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ORIGINAL ARTICLE

Behavioral Couples Therapy for Substance Abusers: Where Do We Go From Here?

Keith Klostermann1, Michelle L. Kelley1, Theresa Mignone2, Lori Pusateri1

and Kristi Wills3

1Department of Psychology, Old Dominion University, Norfolk, Virginia, USA; 2VA Western New York Healthcare System at Buffalo, Buffalo, New York, USA; 3Northpointe Council, Inc., Niagara Falls, New York, USA

Behavioral couples therapy (BCT) is an evidence- based family treatment for substance abuse. The re- sults of numerous investigations over the past 30 years indicate that participation in this treatment by married or cohabiting substance-abusing patients, compared with more traditional individual-based interventions, results in greater reductions in substance use, higher levels of relationship satisfaction, greater reductions in partner violence, and more favorable cost outcomes. This review examines the rationale for using BCT, the empirical literature supporting its use, methods used as part of this intervention, and future research directions.

Keywords behavioral couples therapy, couples therapy, substance abuse treatment

INTRODUCTION

The critical role of the family in the development and maintenance of substance abuse1 is now widely acknowl- edged by researchers and practitioners alike. As a result, a growing number of service providers are working with nonsubstance-using family members to help support the substance user’s attempts at sobriety. During the last three decades, multiple clinical studies have demonstrated the effectiveness of family-based treatment approaches for treating substance users. As an example, in their meta- analytic review of randomized clinical trials, Stanton and Shadish (1997) demonstrated that compared with individual-based interventions that focus exclusively on the substance-using client, family-involved treatments re- sult in higher levels of abstinence.

Indeed, among the various psychosocial interventions presently available to treat alcoholism and drug abuse, it

1The journal’s style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor’s note. Address correspondence to Keith Klostermann, Department of Psychology, Old Dominion University, Room 134C, Mills Godwin Building, Norfolk, VA 23529-0267; E-mail: kklostem@odu.edu.

could be reasonably argued that partner-involved treat- ments are the most broadly efficacious. There is not only substantial empirical support for the use of couple-based treatments in terms of improvements in primary targeted outcomes such as substance use and relationship adjust- ment but also in other areas that are of clear public health significance, including intimate partner violence (IPV) and cost–benefit and cost-effectiveness.

Behavioral couples therapy (BCT) is a theoretically based, manualized, and empirically supported treatment based on social learning theory, which posits that dis- tressed couples engage in interaction patterns character- ized by punishment rather than mutual positive reinforce- ment of relationship benefiting behaviors (Byrne, Carr, & Clark, 2004; Jacobson & Margolin, 1979). While initially developed as a marital therapy model for use in general psychotherapy, in the past three decades, BCT has also been shown to be an effective conjoint treatment for alco- holism and drug abuse (e.g., Emmelkamp & Vedel, 2006). In this review, we will: (1) provide a conceptual ratio- nale as to why couples therapy for substance-using pa- tients may be particularly appealing compared with more traditional individual-based approaches; (2) describe the- oretical and practical considerations when implementing couples therapy with patients; (3) describe recent variants of the standard BCT model and discuss preliminary evi- dence supporting their efficacy with substance-using pa- tients; and (4) identify future BCT research directions.

BCT FOR SUBSTANCE USERS: RATIONALE

Theoretical Rationale for Use of Couples Therapy to Treat Substance Use Disorders The interconnection between substance use and relation- ship distress appears to be marked by what can be best

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described as “reciprocal causality.” Alcoholism and drug use by one partner often appears to contribute to relation- ship problems that are observed in these dyads (e.g., high levels of relationship dissatisfaction, instability, conflict, sexual dissatisfaction, psychological distress, violence). At the same time, relationship dysfunction is strongly linked to substance use and appears to be a major con- tributing factor to relapse among alcoholics and drug users after treatment (e.g., Epstein & McCrady, 1998; Lemke, Brennan, & Schutte, 2007; Maisto, O’Farrell, McKay, Connors, & Pelcovitz, 1988). Thus, substance use and relationship problems seem to reinforce one another, thereby creating an unhealthy and dysfunctional cycle, from which couples often have difficulty disengaging.

BCT has two primary objectives that evolved from a recognition of the interrelationship between substance use and family interaction: (1) eliminate problem-producing drinking and drug use and harness the support of the relationship to positively support the patient’s efforts to change and (2) alter dyadic and family interaction patterns to promote a family environment that is more conducive to long-term stable abstinence. Thus, the goal of BCT is to create a “virtuous cycle” (i.e., enlisting the nonsubstance- abusing partner’s support in the client’s recovery) between substance use recovery and relationship functioning by us- ing interventions designed to address both sets of issues concurrently and reinforce positive behaviors.

