Behavioral Couples Therapy for Substance Abuse

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1 Behavioral Couples Therapy for Substance Abuse Keith Klostermann and William Fals-Stewart Abstract Behavioral Couples Therapy (BCT) is an evidence-based conjoint treatment for substance abuse. The results of numerous investigations conducted over the past 25 years reveal that, compared to individualbased interventions, participation in BCT by married or cohabiting drug- and alcohol-abusing patients results in greater reductions in substance use, higher levels of relationship satisfaction, greater reductions in partner violence, and more favorable cost outcomes. This article provides an overview of the research support for BCT. In addition, this review examines the rationale for using BCT, the empirical literature supporting its use, methods used as part of this intervention, and future directions in this programmatic line of research. Keywords: Behavioral Couples Therapy, Conjoint Treatment for Substance Abuse, Drug Abuse Treatment, Alcoholism Treatment. The contribution of the family in the development and maintenance of substance abuse has been the focus of considerable research and is now widely accepted by both researchers and practitioners alike. As such, an increasing number of investigators and treatment providers are exploring the interrelationship of family factors and substance abuse, with the clinical applications of marital and family therapy to the treatment of alcoholism and drug abuse. In fact, recent meta-analytic reviews of randomized clinical trials have concluded that family-involved treatments result in higher levels of abstinence compared to individual-based interventions that focus exclusively on the substance-abusing client (e.g., Stanton & Shadish, 1997). Behavioral Couples Therapy (BCT) is a partner-involved conjoint treatment for drug and alcohol abuse with strong empirical support for its effectiveness (O Farrell & Fals-Stewart, 2003). The goal of this paper is to describe (a) the theoretical rationale for the use and effectiveness of BCT, (b) typical treatment methods used as part of the BCT intervention, and (c) research findings supporting the effectiveness of BCT in multiple domains of functioning. In addition, we also note some of the limitations in the BCT literature and discuss the future directions of this programmatic line of research. Theoretical Rationale Broadly speaking, BCT assumes distressed couples have low rates of rewarding interactions and high rates of punishing interactions, frequent negative interactions, and deficits in communication and conflict resolution (Longabaugh et al., 2005). Thus, BCT is based on the premise that improvements in couples or family functioning is the active ingredient that brings about reductions in substance abuse (McCrady, Epstein, & Kahler, 2004; Morgenstern & McKay, 2007). There are several lines of converging evidence that indicate substance abuse and relationship distress co-vary. In contrast to well-functioning dyads, couples in which one of the partners abuses drugs or alcohol usually have extensive relationship problems, often characterized by comparatively high levels of relationship distress, instability, aggression (i.e., verbal and physical), and sexual problems (O Farrell, Choquette, Cutter, & Birchler, 1997), which often result in significant levels of psychological distress in both partners and children in the home 81

2 (Fals-Stewart, Kelley, Cooke, & Golden, 2003; Kelley & Fals-Stewart, 2002; Moos & Billings, 1982). Although chronic substance use is correlated with reduced marital satisfaction for both spouses, relationship dysfunction also is associated with increased problematic substance use and is related to relapse among alcoholics and drug abusers after treatment (e.g., Maisto et al., 1988). Thus, the relationship between substance use and marital problems is not unidirectional, with one consistently causing the other; in other words, each can serve as a precursor to the other. Along these lines, there are several relationship-based antecedent conditions and reinforcing consequences of substance use. For example, poor communication and problem solving, arguing, disputes over finances, and nagging are common precursors to substance use. The resulting family interactions, in turn, can indirectly facilitate continued drinking or drug use once these behaviors have developed; the negative effects of substance use on the family may lead to or exacerbate substance use (Moos, Finney, & Cronkite, 1990) and can, and very often do, precipitate relapses at any point in the recovery process. Given the reciprocal relationship between substance use and family interaction, it seems that interventions that focus largely or exclusively on the individual substance-abusing client may not be optimally effective. Nevertheless, the standard format for substance abuse treatment is individual-based therapy. BCT, on the other hand, has two primary objectives that evolve from the conceptualization of substance use and relationship functioning described above: (1) reduce or eliminate substance use and utilize the family to positively support the client s efforts to change and (2) alter dyadic and family interaction patterns to promote a