Behavioral Couples Therapy for Male Methadone Maintenance Patients: Effects on Drug-Using Behavior and Relationship Adjustment

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1 BEHAVIOR THERAPY 32, ,2001 Behavioral Couples Therapy for Male Methadone Maintenance Patients: Effects on Drug-Using Behavior and Relationship Adjustment WILLIAM FALS-STEWART University at Buffalo, The State University of New York TIMOTHY ~. O'FARRELL Harvard Medical School and Veterans Affairs Medical Center, Brockton, Massachusetts GARY R. BIRCHLER Veterans Affairs Medical Center and University of California, San Diego School of Medicine Married or cohabiting substance-abusing men (N = 36) who were entering methadone maintenance (MM) treatment were randomly assigned to receive either individual-based methadone maintenance (IBMM) services 0.e., twice-weekly individual counseling plus methadone) or an equally intensive behavioral couples therapy (BCT) treatment condition (i.e., once-weekly couples therapy involving their female partner, once-weekly individual counseling, and methadone). Drug use and relationship satisfaction measures were collected at baseline, weekly during treatment, and at posttreatment. Male partners in the BCT condition had fewer opiateand cocaine-positive urine samples during treatment than male partners in the IBMM condition. Couples who participated in BCT also reported higher levels of relationship happiness during treatment and higher dyadic adjustment at posttreatment than couples in which male partners participated in IBMM. Furthermore, patients in the BCT condition reported greater reductions in drug use severity and family and social problems from baseline to posttreatment than patients in the IBMM condition. These findings suggest BCT may improve treatment response for married or cohabiting MM patients. This research was supported in part by the Department of Veterans Affairs and grants from the National Institute on Drug Abuse (R01DA12189) and the National Institute on Alcohol Abuse and Alcoholism (R01AA10356 and K02AA00234). Portions of thig article were presented at the 30th Annual Convention of the Association for Advancement of Behavior Therapy, New York. Address correspondence to William Fats-Stewart, Research Institute on Addictions, 1021 Main Street, Buffalo, NY ; wstewart@ria.buffalo.edu / /0 Copyright 2001 by Association for Advancement of Behavior Therapy All rights for reproduction in any form reserved.

2 392 FALS-STEWART ET AL. Behavioral couples therapy (BCT) has been shown to produce superior dyadic functioning among distressed couples compared to no-treatment or nonspecific control conditions (e.g., Hahlweg & Markman, 1988) and is equaltoor more effective than other therapies for,reducing relationship distress (e.g:, Gurman, Kniskern, & Pinsof, 1986). Additionally, a growing body of research indicates that BCT is associated with positive outcomes for alcoholic Couples, both in terms of drinking behavior andrelationship adjustment (e.g:, McCrady, Stout, Noel, Abrams, & Nelson, 1991; O'Farrell, Cutter, Choquette, Floyd, & Bayog, 1992). Aswith alcoholic dyads, the relationships of couples in which one or both partners primarily ingest psychoactive substances other than alcoh61 ~ tend to be relatively distressed (Fals-Stewal~, Birchler, O'Farrell, 1999). Fals-Stewart, Bh-chler ~ ando'fanell (1996)conducted the first randomized clinical trials examining the effect of BCT with drug,abusing couples. In this study, married or. cohabiting male substance-abusing patients (N = 80)who were entering individual outpatient treatment were randomly assigned to one of two equally intensiv e treatments! (a) behavioral couples therapy plus individualbased treatment (BCT) or (b) individual-based treatment (IBT) only. Drug use and relationship adjustment measures were collected at pretreatment, posttreatment, and at 3-, 6-, 9-, and 122month follow-up. Male partners in the BCTcondition reported significantly fewer days of drug use, longer periods of abstinence, fewer drug-related an'ests, and fewer drug-related hospitalizations through the 12-month follow-up period than male partners receiving IBT only. In addition, couples who received BCT as part of individual-based treatment had better relationship outcomes, in terms of more positive dyadic adjustment, less time separated, and less domestic violence (O,Neil, Freitas, & Fals-Stewart, 1999), than couples in which male partners received IBT only. A subsequent cost outcomes analysis revealed that BCT was more costeffective and cost-beneficial than IBT (Fals-Stewart, O'Farrell, & Birchler, 1997). Similar results were also found when examining the effects of BCT with substance-abusing women and their nonsubstance-abusing male partners (Winters & Fals,Stewart, 2000). However, because the drug-abusing Couples recruited for these investigations were drawn from drug-free outpatient clinics, it remains unclear if BCT would also have similar beneficial effects for other drug abuse treatment populations, such as methadone maintenance (MM) patients. The results of several studies suggest that the addition of family-based treatments improves the efficacy of MM therapy, both in terms of reduced substance use and improved family functioning. For example, Stanton and Todd (1982) Compared the outcomes of 99 male MM patients randomly assigned to One Of four conditions: (a) paid family therapy plus methadone, (b) unpaid family therapy plus methadone, (c) attention placebo (paid family movies) plus methadone, and (d) methadone plus individual counselingl The type of family therapy used in this investigation was structural-strategic therapy (Minuchin, 1974). These investigators found, at 12-month posttreatment follow-up, the

