinforcement techniques:

Whenever homework is assigned, clients should be asked to 

indicate how they will reward themselves for completing it. If they 

have trouble coming up with rewards, suggest that they brainstorm 

to identify something specific from among these general categories:

hobbies reading food/beverages

sports socializing shopping

exercise/walking music/dancing movies

Provide a 

Rationale

Compliance is more likely if clients understand how the assigned task 

will help to address their goals and if they play an active role in developing or selecting the assignment.92 As a general rule, the temptation 

to attempt too much too soon should be resisted; assignments should 

be kept brief and simple at first, only gradually increasing in difficulty 

and complexity over time.89,92

When giving homework assignments, it is crucial that the instructions 

be clear and include sufficient details regarding what is expected. The 
37

Practical Strategies for Improving Client Compliance With Treatment

assignment should indicate the circumstances under which it is to 

be performed, exactly what is to be done, and for how long. However, 

care must be exercised that while providing enough detail, clarity and 

simplicity should not be sacrificed, for this too would increase the 

likelihood of noncompliance. Providing written instructions can help 

overcome the common tendency to forget the assignment or important 

aspects of it. The use of videotaped instructions and demonstrations 

can also be helpful.93

Explore 

Resistance

Explore the clients’ fears or attitude toward the assignment and help 

them anticipate possible roadblocks, negative effects of compliance 

that could interfere with completing the assignment, or problems that 

have arisen in similar situations in the past. Consider physical obstacles such as lack of transportation, childcare problems, or insufficient 

money and interpersonal obstacles such as lack of support or outright 

negative reactions to the new behavior. Attempt to anticipate these 

when the assignment is developed with the client, and make plans for 

coping with potential obstacles or working around them.

Anticipating obstacles will make them seem an expected part of the 

overall recovery process that requires application of a problem-solving 

approach, rather than an indication of failure of the treatment or the 

client. It is helpful if the client can view a problem with an assignment 

as a natural part of the learning process and not as a sign of total failure and an excuse to abandon efforts to change.

Identify 

Reminders and 

Reinforcers

Encourage clients to use cues to remind them of the need to comply 

with assigned tasks. These might include calendar prompts, written 

reminders to oneself, strategic placement of critical items, asking others to provide reminders or to participate in the activity, coordinating 

new activities with established daily routines, and scheduling specific 

times to practice skills.

Self-reinforcement may enhance the likelihood of compliance with 

homework exercises and may also increase the likelihood that the new 

behaviors will continue to be used after treatment has been terminated.89 The possibilities for self-reinforcement are limited only by the 

collective ingenuity of the therapist and the clients. When homework is 

assigned, clients should be helped to plan how they will reward themselves for completing it. If they have trouble coming up with specific 

rewards, suggest that they identify something from among the general 

categories listed in table 2.7.

Verbal self-reinforcement may be used in addition to more concrete 

rewards but should not be the sole consequence of the desired behaviors. As a general strategy, clients should deny themselves access to the 
38

Improving Compliance With Alcoholism Treatment

selected reinforcer until the homework is completed and then reward 

themselves as soon as possible.

Rehearse Most homework assignments are designed to provide practice of new 

skills in order to strengthen them so that they will be readily available 

whenever they are needed. However, practicing skills requires at least a 

minimal ability to perform them in the first place. Therefore, rehearsal 

in the therapy session is necessary to assure that the instructions have 

been understood and that the task can be performed with at least a 

minimal level of competence.92 This may involve both modeling by the 

therapist and active role playing by the client. Rehearsal by the client 

during sessions also provides opportunities for giving feedback and 

differential reinforcement of successively closer approximations to the 

desired behavior.

Monitor and 

Follow Through

Therapists’ checking on homework compliance at each session has been 

demonstrated to have a salutary effect.94 This monitoring may take the 

form of a simple verbal report by the client, ongoing data recording by 

the client, or observations by significant others. Client involvement in 

selecting the method of monitoring is also likely to enhance compliance 

with the assignment. Clients should be praised/reinforced for compliance, initially even for approximations of compliance. If no efforts were 

made to attempt the assignment, or there was only partial compliance, 

the reasons for this should be explored in a nonjudgmental, problemsolving manner, and plans formulated for improving compliance with 

the next assignment. In fact, early dropout from treatment may be 

more likely if noncompliance is ignored.95 Table 2.8 provides a checklist of items to cover when reviewing homework compliance.

Obtain 

Commitments 

To Comply

Therapists should ask whether the client intends to comply with an 

assigned activity and obtain a commitment to do so. Clients in outpatient behavior therapy who give a verbal commitment are more likely 

to comply than those who are merely given the assignment without a 

request for commitment. Those who sign a form indicating that they 

will comply have the highest compliance rates of al1.96 If clients are 

unwilling to make a commitment to comply, explore this unwillingness and problem-solve ways to possibly increase commitment (e.g., 

through adjusting the assignment). Therapists (and sometimes other 

clients in a group) also could try to obtain a public commitment from 

clients who have a record of noncompliance with prior assignments.
39

Practical Strategies for Improving Client Compliance With Treatment

Table 2.8. Checklist for reviewing homework assignments

 Each week ask directly who did and did not complete the previously 

assigned homework.

 Reinforce adherence by praising all approximations to compliance.

 Discuss problems that clients may have had with the homework, but 

keep the main emphasis on the positive aspects of performance.

 For those who did not do an assignment, ask “What could you do to 

ensure that you will be able to complete the next assignment?”

 Emphasize that adherence to assignments is up to the individual. 

The therapist only wants to help clients get what they want.

 Collect written assignments and return them at the next meeting to 

improve compliance.

Additional issues for research programs:

 Keep the discussion of homework compliance within the bounds of 

the treatment protocol.

Use Contracts Many programs make contracts with their clients that cover a variety of 

issues—attendance, confidentiality, behavior, assignment completion. 

Signing such a contract signifies a commitment to the therapist, group, 

or program that encourages the client to comply. Table 2.9 shows a 

group members’ contract that describes expectations such as attendance, confidentiality, and commitment to sobriety during treatment.

This contract encourages the client to attend at least four sessions 

before withdrawing from treatment and to discuss plans to prematurely 

leave treatment with staff. One client who had maintained abstinence 

since treatment onset remained in treatment longer because, when 

reminded of the contract to which he had agreed, he returned to the 

group to discuss his plans to leave. The group then persuaded him 

to continue in treatment longer because of his helpfulness to other 

members.

Behavioral 

Contracts

Behavioral contracts during treatment may also enhance adherence 

to treatment. The negotiations to develop a contract increase clients’ 

involvement in goal setting, provide them with a sense of control over 

treatment planning, and develop a working collaboration with the 

therapist(s), factors that are likely to enhance cooperation with treatment. In addition, the contract’s specification of agreed-upon target 

behaviors provides criteria for monitoring and reinforcing compliance 

and for assessing client progress.
40

Improving Compliance With Alcoholism Treatment

Table 2.9 Cient contract for group therapy

 I agree to participate in this group for six months. Although I do 

retain the right to withdraw, I agree to attend at least the first 4 

sessions to give the group a chance. After that, if I want to leave, 

I will discuss my thoughts with the group before making my final 

decision.

 I agree to attend all group meetings and to be on time for them. If 

something urgent forces me to be late or absent, I will call (phone #) 

in advance to notify the group leaders.

 I accept the goal of total abstinence from alcohol and all drugs of 

abuse. I promise to talk in the group about any drinking or drug 

use that occurs, and about any cravings or fears of relapse that I 

experience. I agree to give a breath sample prior to group sessions.

 I agree that I will not reveal any names or details about the personal 

lives of fellow group members. Although it is all right to talk in 

general terms about my experience in the group, I will protect the 

privacy of other group members.

 I agree to discuss outside contacts that I may have with other group 

members. I realize that secrets or cliques among group members 

can impede the progress of all group members.

For interactional group therapy only:

 I understand that it is important for my own progress in therapy to 

talk about my feelings and my reactions to what happens in the 

group. Doing this will help me better understand my interpersonal 

relationships and problems.

A written copy of the contract, in the client’s hands, can be an effective reminder of exactly what behaviors are required and can help 

cognitively impaired or impulsive clients to organize and focus their 

activities. Behavioral contracts should be renegotiated periodically 

as a means of responding to problems that develop along the way, 

maintaining clients’ sense of continuing involvement in the treatment 

process, and providing a mechanism for gradually shaping increasing 

levels of adherence.

Sobriety 

Contracts

One aspect of substance abuse treatment that lends itself to a contract, 

either written or verbal, is the issue of client sobriety during treatment. 

This issue arises most frequently with alcohol and marijuana. Clients 

who are unwilling or unable to commit to long-term abstinence can 

be problematic in abstinence-oriented treatment programs, especially 

where contact with other clients is likely. One way to deal with this is 
41

Practical Strategies for Improving Client Compliance With Treatment

to ask the client to agree on a certain period of abstinence as a condition of treatment—for the duration of treatment if possible. In some 

cases, even shorter durations of abstinence may need to be negotiated, 

in successive steps.

Most clients are willing to agree to some period of abstinence; many of 

them view it as a demonstration to themselves that they are not hopelessly addicted and can control whether they use or not. If the program 

is not abstinence oriented, then some acceptable level of use should be 

agreed upon at which clients can function satisfactorily and safely and 

are not impaired during treatment sessions.

Contracting for sobriety was employed successfully with a client in 

abstinence-oriented group therapy who continued to have two or three 

lapses a week and who did not appear invested in treatment. Based 

on negotiation with his therapists, the client agreed to strive for one 

full week of abstinence and to practice the coping skills that he was 

learning in group. If he complied with these, he would be allowed to 

continue in treatment. The client met this goal, and his functioning 

both within and outside of his treatment group improved noticeably. 

The contract appeared to help him focus his efforts and provided a 

concrete goal to work for.

Contracts for 

People With Dual 

Diagnoses

Similar agreements may be useful in dealing with the problems of clients with dual diagnoses. For example, a client was so depressed that 

he made no attempt to utilize any of the coping strategies discussed 

during treatment sessions. Furthermore, he was taking medications 

that were being prescribed over the phone by a former doctor in a distant state and was not seeing anyone locally about his depression. His 

primary response to feeling depressed was to sleep, which he would do 

for most of the day on many occasions.

A treatment contract was negotiated with him specifying that, in order 

to remain in treatment, he needed to obtain a psychotherapist locally 

(a number of suggestions were provided) and that he get prescriptions 

only from a local psychiatrist associated with the selected therapist. 

For their part, his group cotherapists agreed to work with him in group 

on more appropriate ways of coping with depression other than sleeping and also on anger management skills.

Be Aware of 

Safety Issues

The issue of commitment to comply is critical when discussing safety 

precautions to be taken by a client expressing suicidal ideation. Such 

a client must be willing to take certain safety measures (e.g., giving 

a weapon to someone for safekeeping, disposing of a supply of pills) 

and to allow verification of compliance, such as by checking with a 
42

Improving Compliance With Alcoholism Treatment

Case History: Alcohol Dependence and Severe Comorbid Psychopathology

A widowed female in her mid 50s sought treatment because of problems related to drinking up to a fifth of 

wine per day for several months. She reported a long history of drinking and other psychiatric problems, 

with previous inpatient and outpatient alcohol and psychiatric treatments. She also reported numerous 

trials with a variety of psychotropic medications. She was seeing a psychiatrist on a monthly basis, which 

she planned to continue.

During her initial interviews, the staff discussed her participation in treatment and provided her with a 

timeline sheet that chronologically described her involvement. The staff explained that this particular 

treatment might differ from her past experiences and described ways in which this kind of treatment 

might help her.

She seemed to understand the various roles of staff and her responsibilities. She was willing to assume 

the client obligations during treatment, including the treatment goal of abstinence, the need to attend 

treatment regularly, and to be honest about any alcohol or drug use. Potential barriers to her participation 

were reviewed, and most were deemed nonproblematic.

The client required extra time to complete her pretreatment assessments because of the complexity of 

her psychiatric history. Her interviewers were empathic regarding her difficulties, and she was praised 

for her patience and cooperative attitude during the assessments. In addition to Alcohol Dependence, 

she also met diagnostic criteria for Bipolar Disorder, Panic Disorder with Agoraphobia, and Obsessive 

Compulsive Disorder. Her prescribed medications at pretreatment were Zoloft and Ritalin. Due to the 

extent and recency of her psychiatric symptoms, she agreed to the recommendation that she see her 

psychiatrist more frequently than once per month and that she obtain other additional support/therapy if 

her symptoms significantly worsened.

Because of recent sobriety, she did not require detoxification before treatment assignment. She was 

given a treatment information handout to help orient her to the treatment, and she denied any negative 

reactions. She accepted our rules of group attendance and was shown the location of the group room.

Before her first group session, her therapists conducted a role induction interview with her to further 

prepare her for treatment. The philosophy of the treatment approach was described in more detail, and 

a group contract specifying expectations regarding attendance, participation in group, maintenance of 

confidentiality, completion of homework assignments, and commitment to sobriety during treatment was 

reviewed. It also was explained that desires to leave treatment prematurely should be discussed with 

the therapists and the group and that she should attend at least four treatment sessions before making a 

final decision to drop out. She verbalized acceptance of the group contract.

The client’s compliance was good in the beginning of treatment. Her breathalyzer readings were all negative and she reported nearly continuous sobriety. She initiated numerous contacts with the staff regarding 

a variety of concerns, including occasional desires to withdraw from treatment (e.g., because of inadequate time to discuss nondrinking concerns, therapists weren’t sufficiently caring, her work schedule was 

too tiring). Occasionally she called to express ambivalence about attending a particular session because 

of other tasks she stated were important (e.g., her laundry), but allowed herself to be persuaded to attend 

(e.g., she was told she would be missed and that staff enjoyed seeing her).

The client kept the staff informed when she noticed increased manic or anxiety symptoms and was able 

to articulate the kind of support she found most helpful. Phone contacts required patience, limit setting, 

problem solving, and empathic listening, and she responded well to suggestions. Referral options were 

discussed to help her better address other issues which became more problematic with sobriety (e.g., 

overspending, anxiety over family issues, reemergence of traumatic memories). The frequency of her 

use of additional therapeutic supports continued to be monitored. 

(continued)
43

Practical Strategies for Improving Client Compliance With Treatment

Case History: Alcohol Dependence and Severe Comorbid Psychopathology (continued)

The therapist noted that her cognitive status fluctuated during sessions. At times she appeared confused 

and disorganized, and the therapists tried to keep her focused when she became tangential. At one point 

the therapists had her change her seat so she could better concentrate on the new topic displayed on the 

chalkboard. Concrete behavioral suggestions were made to help her deal with high-risk situations, and 

weekly contracts were sometimes negotiated to help her follow the suggestions. Enlisting family support 

was downplayed because it was deemed unhelpful in her case; indeed, she sometimes needed help 

setting limits on them. Her therapists, who routinely checked for completion of homework assignments at 

the beginning of each session, praised her for her frequent compliance in this area. Problem solving was 

initiated when she reported occasional difficulties practicing new coping skills, and she participated in 

role plays to help reinforce the new skills.

When the client did not come to a session without a prior cancellation, she was telephoned by one of her 

group therapists the same night. Since her attendance was more sporadic in later months, staff outreach 

efforts were increased, with reminders regarding the date of her last treatment session, her positive contributions to the group, and the achievement associated with completing the treatment. Her attendance 

subsequently improved, such that she attended 18 out of 26 sessions, and she received her certificate of 

treatment completion at her last group session.

significant other. The client must also express willingness to seek professional help if at some later time the suicidal ideation intensifies or 

escalates to actual intent, and the therapist must feel confident that 

the client will comply. If this is not the case, the client may need a formal psychiatric evaluation, or to be taken to an Emergency Room for 

assessment.

Table 2.10 shows a sample safety contract. If there are repeated episodes in which clients are unable to provide convincing assurances of 

their willingness to comply with recommended safety measures, it may 

be necessary to remove them from the study and refer them for more 

intensive treatment.

Reinforce

Compliance

Initially, clients should be reinforced for all approximations to compliance. Shaping of the client’s performance can then occur by reinforcing 

gradually closer approximations to full compliance. Table 2.11 lists 

several strategies which may be used to reinforce client compliance.

Negative reinforcement involves the withholding or reduction of a 

desired item or event as a consequence of behavior. It has been used 

effectively in some instances, although it sometimes leads the client to 

focus excessively on avoiding the negative consequences, rather than 

developing the desired behavior.
44

Improving Compliance With Alcoholism Treatment

Table 2.10. Safety contract

I, __________________________, deny that I have any intention to harm 

myself at the present time. If I begin to feel like hurting myself, I agree that 

I will make no attempt to harm myself and will follow recommendations to 

remain safe by:

1. Telling my group therapists or other staff (phone #) about any suicidal 

thoughts.

