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Section 6
The "Pressures to Change" Procedure for the Families of Addicts

Question 7 | Test | Table of Contents

The "pressures to change" procedure, which was developed by Barber and his colleagues (Barber & Crisp, 1995; Barber & Gilbertson, 1996, in press; Barber, Gilbertson, & Crisp, 1995), requires between one and six sessions depending on whether the intervention is offered in a counseling or self-help format. The procedure involves training the nondrinking partner in the use of environmental contingencies arranged in increasing order of pressure on the drinker to modify his behavior. In the induction session, clients are instructed that the procedure has two fundamental objectives: (1) to provide the woman with a greater measure of control over her life and (2) to place the drinker under escalating pressure to change.

The first level of pressure involves providing the nondrinking partner with feedback and information about the change process. At the first session, the nondrinking partner completes a battery of instruments, including measures of the drinker’s level of alcohol dependence (see Seizer, Vinokur, & Van Rooijen, 1975). The instruments are scored immediately, and clients are invited to comment on the results.

Next, the objectives of treatment are carefully explained. In this first session it is emphasized that the client can never be held accountable for her partner’s drinking, and the client is forewarned that the idea will be challenged should it ever be offered by the drinker or the client as a rationalization for the drinker’s behavior. Pressures to change treatment also takes considerable pains to emphasize that there is no explicit or implicit intention to keep the marriage or partnership together; the client should feel free to end the relationship at any point in the program.

Then clients are provided with education about how drinkers change, especially that pressure from the environment is required and that change is normally an iterative process (see Prochaska & DiClemente, 1988). The difference between pressure and nagging is explained in general terms, and clients are instructed that pressure should not be interpreted to mean quarreling. Finally, the notion of incremental pressure is introduced, and clients are provided with an overview of what will be covered in subsequent sessions.

In the second session, the second and third levels of pressure are normally dealt with together. Level 2 pressure is called "incompatible activities," and the session begins with a discussion of the situations in which the drinker normally becomes intoxicated. This discussion is informed by the results of another questionnaire completed by the client at the first session. The purpose of the questionnaire is to delineate the benefits of drinking for the drinker. Clients are taught to identify and anticipate times of high risk of intoxication and, where possible, to plan activities that are incompatible with drinking too much but that go some of the way toward conferring the benefits of alcohol.

Level 3 pressure is called "responding," and the procedure involves examining the non-drinker’s responses before, during, and after a drinking session. It is surprisingly common for partners unwittingly to respond to the drinker in ways that reinforce the drinking. For example, it is known that some women spend more time interacting with their partner when he is drunk than when he is sober (Billings, Kessler, Gomberg, & Weiner, 1979; Davis & Berenson, cited in McCrady, 1988). Thus, level 3 pressure consists of coaching the nondrinker in the principles of contingency management. Clients are also coached in providing feedback to the drinker and in how to train the drinker to discriminate between acceptable and unacceptable levels of consumption. Partners are also instructed in ways of responding when the drinker is sober to ensure there is incentive to repeat the behavior. Finally, at level 3, clients are taught how to exploit occasions when the drinker is remorseful or in trouble because of his drinking. These are referred to as "crisis times," and clients are provided with a 24-hour help line and coached in how to encourage the drinker to make a call.

Level 4 pressure, or "contracting," involves the nondrinker in negotiating a contract with the drinker to abstain or moderate his drinking at high-risk times. These contracts may involve some transfer of reinforcers in exchange for sobriety. The partner is instructed to ensure that the initial contract is difficult but not impossible, and in the event that the agreement is dishonored, the client is taught how to exploit the occasion by treating it as a crisis time. With each breach of contract by the drinker, the pressure mounts for him to enter treatment.

In its original form, the final level of pressure (level 5) was referred to as "confrontation" and broadly followed the technique developed by Johnson (1973). To begin, partners identified individuals closest to the drinker who were also adversely affected by the drinker’s behavior. These individuals were then taught to write personal testimonials comprising three parts: (I) a declaration of the author’s love for the drinker, (2) feedback about the ways in which drinking was diminishing their relationship, and (3) a simple, unambiguous plea to change or seek help. At level 5, a meeting was arranged, and these testimonials were read aloud to the drinker by each author in turn. Following their first clinical trial with the pressures to change procedure, Barber and his colleagues (1995) softened level 5 pressure from "confrontation" to "involving others." According to Barber and Gilbertson (1996), their almost exclusively female clients were unhappy about employing such confrontational tactics, and most did not comply with level 5 instructions because they thought that the use of programmed confrontation would be stressful and injurious to their relationship with the drinker. Under the modified procedure, level 5 pressure involves rehearsing strategies with clients for training others in the drinker’s social network in the previous four levels of pressure.

In their first controlled trial with this procedure, Barber and Crisp (1995) randomly assigned one male and 31 female partners of heavy drinkers to one of three experimental conditions: (1) pressures to change offered in the form of individual counseling, (2) pressures to change offered in the form of group therapy, and (3) a no-treatment waiting list. As well as monitoring the effects of their intervention on drinkers, the authors also obtained pre and post measures of client well-being, self-esteem, depression, and marital harmony. Results of this study revealed that although approximately two-thirds of previously resistant drinkers volunteered for treatment or gave up alcohol following their partners’ involvement in either form of pressures to change, there was no improvement in clients’ subjective state. Barber and Gilbertson (1996) attributed this null result to the participants’ aversion to the confrontation involved in level 5 pressure.

Thus, in their larger follow-up study, Barber and Gilbertson (1996) modified the procedure as previously described before randomly assigning 45 women and three men to the same three groups as Barber and Crisp (1995), plus a fourth Al-Anon control condition. This study showed that both forms of pressures to change (individual and group) produced similar changes in the drinkers’ behavior to those achieved by Barber and Crisp but that neither no-treatment nor Al-Anon exerted any effect on the drinkers’ alcohol intake. However, only when pressures to change therapy was offered in the form of individual counseling did women also report reductions in personal problems. Moreover, women exposed to Al-Anon reported similar reductions in personal problems in spite of the fact that their partners’ drinking was undiminished.

In their most recent evaluation trial, Barber and Gilbertson (in press) compared the five-session pressures to change counseling procedure with a self-help manual based on the technique and a no-treatment control condition. Thirty-eight female partners of heavy drinkers were randomly allocated to the three conditions. Both forms of the pressures to change technique were found to exert similar and significant effects on the behavior of drinkers (giving up drinking or entering treatment), and both forms also produced significant improvements in the female partners’ level of self-reported depression relative to no-treatment controls. Hence, the authors concluded that when pressures to change intervention is offered in the form of individual counseling or a self-help manual, it is capable of influencing the drinker’s behavior and improving the female partner’s subjective well-being. The pressures to change procedure also has the advantage over the other techniques reviewed of being highly standardized and easy to administer.

Update
Family' members experiences of their older relative's
alcohol and substance misuse

- Johannessen, A., Tevik, K., Engedal, K., Tjelta, T., & Helvik, A. S. (2022). Family' members experiences of their older relative's alcohol and substance misuse. International journal of qualitative studies on health and well-being, 17(1), 2094059. https://doi.org/10.1080/17482631.2022.2094059

QUESTION 7
What are Barber’s five "levels of pressure" in the "Pressures to Change" procedure? To select and enter your answer go to Test.