3 BEHAVIORAL COUPLES THERAPY 393 family therapy conditions had superior outcomes to the attention placebo plus methadone condition and the individual counseling plus methadone condition. In a second study, McLellan, Amdt, Metzger, Woody, and O'Brien (1993) randorrdy assigned 92 male MM patients to one of three treatment groups for a 6- month clinical trial: (a) minimum methadone services (i.e., methadone alone with no other services); (b) standard methadone services (i.e., methadone plus counseling); or (c) enhanced methadone services (i.e., same dose of methadone plus counseling and on-site medical/psychiatric, employment, and family therapy). Results indicated that patients who received the enhanced services that included family therapy had significantly better 3-month outcomes than patients in the other two conditions. In a third study, Catalano and colleagues (Catalano, Gainey, Fleming, Haggerty, & Johnson, 1999) randbmly assigned 144 opiate-addicted parents (75% female) in two MM programs in Seattle to (a) the standard MM program alone, which consisted of methadone dispensing and some individual and group counseling, or (b) the standard MM program plus intensive group parent training in parenting and relapse prevention sldlls along with weekly home-based case management services. At 12-month follow-up, parents who received the enhanced, family-based intervention, as compared with standard MM alone, used heroin and cocaine less, had better skill levels to avoid drug use in problem situations, had instituted more household rules, and had less domestic conflict. For a comprehensive review of family-based treatment for drug abuse, see Stanton and Shadish (1997). However, these and other investigations examining the effect of adding family-based therapy to MM treatment have focused largely on the family-oforigin and not on the spousal system. Given the positive result of BCT with married or cohabiting patients and their intimate partners treated in drug-free outpatient programs, the purpose of the present investigation was to explore the effects of BCT with MM patients, both in terms of relationship adjustment and drug-using behavior, and to extend prior work on family-based treatment for MM patients in a number of ways. First, in some prior studies (e.g., Catalano et al., 1999; McLellan et al., 1993), family therapy was added to treatment-as-usual (TAU) and compared with TAU alone, so that results favoring family therapy may have occurred because patients received more treatment. Therefore, in the present study, BCT was integrated into TAU and we compared equally intensive treatment conditions. Specifically, married or cohabiting patients who were entering MM treatment were randomly assigned either to individual-based methadone maintenance (1-BMM) services (i.e., twice-weekly individual counseling plus methadone) or to an equally intensive BCT condition (i.e., once-weekly couples therapy with their female partner, once-weekly individual counseling, and methadone). Consistent with the findings from Fals-Stewart et al. (1996), we hypothesized that MM patients who participated in BCT as part of standard treatment would have better response to treatment, in terms of reduced drug use and general relationship satisfaction, than MM patients who received standard treatment that did not include BCT.

4 394 FALS-STEWART ET AL. Second, prior work on adding family therapy, individual psychotherapy, and other psychosocial services to MM has taken either the approach that such added services are likely to benefit most or all patients (e.g., McLellan et al., 1993) or that added services should be matched to patients with greater problem severity in the area targeted by the added services (e.g., Woody et al., 1984; McLellan et al., 1997). In the present study, these two different perspectives are examined by testing tile predictions that (a)bct has better drug use and relationship outcomes than IBMM for most patients, reflecting a main effect, and/or (b) the superiority of BCT over IBMM is apparent only or to a greater extent for patients with more severe relationship problems (i.e., the problem area targeted by BCT), reflecting a treatment-by-problem severity interaction. Method Participants Heterosexual couples (N = 36) in which intravenous opiate-using male partners were entering substance abuse treatment at one of two communitybased MM clinics in New York from 1993 to 1996 were studied. Inclusion criteria were as follows: Male partners had to (a) be between 21 and 60 years old; (b) be married for at least 1 year or living witha significant other in a stable common-law relationship for at least 2 years; (c) have medical clearance to engage in MM treatment; and (d) refrain from seeking additional substance abuse treatment except for self-help meetings (e.g., Alcoholics Anonymous, Rational Recovery) for the duration of treatment, unless recommended by his primary individual therapist. Couples were excluded if (a) the female partner met,diagnostic and Statistical Manual of Mental Disorders (DSM- 111-R; American Psychiatri c Association, 1987) criteria for a psychoactive substance use disorder in the last 6 months; (b) if either partner met DSM-Ill- R criteria for an organic mental disorder, schizophrenia, delusional (paranoid) disorder, or other psychotic disorders, or (c) the male or female partner had plans for an imminent departure from the geographic region where the clinics were located that would preclude full participation for the planned duration of the investigation. Of the 36 couples who participated in the investigation, 16 (44%) were drawn from one clinic, and the remainder (n = 20, 56%) from the other treatment site. Comparisons of the sociodemographic and background characteristics of the participants in the two clinics revealed no significant differences. In addition, treatment site was not significantly related to any outcome measures used in the study; thus, data from participants from the two sites were pooled for subsequent analyses. Procedure All applicants to the progams (N = 371) were interviewed by clinical staff members during which general biopsychosocial information was collected.