2. Phoning my outside therapist or psychiatrist (Dr. ________________).

During evening hours, weekends, or holidays, I can deal with suicidal 

thoughts by:

3. Going to a nearby emergency room.

4. Calling a crisis intervention line (phone #, phone #).

Signed ____________________________________________________

Date ______________________________________________________

Use Incentives In one program, clients who complete 6 months of weekly group therapy are given a certificate of completion signed by the therapist and 

staff. This can be a very meaningful token for some clients. Clients’ 

completion of interactional therapy is also commemorated during their 

last session by cake and beverages brought in by the therapists or 

group members. In another program, within one week of each appointment attended, a reward (e.g., special meal or recreational activity) was 

provided by the significant other or the client himself.97

Table 2.11. Potential therapist reinforcers for treatment 

compliance

 Positive reinforcers (for compliance):

— Verbal praise

— An extra therapy session

— Refund of monetary deposit

— Food (snacks, soda)

— Modest prizes (restaurant coupons, movie tickets) 

— Tokens or points that can be exchanged for goods or services

— Special privileges within the treatment setting

— Certificate of completion

 Negative reinforcers (for noncompliance):

— Reduced session length

— Send monetary deposit to least favorite charity
45

Practical Strategies for Improving Client Compliance With Treatment

Recognizing client progress with stars and modest prizes for performing specific behaviors has been effective in increasing clinic attendance 

rates and reducing illicit drug use among clients in a community-based 

methadone treatment program. The stars were exchanged for food, gas 

coupons, or bus tokens.98 In another program, three severely alcoholic 

methadone clients significantly decreased alcohol intake and improved 

clinic attendance when continuation of methadone maintenance was 

made contingent upon daily disulfiram consumption.99

Attendance among dually diagnosed clients in a day treatment program 

was assessed for successive 4-week periods before, during, and after 

an incentive intervention. The incentive consisted of modest rewards 

(e.g., coupons from a local restaurant) offered at the end of each week 

to all clients who attended the program for at least 5 hours a day, on 

3 days per week. The results suggested that modest incentives can 

enhance attendance.100

Incentives have also been shown to improve attendance and outcome 

when added to outpatient behavioral treatment of cocaine dependence. 

Some clients earned points, recorded on vouchers, for negative urine 

specimens. Points were used to purchase retail items in the community, such as YMCA passes, continuing education materials, fishing 

licenses, gift certificates to local restaurants, and camera and bicycle 

equipment. Clients in the reward group were significantly more likely 

to complete the 24 weeks of treatment than clients who could not earn 

points and were also more likely to remain cocaine-free longer.101

Money Deposits Another strategy to reinforce treatment compliance is to ask clients to 

submit a money deposit before treatment, which is returned upon completion of treatment. Clients are informed before treatment onset that 

noncompletion of treatment would result in forfeiture of the deposit 

to a “least favorite charity.” Alternatively, a money deposit obtained 

before treatment could be returned only after the clients complete all 

between-session assignments to which they agreed, or a small amount 

could be returned to the client after each successful completion of an 

assignment. This contingency should be specified in a written contract.92 However, use of a money deposit to enhance compliance may 

be contraindicated for clients with significant financial problems.

Inpatient 

Incentives

Alcohol treatment conducted in inpatient settings could also improve 

compliance by employing a contingency management system. In one 

setting, an accumulation of nine specified accomplishments resulted in 

the acquisition of special privileges. Accumulation of 3 demerits, given 

for inappropriate behaviors, led to a status reduction that was restored 

only by completing 10 additional positive behaviors. Improvement in 

clients’ program participation was seen in several areas, with a decrease 

in resistance to treatment.102
46

Improving Compliance With Alcoholism Treatment

Dealing With Absences

Use Reminders Programs with individual therapy formats allow for some flexibility 

in scheduling, as the client and therapist can find mutually satisfactory times. They are able to schedule appointments during the early 

mornings, evenings, and on Saturdays, in addition to regular daytime 

hours. However, scheduling may be problematic for group therapy clients. This may provide a reason or an excuse for absence.

Letters and telephone calls have been successfully used to remind clients of scheduled appointments. Some programs have given clients a 

calendar with session dates circled to help them schedule their activities around their treatment appointments.47 It also helps to have the 

client identify a visible place to keep the calendar (such as a refrigerator) as a prompt to remember appointments.

Use a Contract Negotiating an attendance contract has been shown to improve treatment attendance. In one program, after male veterans had completed 

28-day inpatient treatment, attendance in aftercare was nearly doubled 

for those clients who received a calendar prompt and an attendance 

contract.97 The calendar prompt consisted of a wall calendar on which 

eight scheduled appointments over a 6-month period were circled in 

red. The contract specified that the calendar be posted in a prominent 

location, that the client attend aftercare, and that he call the alcohol 

program at least one hour in advance of the scheduled appointment if 

unable to attend a session. When possible, contracts were negotiated 

between clients and a significant other, with therapist guidance.

Follow Up When clients miss a session without canceling it, call them the same 

day to check on their status. If it is necessary to leave a message and 

the client does not return the call, follow up with another call to the 

client a day or two later. Phone calls are generally more effective in 

retaining clients than letters, because concerns can be dealt with more 

immediately and directly. This may require calling at odd hours, such 

as early in the morning or on Sundays, to catch the client at home. If a 

client is especially difficult to reach, it may be necessary to contact an 

identified collateral informant to get word to the client to contact the 

therapist or other project staff.

If repeated efforts to reach clients by telephone are unsuccessful, and 

the clients continue to miss sessions, a personalized letter may be sent 

inviting them to contact the staff and return to treatment by a specified 

date. Telephone contacts and personalized letters can significantly, 

and cost effectively, facilitate clients’ return to treatment.
47

Practical Strategies for Improving Client Compliance With Treatment

The approach to the client in such instances should not be heavy 

handed, but rather exploratory and combined with offers of assistance. It may turn out that conflicts, such as a work schedule or 

childcare needs, are preventing attendance. In such instances, initiate 

efforts at problem-solving with the client. It may be helpful to discuss 

the relevance of the treatment approach to the client’s problems. The 

approach to such clients should communicate concern and that they 

are missed. Some clients have returned to treatment when reminded of 

their positive influence on the group and of their specific end date (e.g., 

only two or three more sessions to go).

When absences are due to slips, be respectful, empathic, and nonjudgmental and encourage the client to return to treatment in a sober 

condition to process the experience. Strategies to help address client 

absences from treatment are listed in table 2.12.

Table 2.12. Dealing with absences

 Call client soon after the absence (during evenings or weekends, if 

necessary).

 If client repeatedly cannot be reached by phone, send a 

personalized letter asking client to respond by a certain date.

 If client can be reached, explore reasons for absence.

 Communicate concern and support. Assist client with problemsolving regarding obstacles to attendance.

 Suggest relevance of treatment to the client’s current problems.

 Indicate that the client is missed by the group. Inform clients of their 

positive influence on the group.

 Remind clients that their involvement in this treatment program is for 

a limited time.

 If the absence was due to a slip:

— Be empathic, nonjudgmental.

— Encourage return to treatment to process the experience.

— Identify specific coping skills that could be used to help maintain 

sobriety until next session.

— Recommend involvement of a significant other to enhance 

support for client.

— Recommend additional treatment or AA attendance (if consistent 

with protocol), as needed.

— Maintain phone contact until client returns to group.
48

Improving Compliance With Alcoholism Treatment

Case History: Labile Client

A married female in her early 40s reported drinking at least a pint of vodka up to 4 days per week before 

seeking treatment. She worked part time and reported numerous financial concerns. Past alcohol treatments included an inpatient detoxification and two extended inpatient stays. She reported alcohol 

problems for nearly 20 years and had nearly 41⁄2 years of sobriety up to 2 years ago. She also reported 

numerous marital problems that greatly distressed her, especially her husband’s physical abuse. Before 

seeking treatment, she and her husband were summoned to court for mutual assault charges that 

occurred while she was drunk

The client was educated about participation in the study, and potential barriers to participation were 

reviewed. She completed outpatient detoxification before further assessment and treatment assignment. 

She appeared to meet diagnoses of Major Depressive Disorder, single episode, and Dysthymic Disorder, 

as well as possible Borderline Personality Disorder. During her pretreatment assessments, additional 

treatment referrals for her depression and marital difficulties were discussed, within the limits of her financial constraints. She also signed a suicide contract which further specified possible low-cost treatment 

options when in crisis (e.g., crisis intervention hotlines, services for battered women). She later followed 

up on several of these options.

The staff noted her strengths (creativity, artistic talent) during her pretreatment interviews and pointed out

how her creativity and ability to express feelings would aid her in group. Staff also suggested how the 

group would help provide support with her various problems. She seemed to develop a good relationship 

with the staff, accepted her treatment assignment, and was given a descriptive treatment handout.

She agreed to the group contract that was presented during her induction interview with the therapists. 

Her attendance in interactional therapy was fairly regular during her first 2 months but became problematic thereafter. Early in treatment, she reported sobriety but expressed discomfort with the group’s 

feedback. She perceived herself to be verbally attacked, and repeatedly felt interrupted and not listened 

to, even though her therapists had a different impression. For example, sometimes group members felt 

she spoke too rapidly and dominated the group. When she later tearfully told the group how she felt 

about their feedback and her thoughts of dropping out, she got some positive feedback and was encouraged to stay. On several occasions, the therapists and staff (during phone contacts) attempted to help 

her view the troubling group feedback in a broader, more positive context, and to help her see some of 

the similarities she shared with other group members.

After she missed several groups, it was learned that after nearly 3 months of sobriety, she had a relapse 

and returned to AA. She reported no further problems with physical abuse. She was invited to return to 

group the following week, but she resisted because she was now embarrassed. She also was encouraged to contact some of the treatment referrals for her depression that had previously been discussed.

Although she chose to drop out of the interactional group after seven sessions, she did follow through on 

one of the referrals recommended for treatment of her depression, and at her request, clinical information was faxed to the therapist. Subsequently, she completed all research followup appointments and 

reported significant improvement, but not total abstinence.

Suggest Referrals Discuss options with clients who may require referrals for additional 

treatment (detoxification, partial hospital program, additional therapy 

for depression, anxiety, or couple’s issues). Spouse or family involvement may also be appropriate at this time to provide support and help 

the client secure additional treatment. To help maintain the client’s 

connection with the program, staff should provide clinical information 

for outside treatment, and may even initiate personal contact with clients during their additional treatment.
49

Practical Strategies for Improving Client Compliance With Treatment

The use of appropriate flexibility regarding additional, outside treatment may help retain clients in the program. Client involvement in 

any additional treatment and in self-help groups should be monitored 

during the treatment period. If the absence from the study treatment is 

more than a few sessions, staff should periodically phone such clients 

until they return.

Termination For individual therapy or closed groups (in which all clients complete 

treatment at the same time), termination must be anticipated and discussed a number of sessions in advance so that clients’ anxiety over it 

does not lead to noncompliance and other forms of acting out. Clients 

who report continued problems with drinking, anxiety, depression, 

relationships, and so forth should be informed about possible referrals for additional treatment to help them deal with these issues in the 

immediate posttreatment period.

In open groups with rolling admissions, termination is an ongoing process as individual group members approach their completion date. 

In this case, keep in mind which clients are approaching their final 

sessions and begin preparing them and the rest of the group for the 

separation. The continual process of terminating members, as well as 

the loss of members who drop out prematurely, could be a negative 

experience for group members. The leaders should help clients identify 

and manage their reactions. In this way, the experience can be used as 

a growth opportunity, to learn how to cope appropriately with losses.

Care must be taken to avoid prolonged farewells that would make it 

difficult for the ongoing group to continue without the departing members. To avoid this, put the emphasis on gains made by the departing 

member since starting treatment, on recovery tasks that remain to be 

accomplished, and on strategies for working on them. Continuation of 

the old group through outside contacts with former group members 

who have terminated could be destructive to the remaining group and 

should be discouraged.

Research Note: At the end of treatment, therapists should remind clients that they will be contacted by research staff to begin the research 

followup phase. When possible, the research staff should schedule the 

clients’ first followup appointment at the end of their last treatment 

session. The project coordinator also should remind clients about the 

followup phase, as well as praise them for their treatment involvement, 

and elicit their reactions (both positive and negative) to the treatment. 

In this way, the clients are prepared, at the conclusion of the treatment 

phase of a clinical research protocol, for compliance with the continuing 

research aspects of the study. Clients who did not complete treatment 

are reminded of the followup phase by letters or phone calls.

51

Part 2

Strategies for Enhancing

Therapist Compliance

53

The Use and Development of 

Treatment Manuals

Kathleen M. Carroll, Ph.D.

Kathryn F. Nuro, Ph.D.

Yale University School of Medicine 

New Haven, Connecticut

Overview Treatment manuals that specify and discriminate treatments as well as 

provide guidelines to therapists for their implementation have revolutionized psychotherapy and treatment research.103,104 Therapy manuals 

have become a virtual requirement in clinical treatment research 

in that they define the independent variable.105 They are becoming 

increasingly important in clinical practice as changes in the health 

care system put greater pressure on clinicians to define and evaluate 

the effectiveness of their services. They also help meet the increasing 

demands on training programs to evaluate their methods for training 

therapists for clinical practice.

Psychotherapy manuals also serve many other purposes. These include 

providing a means for objective comparisons of different psychotherapies, setting standards for training and evaluation of therapists, 

establishing clear treatment goals and clinical care standards, fostering replication of clinical trials to other settings, facilitating transfer 

of promising treatments from research to clinical settings, providing a 

means of linking treatment processes to outcome, and reducing variability in outcome due to therapist effects.103,104,106–108

Manuals and

Treatment

Compliance

A major function of manuals is to define what therapists and clients 

should and should not do in the course of treatment. Defining and clarifying client expectations is very important in facilitating compliance, 

and the use of manuals can assure a clear understanding between 

client and therapist about their respective roles and all aspects of the 

protocol.
54

Improving Compliance With Alcoholism Treatment

Manuals define the theoretical underpinnings of a treatment, the goals 

of a treatment, the strategies the therapist uses to reach those goals, 

and how that treatment is different from other treatments. They also 

articulate a set of guidelines that steer the therapist through the conduct of that treatment. Thus, manuals define behaviors prescribed and 

proscribed for both therapist and clients in the course of a treatment.

Manuals also sharpen distinctions between specific and nonspecific 

aspects of a given therapy. Nonspecific ingredients refer to aspects of 

treatment that are common across most psychotherapies, including 

education, support, attention, a convincing rationale, expectations of 

improvement, the skill of the therapist, and the quality of the therapeutic relationship.109,110

Specific components refer to a treatment’s active ingredients—those 

techniques and interventions that are unique to or characterize particular psychotherapies. Examples of specific ingredients include 

skills training in cognitive-behavioral approaches, transference interpretations in psychoanalytic approaches, eliciting self-motivational 

statements in motivational approaches, and fostering the client’s 

involvement in Alcoholics Anonymous (AA) in 12-step facilitation.

Therapist

Compliance

Therapist compliance can be defined as the degree of adherence to the 

guidelines specified in a treatment manual. Treatment manuals define 

standards by which therapist adherence may be monitored along several dimensions.

■ Structural. The ideal or minimal number, duration, or frequency of 

sessions. Group, individual, or family format. How topics are introduced and processed. How the session flows.

■ Goals and subgoals. Is the treatment goal abstinence or reduced 

drinking? The process by which the client and therapist will reach 

their goals (e.g., skills training, increased insight, involvement 

with self-help). Other target symptom and problems that might be 

addressed by this treatment.

■ Active ingredients. The characteristic or unique aspects of the treatment through which therapeutic effects are expected to occur. The 

process through which these active ingredients are expected to 

affect drinking behavior and other target problems.

■ Treatment boundaries. The range of topics, interventions, or processes that would be expected to define this treatment. Topics, 

interventions, or processes that would be proscribed or discouraged in this treatment.
55

The Use and Development of Treatment Manuals

■ Nonspecific aspects. Nonspecific aspects (e.g., providing education, 

a supportive relationship) that are important to the outcome of this 

treatment. How the therapeutic relationship is to be characterized. 

Aspects this treatment shares with other treatments. How therapists should handle the balance between specific and nonspecific 

elements of therapy. Whether sessions are primarily didactic or collaborative and how structured they are.

Compliance

Versus

Competence

There is an important distinction between adherence/compliance, that 

is, the degree to which the therapist follows the guidelines laid out in 

the therapy manual, and therapist competence, which refers to the 

therapist’s level of skill in delivering that treatment. Adherence and 

competence are not necessarily closely related. A therapist can follow a treatment manual word for word and not deliver that treatment 

competently or skillfully (e.g., with an appropriate level of flexibility 

and understanding of a particular client, using appropriate timing and 

language).

In some cases, extremely high adherence (e.g., a wooden, mechanistic, 

rote repetition of material in the manual) may be indicative of very low 

competence in a therapist. High compliance and low skillfulness may 

also occur when a therapist delivers a technique perfectly but at an 

inappropriate time that is insensitive to the needs of a particular client.