family environment that is more conducive to long-term abstinence. Primary BCT Treatment Components BCT methods used to address substance use. As noted above, the goals of BCT are to eliminate abusive substance use and alter dyadic and family interaction patterns to promote a family environment that is more conducive to sobriety. Regarding the relationship, a major objective is to modify substance-related interaction patterns between partners, such as nagging about past drinking and drug use and ignoring or otherwise minimizing positive aspects of current sober behavior. Thus, during the first session, the therapist and couple develop a Recovery Contract in which the partners agree to engage in a daily Abstinence Trust Discussion, which is a brief verbal exchange in which the substance-abusing partner declares his or her intent not to drink or use drugs that day. The nonsubstance-abusing partner, in turn, responds by expressing positive support and encouragement for the client s efforts to remain abstinent. In addition, for clients medically cleared and willing to take abstinence-related medications (e.g., naltrexone, disulfiram), the Abstinence Trust Discussion may be slightly modified so that the nonsubstanceabusing partner may also witness and verbally reinforce the daily ingestion of medications. As part of this process, the nonsubstance-abusing partner also tracks the performance of the Abstinence Trust Discussion (and consumption of medication, if applicable) on a daily Recovery Calendar, which is provided by the therapist. A critical component of the Recovery Contract is the agreement between partners to not discuss past drinking or drug use or fears of future substance use between scheduled BCT sessions. In particular, partners are asked to only discuss these issues during BCT therapy sessions, which can be monitored by the therapist. The purpose of this agreement is to reduce the possibility of substance-related conflicts occurring between therapy sessions, which can trigger relapses. Many contracts also require partners regular attendance at self-help meetings (e.g., Alcoholics Anonymous, Nar-Anon, Al-Anon), which are also recorded on the Recovery Calendar during the course of treatment. 82

3 In the beginning of each BCT session, the therapist reviews the Recovery Calendar to determine overall compliance with the contract. In addition to providing a daily record of progress (which is rewarded verbally by the therapist at each session), the calendar also provides a visual (and temporal) record of any difficulties with compliance, which can subsequently be discussed in couples sessions. Typically, the partners are asked to perform behaviors that are components of their Recovery Contract (e.g., Abstinence Trust Discussion, consumption of abstinence-supporting medication) in each BCT session and then assigned these activities as home practice. The purpose of the in-session practice is twofold: (1) to highlight the importance of the Recovery Contract, and 2) to allow the therapist to observe the partners behaviors, providing corrective feedback as needed. BCT methods used to enhance relationship functioning. Using a series of behavioral assignments, another goal of BCT is to increase positive feelings, shared activities, and constructive communication, which are believed to be important components in supporting and maintaining abstinence. For example, the Catch Your Partner Doing Something Nice exercise asks each partner to notice one pleasing behavior performed by the other each day. In the Caring Day assignment, each partner chooses a day to surprise the other with a special activity he or she believes the other would enjoy. In the Shared Rewarding Activities task, together the partners plan and engage in mutually-agreed upon activities. Finally, by learning Communication Skills, the substance-abusing client and his or her partner are better prepared to handle stressors as they arise, and by extension, reduce the risk of relapse. Topics such as paraphrasing, empathizing, and validating are taught, rehearsed in session, and practiced at home as part of the communication component of BCT. The rationale behind these exercises is simple: Typically, substance abusers families have ceased engaging in shared pleasing activities. Moreover, participating in such activities has been associated with positive recovery outcomes (Moos, Finney, & Cronkite, 1990). Couples-based relapse prevention and planning. Relapse prevention occurs during the final phase of BCT. Prior to termination, the partners develop a written plan (i.e., Continuing Recovery Plan) designed to promote stable abstinence (e.g., continuation of a daily Abstinence Trust Discussion, attending self-help support meetings, etc.) and list contingency plans in the event a relapse should occur (e.g., contacting the therapist, engaging in self-help support meetings, contacting a sponsor). Interestingly, one of the most difficult tasks in creating the Continuing Recovery Plan for many couples is the negotiation of the posttreatment duration of the agreed-to activities. Simply stated, many couples have difficulty agreeing upon the duration of the contract activities. In general, the substance-abusing partner typically wants a life that does not involve structured