5 BEHAVIORAL COUPLES THERAPY 395 Married and cohabiting male applicants (n = 89) were asked, along with their partners, to participate in a more extensive interview to determine eligibility for the study. Nineteen program applicants declined our request, with most stating that they did not want their female partners involved in their treatment. Twenty-seven couples who agreed to participate in further interviewing met one or more of the study's exclusion criteria (i.e., 17 female partners met DSM-III-R abuse or dependence criteria on one or more psychoactive substances; 8 female partners met DSM-11I-R criteria for one or more psychotic disorders; 2 couples reported that they were planning to move from the area). Of the 43 couples remaining, partners met with a research assistant for two pretreatment assessment interviews, during which diagnostic, chinking and drug use, and couple adjustment information was collected. After receiving a verbal and written overview of the study, the partners signed consent forms indicating their understanding of the treatments and their willingness to participate. Couples were then randomly assigned to one of two primary treatment conditions: IBMM services or BCT. 1BMM services. For the couples assigned to this intervention, the male partner was the only member of the dyad who received formal treatment provided by the clinics. He met with a therapist for two 60-minute individual therapy sessions each week. The goal of this intervention was to help these patients develop skills that would assist in their efforts to reduce illicit drug and alcohol use. The emphasis of these sessions was on cognitive and behavioral coping skills training. Skills that were addressed included managing thoughts about drugs via cognitive-behavioral restructuring, problem-solving for alternatives to drug use, increasing pleasant activities without the use of drugs or alcohol, relaxation training, anger management, improving drugand drink-refusal skills, assertiveness training, and enhancing social support networks. Homework was assigned after each session to encourage participants to practice skills in other, more natural settings. The intervention was adapted from that used in cognitive-behavioral treatment programs for alcoholism and has been shown to be effective with patients who abuse other drugs (e.g., Rohsenow, 1995). Therapists were given a written outline of material to be covered during each week of the treatment, from which they could deviate if patient crises arose. This treatment was provided by counselors employed by the respective treatment agencies and is the standard treatment package for all patients who enter these programs. For all male partners in this condition, standard methadone dose of 60 mg/ d was increased when either the patient requested an increase or when opiatepositive urine samples were detected. All requests for changes in the methadone dose were made by the primary counselors to the project physician. Patients were eligible for up to two take-home doses per week after they completed 6 weeks of treatment and were employed at least 20 hours/week. All of the counselors who provided the individual-based treatment package (n = 2) were state-certified substance abuse counselors and held masters' degrees. All of these therapists had at least 2 years of prior supervised experi-

6 396 FALS-STEWART ET AL. ence using cognitive-behavioral interventions to treat drug abuse. These counselors were supervised weekly for 1 hour by a state-certified social worker (CSW) to ensure that the treatment techniques used by the therapists were consistent with the cognitive-behavioral treatment framework. In addition, four randomly selected sessions for each case were audiotaped; these tapes were rated by the supervisor to determine level of adherence and compliance with the designed treatment approach. We collected random urine and blood alcohol breath samples weekly from these participants under supervised conditions. The results of the blood alcohol breath samples were revealed to the patient at the time of collection; findings ti'om the urine assays were shared with the patient the following week. During the investigation, only 1 palxicipant provided a single blood alcohol breath sample that indicated recent alcohol use. Female partners were asked to come to the clinic once per week with their male partners so both could completea brief measure of partners' general happiness with their relationship. However, the couples did not meet conjointly with a therapist to complete this inventory, nor did therapists discuss the results of patients' urine or breath tests with their female parmers. Five couples assigned to this condition left prior to completion of treatment (two couples withdrew consent for continued participation after four sessions; the male partners in three couples left the program unannounced after 2 to 4 sessions, moved, and could not be found). Thus, from the 22 couples randomly assigned to the individual-based only treatment condition, the data from 17 couples remained for the analyses. BCT treatment package. In addition to one 60-minute weekly individual session (which emphasized cognitive-behavioral coping skills training as described for male partners in the IBMM condition), male and female partners met conjointly with a therapist once per week over a 12-week period for 60-minute BCT sessions. The first two sessions consisted of describing the couples' treatment package to be used, reviewing and discussing the couples' relationship assessment data, and conducting crisis intervention sessions for drug or alcohol use and other relationship problems. Additionally, the partners negotiated a verbal agreement (i.e., a "sobriety trust discussion") that (a) the partners would discuss the status of the male patient's sobriety from illicit drugs and alcohol each day, (b) male partners would commit during this discussion to remaining sober for the next 24 hours, and (c) female partners would acknowledge their male partner's sobriety in a positive fashion, contingent on sobriety. The purpose of the sobriety trust discussion, which continued throughout the BCT sessions, was to reward abstinence from illicit drugs and alcohol and provide a constructive communication ritual as an alternative to couple conflict about past drug-related problem s or feared future relapses. The remaining ses'sions were used to (a) help male parmers remain abstinent from illicit drugs and alcohol by reviewing and reinforcing compliance with the couples' agreement to discuss the male partners' sobriety, (b) ex-

7 BEHAVIORAL COUPLES THERAPY 397 plore strategies to cope with cravings to use illicit drugs or alcohol, (c) conduct crisis intervention for drug- or alcohol-using episodes, (d) learn more effective communication skills, such as active listening and expressing feelings directly, and (e) increase positive behavioral exchanges between partners by encouraging them to acknowledge pleasing behaviors and plan shared recreational activities that did not include drug or alcohol use. Many of these skills were practiced during these therapy sessions; weekly homework assignments reinforcing the therapy session content were also ~ven. Urine and blood alcohol breath samples were collected randomly from patients each week. Both partners completed a relationship happiness scale each week. In terms of initial dose, procedures for changes in dose, and criteria for take-home doses, the administration of methadone was the same as that described for the IBMM. Urine analysis results were shared with the male patient and his female partner during the phase of treatment in which the female partner participated. These sessions were conducted by one of two master's-level therapists, all of whom were employed by the clinics and were recruited to conduct conjoint therapy sessions for these couples as part of their employment responsibilities. BCT training for these therapists consisted of directed reading on BCT (e.g., Jacobson & Margolin, 1979) and viewing videotapes of the first author conducting simulated BCT sessions with couples. A written outline of general session content to be covered each week was given to each therapist, with the understanding that planned interventions could be modified, at the discretion of the therapist, to address emergency situations (e.g., male partnet's relapse, couple separation, etc.). All of these therapists had at least 2 years of prior supervised experience using cognitive-behavioral interventions to treat drug abuse. These counselors were supervised weekly for 1 hour by a CSW to ensure that the treatment techniques used by the therapists were consistent with the BCT framework. As with the IBMM condition, four randomly selected sessions for each case were audiotaped and rated by the supervisor for adherence and compliance. Of the 21 dyads assigned to this condition, 2 dropped out after less than four BCT sessions and refused to providefurther information. This left data from 19 couples for the subsequent analyses. Treatment phases for male partners receiving BCT and those receiving IBMM. During the assessment phase, which lasted roughly 1 week, all patients participated in a standard psychosocial intake assessment interview, which consisted of an assessment battery, physical examination, and a supervised period of methadone dose adjustment. Patients' initial dose of methadone was between 30 mg/d and 40 mg/d. The dose was adjusted upward to a minimum of 60 mg/d during the assessment week. All patients in the investigation were able to tolerate the 60 mg/d dose with no reports of sedation or other side effects. During the next 3 weeks, male partners in both conditions participated in