Conversely, cases of high skillfulness and low competence can exist, 

for example, when a therapist empathetically responds to the client 

and provides incisive interpretations at the precise moment they are 

most likely to be helpful, but rarely touches on material described in 

the manual.

Moreover, a therapist’s adherence and competence are not necessarily 

static entities. For example, adherence may vary across time, where 

some therapists may start a treatment with high adherence but drift 

away from following manual guidelines during the course of treatment. 

Similarly, a therapist’s competence may vary across clients, for example, with client difficulty, psychopathology, or the therapist’s liking for 

the client.

Furthermore, competence is not necessarily a generic factor that is uniform across different types of therapies. Instead, competence should be 

conceived and assessed relative to the specific treatment the therapist 

is expected to deliver.111 Although traditional nonspecific aspects of 

therapy (e.g., empathy, warmth, support) have been assumed to be 

universal indicators of therapist skillfulness, these nonspecific indicators may not be accurate nor even adequate proxies for skillfulness in 

all therapies. For example, empathy and warmth may be important 
56

Improving Compliance With Alcoholism Treatment

indices of competence in some therapies (e.g., Rogerian) but may be 

superfluous to others. Therefore, manual developers should lay out 

guidelines for determining competence that are specific to their type of 

therapy.

Linkage of 

Client and 

Therapist 

Compliance

Therapist adherence and client compliance are inextricably linked. A 

client cannot be expected to comply with a given suggestion or intervention unless the therapist complies with the treatment manual 

by delivering that intervention. Several dimensions of client compliance are linked with treatment integrity and therapist adherence. For 

example, whether clients comply with an intervention depends entirely 

on whether the therapist asks them to do it and to a large extent on 

whether or not the therapist specifies exactly what the assignment or 

suggestion would entail, asks the clients if they would comply, makes 

clear how complying with the intervention or suggestion might be helpful, works through possible obstacles and resistances, and follows 

through by asking the clients whether they did comply.

This implies that complete assessment of client compliance entails a 

several-step process that emphasizes linkage of client and therapist 

compliance. First, did the therapist prescribe the client behavior (e.g., 

ask the client to go to a 12-step meeting, ask the client to record his 

cravings for alcohol during the next week)? Second, did the therapist 

prescribe the client behavior adequately and competently (e.g., did the 

therapist provide a rationale for 12-step meetings or self-monitoring, 

discuss the steps that would be necessary to locate, select, and go 

to a meeting or do the self-monitoring, ask the client whether s/he 

was likely to comply with the prescription, was the prescription appropriately timed for that particular client). Finally, did the client follow 

through on the prescription? Thus, assessment of client compliance 

for some aspects of treatment would be predicated on assessment of 

therapist adherence.

This also suggests that an important strategy to foster client compliance would be clearly specified expectations for client compliance 

(e.g., number of sessions, policy around missed or canceled sessions, 

extra-treatment assignments, in-session behavior). Strategies and 

techniques to address client noncompliance are important as well.

Manual 

Content

While the specific content of a manual will vary with each treatment 

and with each population, a number of generic features are common to 

most manuals. Table 3.1 provides a checklist for domains that should 

be considered in developing a new treatment or describing a standard 

one. Not all of them will apply to a given manual, but they should all 

be considered when attempting to thoroughly define a treatment. The 

more comprehensive and specific the manual, the easier it will be for 
57

The Use and Development of Treatment Manuals

Table 3.1. Treatment manual checklist

 Overview, description and rationale 

— General description of approach

— Background and rationale for treatment

— Theoretical mechanism of action (what makes this treatment work?)

— Empirical evidence supporting the effectiveness of this approach

— How is the treatment described to the client?

 Conception of alcohol abuse/dependence 

— Etiological factors

— Factors associated with cessation of use

— Agent of change (e.g., client, therapist, group affiliation)

— What is the conceptual framework around which cases are formulated and understood?

— How are alcohol use and associated problem assessed by the therapist?

 Goals and goal-setting

— Overall treatment goal (abstinence, harm reduction)

— Evaluating client goals

— Identification of other target behaviors and goals

— Negotiation of changes in therapeutic goals and contracts negotiated?

 Contrast to other treatments for alcohol and related disorders

— Approaches which are most similar to this approach

• How does this approach differ from similar approaches?

— Approaches most dissimilar to this approach

 Specification of active ingredients, therapist behaviors prescribed and proscribed

— What are the specific active ingredients that are unique and essential to this treatment?

— What interventions are essential to this treatment but not unique?

— What interventions or processes are recommended but not essential or unique?

— What interventions or processes are prohibited or not characteristic of this treatment?

— What interventions may be harmful or countertherapeutic in the context of this treatment?

 Client-counselor relationship

— What is the ideal therapist role in this treatment (educator, collaborator, teacher, peer, adviser)

— How important is the therapeutic relationship to the outcome of the treatment? 

— Strategies the therapist uses to develop desired relationship

— Strategies the therapist uses to address poor or weak therapeutic relationship

 Format

— Variations for individual, group, family, other formats

— Variations for different settings: inpatient, outpatient, residential, aftercare, other 

— Recommended frequency and duration of sessions

— Variations for closed and open-ended formats
58

Improving Compliance With Alcoholism Treatment

Table 3.1. Treatment manual checklist (continued)

 Session format and content

— What is the format of a ’typical’ session?

— How does the session begin and end?

— Are there a series of topics or themes to be covered?

— Are there required versus elective sessions?

— How are session topics or sequences selected?

— How structured are the sessions? Is level of structure important to outcome?

• Who talks more?

• How directive is the therapist?

• Is an explicit agenda set? How is the agenda set?

— Is the client given extra-session tasks?

• What is the purpose of these tasks?

• How are assignments selected?

• How are assignments given to the client?

• How does the therapist respond to the client’s completion of an assignment? How is it integrated into the work of therapy?

• How does the therapist respond to the client’s failure to complete an assignment?

— Session by session content (e.g., Session 1):

• How does the therapist introduce him/herself?

• What information does the therapist collect about the client? What does s/he especially listen 

or probe for?

• How is the disorder (usually alcohol abuse or dependence) characterized to the patient?

• How are treatment goals negotiated?

• How is the treatment strategy introduced to the client?

• Do the therapist and client agree on a treatment contract? What does it consist of (e.g., number and type of sessions, policy about canceling and lateness, extra-treatment phone calls)?

• What, if any, extra-session tasks are assigned? What rationale does the therapist provide 

about extra-session tasks?

— Troubleshooting: What problems are usually encountered in the first session? What are some 

methods the therapist might use to avoid or address these problems in a manner consistent with 

the general theory of this treatment?

— Session 2 – Session N

• How does the therapist greet the client?

• How does the therapist assess substance use since the last session?

• How does the therapist review completion of any extra-session assignment?

• What is the second session topic and goals? How is it selected? How is it introduced?

- How is it introduced in the context of the client’s current concerns and problems?

- What are the key ideas to be introduced in the second session?
59

The Use and Development of Treatment Manuals

Table 3.1. Treatment manual checklist (continued)

— Managing transitions

• How does the therapist determine the client’s readiness to move on to a new stage of 

therapy?

• How does the therapist judge the core issues to be covered in the treatment?

• How does the therapist decide whether to work through or repeat old material or move on?

• How does the therapist determine the client’s readiness for termination? How is termination 

introduced and discussed?

• How does the therapist time key interventions or activities to maximize their usefulness to 

the client?

 Compatibility with adjunctive treatments (e.g., pharmacotherapy, family therapy) 

— How are adjunctive treatments integrated and monitored?

— Role of AA and other self-help groups

 Clinical care standards

— How does the therapist assess substance use that may have occurred since the last session?

— How does the therapist assess treatment progress?

— How does the therapist respond to lack of progress or clinical deterioration?

— How does the therapist assess and respond to expressions or hints of suicidal or homicidal 

ideation?

— How does the therapist respond to a contradiction between a client’s self-report of alcohol use 

and a collateral source?

 Troubleshooting: Strategies for dealing with common clinical problems

— Therapist response to lateness

— Therapist response to missed sessions 

— Strategies for dealing with low motivation 

— Strategies for dealing with recurrent crises 

— Therapist’s response to slips and relapses

— Therapist’s response to clients who come to sessions while intoxicated

— Strategies for clients who appear to understand but don’t follow through on agreed upon 

suggestions

— Strategies when the client’s significant others convey disagreement with goals of therapy or 

interfere in the client’s progress.

 Target population

— Characteristics of individuals who are well-suited for this approach 

— Characteristics of individuals who might be poorly suited for this approach
60

Improving Compliance With Alcoholism Treatment

Table 3.1. Treatment manual checklist (continued)

 Meeting the needs of special populations. Suggested variations in the treatment for clients who 

have the following common comorbid problems 

— Depression

— Anxiety and posttraumatic stress disorders

— Antisocial personality disorder

— Concurrent drug use

— Psychotic disorders

— Cognitive impairment

— Medical problems

— Unstable living situations

 Therapist characteristics and requirements

— Training, credentials, and experience required 

— Therapist recovery status (essential, helpful, irrelevant) 

— Ideal personal characteristics of counselor

 Therapist training

— Components and goals of training, training materials available 

— Training cases required

— Common problems encountered in training

— Standards for determination of therapist competence 

— Availability of ratings and assessments of therapist competence

 Supervision

— Recommendations of type (group, individual) and intensity of supervision

— Common problems involved in training novice therapists to use this approach 

— Common problems involved in training more experienced therapists to use this approach

— Strategies to address therapist drift in treatment delivery

— Strategies to help therapists balance adherence and competence 

— Strategies for supervision sessions; use of videotapes and rating systems

therapists to follow and the less likely a therapist will deviate from the 

intentions of the program when faced with a clinical situation or problem not specified in the manual.

Treatment 

Definition

■ Overview and theoretical rationale. The background or rationale for 

the treatment, how it works, how and when the therapist explains 

the treatment to the client. Include empirical evidence that supports the effectiveness of the treatment with the given population.

■ Conception of the disorder. How the treatment conceives the etiology 

of alcohol use disorders, the essential steps or processes needed to 

reduce alcohol use and alcohol-related problems, and the agent 

of change for this treatment—the client, the therapist, particular 

treatment processes, group affiliation?
61

The Use and Development of Treatment Manuals

■ Goal setting. Whether the treatment is abstinence oriented or 

focuses on the reduction of alcohol use and how this is introduced 

to the client. How the therapist should respond to a client who 

does not share the treatment goal; how goals relating to other target behaviors and problems (e.g., psychopathology, marital discord) 

are defined; and how treatment goals are determined, monitored, 

and renegotiated as well as how important transitions in the treatment are negotiated.

■ Differentiation from other treatments. Other types of treatment that 

are most similar and those that are most dissimilar to this treatment. Exactly how this treatment differs from similar treatments 

for this disorder. See table 3.2 for a sample chart that highlights 

differences between the treatments used in Project MATCH.

■ Therapist behaviors prescribed and proscribed. Specific ingredients 

that are unique to or characterize this treatment. Interventions 

or processes required to be delivered to each client. Interventions 

or processes that are recommended but not unique. Proscribed 

interventions or processes. Interventions that might be countertherapeutic to deliver in the context of this treatment. Are there 

interventions that might have a negative effect on some clients?

■ Client-therapist relationship. Therapist’s role, client’s role, optimal 

client-therapist relationship. Importance of relationship issues relative to other aspects of the therapy and to the outcome of the 

therapy. Strategies a therapist might use to develop the desired 

relationship and to address poor or weak therapeutic relationships.

■ Treatment format. How the treatment is delivered (individual, group, 

self-guided, family). The recommended length and frequency of sessions, the recommended duration of treatment, and variations of 

the treatment that would be required for different settings (inpatient, outpatient) or formats (group versus individual).

■ Session format and content. How typical sessions begin and end, 

whether a series of topics are to be covered, and how the therapist 

determines what issues are to be covered in each session. Whether 

the treatment involves a set of required topics to be delivered and 

if there are elective topics or sessions. The specific goals or aims of 

each topic. How the therapist decides which elective sessions are 

to be delivered to the client. Whether sessions are structured. If 

clients are given extra-session tasks, how these are introduced and 

monitored.

■ Adjunctive treatments. Compatibility with other treatments, such 

as family therapy or pharmacotherapy. How these are integrated 

Treatment 

Implementation
62

Improving Compliance With Alcoholism Treatment

Table 3.2 Contrasts between Project MATCH therapies

Twelve-Step Facilitation Cognitive-Behavioral Motivational Therapy

Goals of treatment Encourage person to accept his/her 

alcoholism and understand it as a 

progressive fatal disease.

Facilitate integration into AA.

Help person master coping behaviors as 

effective alternatives to alcohol use.

Increase self-efficacy. 

Maximize the person’s motivation and 

commitment to change his/her drinking.

Therapy approach Disease oriented. Cognitive-behavioral. Motivational.

Agent of change Treatment 

Fellowship/Higher Power

Treatment 

Mastery of skills

Patient

Labeling Labeling the patient as "alcoholic" is 

encouraged, as this label provides the 

framework for treatment. Acceptance 

of the diagnosis is necessary; it 

determines a set of symptoms (e.g., 

lack of control, denial) and the steps 

required for recovery.

Labeling discouraged; alcohol abuse/ 

dependence is conceived as overlearned behavior that can be broken 

down into a finite set of discrete problem 

situations and behaviors.

Labeling is strongly discouraged. 

Alternative conceptions of alcoholrelated problems are accepted and 

encouraged.

Control Emphasis on loss of control. The 

patient cannot control drinking, has the 

disease of alcoholism and is powerless 

to control. Patients can control whether 

they have the next drink, use AA or 

accept the idea that drinking can be 

controlled.

Emphasis on self-control. Patients make 

decisions regarding drinking over which 

they have control. Patient can learn 

to understand and better control the 

decisionmaking process. Patient can 

exert self-control by choosing alternative 

behaviors and cognitions.

Emphasis on choice. Patient has 

full control over the decision to alter 

drinking.

Responsibility Patient is not responsible for disease 

of alcoholism but is responsible for 

own sobriety, by "working" the 12-step 

program.

Patient responsible for own behavior. 

Emphasis on enhancing self-efficacy 

through skills training.

Patient responsible for own choices. 

Emphasis on autonomy.

Conception of 

craving

Because of disease process, patient’s 

body will crave alcohol periodically. First 

drink will trigger craving: "one drink, a 

drunk."

Craving as conditioned response. 

Craving can be coped with and reduced 

through stimulus control, urge control, 

etc.

Patient free and capable of developing 

strategies for dealing with craving on 

his/her own.

Strategies for 

addressing 

ambivalence and 

motivation

Remember last drunk. Alcoholism is a 

disease that motivates denial; educate 

patient about "sinister" aspects of the 

disease. Current problems attributed to 

disease.

Positive/negative consequences of 

decisions to drink or stay abstinent. 

Instill belief that effective coping will 

provide alternatives to drinking.

Acknowledge validity of patient’s 

feelings; elicit self-motivational 

statements. Provide feedback. Empathic 

listening, primacy of patient’s choice. 

Deploy discrepancy.

Therapist’s 

response to alcohol 

use

External, uniform approach. Use AA 

social network (call sponsor, go to 

meeting). Remember and use slogans.

Individualized approach. Examine 

antecedents, behaviors and 

consequences. Develop and use 

individualized set of coping strategies 

(challenge cognitions, problem-solve, 

etc.)

Internal, individualized approach. 

Review progress, review/evaluate initial 

plan, renew motivation and commitment. 

Reevaluate decision and plan based on 

new information gained from drinking.

"Do not think you can control the 

consequences of use."

"You can learn skills to avoid lapses 

and prevent lapses from becoming 

relapses."

"It’s up to you whether you drink or not."

Coping behaviors AA fellowship/network constitute a 

ready-made set of strategies and the 

one preferred solution.

Individualized set of strategies, 

generalizable problem-solving 

approach. Specific training in drink 

refusal skills, urge control, altering 

cognitions, emergency planning, social 

skills, affect management, job seeking 

skills, etc.

Patient free to develop own coping 

strategies. Development of strategies 

encouraged, but these are not provided

by the therapist. Encourage to use 

personally effective coping strategies.

Negative cognitions Generally interpreted as evidence of 

rationalization and denial (e.g., "stinking 

thinking").

Identified, examined and challenged; 

encourage alternative perceptions/

cognitions.

Accepted as valid; met with exploration, 

reflection and feedback.

Phone calls/crises Refer patient to AA/sponsor. "Use the 

fellowship."

Encourage patient to implement coping 

strategies.

Meeting patient’s concerns with 

reflection and elicitation of client’s plan 

of action.

Two permissible emergency sessions. Two permissible emergency sessions. Two permissible emergency sessions.

Source: Donovan et al. 1994.121 Reprinted with permission from Journal of Studies on Alcohol, Supplement No. 12, pp. 138–148, 1994. Copyright by Alcohol 

Research Documentation, Inc., Rutgers Center of Alcohol Studies, Piscataway, NJ 08855.
63

The Use and Development of Treatment Manuals

into the treatment and monitored. The role of AA or other self-help 

groups.