Primary BCT Treatment Elements In the early stages of treatment, therapists delivering BCT concentrate on shifting the focus from negative feelings and interactions about past and possible future drinking or drug use to positive behavioral exchanges between part- ners. In later sessions, emphasis is placed on communica- tion skills training, problem-solving strategies, negotiat- ing behavior change agreements, and continuing recovery strategies.

BCT Methods Used to Address Substance Use As the term BCT implies, the therapist treats the substance-using patient with his or her intimate partner and works to build support for abstinence from within the dyadic system. The therapist, with extensive input from the partners, develops and has the partners enter into a “recovery contract” (which is also referred to as a “so- briety contract”). As part of the contract, partners agree to engage in a brief, daily “sobriety trust discussion,” in which the substance-using partner explicitly states his or her intent of not to drink or use drugs that day. In turn, the patient’s partner verbally expresses positive support for the patient’s efforts to remain sober and tracks per- formance of this activity on a daily calendar provided by the therapist. As a condition of the recovery contract, both partners agree not to discuss past drinking or drug use or fears of future substance use when at home (i.e., between scheduled couple therapy sessions) during the course of couples treatment. Thus, the focus of treatment is on the present and the future, rather than dredging up issues and problems from the past. Simply stated, the couple can- not change the past but, in BCT, has an opportunity for a

different present and future. Partners are asked to reserve such discussions for the couple therapy sessions, which can then be monitored and, if needed, mediated by the therapist. Many contracts also include specific provisions for partners’ regular attendance at self-help meetings (e.g., Alcoholics Anonymous, Al-Anon).

At the start of a typical BCT session, the therapist re- views the calendar to ascertain overall compliance with different components of the contract. The calendar pro- vides an ongoing record of progress that is reviewed by the therapist and clients at each session and provides a vi- sual (and temporal) record of problems with adherence to home practice assignments that can be addressed by the therapist and couple. For couples who have difficulty in maintaining the calendar, the therapist works with the partners to identify potential barriers as well as strategies that may be implemented to overcome any obstacles. In an effort to ensure that between-session activities are per- formed correctly, at each session, the therapist asks the couple to perform the assigned tasks and provides correc- tive feedback as needed.

BCT Methods Used to Enhance Relationship Functioning Through the use of standard couple-based behavioral as- signments, BCT also seeks to increase positive feelings, shared activities, and constructive communication; these relationship factors are viewed as conducive to sobriety. Catch Your Partner Doing Something Nice (Turner, 1972) has made each partner notice and acknowledge one pleas- ing behavior performed by the other each day. In the Car- ing Day assignment (e.g., Liberman, Wheeler, deVisser, Kuehnel, & Kuehnel, 1980), each partner is asked to sur- prise their significant other with a day of special things that show care for their partner. Planning and engaging in mutually agreed-upon Shared Rewarding Activities (e.g., O’Farrell & Cutter, 1984) is important because years of alcohol and drug abuse may have resulted in the cessation of conjoint shared pleasing activities. As a result, each activity must involve both partners, either as a dyad or with their children or other adults, and can be performed at or away from home. Teaching Communication Skills (e.g., Gottman, Notarius, Gonso, & Markman, 1976) such as paraphrasing, empathizing, and validating can help the substance-using patient and his or her partner better ad- dress stressors in their relationship and in their lives as they arise, which is also viewed as reducing the risk of relapses.

Couples-Based Relapse Prevention and Planning Relapse prevention (RP) occurs during the final stages of BCT. In this phase, the partners develop a written plan (i.e., Continuing Recovery Plan) designed to promote stable abstinence (e.g., continuation of a daily Sobriety Trust Discussion, attending self-help support meetings) and list contingency plans should a relapse occur (e.g., re- contacting the therapist, reengaging in self-help support meetings, contacting a sponsor) posttreatment. A key ele- ment in creating the Continuing Recovery Plan for many couples is the negotiation of the posttreatment duration

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of the agreed-to activities, which is often a problem for many partners. As an example, the substance-using part- ner may want a life that does not involve the structured exercises that are part of BCT, whereas the nonsubstance- using partner is often apprehensive and suspicious about the progress made in treatment (i.e., relationship improve- ment, abstinence) and thus advocates for continued in- volvement with certain activities (e.g., self-help meeting attendance, Sobriety Trust Discussions). In this situation, partners develop a mutually agreed-to, long-term grad- ual reduction of the frequency of the activity until it is eliminated (e.g., for the first month, daily Sobriety Trust Discussion with observed medication taking, as was done during active treatment; for the second month, the Sobri- ety Trust Discussion is performed three times per week with observed medication taking; for the third month, the Sobriety Trust Discussion is performed once per week with observed medication taking, and so forth). If prob- lems arise with any of the planned transitions, partners are encouraged to contact their BCT counselor.

