Program Profile: Behavioral Couples Therapy for Substance Abuse

This is a therapy approach for drug- and alcohol-abusing couples and their families. The program is rated Promising. After 1 year, patients reported statistically significant reductions in drinking consequences; partner violence; and alcohol, drug, and family–social addiction severity index scores, compared with the comparison group. There were no statistically significant effects on other addiction severity indicators, days abstinent from substances, or relationship satisfaction.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals/Target Population

Behavioral Couples Therapy for Substance Abuse (BCT) is a family-based therapeutic approach for drug- and alcohol-abusing individuals and their partners. Research has shown that family and relationship factors appear to play a critical role in a patient’s abstinence from substance abuse and relapse after treatment. Therefore, involvement of intimate partners in the therapeutic process could increase the success of treatment and reduce the risk of relapse (Fals–Stewart and Birchler 2001; Fals–Stewart, O’Farrell and Birchler 2004). BCT is designed to address substance abuse problems while concurrently dealing with a patient’s family and relationship issues. The goal of BCT is to provide both individual and couples treatment to help drug- or alcohol-using individuals develop skills to change their behavior and improve their family relationships.

Program Components/Key Personnel

BCT patients are required to remain abstinent from drugs and alcohol through a sobriety contract, which is verbally agreed to and is reinforced with the help of the patient’s significant other. Patients are taught communication skills such as active listening and expressing feelings directly. They are also taught Cognitive–Behavioral Therapy skills to cope with exposure to drugs, identify high-risk situations, deal with cravings, and confront thoughts of use. Couples are encouraged to find positive behaviors and enjoyable activities that can be shared together to increase relationship satisfaction.

Meetings usually last 60 to 90 minutes and include individual, group, and couples’ sessions. BCT consists of three phases: 1) orientation, 2) primary treatment, and 3) discharge. During the 4-week orientation phase, basic medical information and history are collected. Patients attend the individual and group therapy sessions during this phase. The primary treatment phase lasts 12 weeks. Couples therapy sessions are added to the ongoing individual and group sessions. Couples are also asked to complete a Marriage Happiness Scale each week to measure the general happiness of partners in the relationship. During the 8-week discharge phase, patients attend only individual therapy sessions.

Throughout treatment, patients are required to submit urine or blood–alcohol breath samples at each session, though only one urine sample is tested a week.

Treatment can be delivered by a master’s-level therapist trained in BCT and supervised by a licensed certified social worker or by state-certified substance abuse counselors.

Study 1

Fals–Stewart and colleagues (2000) reanalyzed data originally collected for an evaluation conducted by Fals–Stewart, Birchler, and O’Farrell (1996). The 2000 study assessed the effectiveness of Behavioral Couples Therapy for Substance Abuse (BCT) in rates of individual change on marital adjustment and percentage of days abstinent from substance use, compared with a comparison group of those who received individual based treatment (IBT) with no couples therapy at 12 months’ follow-up. Of the 86 couples randomly assigned to either the BCT or IBT, 3 from each group were excluded from this analysis for not completing at least half of the assigned sessions. The final sample consisted of 40 couples in BCT and 40 couples in IBT.

Couples were recruited when the husband or cohabiting male partner entered one of two community-based outpatient clinics for substance abuse. Male patients had to be a) between 20 and 60 years old, b) either married for at least 1 year or in a stable cohabitating relationship for at least 2 years, c) meet abuse or dependence criteria per the Diagnostic and Statistical Manual of Mental Disorders, Third Addition Revised (DSM–3–R), for at least one psychoactive drug, with the primary drug of abuse not being alcohol, d) agree to abstain from drug use during treatment, and e) agree to refrain from seeking additional substance abuse treatment except self-help meetings such as Alcoholics Anonymous.

The participating husbands were on average 34.1 years old, high school educated, and had an average of two children. Eighty-four percent of the husbands were White, 13 percent were Black, and 4 percent were Hispanic. Husbands reported problematic drug and alcohol use for many years (alcohol use for an average of 8.4 years; opiate use for an average of 7.3 years; cocaine use for an average of 7.0 years; and cannabis use for an average of 7.4 years) and a low percentage of days abstinent (29.8 percent on average) from drug and alcohol use in the previous year. There were no statistically significant differences between the groups on these variables at baseline.

Husbands in the BCT group received one 60-minute weekly individual session, one 90-minute weekly drug abuse counseling therapy group, and one 60-minute weekly counseling session with their partners. Male patients in the IBT group received two 60-minute individual therapy sessions and one 90-minute group therapy session each week to teach coping skills to help patients remain abstinent of drugs and alcohol. The only difference between the BCT and IBT groups was that during the 12-week primary treatment phase, the BCT participants received one couples therapy session and one individual session each week, while the IBT cases received two individual sessions each week. Urinalysis and blood alcohol breath samples were taken weekly.