■ Clinical care standards. How, and how often, alcohol and other 

substance use is monitored (e.g., breathalyzers, urine toxicology 

screens). How contradictions between client self-reports and collateral sources are discussed with the client. How the therapist 

responds to a client who is suicidal or homicidal. How the therapist 

determines the need to refer the client to a more intensive level of 

care.

■ Troubleshooting. How the therapist should respond to common 

clinical problems that arise in the course of alcoholism treatment, 

e.g., missed sessions, lateness, frequent crises, coming to sessions 

while intoxicated, other forms of noncompliance. Whether these 

strategies are largely generic or specific to the type of treatment 

being delivered.

■ Variations for special populations. How the treatment is adapted 

to meet the needs of client types typically encountered in alcohol 

treatment settings. Variations or changes necessary for clients who 

may be depressed, antisocial, anxious, cognitively impaired or have 

posttraumatic stress disorder, few social resources, and so on. 

Particular client types or characteristics for which this treatment 

is ill-suited. Limits on the flexibility therapists may use in tailoring 

the treatment to meet individual client needs.

Therapist 

Training and 

Supervision

■ Therapist characteristics and training. Any training or education required for therapists to conduct this treatment effectively. 

Procedures used to train therapists to conduct this treatment. 

Available training materials (e.g., trainers manuals, videotaped 

examples). Standards that must be met before a therapist is certified to deliver this treatment.

■ Therapist competence. What determines how well the therapist 

performs the treatment. The characteristics that would describe 

a therapist performing this treatment optimally and how this is 

assessed. The characteristics that would identify a therapist performing this treatment poorly. Relevance of generic therapist skills 

(e.g., empathy, spontaneity, warmth) to the conduct and outcome 

of this treatment. Any assessment instruments available for evaluating therapist adherence and competence.

■ Supervision. Training or education required for supervisors. Level 

and intensity of supervision recommended or required for therapists 

delivering this approach. Important aspects of treatment delivery 

for supervisors to monitor. Any aspects of treatment delivery or 
64

Improving Compliance With Alcoholism Treatment

competence that are particularly difficult for novice therapists to 

master. Common mistakes made by more experienced therapists, 

and some strategies a supervisor would use to address therapist 

drift in adherence.

Manual Style An important general strategy to enhance therapist compliance and 

adherence with therapy guidelines is to make it easy for therapists to 

understand and thus to follow the manual. Because a manual is more 

or less a set of instructions for undertaking a highly complex task, the 

clearer, more specific, and detailed those instructions, the more likely 

the treatment as practiced will reflect the manual writer’s intentions 

and the greater consistency across therapists (see table 3.3).

Table 3.3. Therapist-friendly manuals

 Anticipate common clinical problems

 Anticipate client heterogeneity

 Provide troubleshooting guidelines

 Cover process as well as technique

 Build in flexibility and clarity

 Include summaries and outlines

 Provide guidance around therapeutic choice points

Anticipate 

Real-World 

Problems

Manuals should anticipate that some clients will be poorly motivated, 

ambivalent, psychiatrically unstable, inarticulate, cognitively impaired, 

involved in abusive relationships (or all of the above) and should provide 

explicit guidance for addressing these issues. Similarly, if a treatment 

is contraindicated for a particular client type, the manual should say 

so explicitly.107 This is particularly important when a manual might be 

used by novice or inexperienced therapists.

Manuals are often written around the ideal client, but there are few 

ideal clients in actual clinical practice. Manuals geared only to such 

clients are likely to have limited usefulness to therapists. Moreover, 

while therapist adherence is likely to be high with easy clients, adherence is less likely with more impaired or difficult clients. Therapists 

may be most likely to drift from manual guidelines with more difficult 

clients, as they struggle to address complex clinical issues.
65

The Use and Development of Treatment Manuals

Include 

Troubleshooting 

Guidelines

Just as there are few ideal clients, few treatments proceed without 

some snags and difficulties along the way. Therapists are most likely 

to deviate from manual guidelines and borrow from other approaches 

when they encounter such clinical problems. Therapist-friendly manuals anticipate and provide guidance for handling common clinical 

problems encountered in alcohol treatment in a manner consistent 

with the theoretical background of the treatment.

Issues where specific guidelines are most likely to be helpful include:

■ Lateness to sessions

■ Missed sessions

■ Clients who come to sessions while intoxicated

■ Clients whose lives are so consumed by alcohol-related crises that 

they cannot settle down to do the work of therapy

■ Clients with little or no intention of stopping substance use

■ Client’s whose self-reports of substance use do not match those of 

collateral sources

■ Spouses or significant others who are substance abusers

■ Clients who say their sponsors told them not to be compliant with 

treatment

Manuals should also provide some guidance to the therapist in determining when these problems have eclipsed the benefits the treatment 

might provide, that is, when it is time to refer the client to another type 

or more intensive form of treatment.

Cover the Basics Point out that adherence to the manual should be balanced with clinical 

judgment. Therapists are frequently anxious about their performance 

when working with a manual. Although this anxiety usually abates 

during training and as they become more confident in the treatment 

and their own experience, the manual itself can attempt to directly 

confront this apprehension.

No supervisor would encourage a therapist to plunge ahead with difficult therapeutic tasks without first establishing rapport, formulating 

the case, agreeing on treatment goals, and building a working alliance. 
66

Improving Compliance With Alcoholism Treatment

However, few manuals explicitly point out the importance of these more 

fundamental tasks of treatment as a prerequisite for moving ahead 

to other, treatment-specific tasks. The central importance of clinical 

competence and nonspecific elements of therapy should not be ignored 

when developing treatment manuals.

Thus, a therapist-friendly manual should:

■ Stress and articulate definitions of therapist competence (as well as 

adherence) in the conduct of the specific treatment

■ Specify the role of nonspecific aspects of treatment and how they 

are to be balanced with treatment-specific techniques

■ Define the fundamental requirements and indicators of progress that must be present before each new stage or technique is 

undertaken

■ Discuss techniques that therapists might use to address problems in nonspecific aspects of therapy, particularly the therapeutic 

alliance.

Required 

Versus Optional 

Elements

Manuals should have built-in flexibility rather than giving the impression that all interventions are created equal and that they should be 

delivered frequently or in all sessions. Treatment developers usually 

expect some interventions to be present in all sessions and some in 

only selected sessions, as appropriate. Thus, therapist adherence may 

be facilitated to the degree that there is clarity regarding the essential, 

key, active ingredients of the therapy that must be delivered and those 

that are optional or indicated only for specific clients or in particular 

circumstances.

Specification of which interventions fall into the following categories 

will make the treatment developers’ intentions clearer to the therapists 

and thus easier to follow:

■ Interventions, behaviors, or processes that are unique and essential to that treatment

■ Interventions, behaviors, or processes that are essential to the 

treatment but not unique to it

■ Interventions, behaviors, or processes that are acceptable within 

the therapy but are not essential or unique

■ Interventions, behaviors, or processes that are proscribed.111
67

The Use and Development of Treatment Manuals

Tailor the 

Treatment

Specifying the strategies by which the therapist can tailor the treatment 

to meet the needs of specific clients is important. Examples include 

the distinction between core versus elective sessions in the Cognitive 

Behavioral Therapy (CBT) and Twelve-Step Facilitation (TSF) treatments in Project MATCH, and the four problem types of Interpersonal 

Psychotherapy (IPT).112

Manuals should also make clear the range of interventions and therapist styles that are acceptable practice within the confines of the 

treatment and which interventions or behaviors are proscribed in the 

therapy. If a commonly used therapeutic intervention is proscribed, 

then the manual should suggest an alternate intervention.

A clear statement regarding possible negative effects or countertherapeutic interventions is likely to enhance the helpfulness of a manual 

to therapists.107 In other words, clarity about what not to do or what 

might actually hurt the client is a key aspect of treatment definition 

and is particularly important if a treatment is to be taught to relatively 

novice therapists.

Summaries and 

Outlines

Therapists may find it helpful to refer to brief session summaries or 

outlines to remind them of a few key points to be conveyed. This may 

be particularly useful in treatments with a more didactic focus, where 

a number of points are to be covered in a single session. An example of 

a therapist reminder sheet used in Project MATCH is given in table 3.4. 

Similarly, treatment outlines to which therapists may refer just before 

a session may be extremely helpful in cuing them to key elements to 

convey during the session.

Decision Points Therapists conducting manual-guided treatments are often faced with a 

wide array of possible interventions and strategies, with comparatively 

little guidance about which intervention to select at different phases 

of treatment. Manuals should define important transition points in 

therapy (e.g., early to late abstinence, focus solely on alcohol to greater 

focus on psychiatric symptoms, when to focus on termination-related 

issues) and provide clear guidance to therapists about moving through 

them. Decision trees for determining a client’s stage in treatment and 

readiness to move on may also be helpful and may minimize excessive 

drift at these decision points in clinical practice.

Providing rules of thumb or general strategies the therapist can use to 

organize complex treatments and maintain appropriate treatment goals 

is likely to enhance the usefulness of a manual. An excellent example 

of this approach is the use of the Core Conflictual Relationship Theme 

method113 to focus dynamically oriented therapies.
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Improving Compliance With Alcoholism Treatment

Table 3.4. Twelve-step facilitation checklist

Form ____/____

CRU ____/____

Client ID ____/____/____/____

Therapist ID ____/____/____/____

Date____/____/____/____/____/___

Treatment week (1-12) ____/____

Session number ____/____

PLEASE COMPLETE THE FOLLOWING BASED ON THIS SESSION WITH THE CLIENT— Do not 

complete if this was an emergency session or if the session was truncated due to client intoxication.

1. Was this a core or elective session? 

1=Core 2 = Elective

2. What session topic was covered this week? 

1 = Introduction 8 = HALT

2 = Step 1 / Acceptance 9 = Steps 4 & 5 / Moral Inventory

3 = Steps 2 & 3 / Surrender 10 = Sober Living

4 = Getting Active 11 = Conjoint Session 1/Enabling

5 = Genogram 12 = Conjoint Session 2/Detaching

6 = Enabling 13 = Termination

7 = People, Places, Things

Approximately how many minutes of this session were devoted primarily to discussion of the manual session topic 

for this week? ____ ____ minutes

3. Did you check completion of last sessions’s recovery tasks?

1=No 2=Yes 9=N/A none assigned last session

4. How many AA meetings (any type) did the client attend since the last session? ____ ____

5. Did the client make journal entries since the last session? 1=No 2=Yes 9=N/A

6. Did the client read assigned AA literature since the last session? 1=No 2=Yes 9=N/A

If so, from what source(s)?

1=Big Book 2=12/12 3=Living Sober 4=Other:_________________________________

7. To what extent did you review the client’s REACTIONS TO LAST SESSION’S RECOVERY TASKS (e.g., 

12 Step meetings, assigned readings, obtaining a sponsor, using the telephone to contact AA peers, written 

assignments)? 

1 2 3 4 5

 Not at all a little somewhat considerably extensively

8. Did you ASSIGN A RECOVERY TASK for next week?

1=No 2=Yes. Please describe.______________________________________________________
69

The Use and Development of Treatment Manuals

Table 3.4. Twelve-step facilitation checklist (continued)

9. To what extent did you discuss the client’s acceptance of his/her disease, its implications, or its symptoms or 

discuss the DISEASE CONCEPT OF ALCOHOLISM?

 1 2 3 4 5

 Not at all a little somewhat considerably extensively

10. To what extent did you explore the client’s DENIAL/resistance (e.g., avoiding meetings, minimizing negative 

consequences), OR discuss the client’s resistance to following 12 Step recovery in terms of his/her denial OR 

discuss the client’s need to surrender?

 1 2 3 4 5

 Not at all a little somewhat considerably extensively

11. To what extent did you encourage the client to BECOME ACTIVE (e.g., 12 Step meeting attendance, getting a 

sponsor) OR plan specific AA-related activities for the week (e.g., speaking or helping at a particular meeting, 

use of the telephone) OR encourage the client to use AA involvement as a means of coping?

 1 2 3 4 5

 Not at all a little somewhat considerably extensively

12. To what extent did you explicitly refer to 12 STEP RECOVERY OR interpret or explain a particular step to the 

client OR invoke a particular step concept during the session OR discuss the client’s progress through the 

steps? 

 1 2 3 4 5

 Not at all a little somewhat considerably extensively

13. To what extent did you explicitly invoke the concept of SPIRITUALITY or a HIGHER POWER as a source of 

strength, hope, and guidance in the client’s working a recovery program (e.g., invoking the Serenity Prayer, 

reference to Steps 2 or 3)?

 1 2 3 4 5

 Not at all a little somewhat considerably extensively

14. To what extent did you ASSESS THE CLIENT’S DRINKING since the last session?

 1 2 3 4 5

 Not at all a little somewhat considerably extensively

15. To what extent did you discuss or address the client’s current COMMITMENT TO ABSTINENCE?

 1 2 3 4 5

 Not at all a little somewhat considerably extensively

16. To what extent did you discuss, review, or reformulate the client’s GOALS FOR TREATMENT?

 1 2 3 4 5

 Not at all a little somewhat considerably extensively
70

Improving Compliance With Alcoholism Treatment

Criticism of 

Manuals

As influential as treatment manuals have been to both research and 

clinical practice, they have also been subject to a number of criticisms. 

Those which are relevant to issues of therapist adherence and compliance are summarized briefly below, while broader issues have been 

reviewed elsewhere.114 These are included here to heighten awareness 

of individuals interested in developing treatment manuals to their common pitfalls and problems and to encourage attempts to address these 

limitations.

Form Versus 

Substance

A frequent, and important, criticism of psychotherapy manuals is 

that they emphasize the form rather than the substance of therapeutic competence.114–116 That is, manuals emphasize specific techniques 

over competent delivery of those techniques in the context of a positive therapeutic relationship. Part of this view of manuals arises from 

the recency of manuals as a methodological development in psychotherapy research. Most of the pioneering manuals written in the 1980s 

were developed for use in large-scale psychotherapy research studies, 

which used experienced and closely supervised therapists. Thus, these 

manuals were designed not to teach basic psychotherapy process skills 

to novice therapists, but to efficiently convey the specific techniques 

to be integrated into the repertoire of seasoned clinicians as a means 

of reducing variability in the treatment variable. However, the more 

recent proliferation of manuals into clinical practice and their more 

widespread use in the training of therapists107,117–119 has led to a greater 

emphasis on the need to address more fundamental therapist skills in 

the training process. While there is emerging consensus that adherence can be enhanced through the use of manuals, whether manuals 

can teach competence is much less clear. For example, a recent study 

found that although manual-guided training did enhance therapist 

adherence, it may have led to unanticipated and potentially negative 

changes in other aspects of therapist interpersonal behavior.120

Thus, rather than a complete repudiation of manuals, this criticism 

should drive home the point that manuals are merely a tool. Manuals 

were not intended to be substitutes for training and supervision of 

therapists, nor are they in and of themselves sufficient to train therapists. This highlights that manuals should be used as adjuncts to, 

but not substitutes for, careful, thorough training and supervision of 

therapists as well as careful therapist selection. Thus, it is strongly 

urged that manuals include a section on recommended procedures 

for training and supervising therapists to use the approach, as well 

as specification of basic educational and experience requirements for 

therapists.

Mechanization 

of Therapy

As discussed above, manualization of a treatment involves defining, 

specifying, and distinguishing it from other treatments. Thus, a frequent criticism is that manuals emphasize the codification of often 
71

The Use and Development of Treatment Manuals

artificial differences between treatments at the price of nonspecific 

beneficial aspects of therapy, such as spontaneity and flexibility. In 

other words, the aspects of psychotherapy that are more “art” than 

“science” are frequently omitted or underemphasized in the process 

of manualization, which can render manualized treatments as rigid, 

mechanistic “cookbooks” devoid of reference to important therapeutic 

processes. Moreover, some of the complex processes of therapy may 

not be adequately captured in manualized form, and therapies that are 

less prescriptive or behavioral lend themselves less well to specification 

in manuals.104

In practice, rigidity in manuals is often offset by an emphasis on flexibility and competence in training and supervision. However, manual 

developers might do well to try to take on the task of building greater 

flexibility and sophistication into manuals, for example by including 

detailed case examples, stressing the importance of therapist responsiveness at key therapeutic choice points, and developing videotaped 

training aids that illustrate therapists exhibiting effective therapeutic 

versatility while adhering to manual guidelines.

Update Often It is very useful to develop second-generation manuals that incorporate 

the clinical wisdom that is accumulated gradually by conducting and 

supervising therapy in clinical practice but is rarely articulated and 

reflected in manuals. Psychotherapy manuals, particularly those used 

in clinical trials, are often constructed quite quickly, often in the first 

few months of a trial. Thus, they do not reflect the clinical sophistication and richness that is gained during the course of the study, as the 

treatment is implemented with a wide variety of clients and as omissions in the original manual are identified and filled in.

Supervisors, therapists, and other involved personnel should keep 

notes that can be used to broaden and enrich subsequent versions 

of the treatment manual. It should be considered a work in progress 

rather than a finished product.