Session Structure and Treatment Duration BCT sessions tend to be moderately to highly structured. Simply stated, each BCT session consists of three ob- jectives: (1) review of relationship problems, any sub- stance use, and home practice; (2) introduction of new material; and (3) assign home practice. A typical BCT session begins with an update on any drinking or drug use that has occurred since the last session. Compliance with the recovery contract is reviewed and any barriers to compliance are discussed and addressed. The session then transitions to a review of any home practice from the pre- vious session. Relationship or other difficulties that may have arisen during the last week are then addressed during the session, with the goal being problem resolution. Next, new material (e.g., instruction in and rehearsal of skills to be practiced at home during the week) is introduced and modeled in front of the therapist to ensure that the activity is conducted correctly. At the end of each session, partners are given specific home practice assignments to complete before the next scheduled session.

In response to the desire to better meet the diverse needs of clients and their partners, the standard BCT model has evolved into several offshoot approaches in the general psychotherapy treatment arena. These variations include enhanced cognitive behavioral therapy (ECBT), self-regulatory couple therapy (SRCT), and integrative- behavioral couples therapy (IBCT; Kelly & Iwamasa, 2005). Each of these approaches is built upon the BCT framework but possesses characteristics that distinguish them from the standard model as well as from each other. For example, in ECBT, the couples dysfunction is believed to result from intrapersonal factors (i.e., cognitions and emotions) and environmental factors; thus, treatment is focused on these two areas (Chapman & Dehle, 2002; Epstein & Baucom, 2002). The goal of SRCT is to help each partner identify ways to alter his or her own thinking and behavior in the hope of increasing relationship satis- faction (Halford, 1998). Couples in IBCT are taught con-

textual and behavioral strategies to increase acceptance of one another (Christensen, Jacobson, & Babcock, 1995). While the emphasis in each of these variant approaches is different, one commonality across all three is the impor- tance of individual accountability and change rather than changing couple interactions (Kelly & Iwamasa, 2005).

RESEARCH FINDINGS ON BCT

Primary Outcomes: Effects on Substance Use and Relationship Adjustment Couples therapy for treating alcohol and drug use has re- ceived extensive empirical scrutiny, with most research focusing on BCT. O’Farrell et al. (1985) randomly as- signed male alcoholics and their female partners to al- coholism counseling (e.g., 12-step facilitation, disulfiram encouragement), alcoholism counseling along with inter- actional couples group therapy, or alcoholism counseling along with BCT. While participants in the BCT condition reported relationship benefits during the two-year follow- up, men in all conditions improved significantly as indi- cated by the number of nondrinking days. McCrady et al. (1986) examined the impact of spouse involvement in be- havioral interventions for alcoholism. More specifically, this study compared minimal spouse involvement (MSI), alcohol-focused spouse intervention (AFSI), or BCT in a sample of 37 alcohol-abusing patients and their part- ners. Findings revealed that BCT was superior to AFSI and MSI in reducing alcohol use and increasing relation- ship satisfaction at posttreatment and during the 18-month follow-up phase of the study. In a sample of problem drinkers, Walitzer and Derman (2004) compared individ- ual, cognitive behavioral therapy (CBT), AFSI, and BCT. Although participants in both the BCT and AFSI con- ditions outperformed those assigned to the CBT condi- tion in terms of drinking outcomes at posttreatment and follow-up, BCT did not produce significantly better re- lationship satisfaction than AFSI. More recently, Vedel, Emmelkamp, and Schippers (2008) enrolled 64 alcohol disorder patients (male and female) and their partners in BCT or CBT. While drinking outcomes were similar at posttreatment for clients in each condition, participants in the BCT condition reported greater relationship satisfac- tion. Importantly, improvements in specific objectives of BCT (i.e., positive communication, shared activities, and negotiation of agreements) have been positively correlated with marital satisfaction in couples taking part in BCT.

Collectively, research has shown that BCT results in equal or great likelihood of client abstinence. Moreover, with few exceptions (see Walitzer & Derman, 2004), BCT has been shown to result in superior outcomes in terms of relationship functioning.

BCT With Female Substance-Using Clients Dyadic conflict and relationship stress may have partic- ularly strong links to problematic use and relapse for women. For instance, Green, Pugh, McCrady, and Epstein (2008) found that 47% of alcohol-abusing women in sub- stance user treatment indicated martial situations (e.g., an

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argument with her partner) as reasons for drinking. Sim- ilarly, Lemke et al. (2007) found that family problems and emotional distress were linked to relapse for alcohol- abusing women. Moreover, in a study of 102 women and their partners, Graff et al. (2009) found that women re- ported attending more treatment sessions and were more engaged in treatment if they were in more satisfying mar- tial relationships, had fewer children at home, reported fewer alcohol dependence symptoms, diagnosed with an alcohol problem at a later age, and had partners who condoned and encouraged their drinking behavior. Be- cause relationship factors appear to have a critical role in the maintenance and exacerbation of substance use for women, interventions such as BCT, which are specifically designed to address both relationship and substance-use- related issues concurrently, would seem likely to have a particular benefit for substance-using women.