8 398 FALS-STEWART ET AL. the initial treatment phase of the program, during which they began twiceweekly 60-minute cognitive-behavioral individual therapy sessions (as delineated in the section describing the IBMM sessions) with their individual counselor. During the next 12 weeks, which will be referred to as the primary treatment phase, the male partners randomly assigned to the BCT condition began attending conjoint sessions with their partners one time weekly, in addition to one 60-minute cognitive-behavioral individual session each week. Use of weekly BCT sessions during the primary treatment phase is the same frequency of couples therapy sessions used in other studies examining BCT with matxied: or cohabiting drugtabusing patients (e.g, Fals-Stewart et al., 1996). Male partners not assigned to the BCT condition continued to attend two 60,minute cognitive-behavioral sessions each week. Data used in the present investigation to examine participants' drug-using behavior and relationship adjustmen t were collected.from the beginning of the assessment phas e through to the completion of the primary treatment phase. After completion of the primary treatment phase, all of the male partners were referred back to the standard treatment provided by the clinics (i.e., IBMM). In total, patients in both conditions were scheduled to receive 30 therapy sessions over the course of the three phases of treatment. During all phases( weekly urine and blood alcohol breath samples were collected and analyzed. At any time dm'ing the patients' treatment in either condition, they were allowed to attend emergency individual counseling sessions, which were held at the discretion of the patient and his assigned counselor. For patients in the IBMM condition, the mean (SD) methadone dose during the primary treatment phase was 75.3 (12.2) mg/d, with a range of 60 mg/d to 100 mg/day. For patients in the BCT condition, the mean (SD) methadone dose during theprimary treatment phase was 75.2 (111.6) mg/d, with a range of 60 mg/day to 100 mg/day. The difference between patients ~n the IBMM and BCT conditions in methadone dose during the primary assessment phase was not significant, F(1,34) = 1.41, ns, nq z =.04.1 Measures Relationship adjustment. The Dyadic Adjustment Scale (DAS; Spanier, 1976) is a commonly used relationship adjustment inventory. Scores on this scale range from 0 to 151, with higher scores indicating better relationship adjustment; a total score of 100 has been the traditional cutoff point for relationship distress. As noted in the original reference, this scale has good to excellent reliability and validity. The DAS has excellent internal consistency and has been shown to have high discriminant and concurrent validity. The DAS was administered at baseline (i.e., during the assessment phase) and i The relationship between methadone dose and the various outcome indicators used in the hwestigation was examined and was not significant. The results from these analyses are available from the first author upon request.

9 BEHAVIORAL COUPLES THERAPY 399 posttreatment (i.e., during the last week of the primary treatment phase) to male and female partners in both conditions. The Marital Happiness Scale (MHS; Azrin, Naster, & Jones, 1973) is a 10-item scale that measures general happiness within a dyadic relationship. Mean couple scores can range from 0 to 10, with higher scores indicating greater relationship satisfaction. This measure was administered to partners in both treatment conditions each week of the primary treatment phase. Drug use. All male partners were interviewed at baseline and posttreatment with the Addiction Severity Index (ASI; McClellan, Luborsky, O'Brien, & Woody, 1980), administered by trained bachelor's-level technicians. The ASI is a 45-minute semistructured interview that measures the lifetime and recent (past 30 days) severity of problems in seven areas of functioning: alcohol, drug, employment, family-social, legal, medical, and psychiatric. Composite scores for each area assessed were calculated; these are based on weighted combinations of individual items that provide reliable, valid, and Sensitive measures of problem severity, in the seven areas noted, for the 30 days prior to the interview. Composite scores range from 0 to 1.0, with higher scores indicating greater impairment in the area of functioning being assessed (McClellan et al., 1985). Using procedures recommended and commonly used by other investigators (see Verebey & Tamer, 1991), urine samples were analyzed quantitatively for 10 common drugs of abuse: cannabis, cocaine, marijuana, opiates, barbiturates, amphetamines, benzodiazepines, methaqualone, methadone, and phencyclidine. Blood alcohol breath samples also were obtained to assess recent alcohol consumption. Each partner was interviewed separately with the Structured Clinical Interview for DSM-III-R (SCID; Spitzer, Williams, Gibbon, & First, 1990), administered by one of two master's-level interviewers (both of whom were trained by the first author, who has extensive experience administering the SCID). Interrater reliability was assessed using a paired-rater design. Videotaped interviews of 20 patients entering a drug abuse treatment center were independently observed by both primary interviewers and by the first author. Kappas between the two primary interviewers for the substance use disorders ranged from 1.0 to.80; for all disorders, kappas ranged from 1.0 to.75. Kappas between the first author and the primary interviewers for the substance use disorders ranged from 1.0 to.90; for all diagnoses, kappas ranged from 1.0 to.71. These kappas reflect good to excellent observer agreement (Landis & Koch, 1977). Treatment satisfaction. During the final week of the primary treatment phase, male patients completed the Client Satisfaction Questionnaire (CSQ- 8; Larsen, Attkisson, Hargreaves, & Nguyen, 1979), an 8-item measure designed to assess client satisfaction with provided services. Scores range from 0 to 32, with higher scores indicating greater satisfaction with the treatment services provided.