73

A Case Study in Clinical Supervision: 

Experience From Project MATCH

Georgann Witte, Ph.D.

Connecticut Psychological Group 

Hamden, Connecticut

Charles H. Wilber, M.Ed. 

Program Manager

Addiction Recovery Service 

The Institute of Living

Hartford, Connecticut

This chapter describes the rationale, practice, and outcome of the 

supervision in Project MATCH, where compliance was a critical component of the research design. The primary and most important aim 

of the supervision was to ensure the delivery of high-quality, effective 

treatment services in a professional and ethical manner to all clients. 

Maintaining the consistency of treatment obviously is vital to making 

sense of outcomes in psychotherapy research: poor therapist compliance to the treatments being assessed is a major factor contributing 

to inconclusive results in large clinical trials. Thus, a second primary 

goal of the supervision was to assure the homogeneity of treatment 

across time, across settings, and across therapists: to make certain 

that a given treatment replicated, as closely as possible, the treatments 

detailed in the manuals, and that it did so for the duration of the 

research project.

Levels of 

Supervision

Prior to starting the treatment phase of the research, two levels of 

supervision were established. Responsibility for on-site clinical and 

administrative overview was delegated to the site directors, who were 

responsible for daily details of the project. Typically, site supervisors met weekly for supervision with therapists and were available as 

needed for urgent clinical and procedural questions.
74

Improving Compliance With Alcoholism Treatment

Each therapist also had a central supervisor, not based at the local 

site. Having a central supervision team in addition to the site supervisors was a component of the project explicitly designed to ensure 

compliance with the treatment manuals across sites, and to prevent 

“drift” either within a site or across sites over time.

This goal was accomplished through several procedural and structural 

details. Each central supervisor was responsible for only one treatment type, for example, cognitive-behavioral therapy, but was assigned 

a number of therapists to supervise, from more than one site. Thus, 

any divergence of practice for that treatment, from either a particular 

therapist or site, would be immediately evident.

The central supervisors themselves met regularly as a group to discuss 

common themes or problems emerging in the individual supervision 

and worked as a team to standardize supervision for the project as 

a whole. This had the aim of reducing variability in the advice given 

to therapists, within and across treatment components, and ensuring 

consistent supervision across all sites for the duration of the project. 

Whenever a project has a central supervision group, that team should 

meet regularly to discuss problems in the overall study.

Pilot Phase 

Therapist 

Training

Following training, each clinician was assigned at least two training cases and treated these cases following the manuals, under close 

supervision. During this pilot phase, supervision from both the local 

site and central supervision team was conducted weekly. Every session 

was videotaped and reviewed to ensure detailed coverage of techniques 

and the structure of the entire sequence of each protocol. After two 

cases were completed to the satisfaction of the site and central supervisors, the clinician could be certified as a study therapist. A small 

number of clinicians is expected to decline participation at this stage, 

due to the constraints of manual-guided therapy and the demands of 

close supervision.

Main Study 

Supervision 

Procedures

During the main phase of treatment, individual telephone supervision 

was conducted every other week between the central supervisors and 

therapists about specific sessions and general clinical issues related 

to each case. Procedurally, the centralized supervision involved having 

the site therapists videotape every session with every client. Of interest 

to the supervision was the requirement that the camera be directed at 

the therapist, not at the client. This allowed supervision of the nonverbal aspects of treatment and helped maintain client confidentiality.

Once a given session was recorded, a tape was sent to the central supervision site. The central supervisor viewed approximately one-quarter of 
75

A Case Study in Clinical Supervision: Experience From Project MATCH

the sessions, taking a sample from the beginning, middle, and end of 

therapy. The supervisor also rated each tape using several scales—one 

to assess specific techniques in each treatment manual and others to 

rate general therapist skillfulness and therapeutic alliance.

These ratings gave the supervisors specific behaviors and techniques 

that therapists would be expected to demonstrate over the course of 

treatment sessions, and provided a ground for discussion of technique 

in supervision, in addition to the manuals. The central team supervisors discussed these ratings frequently to assure consistency in ratings 

across supervisors and treatment conditions.

A formal reliability check midway through a study in which supervisors rate a sample of tapes from different treatment conditions is 

recommended to establish levels of interrater reliability and ensure 

that the ratings are applied similarly across therapists and treatments.

Telephone supervision, based at a central site, entailed benefits to the 

project, some not immediately apparent at the outset. At a basic level, it 

afforded the therapists a private discussion focused entirely and purely 

on therapeutic issues: the central supervisors were unconnected with 

the local questions of hiring, administration, and evaluation at the sites. 

This gave the therapists scope to engage freely with the supervisors on 

clinical questions, with license to admit and correct mistakes, without fear of the effects on performance evaluation. However, giving site 

supervisors some feedback about the performance of site therapists, 

whether in the form of a summary of objective ratings or informally, 

appears necessary to redirect local supervision or review training.

In addition to individual supervision, sites were also given periodic 

group supervision for each treatment condition, usually via a conference call, on a monthly basis. The purpose of these exchanges was to 

discuss compliance or treatment issues that had risen for the site in 

general, and to review the objective feedback provided to the sites by 

the central supervisors.

Site supervisors participated in the group supervision for each treatment condition, to ensure that important issues were clearly understood 

between the local and central teams, thus easing potential frictions or 

miscommunications. For example, supervisors did not initially have 

an explicit policy for managing clinical deterioration (defined as a client needing a high or more intensive level of care, whether urgently or 

subacutely). Group supervision provided a forum for free discussion of 

this problem in a way that addressed the needs and concerns of the clinicians, the research needs of the site supervisors, and the compliance 

issues of the central supervision team, leading to an explicit policy that 

had the support of all involved.
76

Improving Compliance With Alcoholism Treatment

The general quality of the treatment was monitored over time as well 

as compliance with the manuals. If a therapist’s performance deviated 

either from good levels of competence or adherence to the manual, 

as measured by the central supervisor's ratings, for more than two 

sessions, that clinician was “redlined” for special attention. These 

therapists received no new clients, and the frequency of supervision 

increased from monthly to weekly until performance again returned 

to a satisfactory level. At times, tapes from other therapists who were 

more successful at a particular treatment were used to supplement the 

training of a redlined therapist. If these measures failed to change a 

therapist’s performance, decertification was used to prevent problems 

for the research or harm to clients.

General Issues

in Supervision

Central supervisors attempted to observe a number of basic principles to ensure the effectiveness of supervision (table 4.1). For example, 

supervisors clearly defined their roles relative to the site directors 

and within the research program. Given the possibility of confusion, 

with two types of supervision, central supervisors strove to maintain 

consistency at basic levels such as regularity of appointments and 

structure of the supervision, as well as in presenting a consistent 

approach to supervision. Supervision was presented as a collaborative 

endeavor, with mutual respect and a positive emphasis on the clinician’s strengths, and competence was highlighted whenever feasible.

Table 4.1. Checklist for effective supervision and enhancing 

therapist compliance in manual-guided therapies

 Define participants’ roles and parameters of supervision.

 Clarify goals of supervision.

 Discuss limits of confidentiality in a research project.

 Clarify the role of measures of therapist performance in treatment 

research.

 Keep supervision concrete and structured.

 Use examples from session videotapes and audiotapes.

 Refer frequently to the manual.

 Provide supervision as soon as possible after sessions are 

conducted, at a consistent time and date.

 Update therapists with newsletters and memos describing 

interesting examples, clarification of materials in manuals, and 

creative strategies for handling clinical problems.

 Provide effective alternate interventions for proscribed techniques.
77

A Case Study in Clinical Supervision: Experience From Project MATCH

A crucial clarification the supervision team addressed early in the project involved the constraints of therapy and supervision in treatment 

research. The limited goal of research supervision—to enhance therapist compliance with the treatment manuals while providing quality 

care—was openly stated, in contrast to more typical aims of supervision, such as preparation for licensure, advanced training, and so 

forth.

As a corollary, the limited parameters of the supervisor relationship 

within the confines of a research study, and for a limited time period, 

were explicitly described as well. The limited role of the therapists 

themselves in conducting time-limited therapy for a circumscribed 

set of problems was another theme constantly reinforced, particularly 

given the natural tendency to expand the scope of treatment for those 

accustomed to open-ended therapy. Together, these reminders tended 

to keep the supervision tightly focused on the treatments and the clients, and reduced digressions.

All supervision shared a commitment, insofar as possible, to provide 

specific behavioral feedback (“use this technique here”). In part, this 

was a reflection of the structure and detail of the treatment manuals 

themselves, but it also derived from a belief that behavioral feedback 

was more useful to clinicians and would be likely to increase compliance as well. A review122 of evaluations of trainees and supervisors 

noted that trainees rate supervision as better when it is structured and 

provides clear feedback, the most effective feedback being that which 

embodies clearly stated objectives.

Increasing structure in supervision through outlines of techniques or 

other adjunctive material appears to lead to more change in trainees 

as wel1.122 Moreover, others108 have suggested that the use of manuals with explicit techniques can facilitate mastery in trainees, even as 

rated by clients, in addition to supervisors. Central team supervision 

generally tried to refer to the treatment manual in every supervision 

session to emphasize its centrality, especially as the study continued 

and clinicians assumed that they knew and remembered the manuals perfectly, without checking. This constant return to the manuals 

served as a check on the tendency of even well-trained and committed 

therapists to drift over time.

On the other hand, overly strict adherence to the manuals represented 

a clear problem in supervision, especially with less experienced therapists (table 4.2). For example, some clinicians would become so focused 

on the suggested topics or interventions in a specific model that client 

concerns would not be addressed, or material relevant to the client 

would not be offered. The problem tended to diminish as the therapists 

became more familiar with the treatment protocols, and viewed them 

more as “second nature”.
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Improving Compliance With Alcoholism Treatment

Table 4.2. Common problems in therapist compliance with 

manual-guided therapies

 Overly strict conformance to the manual

— Failure to select interventions appropriate to client

— Giving the impression that the manual, rather than the client, 

determines the course of therapy

 Failure to adapt treatment to client

— Use of inappropriate language or terms

— Failure to attend to client concerns

 Looseness in conforming to the manual

— Covering manual material only at end of session

— Failure to fully cover core interventions

 Contamination

— Using techniques from other treatments

— Using language and terms associated with other treatments

A crucial function of supervision in this respect was to reframe client 

problems and characteristics within the terms of the respective models 

of treatment and to search for alternate, appropriate interventions that 

were congruent with the model. More subtle problems, such as using 

language and concepts appropriate to the client, were also addressed 

within the models. Thus, the therapists were gradually led, through 

supervision, to view the treatment manuals not only as collections of 

distinct techniques, but as embodying concepts and principles that 

had the flexibility to meet the needs of each client.

Variants in the clinicians themselves also required changes in supervision. Pertinent individual differences included level of training and 

experience, level of skill, defensiveness, resistance, and openness to 

change, to mention only the characteristics most striking to supervisors. Differing skills and experiences led supervisors to alter the 

content of supervision to best meet the needs of the clinicians. For 

example, relatively inexperienced or less well-trained therapists clearly 

required, and wanted, intense work on developing specific skills such 

as role-playing or relaxation training. More advanced clinicians, who 

had shown mastery of these skills, were more interested in discussing 

formulations, or relationship issues. Supervisors attempted to respect 

these interests by acknowledging competence, but keeping the discussion within the parameters of the particular model. For example, 

cognitive-behavioral therapy (CBT) supervisors would contain discussions of formulations or transference within the behavioral model, and 

would discourage examining cases from other theoretical perspectives 

not in the manual.

Therapists also differed considerably in their defensiveness or resistance to structured feedback, with those who had worked previously 

in research settings generally being more receptive to direct feedback. 
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A Case Study in Clinical Supervision: Experience From Project MATCH

Clearly, having one’s performance as a therapist videotaped rendered 

certain kinds of resistance more difficult, and on a more subtle level, 

gave therapist and supervisor something concrete to which both could 

refer in making comments. Using detailed and highly structured manuals as a basis for supervision also appeared to make clinicians less 

defensive and more receptive to direct feedback, since this structure 

was an acknowledged fact that limited the scope of clinician judgement 

and exposure.

The highly structured, time-limited nature of the interventions also 

served to alter the classical model of supervision. From a psychodynamic perspective, supervision develops in a parallel process to 

therapy, and an exploration and resolution of relationship issues, such 

as transference, in the supervision affects the outcome of the therapy as well. The clear structure, and emphasis on concise, immediate 

behavioral feedback in manual-driven therapy, minimized these issues 

for supervisors and clinicians alike.

So much was structured and focused, not by the supervisor, but by 

the research requirements and manuals, that transferential elements 

had limited scope. Supervisors did not view this as a problem, since 

the aims of supervision were not to explore these issues, but to ensure 

therapist compliance. This is not to say that relationship issues were 

unimportant, but they did not form the central focus of supervision. 

An objective assessment of the quality of supervision by the study 

therapists suggested that even in structured, manual-guided therapy, empathy remained an important aspect of effective supervision 

nonetheless.

Another issue in supervision, more unique to treatment research, concerned the problem of perceived mismatches between the client and the 

treatment modality. Experienced clinicians in particular often quickly 

noticed that some clients were not the best fit for a certain therapy; 

a natural response in this case would be to alter one’s treatment to 

best meet the needs of the client. However, such alterations, if they 

deviated substantially from the manual and particularly if they overlapped with a comparison condition, would adversely affect treatment 

integrity. Supervisors thus were faced with the task of reconciling the 

needs of the clients and the therapist’s inclination with the restrictions 

of treatment-matching research. In part, this problem was addressed 

by the treatment manuals themselves, which had incorporated some 

flexibility. For example, the CBT manual offered the clients a choice of 

topics or issues once the core six sessions were covered; often a client’s 

requests could be accommodated by simply promising to discuss the 

issue soon, when the essential materials had been reviewed.

In other cases, the supervisors and therapists faced more difficult 

choices. If, in the judgement of the central and site supervisors, a client’s problems could not be addressed with the treatment outlined in 

the manual, therapists could deviate from the protocol. Even in these 

instances, supervisors attempted to preserve treatment integrity by 
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Improving Compliance With Alcoholism Treatment

suggesting interventions consistent with the model that underlay the 

manuals, for example, a 12-step intervention rather than a dynamic 

or behavioral intervention for a 12-step client. In cases of clinical deterioration, clients were referred immediately to the most appropriate 

type and level of care. Clinicians choosing not to abide by the manuals 

were a relatively rare occurrence in this study, and in the opinion of 

the supervisors, represented less of a threat to treatment integrity than 

gradual drift.

Treatment-Specific Issues in Supervision

CognitiveBehavioral 

Therapy

The cognitive-behavioral treatment manual contained a number of 

possible interventions and a choice of elective sessions in contrast to 

the 12-step and motivational enhancement interventions. A frequent 

problem that emerged in CBT as a consequence was a failure to select 

appropriate electives and interventions that suited the client’s problems. Supervision attempted to address this problem by helping the 

therapist develop a comprehensive formulation of the client in CBT 

terms, and an overall treatment plan, rather than simply responding 

to the client’s symptoms in a piecemeal fashion.

Other problems encountered in CBT included neglect of homework 

assigned to clients and failure to use role plays. These simpler problems tended to diminish over time with reminders and with practice as 

the therapists became more familiar with the interventions.

Other common mistakes involved the use of incompatible terminology, such as Alcoholics Anonymous phrases or family systems terms, 

but these were easy to illustrate and correct with videotapes. Future 

supervision efforts with manual-guided treatments might achieve even 

greater compliance by addressing pitfalls explicitly during training and 

the early phases of supervision.

Twelve-Step 

Facilitation

Although the 12-step facilitation manual was clearly written and easy 

to follow, several consistent problems with 12-step facilitation therapists had to be addressed early in the process of supervision. A frequent 

problem with this group of therapists was too much self-disclosure. 

Approximately one-half of this model’s therapists were themselves in 

recovery, and there was the tendency to slip into personal anecdotes 

sometimes unrelated to what the client was discussing. While some 

self-disclosure might be helpful in establishing a positive relationship, 

as a general rule, self-disclosure can foster further resistance and shift 

the focus away from the client and should be avoided.
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A Case Study in Clinical Supervision: Experience From Project MATCH

A second problem frequently seen in the 12-step therapists was being 

too rigid about clients’ completion of between-session assignments. 

Some of the therapists would become anxious and frustrated by noncompliance in the early sessions as they began to introduce the 12-step 

material, rather than being more facilitative. Directing supervision to 

the needs of the client rather than the therapist typically was effective 

in addressing this problem.

Measures of

Supervision To assess the quality and consistency of the supervision itself, researchers might consider using objective measures of supervision effectiveness 

in treatment outcome studies. A review of current questionnaires in 

the research literature revealed no available questionnaires that could 

be adapted to a model of supervision that was based on treatment 

manuals and videotape.