In a recent study by McCrady Epstein, Cook, Jensen, and Hildebrandt (2009), BCT for alcohol use disorders (alcohol behavioral couple therapy [ABCT]) was more ef- fective than individual therapy for alcohol use disorders (alcohol behavioral individual therapy [ABIT]) regard- ing percentage of days abstinent (PDA) and percentage of days of heavy drinking (PHD). In addition, women with poorer baseline relationship functioning showed greater improvement on PDA during treatment with ABCT than with ABIT. Women with better baseline relationship func- tioning showed greater improvement during and after treatment on PDH as compared with those who partic- ipated in ABIT. ABCT also showed greater benefit for women who had associated Axis I and Axis II disorders (McCrady et al., 2009).

BCT for Gay and Lesbian Couples Studies consistently report higher drug and alcohol use among lesbian, gay, bisexual, and transgendered (LGBT) women (Cochran & Mays, 2009; McCabe, Hughes, Bostwick, West, & Boyd, 2009). For instance, McCabe et al. (2009) found that compared with heterosexual women, LGBT women had greater odds for past year substance abuse and dependence. These results, based on a national sample, are consistent with findings based on California (Cochran & Mays, 2007) and New York (Meyer, Schwartz, & Frost, 2008) samples. Moreover, other factors that may need to be considered for sexual minorities are sexual minority stress, social and commu- nity support/isolation, internalized homophobia, and con- cealment. More specifically, it may be the case that many LGBT couples do not obtain treatment because they are not out/experience high internalized homophobia, fear ad- ditional discrimination, may be unable to obtain insurance via their partners, and so forth. Unfortunately, system- atic examinations of LGBT individuals treated with BCT are lacking. Clearly, this is an important area for future investigation.

IPV The results of multiple studies suggest that roughly two- thirds of the married or cohabiting men entering treat-

ment for alcoholism, or their partners, report at least one episode of male-to-female physical aggression in the year prior to program entry. Estimates of physical aggres- sion among men entering substance user treatment pro- grams are four times higher than IPV prevalence estimates from nationally representative surveys (e.g., O’Farrell & Murphy, 1995). Mignone, Klostermann, and Chen (2009) found that the likelihood of male-to-female physical ag- gression was nearly eight times higher on days of drinking than on days of no drinking for married or cohabiting men after completing alcoholism treatment. A prelimi- nary study revealed that BCT has been associated with a 60% reduction of IPV prevalence and frequency among alcohol- and drug-abusing men and their nonsubstance- using female partners during the year after treatment com- pared with baseline levels (O’Farrell et al., 2004).

Cost Outcomes O’Farrell, Choquette, Cutter, Floyd, et al. (1996) pre- sented cost outcomes comparing equally intensive, manualized treatments: (1) BCT along with individual counseling; (2) interactional couples therapy along with individual counseling; and (3) individual counseling only. The cost–benefit analysis of BCT along with individual alcoholism counseling revealed that: (1) average costs per case for alcohol-consumption-related hospital treatments and jail stays decreased from about $7,800 in the year be- fore to about $1,100 in two years after BCT, with cost savings averaging about $6,700 per case; and (2) a benefit- to-cost ratio of $8.64 in cost savings for every dollar spent to deliver BCT. None of the positive cost–benefit results observed for BCT were found for subjects assigned to the interactional couples therapy along with individual alco- holism counseling condition, in which posttreatment uti- lization costs increased.

O’Farrell, Choquette, Cutter, Brown, et al. (1996) pre- sented cost outcomes for a second study in which manual- ized BCT with added couples RP sessions was compared with manualized BCT alone. Costs of treatment delivery and health and legal service utilization were measured for 12 months prior to BCT and 12 months after BCT. Results of cost–benefit analyses revealed that both standard BCT and for the longer and more costly form of BCT with addi- tional RP sessions showed decreases in health care utiliza- tion and legal costs after treatment with an average cost savings per case of $5,053 for BCT only and $3,365 for BCT-plus-RP. The benefit-to-cost ratios for every dollar spent were $5.97 for BCT only and $1.89 for BCT-plus- RP in cost savings for every dollar spent. Despite the fact that adding RP to BCT led to less drinking and better rela- tionship adjustment, it did not lead to greater cost savings (e.g., decrease in health and legal service utilization) or a more favorable benefit-to-cost ratio than BCT only. In fact, adding RP to BCT nearly doubled the cost of deliv- ering the standard BCT protocol. Moreover, the results of cost-effectiveness analyses indicated that BCT only was more cost-effective than BCT-plus-RP in producing ab- stinence from drinking; however, the two treatments were equally cost-effective when marital adjustment outcomes

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were considered. Since BCT only was less effective clin- ically compared with BCT-plus-RP in terms of abstinent days, it was the lower cost of BCT only that produced its greater cost-effectiveness in relation to abstinence.