10 400 FALS-STEWART ET AL. Statistical Analyses For the univariate and multivariate analyses of variance (ANOVA and MANOVA, respectively), full factorial models were run to.test for the hypothesized main effects and interactions. For the ANOVA within-subjects factors, the univariate tests were used, with a Huynh-Feldt correction for inflated Type I error due to violations of sphericity. For MANOVAs, Pillai's Trace was evaluated for significance. Type Ill sums of squares were used in all models. In the analyses, baseline DAS couple score was used as a measure of relationship problem severity, which was included in the models to determine if problem severity was related to measures of treatment response and outcome. Baseline 'DAS couples' scores were entered into the univariate and multivariate general linear models as continuous independent variables. The SAS statistical analysis computer program was used for all analyses. Sample Characteristics Results Table 1 presents the baseline characteristics of the participants in the two groups. Random assignment was effective; ANOVA and chi-square tests indicated that the groups did not differ significantly (i.e.,p <.05) on any of these sociodemographic variables. Amount of Therapy Received and Satisfaction With Treatment Services Provided We found no significant differences between the number of scheduled counseling sessions attended by male partners in the BCT condition (M = 20.3, SD = 4.2) and male partners in the IBMM condition (M = 19.6, SD = 5.4) during the 12-week primary treatment phase, F(1, 34) = 1.49, ns, nq 2 =.04. Therapy satisfaction ratings, based on CSQ-8 scores, showed a high degree of satisfaction for male partners in the BCT condition (M = 27.9, SD = 6.4) and the IBMM treatment (3//= 25.5, SD = 6.7) and were not significantly different, F(1, 34) = 1.77, ns, Xl 2 =.05. The only difference between the groups was as intended, with the patients in the BCT condition having couples sessions and those in the individual-based treatment condition not receiving conjoint treatment. Couples in the BCT condition attended an average of 9.0 (1.4) scheduled BCT sessions. Thus, BCT and IBMM appeared to be equally credible and satisfying treatments in that. they did not differ on therapy satisfaction ratings or session attendance. Comparisons of Participants in BCT and IBMM Treatments: Substance Use Monthly urinalysis results. The mean numbers of opiate-positive and cocaine-positive urine samples per month during the 16 weeks of the study (i.e., during the assessment, initial, and primary treatment phases) for male partners in the IBMM and BCT conditions are shown in Figure 1. For the

11 BEHAVIOI1AL COUPLES THERAPY 401 TABLE 1 PRETREATIVlENT CIrIARACTERISTICSFOR MALE METHADONE MAINTENANCE PATIENTS AND THEIR FEMALE PARTNERS FOR THE ENTIRE SAMPLE AND FOR EACH TREATMENT CONDITION.e Entire Sample BCT IBMM Characteristic (N = 36) (n = 19) (n = 17) Male partnetz' age, M (SD) Female partners' age, M (SD) Male partners' education, M (SD) Female partners' education, M (SD) Years married, M (SD) Number of children, M (SD) Weekly income ($) for family, M (SD) Male partners' (and female partners') racial/ethnic composition a White African-American Hispanic Male partners' substance abuse: No. of years of problematic Alcohol use, M (SD) Opiate use, M (SD) Cocaine use, M (SD) No. (%) who previously had been involved with MM treatment 38.1 (7.5) 38.7 (7.1) 37.4 (7.9) 36.0 (7.3) 36.9 (6.8) 35.1 (7.9) 12.0 (2.0) 11.9 (1.9) 12.1 (2.0) 12.2 (2.3) 12.4 (2.5) 12.0 (2.3) 7.2 (3.9) 7.4 (4.2) 7.0 (3.6) 0.8 (1.1) 0.9 (1.0) 0.8 (1.4) (120.3) (111.4) (122.6) 18 (20) 9 (11) 9 (9) 15 (14) 8 (7) 7 (7) 3 (2) 2 (1) 1 (1) 8.0 (5.1) 8.2 (4.8) 7.8 (5.9) 10.3 (6.1) 10.0 (7.5) 10.6 (5.4) 5.7 (3.2) 5.8 (2.2) 5.6 (4.0) 6 (17) 4 (21) 2 (13) Note. BCT = Behavioral Couples Therapy; IBMM = Individual-Based Methadone Maintenance Treatment; lvlm = Methadone maintenance. a Numbers in parentheses represent the female partners' raeial/ethrfic composition for the BCT and individual-based treatment conditions. opiate-positive urine results, a factorial A.NOVA revealed significant effects for group, F(1,32) = 7.28, p <.01,,q2 =.20, time F(3, 96) = 5.44,p <.01; "02 =.15, and a Group X Time interaction, F(3, 96) = 4.95, p <.01,,q2 =.13. Nonsigl~ficant effects were found for baseline DAS, F(1, 32) = 1.94, ns,,q2 =.06, Group baseline DAS, F(1, 32) = 1.77, ns, aq 2 =.05, baseline DAS X Time interaction, F(3, 96) = 1.51, ns, -02 =.05, and the Group X baseline DAS Time interaction, F(3, 96) = 1.34, ns, '02 =.04. The same pattern of results was found for the cocaine-positive urine results. The factorial ANOVA revealed significant effects for group, F(1,32) = 5.94,p <.01, ~12 =.16, time F(3, 96) = 6.03,p <.01, -02 =.16, and a Group Time interaction, F(3, 96) = 3.01, p <.05, -02 =.09. Nonsignificant effects were found for baseline DAS, F(1,32) = 1.61, ns, -02 =.05, Group X baseline DAS, F(1,32) = 1.64, ns,,q2 =.05, baseline DAS X Time interaction,