The Psychotherapy Supervision Questionnaire (table 4.3) is a brief, 

32-item survey designed specifically to assess the process of supervision in manual-guided therapy. Several study supervisors devised 

items, following four dimensions frequently discussed in the literature 

as important in the supervision process:

■ Level of Comfort with a supervisor

■ Level of Congruence between the therapist and supervisor on 

interventions, goals, and strategies that could be utilized in psychotherapy with particular clients

■ Rapport (i.e., openness, honesty, and respect)

■ Supervision that is Consistent with a particular theoretical model.

The scale items were evaluated using standard reliability and validity procedures and then were employed to evaluate supervision in the 

project.
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Improving Compliance With Alcoholism Treatment

Table 4.3. Psychotherapy Supervision Questionnaire

Below are a series of statements on the quality of supervision in psychotherapy. Please rate each statement 

about your psychotherapy supervision by circling a number after each statement indicating the degree 

to which your supervision reflected that statement. Please base your ratings only on the past 90 days of 

supervision.

1. My supervisor taught me specific therapy skills or techniques as related to the treatment manual.

 Never Sometimes Always

 1 2 3 4 5

2. My supervisor helped me understand my client’s personality and how this affects the treatment process.

 Never Sometimes Always

 1 2 3 4 5

3. My supervisor helped me understand better my feelings, thoughts, and behaviors toward my clients.

 Never Sometimes Always

 1 2 3 4 5

4. My supervisor helped me understand better my clients’ style of relating to me as their therapist.

 Never Sometimes Always

 1 2 3 4 5

5. My supervisor helped me understand how my own personal characteristics or behavior helped or 

hindered my effectiveness as a psychotherapist with a particular client.

 Never Sometimes Always

 1 2 3 4 5

6. My supervisor was overly critical of me.

 Never Sometimes Always

 1 2 3 4 5

7. My supervisor was direct and clear in informing me of my strengths as a therapist.

 Never Sometimes Always

 1 2 3 4 5

8. My supervisor expected me to do most of the problem solving in supervision rather than give me the 

answers.

 Never Sometimes Always

 1 2 3 4 5

9. During supervision, my supervisor helps me focus on the goals of the treatment sessions as described in 

the treatment manual.

 Never Sometimes Always

 1 2 3 4 5

10. My supervisor explored my personal background to help me overcome problems I was having.

 Never Sometimes Always

 1 2 3 4 5
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A Case Study in Clinical Supervision: Experience From Project MATCH

Table 4.3. Psychotherapy Supervision Questionnaire (cont.)

11. My supervisor reviewed with me specific selections of the videotapes of my therapy.

 Never Sometimes Always

 1 2 3 4 5

12. My supervisor and I agree on the appropriate treatment plans for my clients.

 Never Sometimes Always

 1 2 3 4 5

13. My supervisor gave me immediate feedback on my cases.

 Never Sometimes Always

 1 2 3 4 5

14. My supervisor expressed reservations about the style in which I interacted with my clients.

 Never Sometimes Always

 1 2 3 4 5

15. My supervisor was open to critical feedback regarding my satisfaction with supervision.

 Never Sometimes Always

 1 2 3 4 5

16. My supervisor was supportive of me when I made mistakes.

 Never Sometimes Always

 1 2 3 4 5

17. My supervisor was direct and clear in informing me of my weaknesses as a therapist.

 Never Sometimes Always

 1 2 3 4 5

18. My supervisor gave me a clear idea of how he or she really regards my work.

 Never Sometimes Always

 1 2 3 4 5

19. My supervisor provided supervision that challenged me to rethink my psychotherapeutic approach.

 Never Sometimes Always

 1 2 3 4 5

20. My supervisor’s basic approach to therapy is different from mine.

 Never Sometimes Always

 1 2 3 4 5

21. My supervisor encouraged me to express my thoughts and feelings regarding his/her supervision of me.

 Never Sometimes Always

 1 2 3 4 5

22. My supervisor made me feel anxious when talking with him or her.

 Never Sometimes Always

 1 2 3 4 5
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Improving Compliance With Alcoholism Treatment

Table 4.3. Psychotherapy Supervision Questionnaire (cont.)

23. My supervisor was honest with me.

 Never Sometimes Always

 1 2 3 4 5

24. My supervisor kept to the plan about content of supervision.

 Never Sometimes Always

 1 2 3 4 5

25. My supervisor and I thought similar about the ways of intervening with clients.

 Never Sometimes Always

 1 2 3 4 5

26. During the process of supervision, my supervisor adhered to the model of therapy presented in the 

treatment manual.

 Never Sometimes Always

 1 2 3 4 5

27. During the course of the supervision, my supervisor frequently referred back to the treatment manual 

when explaining a point.

 Never Sometimes Always

 1 2 3 4 5

28. During supervision time, my supervisor and I were able to resolve any differences that arose between 

the two of us about the client’s treatment plan.

 Never Sometimes Always

 1 2 3 4 5

29. My supervisor related to me more as a colleague during our supervision time rather than as someone 

who had authority over me.

 Never Sometimes Always

 1 2 3 4 5

30. My supervisor gave me suggestions about my cases that were confusing.

 Never Sometimes Always

 1 2 3 4 5

31. Because of my supervisor, I have a better understanding of how my therapy style can become more 

consistent with the treatment manual.

 Never Sometimes Always

 1 2 3 4 5

32. My supervisor helps me adapt my therapeutic interventions into interventions that fit the treatment 

manual.

 Never Sometimes Always

 1 2 3 4 5
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A Case Study in Clinical Supervision: Experience From Project MATCH

Relationship

Between

Supervision

and Therapist

Compliance

Our final impression of the videotaped model of supervision is that, 

within particular parameters, this model can be an efficient and effective alternative to the more classical model of sit-down, face-to-face 

style of supervision, particularly in a large multiple-site psychotherapy 

study. We confirmed, through our own internal quality assurance survey, that the guidelines we adhered to increased therapist compliance 

and appeared to reduce resistance to the particular treatments and 

improved therapist-supervisor congruence during supervision.

We established that compliance-resistance could be managed in four 

ways: by using the manual, using videotapes, providing immediate 

feedback on ratings, and developing rapport and empathy in the telephone supervision.

Our final conclusion is that a videotape-based type of supervision can 

work provided that it is frequent, focused on the manual, and uses the 

above guidelines to increase compliance and deal with therapist resistance. Supervision delivered in this way may also contribute to client 

compliance and improvement in retention in psychotherapy studies.

Bibliography Carifo, M.S., and Hess, A.K. Who is the ideal supervisor? Professional 

Psychology: Research and Practice 18:24–25, 1987. 

Crick, P. Good supervision: On the experience of being supervised.

Psychoanalytic Psychotherapy 5:235–245, 1991.

Halgin, R.P., and Murphy, R.A. Issues in the training of psychotherapists. In: Bongar, B., and Beutler, L.E., eds., Comprehensive 

Textbook of Psychotherapy. New York: Oxford University Press, 

1994. pp. 434–455

Rounsaville, B.J.; Chevron, E.S.; Prusoff, B.A.; Elkin, I.; Imber, S.; 

Sotsky, S.; and Watkins, J. The relation between specific and 

general dimensions of the psychotherapy process in interpersonal 

psychotherapy of depression. Journal of Consulting and Clinical 

Psychology 55:379–384, 1987.

87

Appendix

Overview of Project Match

Many of the strategies described in this manual are those used in 

Project MATCH,123 an NIAAA-sponsored, multisite collaborative study 

evaluating patient-treatment matching in alcohol-dependent individuals. As described in detail elsewhere,124 Project MATCH involved two 

independent but parallel matching studies, one with clients recruited 

from outpatient settings (N=954), the other with clients receiving aftercare treatment following inpatient treatment (N=774). Treatment was 

provided in 10 sites affiliated with 8 clinical research units (5 outpatient, 5 aftercare) to provide geographic as well as client heterogeneity.

Subjects Inclusion and exclusion criteria were used to define a heterogeneous 

sample of alcohol patients who were treatable within the limits of 

weekly outpatient or aftercare therapy, and thus were comparatively 

broad. Inclusion criteria included:

■ Current DSM-III-R diagnosis of alcohol abuse or dependence

■ Alcohol as the principal drug of abuse

■ Drinking during the 3 months prior to study entry

■ Minimum age of 18

■ Sixth grade reading level

■ Absence of legal or probation/parole requirements that might interfere with participation in the protocol.

Exclusion criteria included:

■ Current DSM-III-R diagnosis of sedative, stimulant, cocaine, or opiate dependence

■ Intravenous drug use in the past 6 months

■ Current danger to self or others

■ No clear prospects for residential stability
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Improving Compliance With Alcoholism Treatment

■ Inability to identify at least one locator for assistance in followup 

tracking

■ Severe organic impairment or acute psychosis

■ Planned involvement in a more intensive form of treatment for alcohol problems than that provided by MATCH.123

Subjects were assessed at baseline and at 3-month intervals after randomization to treatment (i.e., 3, 6, 9, 12, and 15 months).

Forms Subjects were screened to determine their need for medically supervised detoxification before entering treatment. Those who agreed to 

outpatient detoxification were required to read and sign a contract (see 

sample) that spelled out the details of the agreement. All subjects were 

required to read and sign consent forms (see sample) before participating in treatment.

Treatments Subjects were randomly assigned to one of three manual-guided 

psychosocial treatment conditions: Twelve-Step Facilitation (TSF), 

Cognitive-Behavioral Coping Skills Training (CBT), or Motivational 

Enhancement Therapy (MET). Treatments were delivered in individual 

sessions over 12 weeks, with weekly sessions for CBT and TSF. MET 

consisted of four sessions, occurring during the first, second, sixth, 

and twelfth weeks.

Treatments were selected on the basis of their meeting several criteria,124 including:

■ Documentation of clinical effectiveness

■ Potential for revealing matching effects

■ Applicability to the existing treatment system

■ Distinctiveness from comparison treatments

■ Feasibility of implementation within the constraints of a clinical 

trial.

CognitiveBehavioral 

Therapy

CBT125 is based on the principles of social learning theory and views 

drinking behavior as functionally related to major problems in the individual’s life. It posits that addressing this broad spectrum of problems 

will prove more effective than focusing on drinking alone. Emphasis 

is placed on overcoming skill deficits and increasing the individual’s 
89

Appendix: Overview of Project MATCH

Sample outpatient detoxification contract

Patient’s Name: ___________________________________________________________________

Physician: __________________________________ Clinical Coordinator: ___________________

Nurse: __________________________________________________________________________

I have already agreed to participate in the ________________________alcoholism treatment program. 

I understand that I am to be medically detoxified from alcohol on an outpatient basis. I am being treated 

with ________________________ for signs and symptoms of withdrawal. I understand that this medication may cause drowsiness and/or impair my ability to operate machinery or a motor vehicle. I also 

understand that it can be dangerous to drink alcohol while taking this medication.

Some of the following symptoms may occur during the withdrawal process:

shakiness or trembling excessive sweating

extreme nervousness restlessness

Other more serious symptoms of withdrawal are:

recurrent vomiting

diarrhea—more than three loose bowel movements in 24 hours

persistent or severe headaches

any change in: vision, hearing, skin sensations

If you begin to experience any of these symptoms, contact the Program Staff immediately. Dial xxx-xxxx 

and ask for (nurse). If she is unavailable, call Dr. (Project Coordinator), at yyy-yyyy. If it is after the hours 

of 8 a.m. to 5 p.m. Monday–Friday, a weekend, or neither of the other two contact people are available, 

please dial zzz-zzzz and ask the operator to page Dr. (name). If you feel that your medical symptoms 

need immediate attention, please go to the nearest Emergency Room.

I agree to identify another person _____________________________, phone number ___________ 

who will assist me in monitoring the prescribed medication. Alternatively, I agree to come in for daily 

appointments for evaluation of withdrawal and medication monitoring, if this is deemed medically necessary. I agree not to ingest any alcohol during detoxification period.

I understand that should my medical condition worsen, I will be asked to seek admission to an inpatient 

alcohol detoxification facility where my medical status can be monitored more closely and appropriate 

treatment provided.

I have read and understand the above statements and I agree to abide by them.

Client’s Signature______________________________________________Date_____________

Physician Signature____________________________________________Date_____________
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Improving Compliance With Alcoholism Treatment

Sample informed consent form for participation in treatment-matching outpatient study

I, ______________________________________, agree to participate as a subject in a research project 

studying how different people benefit from two different types of outpatient treatment for problems 

associated with the use of alcohol. I understand that the study will involve treatment consisting of 26 

weekly group sessions. Treatment will be based on one of the following approaches: (1) group therapy 

to foster insight into the way that I relate to other people, or (2) group therapy based on learning new 

coping skills. Which type of treatment I receive will be decided by the investigators on a random basis, 

but I understand that I will not be told which method of assignment is being used in my case.

I understand that if detoxification appears necessary I will receive a medical evaluation and may 

be detoxified on an outpatient basis prior to entry into the study; I will be responsible for the cost of 

medications for outpatient detoxification. If inpatient detoxification is recommended, the costs for that 

will be my responsibility. I understand that I will also be responsible for the cost of any medical care 

recommended by the Project’s Medical Director or for the cost of more intensive treatment that would be 

recommended if my condition worsens in spite of the treatment I receive in this study. 

As part of the research evaluation, I will be asked to give samples of my breath and blood for analysis 

at the beginning of the study. I will also be interviewed and asked to fill out questionnaires concerning 

many different aspects of my personal history and pattern of alcohol and drug use. This will require a few 

hours of my time, on two different occasions. In order to be assigned to treatment, I need to be sober 

during the evaluations. 

Each week, before group therapy, I will be given a breath test and sometimes a brief questionnaire. At 

the end of the study I will be asked to fill out some more questionnaires and be interviewed again. This 

will take about two hours. Additional followup interviews will be conducted at 3, 6, 9 and 12 months after 

the end of my treatment. I will also be asked to give samples of blood and urine at some of the followup 

visits.

I have been told that I will receive compensation for the followup visits according to this schedule:

Interview at the end of treatment ..................................................$50

Telephone interview 3 months later ..............................................$20

Interview 6 months after treatment ...............................................$50

Telephone interview 9 months after treatment ..............................$20

Interview 12 months after treatment .............................................$50

I hereby give my consent for the audiotaping of treatment sessions for the sole purpose of evaluating the 

treatment I receive.

I understand that a person identified by me (e.g., spouse, child, parent, or other relative or friend) will 

be asked about my well-being by a member of the evaluation staff. This individual will be called and 

asked about the presence or absence of any problems with alcohol and about my social adjustment. I 

understand that the purpose of these contacts will be to have an ongoing assessment of the effects of 

treatment in my case. I also agree to provide names of several people who will know my whereabouts 

over the next 18 months so that they may help the research staff to locate me if I change my address 

without notice. If no one knows my whereabouts, I agree that public information sources, such as motor 

vehicle records, telephone directories, Social Security Office information, or public access locator 

services, may be used to locate me. I am providing my Social Security number for later use in locating 

me, if necessary. I understand that this will be handled in a confidential manner, like all other information 

I provide. 

Risks. We can foresee very few risks that might occur if you decide to participate in the study. The 

treatment you will receive will not differ much from what you would receive at this clinic if you decide not 

to participate in the study.

(continued)
91

Appendix: Overview of Project MATCH

Sample informed consent form (continued)

There is minimal risk associated with giving blood samples. Your blood will be drawn by trained 

technicians. It may hurt slightly or leave a black and blue mark from the needle stick. The amount of 

blood taken (2 vials) will be that usually required for regular medical laboratory tests.

We will make every effort to ensure your confidentiality. Your name will not appear in any publication or 

be released to anyone without your written consent. Information provided to the research staff will be 

kept strictly confidential and will not be shared with the person who provides the treatment to you. Also, 

the content of the interviews with you will not be revealed to your family, and the content of the interview 

with your family member or friend will not be revealed to you.

Benefits. Your participation in this study may benefit you in several ways, such as continued abstinence 

from alcohol and/or other improvements in your life. Another benefit is that the normal fees for the 

treatment program will be waived. Even if there are not specific benefits for you personally, this study 

might provide information that can be used to help other subjects in the future.

Subject Obligations. We would like you to tell us about any times you use any alcohol or other 

psychoactive drugs while in the study. We know that people are not perfect and that stopping alcohol 

use can be quite hard. In order to be helpful to you, we simply need to know about your alcohol use. The 

urine and breath tests enable us to be certain of our results. The only ways you might be dismissed from 

the study is if you repeatedly do not show up, are repeatedly intoxicated at the treatment sessions or at 

the time of the interviews, and if you are untruthful about your alcohol use. Your, obligation to the study is 

to do your best to stop using alcohol, to be honest about yourself and your problem, and to be available 

at the right times for tests and group therapy.

Other Information. One of your therapists or a therapist on call will be available by calling the 

Project Coordinator, (name), at (phone #), or the Principal Investigator, (name), at (phone #). You are 

encouraged to call at any time with questions or problems.

