Behavioral Couples Therapy for Substance Abuse (BCT) is a family-based treatment approach for substance- and alcohol-abusing couples and their families. The assumption underlying BCT is that therapeutic interventions that are designed to address substance abuse problems while concurrently dealing with a patient's family and relationship issues may provide a significant benefit because family and relationship factors appear to play a critical role in a patient’s abstinence from substance abuse and relapse after treatment. Involvement of intimate partners in the therapeutic process could increase the success of treatment and reduce the risk of relapse.
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: orientation, primary treatment, and 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.
Fals–Stewart and colleagues (2000) reanalyzed data from the Fals–Stewart, Birchler, and O’Farrell (1996) study to compare the change in substance use frequency and dyadic adjustment between intervention groups. The sample consisted of 86 couples randomly assigned to Behavioral Couples Therapy for Substance Abuse (BCT) or individual-based treatment (IBT). Of the 86 couples randomized, 3 from each intervention 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, c) meet abuse or dependence criteria per the Diagnostic and Statistical Manual of Mental Disorders, Third Addition Revised (DSM–III–R) for at least one psychoactive drug, d) agree to abstain from drug use during treatment, and e) agree to refrain from seeking additional substance abuse treatment. Excluded couples were those in which the female met DSM–III–R criteria for abuse or dependence of a psychoactive drug, either partner met DSM–III–R criteria for an organic mental disorder, or if either partner participated in a methadone maintenance program and had sought additional outpatient support.
Male patients in the IBT group received two 60-minute individual therapy sessions and one 90-minute group therapy session each week. This intervention aimed to teach coping skills to help patients remain abstinent of drugs and alcohol. Urinalysis and blood alcohol breath samples were taken weekly.
Data was 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 was measured with the Timeline Followback Interview (TLFB), using the percentage of days abstinent (PDA) index. Relationship adjustment was measured with the Locke–Wallace Marital Adjustment Test (MAT) by averaging scores from each partner.
Winters and colleagues (2002) looked at females entering substance abuse treatment and their male partners to examine the effect BCT had on relationship satisfaction and substance use. Seventy-five patients were randomly assigned to either BCT (n= 37) or IBT (n= 38) interventions. Patients in the IBT intervention group received twice-weekly 60-minute individual therapy sessions and once-weekly 90-minute group therapy sessions. Both intervention groups were required to give weekly urine and blood–alcohol breath samples.
Females 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, c) met abuse or dependence criteria for at least one psychoactive drug per the DSM–IV, d) agreed to refrain from substance use, and e) agreed to not seek additional treatment. A couple was excluded if the male partner met DSM–IV criteria for drug abuse or dependence in the past 6 months, if either partner met DSM–IV criteria for a mental or psychotic disorder, or if the female patient was in a methadone maintenance program.
Relationship satisfaction was measured using the Dyadic Adjustment Scale (DAS) and the Marital Happiness Scale (MHS). Substance use was measured using the TLFB and the Addiction Severity Index. Surveys were completed at pretreatment, at discharge, and at 3 months, 6 months, 9 months, and 1 year posttreatment. The MHS was also completed weekly during treatment.
Fals–Stewart, Birchler, and Kelley (2006) used a randomized controlled trial to examine whether BCT participants would report lower frequency alcohol use and higher relationship satisfaction than the comparison groups. They also looked at the effect of BCT on partner violence. Participants were female alcoholics entering treatment and their non–substance abusing male partners. Couples were assigned to one of three interventions: BCT with IBT, IBT only, or psychoeducational attention control treatment (PACT). Each intervention was assigned 46 couples who met the study criteria and were not significantly different. Women in the IBT intervention participated in individual therapy without a couple’s component. Women in the PACT intervention attended individual therapy, while their partners attended lectures about substance abuse.
To be included in the study, 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, c) meet alcohol abuse or dependency criteria according to the DSM–IV, d) have alcohol as their drug of choice, e) agree to remain abstinent of alcohol or other drugs during treatment, and f) agree to not seek other substance abuse treatment unless recommended by their counselors. A couple was excluded if the male partner met DSM–IV criteria for a substance use disorder or if either partner showed evidence of a psychotic disorder. All eligible couples gave informed consent to participate.
Alcohol use was measured by a PDA index derived from the TLFB. Adverse drinking consequences were measured with the Drinker Inventory of Consequences (DrInC). Relationship satisfaction was measured by the DAS. Partner violence was measured by items taken from the Conflict Tactics Scale of the TLFB–Spousal Violence (TLFB–SV) method. Participants completed interviews as they entered the study, at the end of the discharge phase, and every 3 months thereafter for 12 months.
The study by Fals–Stewart and colleagues (2000) found that at pretreatment and immediately following posttreatment both intervention groups had no significant difference in percentage of days abstinent (PDA). But at the 3- and 6-month follow-up periods the Behavioral Couples Therapy for Substance Abuse (BCT) group showed a significantly greater PDA than the individual-based treatment (IBT) group showed. Over the entire follow-up period, the BCT group showed a significantly larger proportion of patients reporting significant reductions in substance use, when compared to those in the IBT group.
Relationship adjustment scores at pretreatment were not different. But immediately posttreatment and at the 3-month follow-up, the BCT group had significantly higher scores. Compared over time, the BCT group showed significant improvements on their Marital Adjustment Test (MAT) scores, when compared with couples in the IBT group. Couples in the IBT group showed significant deterioration of scores over time.
The study by Winters and colleagues (2002) showed that couples in the BCT intervention reported significantly higher Marital Happiness Scale (MHS) scores during weeks 5–12 of treatment than couples in the IBT group reported. Relationship adjustment from the DAS scores was significantly higher for the BCT group during the 3- and 6-month follow-ups but not at any other time.
At the 3-, 6-, and 9-month follow-ups, BCT patients showed a significantly higher PDA than the IBT group, but no significant difference was found at any other point in time. The BCT group relapsed at a significantly slower rate than the IBT group over time.
There was no significant difference between interventions for PDA at pretreatment and posttreatment or rate of change during treatment in the Fals–Stewart, Birchler, and Kelley (2006) study. Over the 12-month follow-up period, however, BCT patients increased their drinking at a significantly slower rate than patients in IBT or psychoeducational attention control treatment (PACT).
During treatment, BCT couples had a faster rate of improvement in relationship satisfaction than couples in IBT or PACT. Immediately posttreatment, BCT couples had higher Dyadic Adjustment Scale (DAS) scores and declined at a slower rate during the 12-month follow-up period.
At pretreatment there were no differences between interventions on the Drinker Inventory of Consequences (DrInC) or the Conflict Tactics Scale of the Timeline Followback Interview–Spousal Violence (TLFB–SV). The 12-month follow-up revealed significantly greater reductions on the Interpersonal, Intrapersonal, and Social Responsibility subscales of the DrInC and in the Days Any Violence (Male to Female and Female to Male) subscales of the TLFB–SV for the BCT couples.