12 402 FALS-STEWART ET AL. 3. I s- Panda " '-.o o '~ "'e,. "~ 2-3. Panel B --*- Bcr - o- IIIMM i Month of'lh:a~ent Month of Treatment Fie. 1. Mean number of opiate-positive urine samples per month (Panel A) and cocainepositive urine sample per month (Panel B) during the assessment and initial treatment phases (Month 1) and primary treatment phase (Months 2-4) for male partners in the BCT and IBMM conditions. F(3, 96) = 1.06, ns,.q2 =.03, and the Group baseline DAS Time interaction, F(3, 96) = 1.33, ns, ~12 =.04. To further explore the differential changes in the number of opiate-positive urine samples for patients in the two conditions, simple effects analyses were performed. A pooled error term was used for these analyses; significance was evaluated using a quasi-f statistic. 2 Significant differences (p <.05) were found between the BCT and IBMM groups during the second, third, and fourth months of treatment. For the cocaine-positive urine samples, simple effects analyses revealed significant differences (p <.05) between the BCT and IBMM groups during the second and third months of treatment; the difference between patients in the IBMM and BCT condition during the fourth month was not significant. ASI composite scores. The composite AS/scores for male partners in the IBMM and the BCT conditions are shown in Table 2. Difference scores between ASI composite scores at baseline and posttreatment were used as dependent measures in the MANOVA. We found a significant omnibus effect for group, F(5, 28) = 2.94, p <.05, multivariate.q2 =.34. However, we did not find significant effects for the baseline DAS score, F(5, 28) , ns, multivariate.q2 =.24, or the Group baseline DAS score interaction, F(5,28) = 1.58, ns, multivariate.q2 = The quasi F statistic is not distributed as F. Satterthwaite (1946) describes a commonly used method for calculating adjusted degrees of fi-eedom for the quasi F statistic that permits this statistic to be evaluated using a standard F table. However, using the formulas described by Satterthwaite can lead to denominator degrees of freedom that are negative. In the present investigation, an alternative quasi F statistic is used, the calculation for which is described by Keppel (1991, pp ).

13 BEHAVIORAL COUPLES THERAPY 403 TABLE 2 MEAN (STANDARD DEVIATION) ADDICTION SEVERITY INDEX COMPOSITE SCORES OF MALE PARTNERS WHO RECEIVED BEHAVIORAL COUPLES THERAPY (BCT) AND MALE PARTNERS WHO RECEIVED INDIVIDUAL-BASED METHADONE MAINTENANCE TREATMENT (IBMM) Treatment Condition Index/ F-to- Assessment Period BCT IBMM Remove F Medical Baseline 0.29 (0.06) 0.25 (0.07) Posttreatment 0.25 (0.08) 0.25 (0.06) Paired t Employment Baseline 0.58 (0.09) 0.56 (0.08) Posttreatment 0.54 (0.08) 0.54 (0.08) Paired t Alcohol Baseline 0.32 (0.06) 0.33 (0.07) Posttreatment 0.27 (0.06) 0.34 (0.08) Paired t Drng Baseline 0.44 (0.08) 0.41 (0.09) Posttreatment 0.16 (0.09) 0.28 (0.08) 4A2" 4A4" Paired t 2.79** 2.13" Legal Baseline 0.09 (0.08) 0.13 (0.09) Posttreatment 0.07 (0.06) 0.09 (0.08) Paired t Family-Sociai Baseline 0A7 (0.08) 0.54 (0.09) Posttreatment 0.23 (0.06) 0.46 (0.08) 4.31" 4.26* Paired t 2.89** 1.89 Psychiatric Baseline 0.32 (0.08) 0.28 (0.09) Posttreatment 0.11 (0.06) 0.14 (0.08) Paired t 2.41" 2.32* Note. BCT = Behavioral Couples Therapy; IBMM = Individual-Based Methadone Maintenance services; Degrees of Freedom, respectively, for F-to-remove values were 1 and 27; for univariate F values, 1 and 34; and for paired ts, 35. * p <.05; ** p <.01. The nature of the omnibus multivariate main effect for group was examined using univariate and multivariate comparisons. For between-group univariate comparisons, omnibus one-way ANOVAs were performed on each of the seven ASI subscales. Univariate tests are commonly used to further evaluate variables after a significant multivariate group difference. However,