You are free to choose not to participate. If you do become a subject you are free to withdraw from 

this study at any time. If you decline to participate or if you withdraw, it will not adversely affect your 

relationship with this clinic or the doctors here; a list of alternative treatment providers is available upon 

request, and, if you wish, the staff will make recommendations to assist you in making your choice from 

among them.

Please feel free to ask about anything you don’t understand. Please consider this research and the 

consent form carefully before you agree to participate. You may take as much time as necessary to think 

it over.

I, the undersigned, have understood the above explanation and give consent to my voluntary 

participation in this research project. I have received a copy of this consent form.

Date: ____________________________ Location: ________________________________________

Social Security #: ___________________________________________________________________

Signature of Subject: ________________________________________________________________

Witnessed by: _____________________________________________________________________

Investigator/Person Obtaining Consent Signature: _________________________________________
92

Improving Compliance With Alcoholism Treatment

ability to cope with high-risk situations that commonly precipitate 

relapse, including both interpersonal difficulties and intrapersonal 

discomfort, such as anger or depression. The program consists of 12 

sessions with the goal of training the individual to use active behavioral or cognitive coping methods to deal with problems, rather than 

relying on alcohol as a maladaptive coping strategy. The skills also 

include a means of obtaining social support critical to the maintenance 

of sobriety.

Twelve-Step 

Facilitation

TSF126 is grounded in the concept of alcoholism as a spiritual and medical disease. The content of this intervention is consistent with the 12 

Steps of Alcoholics Anonymous (AA), with primary emphasis given to 

Steps 1 through 5. In addition to abstinence from alcohol, a major goal 

of the treatment is to foster the patient’s commitment to participation 

in AA. During the course of the programs’ 12 sessions, patients are 

actively encouraged to attend AA meetings and to maintain journals 

of their AA attendance and participation. Therapy sessions are highly 

structured, following a similar format for each week that includes 

symptoms inquiry, review and reinforcement for AA participation, 

introduction and explication of the week’s theme, and setting goals for 

AA participation for the next week.

Motivational 

Enhancement 

Therapy

MET61 is based on principles of motivational psychology and is designed 

to produce rapid, internally motivated change. This treatment strategy 

does not attempt to guide and train the client, step by step, through 

recovery, but instead employs motivational strategies to mobilize the 

client’s own resources. MET consists of four carefully planned and 

individualized treatment sessions. The first two sessions focus on 

structured feedback from the initial assessment, future plans, and 

motivation for change. The final two sessions at the midpoint and end 

of treatment provide opportunities for the therapist to reinforce progress, encourage reassessment, and provide an objective perspective on 

the process of change.

Therapist 

Training, 

Supervision, 

and Monitoring

Extensive efforts were made to provide Project MATCH treatments at 

a high and consistent level of integrity and quality through the use 

of a comparatively elaborate protocol for selecting and training therapists, as well as monitoring their implementation of study treatments 

throughout the protocol. For example, the following selection criteria 

were required of MATCH therapist candidates:

■ Completion of a master’s degree in counseling, psychology, social 

work or a closely related field, or certification as an alcoholism 

counselor

■ At least 2 years of clinical experience after completion of degree or 

certification
93

Appendix: Overview of Project MATCH

■ Submission of a taped clinical work sample to the Principal 

Investigator at each clinical research unit and to the Coordinating 

Center for review

■ Commitment to and experience with the MATCH treatment that the 

therapist would be conducting

■ Experience treating alcoholics or a closely related clinical population.

By setting uniform training and experience standards across conditions, while also seeking credible therapists representative of the 

usual practitioners of the study treatments, these selection criteria 

were intended to strike a balance between comparability of therapists 

across treatment conditions and generalizability of findings to the 

broader field of alcohol treatment.105

Training and supervision of Project MATCH therapists was centralized at the Coordinating Center using methods developed in previous 

large-scale collaborative studies.127 All therapists attended a training 

seminar that included:

■ Background and rationale for Project MATCH

■ Detailed review of the pertinent treatment manual

■ Review of taped examples of treatment sessions

■ Practice exercises

■ Extensive discussion of unique issues related to treating clients in 

matching studies, particularly consideration of challenges related 

to treating a heterogeneous patient population while conforming to 

manual guidelines.

Each therapist was then assigned a minimum of two training cases, 

which were conducted following the MATCH protocol and supervised 

by Coordinating Center supervisors in weekly individual sessions, in 

addition to weekly group supervision that was provided at each of the 

research units.

After certification, therapist adherence and competence were monitored through several sources during the main phase of the study.

■ First:

— All sessions were videotaped and sent to the Coordinating 

Center, where one-third of each subject’s sessions were reviewed 

by the Yale-based supervisors.

— Telephone supervision was provided monthly by the Coordinating 

Center supervisors and supplemented with weekly onsite supervision at each Clinical Research Unit.
94

Improving Compliance With Alcoholism Treatment

All monitored treatment sessions were rated for therapist skillfulness, 

adherence to manual guidelines, and delivery of manual-specified 

active ingredients unique to each approach. These ratings were 

sent monthly to the Project Coordinators at each site to alert local 

supervisors of therapist drift. Therapists whose performance deviated in quality or adherence to the manual were “redlined” by the 

Coordinating Center supervisors. Redlined therapists were not 

assigned new subjects and the frequency of their supervision was 

increased from monthly to weekly until the therapist’s performance 

returned to acceptable levels.

■ Second:

— Session tapes were evaluated for therapist adherence and competence by independent raters who were blind to treatment 

conditions using the MATCH Tape Rating Scale, which assesses 

therapist behavior of 5 types: CBT techniques, TSF techniques, 

MET techniques, therapy structure, and nonspecific techniques.

— Compliance was also monitored by a study-wide treatmenttracking system, which assessed sessions attended (treatment 

dose) and other aspects of compliance.
95

References

1. DiMatteo, R.M., and DiNicola, D.D. Achieving Patient Compliance. 

Elmsford, NY: Pergamon Press, 1982.

2. Haynes, R.B.; Taylor, D.W.; and Sackett, D.L., eds. Compliance 

in Health Care. Baltimore, MD: Johns Hopkins University Press, 

1979. pp. 1–2.

3. Meichenbaum, D., and Turk, D.C. Facilitating Treatment Adherence. A Practitioner’s Guidebook. New York: Plenum Press, 1987.

4. Sackett, D.L., and Snow, J.C. The magnitude of compliance and 

noncompliance. In: Haynes, R.B.; Taylor, D.W.; and Sackett, D.L., 

eds. Compliance in Health Care. Baltimore, MD: Johns Hopkins 

University Press, 1979.

5. Macharia, W.M.; Leon, G.; Rowe, B.H.; Stephenson, B.J.; and 

Haynes, R.B. An overview of interventions to improve compliance 

with appointment keeping for medical services. JAMA 267:1813–

1817, 1992.

6. Jennings, R.M., and Ball, J.D. Patient compliance with CHAMPUS mental health referrals. Professional Psychology 13:172–173, 

1982.

7. Burrell, C.D., and Levy, R.A. Therapeutic consequences of noncompliance. Improving medication compliance: Proceedings of a 

symposium. Washington, DC: National Pharmaceutical Council, 

1984.

8. Dunbar-Jacob, J. Compliance with antihypertensive regimen: A 

review of the research in the 1980’s. Annals of Behavioral Medicine 

13:31–3, 1991.

9. Coronary Drug Project Research Group. Influence of adherence to 

treatment and response of cholesterol on mortality in the Coronary 

Drug Project. New England Journal of Medicine 303:1038–1041, 

1980.

10. Horwitz, R.I., and Horwitz, S.M. Adherence to treatment and 

health outcomes. Archives of Internal Medicine 153:1863–1868, 

1993.

11. Horwitz, R.I.; Viscoli, C.M.; Berkman, L.; et al. Treatment adherence and risk of death after a myocardial infarction. Lancet

336:542–545, 1990.

12. Startup, M., and Edmonds, J. Compliance with homework assignments in cognitive-behavioral psychotherapy for depression: 

Relation to outcome and methods of enhancement. Cognitive 

Therapy and Research 18:567–579, 1994.
96

Improving Compliance With Alcoholism Treatment

13. Hays, R.D.; Kravitz, R.L.; Mazel, R.M.; Sherbourne, C.D.; 

DiMatteo, M.R.; Rogers, W.H.; and Greenfield, S. The impact of 

patient adherence on health outcomes for patients with chronic 

disease in the Medical Outcomes Study. Journal of Behavioral 

Medicine 17:347–360, 1994.

14. Bond, W.S., and Hussar, D.A. Detection methods and strategies for improving medication compliance. American Journal of 

Hospital Pharmacology 48:1978–1988, 1991.

15. Cowen, M.; Jim, L.K.; Boyd, E.L.; and Gee, J.P. Some possible 

effects of patient noncompliance. JAMA 245:1121, 1981.

16. Freedman, L.S. The effect of partial noncompliance on the power 

of a clinical trial. Controlled Clinical Trials 11:157–168, 1990.

17. Lachin, J.M., and Foulkes, M.A. Evaluation of sample size and 

power for analyses of survival with allowance for nonuniform 

patient entry, losses to follow-up, noncompliance, and stratification. Biometrics 42:507–519, 1986.

18. Lavori, P.W. Clinical trials in psychiatry: Should protocol deviation censor patient data? Neuropsychopharmacology 6:39–48, 

1992.

19. Lee, Y.J.; Ellenberg, J.H.; Hirtz, D.G.; and Nelson, K.B. Analysis of 

clinical trials by treatment actually received: Is it really an option? 

Statistics in Medicine 10:1595–1605, 1991.

20. Feinstein, A.R. ‘Compliance bias’ and the interpretation of therapeutic trials. In: Haynes, R.B.; Taylor, D.W.; and Sackett, D.L., 

eds. Compliance in Health Care. Baltimore, MD: Johns Hopkins 

Press, 1979. pp. 309–322.

21. Baekeland, F., and Lundwall, L. Dropping out of treatment: A critical review. Psychological Bulletin 82:738–783, 1975.

22. Wickizer, T.; Maynard, C.; Atherly, A.; and Frederick, M. 

Completion rates of clients discharged from drug and alcohol 

treatment programs in Washington State. American Journal of 

Public Health 84:215–221, 1994.

23. Carroll, K.M. Enhancing retention in clinical trials of psychosocial treatments: Practical strategies. In: Onken, L.S.; Blaine, J.D.; 

and Boren, J.J., eds. Beyond the Therapeutic Alliance: Keeping 

the Drug Dependent Individual in Treatment. NIDA Research 

Monograph Series #165. Rockville, MD: NIDA, 1997.

24. Drake, R.E.; Alterman, A.I.; Rosenberg, S.R. Detection of substance use disorders in severely mentally ill patients. Community 

Mental Health Journal 29:175–192, 1993.

25. Dubinsky, M. Predictors of appointment non-compliance in community mental health patients. Community Mental Health Journal

22:142–146, 1986.

26. Pristach, C.A., and Smith, C.M. Medication compliance and substance use among schizophrenic patients. Hospital and Community 

Psychiatry 41:1345–1348, 1990.

27. Searles, J.S., and Alterman, A.I., Differential attrition rates in 

alcohol abusing and nonabusing schizophrenic inpatients: A 

methodologic note. Alcoholism: Clinical and Experimental Research

16:705–707, 1992.
97

References

28. Swett, C., and Noones, J. Factors associated with premature termination from outpatient treatment. Hospital and Community 

Psychiatry 40:947–951, 1989.

29. Kofoed, L.L. Chemical monitoring of disulfiram compliance: A 

study of alcoholic outpatients. Alcoholism: Clinical and Experimental Research 11:481–485, 1987.

30. Fuller, R.; Roth, H.; and Long, S. Compliance with disulfiram 

treatment of alcoholism. Journal of Chronic Disease 36:161–170, 

1983.

31. Powell, B.J.; Penick, E.C.; Liskow, B.I.; Rice, A.S.; et al. Lithium 

compliance in alcoholic males: A six month followup study. 

Addictive Behaviors 11:135–140, 1986.

32. Smart, R.G., and Gray, G. Multiple predictors of dropout from 

alcoholism treatment. Archives of General Psychiatry 35:363–367, 

1978.

33. Allan, C. Seeking help for drinking problems from a communitybased voluntary agency: Patterns of compliance amongst men 

and women. British Journal of Addiction 82:1143–1147, 1987.

34. Atkinson, R.M.; Tolson, R.L.; and Turner, J.A. Factors affecting 

outpatient treatment compliance of older male problem drinkers. 

Journal of Studies on Alcohol 54:102–106, 1993.

35. Brizer, D.A.; Maslansky, R.; and Galanter, M. Treatment retention of patients referred by public assistance to an alcoholism 

clinic. American Journal of Drug and Alcohol Abuse 16:259–264, 

1990.

36. Castaneda, R.; Lifshutz, H.; Galanter, M.; Medalia, A.; and Franco, 

H. Treatment compliance after detoxification among highly disadvantaged alcoholics. American Journal of Drug and Alcohol Abuse

18:223–234, 1992.

37. Fink, E.B.; Rudden, S.; Longabaugh, R.; McCrady, B.; and 

Stout, R. Adherence in a behavioral alcohol treatment program. 

International Journal of the Addictions 19:709–719, 1984.

38. Huselid, R.F.; Self, E.A.; and Gutierres, S.E. Predictors of 

successful completion of a halfway-house program for chemicallydependent women. American Journal of Drug and Alcohol Abuse 

17:89–101, 1991.

39. Jones, J.W. Predicting patients’ withdrawal against medical 

advice from an alcoholism treatment center. Psychological Reports 

57:991–994, 1985.

40. Leigh, G.; Ogborne, A.C.; and Cleland, P. Factors associated with 

patient dropout from an outpatient alcoholism treatment service. 

Journal of Studies on Alcohol 45:359–362, 1984.

41. Noel, N.E.; McCrady, B.S.; Stout, R.L.; and Fisher-Nelson, H. 

Predictors of attrition from an outpatient alcoholism treatment 

program for couples. Journal of Studies on Alcohol 48:229–235, 

1987.

42. Pekarik, G., and Zimmer, L. Relation of client variables to continuance in five types of alcohol treatment settings. Addictive 

Behaviors 17:105–115, 1992.
98

Improving Compliance With Alcoholism Treatment

43. Rees, D.W. Changing patients’ health beliefs to improve compliance with alcoholism treatment: A controlled trial. Journal of 

Studies on Alcohol 47:436–439, 1985.

44. Verinis, J.S. Characteristics of patients who continue with alcohol outpatient treatment. International Journal of the Addictions 

21:25–31, 1986.

45. Chick, J.; Riston, B.; Connaughton, J.; Stewart, A.; and Chick, 

J. Advice versus treatment for alcoholism: A controlled study. 

British Journal of Addiction 83:159–170, 1988.

46. Ito, J.R.; Donovan, D.M.; and Hall, J.J. Relapse prevention in 

alcohol aftercare: Effects on drinking outcome, change process, 

and aftercare attendance. British Journal of Addiction 83:171–

181, 1988.

47. 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.

48. Kranzler, H.R.; Burleson, J.A.; Del Boca, F.K.; Babor, T.F.; 

Korner, P.F.; Brown. J.A.; and Bohn, M.J. Buspirone treatment of 

anxious alcoholics: A placebo-controlled trial. Archives of General 

Psychiatry 51:720–731, 1994.

49. Kranzler, H.R.; Burleson, J.A.; Korner, P.; Del Boca, F.K.; et al. 

Placebo-controlled trial of fluoxetine as an adjunct to relapse 

prevention in alcoholics. American Journal of Psychiatry 152:391–

397, 1995.

50. Mason, B.J.; Ritvo, E.C.; Morgan, R.O.; Salvato, F.R.; et al. A double-blind, placebo-controlled pilot study to evaluate the efficacy 

and safety of oral nalmefene HCL for alcohol dependence. Alcohol: 

Clinical and Experimental Research 18:1162–1167, 1994.

51. Murphy, T.J.; Pagano, R.R.; and Marlatt, G.A. Lifestyle modification with heavy alcohol drinkers: Effects of aerobic exercise and 

meditation. Addictive Behaviors 11:175–186, 1986.

52. Monti, P.M.; Rohsenow, D.J.; Rubonis, A.V.; Niaura, R.S.; et al. 

Cue exposure with coping skills treatment for male alcoholics: 

A preliminary investigation. Journal of Consulting and Clinical 

Psychology 61:1011–1019, 1993.

53. Naranjo, C.A.; Bremner, K.E.; and Lanctot, K.L. Effects of citalopram and a brief psycho-social intervention on alcohol intake, 

dependence, and problems. Addiction 90:87–99, 1995.

54. O’Farrell, T.J.; Choquette, K.A.; Cutter, H.S.G.; Brown, E.D.; and 

McCourt, W.F. Behavioral marital therapy with and without additional couples relapse prevention sessions for alcoholics and their 

wives. Journal of Studies on Alcohol 54:652–666, 1993.