FUTURE DIRECTIONS

The effectiveness of BCT for substance-using patients and their partners is no longer in question. In fact, Division 50 of the American Psychological Association (Empiri- cally Supported Treatments for Substance Use Disorders Committee) recently reviewed the outcome evidence for BCT for alcohol dependence and concluded that this treat- ment meets the criteria for “well-established” treatment, which is the highest level of empirical support recognized by Division 50. As a result, new questions are emerging and shaping the research agenda. In addition to provid- ing an overview of the model, this review discussed sev- eral current directions of BCT research. However, gaps in the overall BCT research agenda still exist and must be addressed in future studies. From our vantage point, in- vestigations in the following five areas seem most press- ing: (1) dissemination of BCT to community-based treat- ment programs; (2) exploration of the effects of BCT with dual drug-using couples (i.e., dyads in which both partners have current drug and/or alcohol-consumption- related problems); (3) investigation of the effects of BCT with sexual minority couples; (4) examination of the active components underlying the effects of BCT; and (5) exploring BCT as a stepped care approach; further study of the addition of other intervention components to standard BCT was specifically targeted to enhance im- portant secondary outcomes, particularly decreases in IPV and improvements in children’s psychosocial adjustment.

Dissemination Although BCT has a very strong research support for its efficacy, it is not yet widely used in community- based alcoholism and drug user treatment. McGovern, Fox, Xie, and Drake (2004) examined community addic- tion providers (i.e., Directors [n = 21] and clinicians [n = 89]), experiences, beliefs, and readiness to implement a variety of evidence-based practices. Results were mixed; providers reported more readiness to adopt 12-step fa- cilitation, CBT, motivational interviewing, and RP, while less readiness to implement contingency management, BCT, and pharmacotherapies. McGovern and colleagues concluded that in order for treatments to be successfully disseminated, investigators must clearly demonstrate the relevance of the treatment to clinicians and staff, even if empirical support is already established. Other factors to consider include degree of difficulty in implementation, how closely (or not) the treatment is aligned with the ther- apist’s preferred theoretical orientation or agency coun- seling approach, cost of providing treatment, and whether or not the treatment fills a perceived area of need for the clinic. Each of these areas may serve as a potential barrier to successful dissemination of the treatment.

BCT for Dual Substance-Using Couples Historically, couples in whom both partners have a diag- nosis of an alcohol or other substance use disorder have typically been excluded from BCT clinical trials. A pri- mary tenant of BCT is that there is a support within the dyadic and family systems for abstinence, particularly from the nonsubstance-using partner. However, a chal- lenge in treating dual-using couples is that both partners may not be supportive of abstinence. In particular, com- pared with men, women are more likely to have partners, friends, and family members who use and misuse drugs (Bendtsen, Dahlström, & Lejman, 2002; Hser, Evans, & Huang, 2005) and often report using or discontinuing substance use for the sake of her partner (Sun, 2007). Moreover, having a partner who misuses alcohol or other substances is more strongly associated with higher rates of relapse for women than for men (Grella, Scott, Foss, Joshi, & Hser, 2003). Although treating dual-using cou- ples presents a serious challenge for both men and women, female substance users may be especially likely to face difficulty while seeking treatment and maintaining absti- nence of a substance-using partner because of the social and gender norms.

While there is currently a dearth of research on these types of couples, our clinical and anecdotal experience with partners in these couples suggests that they have fairly poor outcomes. More specifically, one partner’s suc- cess in eliminating his or her substance use seems to change the dynamic between the partners, which often results in the dissolution of the relationship. In most in- stances, however, the treatment-seeking partner fails to stop drinking or using drugs and the relationship sur- vives. While BCT may be ineffective with these cou- ples, given these challenges, it has not been sufficiently researched, especially with drug-using (as opposed to alcohol-dependent) couples, to determine efficacy.

Barring separation or dyadic dissolution (which, in our experience, is infrequent) treatments are needed to con- currently address family issues and substance use. At present, contingency management approaches (i.e., pro- viding voucher incentives for attendance and abstinence by both partners) are being used with some success with these couples. Although the initial findings are encourag- ing, this research effort is in its infancy and more data are necessary before definitive conclusions can be drawn.

Identifying the Active Components of Treatment Despite the efforts of BCT researchers to develop success- ful treatments, conduct rigorous clinical trials, and spell out in treatment manuals what the treatments consist of, little research has actually investigated the active compo- nents of these treatments (Longabaugh, 2007). Although BCT appears to work, very little research has been con- ducted to determine which of the treatment components accounts for the largest variance of change. As noted by Collins, Murphy, Nair, and Strecher (2005), behavioral in- terventions can be considered as an aggregate of a set of components; some may be having the intended effect, oth- ers may be having no effect, and yet others may actually be

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counterproductive and serve to reduce the overall effect of the intervention. Refining the standard BCT intervention to only include active treatment components and eliminate inactive and counterproductive components will result in a more clinically effective, cost-effective, and optimal inter- vention. Thus, future BCT investigators should consider use of experimental research designs to dismantle the ef- fects of the three primary BCT components (i.e., rela- tionship enhancement, continuing recovery, and recovery contract), which may be accomplished through use of fac- torial designs.