14 404 FALS-STEWART ET AL. by themselves, follow-up univariate analyses are not sufficient to understand the unique contribution of each variable to group separation (Wilkinson, 1975). Thus, we also sought to determine the relative (or unique) contribution of each of the ASI subscales to intergroup multivariate difference, using methods described by Huberty and Motzis (1989). 3 We performed a discriminant function analysis, with treatment condition (BCT vs. IBMM) membership as the dependent variable and ASI subscale scores as the dependent variable. F-to-remove values at the final step were used to assess the decrease in group separation for each variable if it were removed from the variable set. F- to-remove thus provides a method to evaluate the significance of the unique contribution of each of the ASI subscales to group separation. The results of the univariate and multivariate analyses are shown in Table 2. These analyses revealed that male partners in both conditions showed significant reductions in the Drug and Psychiatric ASI composites fi'om baseline to posttreatment. Furthermore, male partners in the BCT condition, but not those in the IBMM condition, reported significant reductions in the Family/ Social ASI composite scores. At posttreatment, mate partners in the BCT condition had significantly lower scores on the Drug and Family/Social ASI composite scores than male partners in the IBMM condition. Comparisons of Participants in. the BCT and IBMM: Dyadic Adjustmen.t Weekly MHS scores. Weekly mean scores for male and female partners' data on the MHS are shown in Figure 2. Results of the full factorial ANOVA showed significant effects for group, F(1, 32) = 4.99, p <.05,.q2 =.13, baseline DAS, F(1, 32) = 4.19,p <.05,.q2 =.12, time, F(11,352) = 2.39, p <.01, ~q2 =.07, and a Group Time interaction, F(11,352) = 2.16,p =.06. Nonsignificant effects were found for the Group baseline DAS interaction, F(1,32)= 2.33, ns,.q2 =.07, baseline DAS Time interaction, F(11,352) = 1.36, ns,.qo =.04, and the Group baseline DAS Time interaction, F(11,352) = 1.71, ns,.q2 =.05. Simple effects analyses comparing the MI-IS scores of BCT and IBMM groups at each week of the primary treatment phase revealed that couples in the BCT condition reported significantly higher levels (p <.05) of marital happiness from Week 5 through Week 12. DAS couple scores. At baseline mean (SD) couple DAS scores tbr dyads in the BCT condition, 72.8 (18.1), and those in the IBMM condition, As described by Wilkinson (1975), the approach of examining the unique and independent contribution of each variable to group separation in multivariate analyses follows the logic often reconmaended in standard ordinary least-squares multiple regression models to evaluate predictor variables. Evaluation of the independent contribution of each variable to group separation in multivariate analyses (i.e., univariate F tests) is analogous to examining the zero-order correlations between predictors and outcome variables. Evaluation of the unique contribution of each variable to group separation in multivariate analyses (i.e., F-to-remove tests) is analogous to examining the significance of variables in a standard regression model when all variables of interest are included.

15 BEHAVIORAL COUPLES THERAPY r~..t BCT o- IBIVlM i. i i i ~ L i J i i Week of Pr mm-y Treatment Phase FIG. 2, Mean Marital Happiness Scale (MHS) scores for couples in the BCT and IBMM conditions during each week of the primary tzeatment phase. (19.4), were not significantly different, F(1, 34) = 1.44, ns,,q2.04. However, using baseline DAS scores as a covariate, posttreatment couple DAS scores for dyads in the BCT condition, 97.9 (16.4), were significantly higher than those in the IBMM condition, 79.2 (18.1), F(1, 33) = 8.01, p <.01,.q2 =.20. Discussion The majority of substance-abuse treatment outcome studies indicate that individuals who are dependent on opiates respond favorably to MM treatment, as evidenced not only by significant reductions in opiate, cocaine, and alcohol use, but also by decreasedcriminal activity (e.g., Ball & Ross, 1991; Hubbard et al., 1989). Although methadone itself and the administered dose is a primary active treatment ingredient (for a review of methadone dosing studies, see Strain, 1999), several investigations have found that supplementary psychosocial support services, such as individual counseling, family treatment, and social skills training, enhance the positive effects of MM treatment (e.g., Avants et al., 1999; Kraft, Rothbard, Hadley, McLellan, & Asch, 1997; McLellan et al., 1993). As noted earlier, studies with patients from drug-free outpatient programs suggest that use of BCT in addition to traditional individual counseling results in improved outcome, both in terms of reduced substance use and improved relationship satisfaction. Thus, the purpose of the present investigation was to determine if BCT would have similar positive effects with married or cohabiting MM patients. As hypothesized, results showed that during treatment male MM patients and their nonsubstance-abusing female partners who participated in BCT in

16 406 FALS-STEWART ET AL. addition to standard MM treatment showed significantly greater improvement in relationship satisfaction during treatment and reported significantly higher levels of dyadic adjustment from baseline to posttreatment than married or cohabiting male MM patients who received an equally intensive standard MM treatment only. Furthermore, and perhaps more importantly, patients who received BCT had significantly fewer opiate-positive and cocaine-positiv e weekly urine specimens during most of the treatment period compared to male partners who received standard treatment, indicating reduction in use of these illicit drugs. Patients who received BCT reported greater reductions in drug use severity and family and social problems from baseline to posttreatment than patients receiving standard MM treatment. However, the hypothesized treatment-by-severity interactions were not significant. Thus, patients in the two conditions did not respond differently to their assigned treatment as a function of the severity of their relationship problems. However, these analyses were underpowered; the effect sizes for severn of these interactions were either small- to medium-sized (i.e.,.q2 between.01 and.06; Cohen, 1988). Thus, it is possible that baseline severity of relationship problems differentially influences the effect of BCT, with participants with less severe problems responding better to the intervention. Futnre investigations, using much larger samples, should be undertaken to explore these interactions with adequate statistical power to examine these effects. These findings strongly indicate that, along with individual counseling, certain married or cohabiting MM patients may benefit from BCT, which is consistent with findings from studies examining alcohol- and drug-abusing couples. Although only a minority of MM patients are both married or cohabiting and involved with nonsubstance-abusing partners (e.g.., Kidorf, Brooner, & King, 1997), these patients may be strong candidates for couples-based treatment. In our study, about 20% of patients entering MM treatment were eligible for inclusion. BCT as an adjunct to standard MM treatment not only seeks to enhance skills that are likely to improve overall relationship quality (e.g., problem-solving, communication, conflict resolution), but BCT also incorporates components that directly address substance use behavior (e.g., the sobriety trust discussion). As suggested in O'Farrell and Fals-Stewart (1999), BCT may serve to improve substance use outcomes by (a) training the spouse in the use of simple verbal methods to promote and encourage their male partner's sobriety from illicit drugs and alcohol and (b) reducing stressors within the spousal system that can serve as powerful antecedents to drug or alcohol use (e.g., unresolved disagreements, hostile conflict). In most respects, the findings from the present investigation are similar to and consistent with those found with married or cohabiting drug abusing patients receiving individual-based treatment (IBT) or BCT in outpatient settings. For example, in the Fals-Stewart et al. (t996) study comparing BCT to IBT in outpatient treatment, posttreatment results indicate that, as in the