Data were collected from each partner as couples entered the study, at treatment completion, and every 3 months thereafter for 1 year. Use of alcohol and drugs (i.e., cannabis, cocaine, hallucinogens, inhalants, opiates, phencyclidine, sedative-hypnotics, and stimulants) was measured with the Timeline Followback Interview, using the percentage-of-days-abstinent index, which is the percentage of days in the defined measurement interval that husbands reported no substance use and were not in jail or a hospital for reasons related to drug or alcohol use. Relationship adjustment was measured with the Locke–Wallace Marital Adjustment Test of relationship satisfaction by averaging scores from each partner.

Hierarchical linear modeling with a linear growth curve random effects model specification was used to determine individual change, referring to change of individuals (husbands) or individual couples. Repeated measures analysis of variance were performed to compare the outcomes of husbands’ days abstinent and couples marital adjustment scores between the BCT and IBT groups over six time periods (pretreatment, posttreatment, and at 3-, 6-, 9-, and 12-months’ follow-up). The CrimeSolutions review of this study focused on the results at 12-months follow-up. No subgroup analyses were conducted.

Study 2

Winters and colleagues (2002) conducted a randomized controlled trial to assess the effectiveness of BCT for females entering substance abuse treatment and their male partners, on measures of relationship satisfaction, substance use, and various addiction severity outcomes at 12-month follow-up. Seventy-five couples were randomly assigned to either BCT (n = 37) or IBT (n = 38) conditions.

Females entering substance abuse treatment at one of two community-based outpatient clinics were included in the study if they a) were between the ages of 20 and 60, b) were married for at least a year or living with their male partner for at least 2 years, c) met abuse or dependence criteria for at least one psychoactive drug per the DSM–4, with their primary drug of abuse not being alcohol, d) agreed to refrain from substance use, and e) agreed to not seek additional treatment, except self-help meetings (e.g., Narcotics Anonymous).

During the 12-week primary treatment phase, female patients and their partners in the BCT group received the same treatment as described in Study 1 above, and female patients in the IBT group received the same individual and group therapy sessions. Both groups were required to give weekly urine and blood–alcohol breath samples.

Female partners in the BCT treatment group were on average 33.1 years old, and females in the IBT comparison group were on average 32.7 years old. The study sample were mostly White (68 percent of the BCT group, 71 percent of the IBT group) and had on average two children. Women in both groups reported years of problematic substance use (8.0 years of alcohol use in the BCT group, and 7.7 years in the IBT group; 6.0 years of cannabis use in the BCT group, and 6.2 years in the IBT group; 5.1 years of cocaine use in the BCT group and 5.4 years in the IBT group; and 4.5 years of opiates in the BCT group, compared with 5.0 years in the IBT group). There were no statistically significant differences between the groups on any pretreatment characteristics.

Relationship satisfaction was measured using the Dyadic Adjustment Scale. Substance use was measured using the Timeline Followback Interview (percentage of days abstinent) and the Addiction Severity Index (ASI). The ASI measured lifetime and recent (past 30 days) severity of problems in seven areas of functioning: alcohol, drug, family–social, employment, legal, medical, and psychiatric. Surveys were completed at pretreatment, at discharge, and at 3 months’, 6 months’, 9 months’, and 12 months’ posttreatment. The CrimeSolutions review of this study focused on the results at the 12-month follow-up.

A repeated-measures mixed analysis of variance with a Huynh–Feldt correction for inflated Type I error, and paired t–tests, were used to analyze the differences between BCT and IBT conditions on the relationship satisfaction, substance use, and ASI outcomes at the 12-month follow-up. No subgroup analyses were conducted.

Study 3

Fals–Stewart, Birchler, and Kelley (2006) used a randomized controlled trial to assess the effectiveness of BCT on measures of negative drinking-related consequences and partner violence. Participants were female alcoholics entering treatment and their non–substance abusing male partners. There were 138 couples assigned to one of three interventions: 1) BCT with IBT, 2) IBT only, or 3) psychoeducational attention control treatment. The CrimeSolutions review of this study focused on comparisons between the BCT treatment group (n = 46 couples) and IBT–only comparison group (n = 46).

To be eligible for inclusion, females had to a) be between 20 and 60 years old, b) be married at least 1 year or live with a romantic partner for 2 years, c) meet alcohol abuse or dependency criteria according to the DSM–IV, d) have alcohol as their drug of abuse, e) agree to remain abstinent from alcohol or other drugs during treatment, and f) agree to not seek other substance abuse treatment except self-help meetings unless recommended by their counselors.

The BCT–condition couples participated in sessions as described in Study 1. Female partners’ individual sessions focused on the treatment of alcoholism. In the IBT condition, female partners attended all 32 sessions for treatment of alcoholism by themselves.