BCT as a Stepped Care Approach Despite BCTs demonstrated efficacy, there are large in- dividual differences in patient response to treatment. As noted by McKay (2009), even for the most efficacious treatments, there are a certain number of people who do not respond to treatment; yet in an effort to tightly control the intervention, nonresponding patients receive the same amount of manualized treatment as those who respond well. Research on standardized interventions to treat sub- stance abuse disorders is beginning to shift away from a “one-size-fits-all” perspective and move toward adap- tive interventions. Adaptive interventions, although stan- dardized, call for different dosages of treatment to be em- ployed strategically with patients across time. Given the heterogeneity in patient characteristics and response to treatment, future studies are needed to develop a tailored BCT intervention based on treatment algorithms that dic- tate treatment modifications triggered by the patient’s ini- tial response and changes in symptom severity. Thus, a flexible version of BCT may be more easily disseminated to community providers and more palatable to patients re- ceiving treatment.

Additions to a Standard BCT Targeted to Enhance Secondary Outcomes Preliminary research is currently underway to examine the effect of adding circumscribed interventions (parent skills training and partner violence reduction strategies) to the standard BCT intervention package. However, larger clin- ical investigations are necessary to determine if the ad- dition of these components will enhance the effects of a standard BCT on these secondary outcomes.

CONCLUSION

Couples therapy, as an intervention for alcoholism and drug use, has made substantial strides in recent decades. What the next 30 years of BCT research holds is unclear; many of the future directions for BCT research described in this review were only identified during the last several years as the findings of new and ongoing studies were reported and illuminated new avenues to explore. Thus, on the basis of the findings from current BCT investiga- tions and results from studies in other disciplines, as well as changing public health priorities, the direction of BCT can and will most likely change from what has been out-

lined here. However, the overarching objectives of this programmatic line of research will remain unchanged, as they have been for the last quarter century. First, from a research perspective, BCT investigators will continue to modify, refine, and reevaluate the intervention to make what is already a very effective intervention even more so. Second, from a clinical vantage point, a fundamen- tal goal continues to be a transfer of this well-established treatment technology to standard substance user treatment providers such that BCT will be more available to drug user and alcohol-misusing couples who are likely to ben- efit from participating in the program.

Declaration of Interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

RÉSUMÉ

Thérapie comportementale avec des couples qui utilisent des drogues: Où allons-nous partir d’ici

Behavioral Couples Therapy (BCT) est un traitement de la famille en évidence des problèmes de toxicomanie. Les résultats de nombreuses recherches au cours des 30 dernières années indiquent que la participation à ce traite- ment par mariés ou non toxicomanes patients, compara- tivement à plus traditionnelles interventions individuelles, des résultats de plus grandes réductions de la consomma- tion de substances, des niveaux plus élevés de satisfaction conjugale, des réductions plus importantes dans la vio- lence entre partenaires, et des résultats de coûts plus fa- vorable. Cette revue de la justification de l’utilisation de la BCT, la littérature empirique étayant son utilisation, les méthodes utilisées dans le cadre de cette intervention, et des directions de recherche future.

RESUMEN

La terapia conductual Parejas de Usuarios de Drogas: ¿A dónde vamos desde aquı́?

Comportamiento Terapia de Pareja es un tratamiento basado en evidencia de la familia por uso de dro- gas..Los resultados de numerosas investigaciones durante los últimos 30 años indican que la participación en este tratamiento por casadas o unidas que abusan de sustan- cias pacientes, en comparación con las intervenciones de base individual más tradicional, se traduce en una mayor reducción en el consumo de drogas, mayores niveles de satisfacción de la relación, una mayor reducción en la vio- lencia de pareja, y los resultados de costos más favorables. Esta revisión examina la justificación del uso de BCT, la literatura empı́rica que apoya su uso, los métodos utiliza- dos en el marco de esta intervención, y las direcciones fu- turas de investigación.

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THE AUTHORS Keith Klostermann, Ph.D., is a Research Assistant Professor at the Old Dominion University. Dr. Klostermann’s research interests lie in each of the following general areas: (1) IPV among married or cohabiting substance-abusing patients; (2) marital and family therapy with substance-abusing patients; (3) psychosocial adjustment of families (i.e., parents and children); and (4) parent training

with substance-abusing patients who have custodial children.

Michelle L. Kelley, Ph.D., is a Professor of psychology in the Department of Psychology at the Old Dominion University. Her primary research interests are in the psychosocial functioning of children living with fathers or mothers dependent on alcohol or other drugs and research examining the effectiveness of parent treatment for alcoholism or other substance addiction for children’s immediate and short-

term psychosocial functioning.