55. O’Malley, S.S.; Jaffe, A.J.; Chang, G.; Schottenfeld, R.S.; Meyer, 

R.E.; and Rounsaville, B.J. Naltrexone and coping skills therapy 

for alcohol dependence: A controlled study. Archives of General 

Psychiatry 49:881–887, 1992.

56. Baekeland, L.; Lundwall, L.; and Shanahan, T.J. Correlates of 

patient attrition in the outpatient treatment of alcoholism. Journal 

of Nervous and Mental Disease 157:99–107, 1973.
99

References

57. Allen, J.P., and Litten, R.Z. Techniques to enhance compliance 

with disulfiram. Alcoholism: Clinical and Experimental Research 

16:1035–1041, 1992.

58. Rounsaville, B.J. Can psychotherapy rescue naltrexone treatment of opioid addiction? In: Onken, L.S.; Blaine, J.D.; and J.J. 

Boren, eds. Potentiating the Efficacy of Medications: Integrating 

Psychosocial Therapies With Pharmacotherapies in the Treatment 

of Drug Dependence. NIDA Research Monograph Series Number 

105, NIH Pub. No. 95–3899. Rockville, MD: National Institute on 

Drug Abuse, 1995.

59. Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Foerg, F.E.; Donham, 

R.; and Badger, G.J. Incentives improve outcome in outpatient 

behavioral treatment of cocaine dependence. Archives of General 

Psychiatry 51:568–576, 1994.

60. Higgins, S.T.; Budney, A.J.; Bickel, W.K.; and Hughes, J.R. 

Achieving cocaine abstinence with a behavioral approach. 

American Journal of Psychiatry 150:763–769, 1993.

61. Miller, W.R.; Zweben, A.; DiClemente, C.C.; and Rychtarik, R.G. 

Motivational Enhancement Therapy Manual: A Clinical Research 

Guide for Therapists Treating Individuals With Alcohol Abuse and 

Dependence. NIAAA Project MATCH Monograph Series Volume 2, 

DHHS Pub. No. (ADM)92–1894. Rockville, MD: National Institute 

on Alcohol Abuse and Alcoholism, 1992.

62. Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing 

People to Change Addictive Behavior. New York: Guilford Press, 

1991.

63. Brown, J.M., and Miller, W.R. Impact of motivational interviewing 

on participation and outcome in residential alcoholism treatment. 

Psychology of Addictive Behaviors 7:211–218, 1993.

64. Miller, W.R.; Benefield, R.G.; and Tonigan, J.S. Enhanced motivation for change in problem drinking: A controlled comparison of 

two therapist styles. Journal of Consulting and Clinical Psychology 

61:455–461, 1993.

65. Haynes, R.B. Strategies to improve compliance with referrals, 

appointments, and prescribed medical regimens. In: Haynes, R.B.; 

Taylor, D.W.; and Sackett, D.L., eds. Compliance in Health Care. 

Baltimore, MD: Johns Hopkins University Press, 1979. pp. 2–3.

66. Aronson, J.K., and Hardman, M. ABC of monitoring drug therapy: Patient compliance. British Medical Journal 305:1009–1011, 

1992.

67. Epstein, L.H., and Cluss, P.A. A behavioral medicine perspective 

on adherence to long-term medical regimens. Journal of Consulting 

and Clinical Psychology 50:950–971, 1982.

68. Primakoff, L.; Epstein, N.; and Covi, L. Homework compliance: 

An uncontrolled variable in cognitive therapy outcome research. 

Behavior Therapy 17:433–446, 1986.

69. Epstein, E.E.; McCrady, B.S.; Miller, K.J.; and Steinberg, M. 

Attrition from conjoint alcoholism treatment: Do dropouts differ 

from completers? Journal of Substance Abuse 6:249–265,1994.
100

Improving Compliance With Alcoholism Treatment

70. Keil, T.J., and Esters, R.A. Treatment dropouts: The effect of client 

and ecological variables. International Journal of the Addictions 

17:95–108, 1982.

71. Sheppard, D.; Smith, G.T.; and Rosenbaum, G. Use of MMPI 

subtypes in predicting completion of a residential alcoholism 

treatment program. Journal of Consulting and Clinical Psychology 

56:590–596, 1988.

72. Gordis, E.; Dorph, D.; Sepe, V.; and Smith, H. Outcome of alcoholism treatment among 5578 patients in an urban comprehensive 

hospital-based program: Application of a computerized data system. Alcoholism: Clinical and Experimental Research 5:509–522, 

1981.

73. Miller, W.R. Motivation for treatment: A review with special 

emphasis on alcoholism. Psychological Bulletin 98:84–107, 1985.

74. Peterson, K.A.; Swindle, R.W.; Phibbs, C.S.; Recine, B.; and Moos, 

R.H. Determinants of readmission following inpatient substance 

abuse treatment: A national study of VA programs. Medical Care 

32:535–550, 1994.

75. DiClemente, C.C. Creating compliance: An interactive process 

between patients and providers. In: Mattson, M., and Krasnegor, 

N., Chairs, Behavioral Research in Clinical Trials: Addictive 

Diseases. Symposium conducted at the NIH Reunion Task Force 

Series, The Science of Compliance. National Institutes of Health, 

Bethesda, Maryland, 7 December 1993.

76. Frank, E.; Kupfer, D.J.; and Siegel, L.R. Alliance not compliance: 

A philosophy of outpatient care. Journal of Clinical Psychiatry 

56(suppl 1):11–16, 1995.

77. Patterson, G.R., and Forgatch, M.S. Therapist behavior as a 

determinant for client noncompliance. A paradox for the behavior 

modifier. Journal of Consulting and Clinical Psychology 53:846–

851, 1985.

78. Litten, R.Z., and Allen J.P. Pharmacotherapy for alcoholics with 

collateral depression or anxiety: An update of research findings. 

Experimental and Clinical Psychopharmacology 3:87–93, 1995.

79. O’Farrell, T.J.; Allen, J.P.; and Litten, R.Z. Disulfiram (Antabuse) 

contracts in treatment of alcoholism. In: Onken, L.S.; Blaine, 

J.D.; and Boren, J.J., eds. Integrating Behavioral Therapies With 

Medications in the Treatment of Drug Dependence. NIDA Research 

Monograph No. 150, 1995. pp. 65–91.

80. Stark, M.J.; Campbell, B.K.: and Brinkerhoff, C.V. ‘Hello, may we 

help you?’: A study of attrition prevention at the time of the first 

phone contact with substance-abusing clients. American Journal 

of Drug and Alcohol Abuse 16:67–76, 1990.

81. Bell, J.; Caplehorn, J.R.; and McNeil, D.R. The effect of intake 

procedures on performance in methadone maintenance. Addiction

89(4):463–471, 1994.

82. Zweben, A.; Bonner, M.; Chaim, G.; and Santon, P. Facilitative 

strategies for retaining the alcohol-dependent client in outpatient treatment. Alcoholism Treatment Quarterly 5:3–23, 1988.
101

References

83. Zweben, A., and Li, S. The efficacy of role induction in preventing early dropout from outpatient treatment of drug dependency. 

American Journal of Drug and Alcohol Abuse 8:171–183, 1981.

84. 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.

85. Zweben, A., and Pearlman, S. Evaluating the effectiveness of conjoint treatment of alcohol complicated marriages: Clinical and 

methodological issues. Journal of Marital and Family Therapy 

9:61–72, 1983.

86. Zweben, A.; Pearlman, S.; and Li, S. Reducing attrition from conjoint therapy with alcoholic couples. Drug and Alcohol Dependence 

11:321–331, 1983.

87. Longabough, R.; Beattie, M.; Noel, N.; Stout, R.; and Malloy P. 

The effect of social investment on treatment outcome. Journal of 

Studies on Alcohol 54:465–478, 1993.

88. Marlatt, G.A., and Gordon, J.R., eds. Relapse Prevention. 

Maintenance Strategies in the Treatment of Addictive Behaviors. 

New York: Guilford Press, 1985.

89. Marlatt, G.A. Lifestyle modification. In: Marlatt, G.A., and Gordon, J.R., eds. Relapse Prevention. Maintenance Strategies in the 

Treatment of Addictive Behaviors. New York: Guilford Press, 1985. 

pp. 280–348.

90. McCrady, B.S.; Dean, L.; Dubreuil, E; and Swanson, S. The 

problem drinkers’ project: A programmatic application of sociallearning-based treatment. In: Marlatt, G.A., and Gordon, J.R., 

eds. Relapse Prevention. New York: Guilford, 1985.

91. Rapp, R.C.; Siegal, H.A.; and Fisher, J.H. A strengths-based model 

of case management/advocacy: Adapting a mental health model to 

practice work with persons who have substance abuse problems. 

In: Ashery, R.S., ed. Progress and Issues in Case Management. 

NIDA Research Monograph No. 127, 1992. pp. 79–91.

92. Shelton, J.L., and Levy, R.L., eds. Behavioral Assignments and 

Treatment Compliance. A Handbook of Clinical Strategies. Champaign, IL: Research Press, 1981.

93. Spilker, B. Methods of assessing and improving patient compliance in clinical trials. In: Cramer, J.A., and Spilker, B., eds. 

Patient Compliance in Medical Practice and Clinical Trials. New 

York: Raven Press, 1991. pp. 37–56.

94. Worthington, E.L. Client compliance with homework directives 

during counseling. Journal of Counseling Psychology 33:124–130, 

1986.

95. Gordon, J.R., and Marlatt, G.A. Addictive behaviors. In: Shelton, 

J.L., and Levy, R.L., eds. Behavioral Assignments and Treatment 

Compliance. Champaign, IL: Research Press, 1981

96. Levy, R.L. Relationship of an overt commitment to task compliance in behavior therapy. Journal of Behavior Therapy and 

Experimental Psychiatry 8:25–29, 1977.
102

Improving Compliance With Alcoholism Treatment

97. Ossip-Klein, D.J.; Vanlandingham, W.; Prue, D. M.; and Rychtarik, 

R.G. Increasing attendance at alcohol aftercare using calendar 

prompts and home based contracting. Addictive Behaviors 9:85–

89, 1984.

98. Rowan-Szal, G.; Joe, G.W.; Chatham, L.R.; and Simpson. D.D. 

A simple reinforcement system for methadone clients in a community-based treatment program. Journal of Substance Abuse 

Treatment 11(3):217–223, 1994.

99. Bickel, W.K.; Rizzuto, P; Zielony, R.D.; Klobas, J.; Pangiosonlis, 

P.; Mernit, R.; and Knight, W.F. Combined behavioral and pharmacological treatment of alcoholic methadone patients. Journal of 

Substance Abuse 1:161–171,1988–89.

100. Carey, K.B., and Carey, M.P. Enhancing the treatment attendance 

of mentally ill chemical abusers. Journal of Behavior Therapy and 

Experimental Psychiatry 21(3):205–209, 1990

101. Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Foerg, F.E.; Donham, 

R.; and Badger, G.J. Incentives improve outcome in outpatient 

behavioral treatment of cocaine dependence. Archives of General 

Psychiatry 51:568–576, 1994.

102. Kadden, R.M., and Mauriello, I.J. Enhancing participation in 

substance abuse treatment using an incentive system. Journal of 

Substance Abuse Treatment 8:113–124, 1991.

103. Luborsky, L., and DeRubeis, R.J. The use of psychotherapy treatment manuals: A small revolution in psychotherapy research 

style. Clinical Psychology Review 4:5–15, 1984.

104. Kazdin, A.E. Methods of psychotherapy research. In: Bongar, B., 

and Beutler, L.E., eds. Comprehensive Textbook of Psychotherapy: 

Theory and Practice. New York: Oxford University Press, 1995. pp. 

405–433.

105. Carroll, K.M.; Kadden, R.; Donovan, D.; Zweben, A.; and 

Rounsaville, B.J. Implementing treatment and protecting the 

validity of the independent variable in treatment matching studies. Journal of Studies on Alcohol Suppl 12:149–155, 1994.

106. Crits-Christoph, P.; Baranackie, K.; Kurcias, J.; Beck, A.T.; 

Carroll, K.; Perry, K.; Luborsky, L.; McLellan, A.T.; Woody, G.; 

Thompson, L.; Gallagher, D.; and Zitrin, C. Meta-analysis of therapist effects in psychotherapy outcome studies. Psychotherapy 

Research 1:81–91, 1991.

107. Moras, K. The use of treatment manuals to train psychotherapists: Observations and recommendations. Psychotherapy 

30:581–586, 1993.

108. Rounsaville, B.J.; O’Malley, S.; Foley, S.; and Weissman, M.M. 

Role of manual-guided training in the conduct and efficacy of 

interpersonal psychotherapy for depression. Journal of Consulting 

and Clinical Psychology 56:681–688, 1988.

109. Frank, J.D. Persuasion and Healing. Baltimore: Johns Hopkins 

University Press, 1973.

110. Rozenzweig, S. Some implicit common factors in diverse methods 

of psychotherapy. American Journal of Orthopsychiatry 6:412–

415, 1936.
103

References

111. Waltz, J.; Addis, M.E.; Koerner, K.; and Jacobson, N.S. Testing the 

integrity of a psychotherapy protocol: Assessment of adherence 

and competence. Journal of Consulting and Clinical Psychology 

61:620–630, 1993.

112. Klerman, G.L.; Weissman, M.M.; Rounsaville, B.J.; and Chevron, 

E.S. Interpersonal Psychotherapy of Depression. New York: Basic 

Books, 1984.

113. Luborsky, L., and Crits-Christoph, P. Understanding Transference: The CCRT Method. New York: Basic Books, 1990.

114. Dobson, K.S., and Shaw, B.F. The use of treatment manuals in 

cognitive therapy: Experience and issues. Journal of Consulting 

and Clinical Psychology 56:673–680, 1988.

115. Binder, J.L.; Strupp, H.H.; Bongar, B.; Lee, S.S.; Messer, S.; 

and Peake, T.H. Recommendations for improving psychotherapy 

training based on experiences with manual-guided training and 

research. Psychotherapy 30:599–600, 1993.

116. Docherty, J.P. Implications of the technological model of 

psychotherapy. In: Williams, J.B.W., and Spitzer, R.L., eds., Psychotherapy Research: Where Are We and Where Should We Go?

New York: Guilford, 1984.

117. Dobson, K.S., and Shaw, B.F. The training of cognitive therapists: 

What have we learned from treatment manuals? Psychotherapy

30:573–577, 1993.

118. Luborsky, L. Recommendations for training therapists based on 

manuals for psychotherapy research. Psychotherapy 30:578–580, 

1993.

119. Binder, J.L. Observations on the training of therapists in timelimited dynamic psychotherapy. Psychotherapy 30:592–597, 

1993.

120. Henry, W.P.; Strupp, H.H.; Butler, S.F.; Schacht, T.E.; and Binder, 

J.L. Effects of training in time-limited dynamic psychotherapy: 

Changes in therapist behavior. Journal of Consulting and Clinical 

Psychology 61:434–440, 1993.

121. Donovan, D.; Kadden, R.; DiClemente, C.C.; Carroll, K.M.; 

Longabaugh, R.; Zweben, A.; and Rychtarick, R. Issues in the 

selection and development of therapies in alcoholism treatment 

matching. Journal of Studies on Alcohol Suppl 12:138–148, 1994.

122. Newman, F.L.; Kopta, S.M.; McGovern, M.P.; and Howard, K.I. 

Evaluating trainees relative to their supervisors during the psychology internship. Journal of Consulting and Clinical Psychology

56:659–665, 1988.

123. Project MATCH Research Group. Project MATCH: Rationale and 

methods for a multisite clinical trial matching alcoholism patients 

to treatment. Alcoholism: Clinical and Experimental Research 

17:1130–1145, 1993.

124. Donovan, D.M., and Mattson, M.E., eds. Alcoholism treatment 

matching research: Methodological and clinical approaches. 

Journal of Studies on Alcohol Suppl. 12, 1994.
104

Improving Compliance With Alcoholism Treatment

125. Kadden, R.; Carroll, K.M.; Donovan, D.; Cooney, N.; Monti, P.; 

Abrams, D.; Litt, M.; and Hester, R. Cognitive-Behavioral Coping 

Skills Therapy Manual: A Clinical Research Guide for Therapists 

Treating Individuals With Alcohol Abuse and Dependence. NIAAA 

Project MATCH Monograph Series Volume 3, DHHS Pub. No. 

(ADM)92–1895. Rockville, MD: National Institute on Alcohol 

Abuse and Alcoholism, 1992.

126. Nowinski, J.; Baker, S.; and Carroll, K.M. Twelve-Step Facilitation 

Therapy Manual: A Clinical Research Guide for Therapists Treating 

Individuals With Alcohol Abuse and Dependence. NIAAA Project 

MATCH Monograph Series Volume 1, DHHS Pub. No. (ADM)92–

1893. Rockville, MD: National Institute on Alcohol Abuse and 

Alcoholism, 1992.

127. Elkin, I.; Parloff, M.B.; Hadley, S.W.; and Autry, J.H. NIMH treatment of depression collaborative research program: Background 

and research plan. Archives of General Psychiatry 42:305–316, 

1985.