17 BEHAVIORAL COUPLES THERAPY 407 present study, couples who received BCT reported significantly higher relationship adjustment than those involved in IBT. Additionally, outpatients in BCT had significantly reduced substance use after treatment compared to those in IBT. In their discussion of involving drug-free significant others (including family members) in MM treatment, Kidorf, King, and Brunner (1999) propose a treatment model that utilizes family and friends to support community-based treatment goals, with an important objective being that patients become more involved in drug-free activities. More specifically, these authors recommend that these significant others involve patients in drug-free social activities and observe the patient's participation in these activities. The BCT approach used in the present investigation and used with alcoholic couples attempts to accomplish this aim through a series of partner-involved exercises that are discussed in the BCT sessions and are given as homework assignments to be completed between sessions. One such activity is what is referred to as a "shared rewarding activity" in which the partners identify a mutually agreedupon, drug-free activity that they both enjoy and would be willing to participate in during the ensuing week. Partners plan the activity in session, are assigned to engage in the activity between sessions, and, during the ensuing session, describe how the activity went, any problems, and so forth. Shared rew~ding activities, along with similar exercises, are assigned throughout the course of BCT. This study had some important strengths, including (a) random assignment to treatment conditions, (b) use of well-validated and widely used measures, and (c) consistent monitoring of changes in drug use behavior and relationship satisfaction during the primary treatment phase. However, certain limitations of this study should be highlighted. The investigation used male MM patients and nonsubstance-abusing female partners as its target population, primarily because these couples were the most common in the clinics from which participants were recruited. However, Fals-Stewart et al. (1999) have found that dyads in which only male partners abuse drugs, couples in which only the female partners abuse drugs, and couples in which both partners abuse drugs are significantly different from each other in terms of relationship satisfaction and drug use behavior. Thus, the findings from the present investigation may not generalize to other drug-abusing couple types. Because the number of couples used in the study was small, we chose to compare only two experimental conditions to have sufficient power for most of the analytic comparisons. However, although most of the a priori compari - sons revealed significant differences and were marked by large treatment effects, some comparisons were underpowered. For example, the difference between the BCT and IBMM groups in terms of reductions in alcohol use severity (i.e., ASI alcohol composite scale score) from baseline to posttreatmerit was not significant, although the effect was ~12 =.38, which is considered large (Cohen, 1988). Relatedly, because of the relatively small number of participating couples,

18 408 FALS-STEWART ET AL. the effects of other types of spousal involvement (e.g., other types of relationship treatment, nonspecific involvement of nonsubstance-abusing partners dui-ing treatment) were not examined because using other treatment conditions in the design would have resulted in unacceptable low power for most analytic comparisons. Thus, it was not possible to determine what aspects of BCT led to the differential outcomes observed and whether other types of spousal treatment would have led to similar results. We also did not include other types of couples (e.g., homosexual dyads, couples in which one or both partners have major psychopathology). Future studies are needed to explore the effects of relationship therapies with various types of drug-abusing couples. We also used a very brief assessment period, evaluating couples during treatment and at posttreatment(i.ell roughly 4 months). No longitudinal followup was conducted to assess temporal changes in substance use patterns or dyadic adjustment after discontinuation of the primary treatment phase. In the Fals-Stewart et al. (1996) study using BCT with substance-abusing men, several of the drug-use and relationship-satisfaction differences between patients treated in BCT and those that received standard individual-based outpatient services dissipated over the course of the 12-month posttreatment follow-up. Thus, it is not possible to determine how long the positive effects of BCT observed with themm patients in the present study lasted after discontinuation of BCT and the return to standard treatment. Gradual loss in the strength and consistency of treatment effects for couples therapy after treatment completion has been widely reported in outcome studies of dyads seeking treatment for relationship problems in general (e.g., Pinsof, Wynne, & Hambright, 1996) and in studies that have treated alcoholic couples (e.g., O!Farrell et al., 1992). Thus, it would not be surprising if the effects observed with the participants in the BCT condition dissipated after couples treatment had ended. Future studies of BCT with MM patients should assess these patients and their intimate partners at regular intervals after treatment completion to determine if any treatment effects observed decay over time and, if so, explore the use of interventions to sustain therapy gains after treatment completion. Possible interventions include use of additional conjoint relapse prevention sessions after completion of primary treatment or increases in the time interval between final conjoint therapy sessions, both of which have been found to increase couples' abilities to preserve their gains after treatment (e.g., Bogner & Zielenbach-Coenen, 1984; O'Fan'ell, Choquette, Cutter, Brown, & McCourt, 1993). Findings from this investigation are based on data from a fairly small sample of MM patients, but the results are promising. Although many MM patients are not involved in stable romantic relationships, those who are married and cohabiting and whose partners can participate effectively may respond positively to the addition of BCT to standard MM treatment. Given the relatively few investigations that have examined the effects of psychosocial services on MM treatment, the results supporting the efficacy of BCT observed in this initial investigation merit further study.

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