Theresa Mignone, Ph.D., is a Psychologist at the VA Western New York Healthcare Center. Dr. Mignone’s primary research interest involves treatments for posttraumatic stress disorder (PTSD) and partner violence among married or cohabiting patients in both the general population and military samples.

Lori Pusateri, M.S., L.M.H.C, is a New York State licensed mental health counselor and Health Project Coordinator on a National Institute on Drug Abuse-funded clinical trial examining the effects of fathers’ drug use on the family unit. Ms. Pusateri’s research interests include couples and family treatments and IPV among drug- and alcohol-abusing couples.

Kristi Wills, M.S., C.A.S.A.C, is a New York State Credentialed Alcoholism and Substance Abuse Counselor and Site Coordinator for Northpointe Council, Inc., an outpatient substance abuse treatment facility. Ms. Wills’ research interests include men and women in abusive relationships with using partners as well as the effects of drugs and alcohol on the family system.

REFERENCES

Bendtsen, P., Dahlström, M., & Lejman, B. P. (2002). Sociodemo- graphic gender differences in patients attending a community- based alcohol treatment centre. Addictive Behaviors, 27, 21–33.

Byrne, M. C., Carr, A., & Clark, M. (2004). The efficacy of behav- ioral couples therapy and emotionally focused therapy for cou- ple distress. Contemporary Family Therapy: An International Journal, 26, 361–387.

Chapman, A. I., & Dehle, C. (2002). Bridging theory and practice: A comparative analysis of integrative behavioral couple therapy and cognitive behavioral couple therapy. Cognitive and Behav- ioral Practice, 9, 150–163.

Christensen, A., Jacobson, N. S., & Babcock, J. C. (1995). Integra- tive behavioral couple therapy. In N. S. Jacobson & A. S. Gur- man (Eds.), Clinical handbook of couple therapy (pp. 31–64). New York: Guilford Press.

Cochran, S. D., & Mays, V. M. (2007). Physical health complaints among lesbians, gay men, and bisexual and homosexually ex- perienced heterosexual individuals: Results from the California Quality of Life Survey. American Journal of Public Health, 97, 2048–2055.

Cochran, S. D., & Mays, V. M. (2009). Burden of psychiatric mor- bidity among lesbian, gay, and bisexual individuals in the Cali- fornia Quality of Life Survey. Journal of Abnormal Psychology, 118, 647–658.

Collins, L. M., Murphy, S. A., Nair, V. N., & Strecher, V. A. (2005). A strategy for optimizing and evaluating behavioral interven- tions. Annals of Behavior Medicine, 30, 65–73.

Emmelkamp, P. M., & Vedel, E. (2006). Evidence-based treatment for drug and alcohol abuse. New York: Taylor and Francis.

Epstein, E. E., & McCrady, B. S. (1998). Behavioral couples treat- ment of alcohol and drug use disorders: Current status and inno- vations. Clinical Psychology Review, 18, 689–711.

Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive- behavioral therapy for couples: A contextual approach. Wash- ington, DC: American Psychological Association.

Gottman, J., Notarius, C., Gonso, J., & Markman, H. (1976). A cou- ple’s guide to communication. Champaign, IL: Research Press.

Graff, F. S., Morgan, T. J., Epstein, E. E., McCrady, B. S., Cook, S. M., Jensen, N. K., et al. (2009). Engagement and retention in outpatient alcoholism treatment for women. American Journal on Addictions, 18, 277–288.

BEHAVIORAL COUPLES THERAPY 1509

Green, K. E., Pugh, L. A., McCrady, B. S., & Epstein, E. E. (2008). Unique aspects of female-primary alcoholic relationships. Addictive Disorders & Their Treatment, 7(3), 169–176.

Grella, C. E., Scott, C. K., Foss, M. A., Joshi, V., & Hser, Y. I. (2003). Gender differences in drug treatment outcomes among participants in the Chicago Target Cities Study. Evaluation and Program Planning, 26, 297–310.

Halford, W. K. (1998). The ongoing evolution of behavioral couples therapy: Retrospect and prospect. Clinical Psychology Review, 18, 613–633.

Hser, Y., Evans, E., & Huang, Y. (2005). Treatment outcomes among women and men methamphetamine abusers in Califor- nia. Journal of Substance Abuse Treatment, 28, 77–85.

Jacobson, N. S., & Margolin, G. (1979). Marital therapy: Strate- gies based on social learning and behavior exchange principles. New York: Guilford.

Kelly, S., & Iwamasa, G. Y. (2005). Enhancing behavioral couple therapy: Addressing the therapeutic alliance, hope, and diversity. Cognitive and Behavioral Practice, 12, 102–112.

Lemke, S., Brennan, P. L., & Schutte, K. K. (2007). Upward pres- sures on drinking: Exposure and reactivity in adulthood. Journal of Studies on Alcohol and Drugs, 68, 437–445.