Female partners in the BCT group were on average 32.4 years old, compared with 33.7 years old in the IBT group. Couples in the BCT group had been married or cohabitating for an average of 7.2 years, compared with 6.8 years in the IBT condition. Female partners in both groups were predominately White (57 percent of the BCT condition, and 61 percent of the IBT condition) and had about 7 years of problematic alcohol use. There were no statistically significant differences between conditions on any of these characteristics at baseline.

Alcohol use was measured by a percent-days-abstinent index derived from the Timeline Followback Interview. Adverse drinking consequences were measured with the Drinker Inventory of Consequences, which included five “consequences” subscales: physical, interpersonal, intrapersonal, impulse control, and social responsibility (the CrimeSolutions review of this study reported on total scores on this measure). At admission, female partners were interviewed about their drinking during the 90 days before treatment with the Timeline Followback Interview. After treatment completion and at 90-day intervals thereafter for 12 months, female partners provided information concerning alcohol use since last reporting. Partner violence was measured by items taken from the Conflict Tactics Scale of the Timeline Followback Interview—Spousal Violence method, which included “threw something at partner;” “pushed, grabbed or shoved;” “slapped;” “kicked, bit, or hit;” “hit, or tried to hit, with something;” “beat up;” “threatened with a knife or gun;” “used a knife or gun;” or “other types of physical aggression not otherwise specified.” Although data were collected from both partners, responses of female partners were used in the reported analyses. During each week of treatment, female partners were required to provide a urine and blood alcohol breath sample at each session. Participants completed interviews as they entered the study, at the end of the discharge phase, and every 3 months thereafter for 12 months.

Multiparameter chi-square tests were used to assess the outcomes of total adverse drinking consequences and partner violence at the 12-month follow-up. No subgroup analyses were conducted.

Fals-Stewart, O’Farrell and Birchler (1997) performed a cost–benefit analysis on married or cohabiting substance-abusing male patients who were assigned to Behavioral Couples Therapy (BCT) versus male patients assigned to Individual-Based Therapy (IBT). The benefit-to-cost ratio for men receiving BCT showed $5.00 in cost savings for every treatment dollar spent. The analyses showed that social costs for patients receiving BCT decreased significantly, with an average cost savings of nearly $7,000 per patient for BCT and a net benefit (after paying to deliver BCT) of nearly $5,000 per patient. In contrast, the average cost savings for IBT of nearly $2,000 per patient was not a statistically significant reduction in social costs, and the net benefit (after paying to deliver IBT) was only about $550 per patient.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Fals–Stewart, William, and Gary R. Birchler. 2001. “A National Survey of the Use of Couples Therapy in Substance Abuse Treatment.” Journal of Substance Abuse Treatment 20:277–83.

Fals–Stewart, William, Gary R. Birchler, and Timothy J. O’Farrell. 1996. “Behavioral Couples Therapy for Male Substance-Abusing Patients: Effects on Relationship Adjustment and Drug-Using Behavior.” Journal of Consulting and Clinical Psychology 64(4):959–72.

Fals–Stewart, William, Todd B. Kashdan, Timothy J. O’Farrell, and Gary R. Birchler. 2002. “Behavioral Couples Therapy for Drug-Abusing Patients: Effects on Partner Violence.” Journal of Substance Abuse Treatment 22:87–96.

Fals–Stewart, William, Keith Klostermann, Brian T. Yates, Timothy J. O’Farrell, and Gary R. Birchler. 2005. “Brief Relationship Therapy for Alcoholism: A Randomized Clinical Trial Examining Clinical Efficacy and Cost-Effectiveness.” Psychology of Addictive Behaviors 19(4):363–71.

Fals–Stewart, William, and Timothy J. O’Farrell. 2003. “Behavioral Family Counseling and Naltrexone for Male Opiod-Dependent Patients.” Journal of Consulting and Clinical Psychology 71(3):432–42.

Fals–Stewart, William, Timothy J. O’Farrell, and Gary R. Birchler. 1997. “Behavioral Couples Therapy for Male Substance-Abusing Patients: A Cost Outcomes Analysis.” Journal of Consulting and Clinical Psychology 65(5):789–802.

Fals–Stewart, William, Timothy J. O’Farrell, and Gary R. Birchler. 2001. “Behavioral Couples Therapy for Male Methadone Maintenance Patients: Effect on Drug-Using Behavior and Relationship Adjustment.” Behavior Therapy 32:391–411.

Fals–Stewart, William, Timothy J. O’Farrell, and Gary R. Birchler. 2004. “Behavioral Couples Therapy for Substance Abuse: Rationale, Methods, and Findings.” Science and Practice Perspectives 2(2):30–41.

Kelley, Michelle L., and William Fals–Stewart. 2002. “Couples- Versus Individual-Based Therapy for Alcohol and Drug Abuse: Effects on Children’s Psychosocial Functioning.” Journal of Consulting and Clinical Psychology 70(2):417–27.