Liberman, R. P., Wheeler, E. G., deVisser, L. A., Kuehnel, J., & Kuehnel, T. (1980). Handbook of marital therapy: A positive approach to helping troubled relationships. New York: Plenum Press.

Longabaugh, R. (2007). The search for mechanisms of change in behavioral treatments for alcohol use disorders: A commentary. Alcoholism: Clinical & Experimental Research (Special Issue), 31, S1.

Maisto, S. A., O’Farrell, T. J., McKay, J., Connors, G. J., & Pelcovitz, M. A. (1988). Alcoholics’ attributions of factors af- fecting their relapse to drinking and reasons for terminating re- lapse events. Addictive Behaviors, 13, 79–82.

McCabe, S. E., Hughes, T. L., Bostwick, W. B., West, B. T., & Boyd, C. J. (2009). Sexual orientation, substance use behaviors and substance dependence in the United States. Addiction, 104, 1333–1345.

McCrady, B. S., Epstein, E. E., Cook, S., Jensen, N., & Hildebrandt, T. (2009). A randomized trial of individual and couple behav- ioral alcohol treatment for women. Journal of Consulting and Clinical Psychology, 77(2), 243–256.

McCrady, B. S., Noel, N. E., Abrams, D. B., Stout, R. L., Nelson, H. F., & Hay, W. M. (1986). Comparative effectiveness of three types of spouse involvement in outpatient behavioral alcoholism treatment. Journal of Studies on Alcohol, 47, 459–467.

McGovern, M. P., Fox, T. S., Xie, H., & Drake, R. E. (2004). A sur- vey of clinical practices and readiness to adopt evidence-based practices: Dissemination research in an addiction treatment sys- tem. Journal of Substance Abuse Treatment, 26, 305–312.

McKay, J. R. (2009). Treating substance use disorders with adap- tive continuing care. Washington, DC: American Psychological Association.

Meyer, I. H., Schwartz, S., & Frost, D. M. (2008). Social pat- tern of stress and coping: Does disadvantaged social statuses confer more stress and fewer coping resources? Social Science Medicine, 67, 368–379.

Mignone, T., Klostermann, K., & Chen, R. (2009). The relationship between relapse to alcohol and relapse to violence. Journal of Family Violence, 24, 497–505.

O’Farrell, T. J., Choquette, K. A., Cutter, H. S. G., Brown, E. D., Bayog, R., McCourt, W., et al. (1996). Cost-benefit and cost-effectiveness analyses of behavioral marital therapy with and without relapse prevention sessions for alcoholics and their spouses. Behavior Therapy, 27, 7–24.

O’Farrell, T. J., Choquette, K. A., Cutter, H. S. G., Floyd, F. J., Bayog, R. D., Brown, E. D., et al. (1996). Cost-benefit and cost- effectiveness analyses of behavioral marital therapy as an ad- dition to outpatient alcoholism treatment. Journal of Substance Abuse, 8, 145–166.

O’Farrell, T. J., & Cutter, C. S. (1984). Behavioral marital therapy couples groups for male alcoholics and their wives. Journal of Substance Abuse Treatment, 1, 191–204.

O’Farrell, T. J., Cutter, H. S. G., & Floyd, F. (1985). Evaluating behavioral marital therapy for male alcoholics: Effects on mari- tal adjustment and communication from before to after therapy. Behavior Therapy, 16, 147–167.

O’Farrell, T. J., & Murphy, C. M. (1995). Marital violence before and after alcoholism treatment. Journal of Consulting and Clin- ical Psychology, 63, 256–262.

O’Farrell, T. J., Murphy, C. M., Stephan, S. H., Fals-Stewart, W., & Murphy, M. (2004). Partner violence before and after couples- based alcoholism treatment for male alcoholic patients: The role of treatment involvement and abstinence. Journal of Consulting and Clinical Psychology, 72, 202–217.

Stanton, M. D., & Shadish, W. R. (1997). Outcome, attrition, and family-couple treatment for drug abuse: A meta-analysis and re- view of the controlled, comparative studies. Psychological Bul- letin, 122, 170–191.

Sun, A. (2007). Relapse among substance-abusing women: Components and processes. Substance Use & Misuse, 42, 1–21.

Turner, J. (1972, October). Couple and group treatment of mar- ital discord. Paper presented at the Sixth Annual Meeting of the Association for Advancement of Behavior Therapy, New York.

Vedel, E., Emmelkamp, P. M., & Schippers, G. M. (2008). In- dividual cognitive-behavioral therapy and behavioral couples therapy in alcohol use disorder: A comparative evaluation in community-based addiction treatment centers. Psychotherapy and Psychosomatics, 77(5), 280–288.

Walitzer, K. S., & Derman, K. H. (2004). Alcohol-focused spouse involvement and behavioral couples therapy: Evolution of en- hancements to drinking reduction treatment for male problem drinkers. Journal of Consulting and Clinical Psychology, 72, 944–955.

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