exercises and homework (which are part of BCT), whereas the nonsubstance-abusing partner is often skeptical about the changes made in treatment (i.e., relationship improvement, abstinence) and thus argues for continued involvement with certain activities (e.g., self-help meeting attendance, Abstinence Trust Discussions). Moreover, those couples in which the substance-abusing partner is taking medication to assist with abstinence maintenance (e.g., Antabuse) may express a desire to eventually forgo the daily Abstinence Trust Discussion with the observation of medication taking. In this situation, partners develop a mutually agreed-to, long-term gradual reduction of the frequency of the activity until it is eliminated (e.g., for the first month, daily Abstinence Trust Discussion with observed medicationtaking, as was done during active treatment; for the second month, the Abstinence Trust Discussion is performed three times per week with observed medication taking; for the third month, the Abstinence Trust Discussion is performed once per week with observed medication taking, and so forth). If problems arise with any of the planned transitions, partners are encouraged to contact their BCT counselor. Session Structure and Treatment Duration 83

4 While it can be delivered as a stand alone intervention, BCT is typically delivered as an adjunct to standard individual substance-abuse counseling in outpatient and inpatient substance abuse treatment programs. More specifically, BCT has been offered as a 6- or 12-session treatment, been conducted in individual couple or small group formats, and has been delivered in outpatient mental health clinics and private practice settings. Couple s sessions usually last minutes, with sessions scheduled weekly for weeks. It is important to note that BCT may not be a suitable or appropriate intervention for all substance-abusing individuals involved in intimate relationships. In particular, there are four general considerations that must be taken into account before performing BCT. First, because of the emphasis on the dyadic system to promote abstinence, some evidence of relationship commitment is necessary if potential participants are to be successful in BCT. Thus, one general inclusion criterion is that the partners are married or cohabiting in a stable relationship for at least 1 year, or are separated but are attempting to reconcile. A second criterion, given that BCT is skill-based, is that neither partner can have gross cognitive impairment or psychosis, which would significantly inhibit learning new information, practicing skills, or completing assigned tasks. Third, couples are excluded from participation in BCT if there is an extensive history of severe partner physical aggression. Finally, BCT is most effective with couples in which only one partner has a problem with drugs or alcohol. Couples in which both partners abuse substances (i.e., dually addicted couples ) are often not supportive of abstinence; thus, the relationship in these couples may be counterproductive to the goals of treatment and actually serve to promote continued drinking or drug use (e.g., Fals-Stewart, Birchler, & O Farrell, 1999). BCT Research Findings There is compelling evidence for the efficacy of BCT. Numerous studies over the past 30 years have compared drinking and relationship outcomes for alcoholic clients and their partners treated with BCT to various forms of individual-based therapy. Outcomes were measured at 6- months posttreatment in earlier studies and at months after treatment in more recent investigations. The studies show a fairly consistent pattern of more abstinence and fewer alcoholrelated problems, happier relationships, and lower risk of marital separation for alcoholic clients who receive BCT than for clients who receive only individual treatment (Azrin, Sisson, Meyers, & Godley, 1982; Bowers & Al-Rehda, 1990; Hedberg & Campbell, 1974; McCrady et al., 1991; O Farrell et al., 1992). Traditionally, BCT research has focused on the effects of BCT for alcoholism. More recently, however, investigators have started examining the effects of BCT for clients who abuse substances other than alcohol (e.g., Winters, Fals-Stewart, O Farrell, Birchler, & Kelley, 2002). In the first randomized study of BCT with married or cohabiting drug-abusing clients, Fals- Stewart, Birchler, and O Farrell (1996) compared BCT to individual-based treatment for married or cohabiting male clients entering outpatient treatment. Findings indicated that, compared to clients in the individual-based treatment condition, those who received BCT had fewer days of drug use, fewer drug-related arrests and hospitalizations, and a longer time to relapse after treatment completion. In addition, couples in the BCT condition also reported improved relationship functioning and fewer days separated due to relationship discord than couples whose partners received individual-based treatment only. Similar results favoring BCT over individualbased counseling were observed in another randomized clinical trial in which married or cohabiting male clients were in a methadone maintenance program (Fals-Stewart, O Farrell, & Birchler, 2001). While BCT studies have typically recruited samples of married or cohabiting substanceabusing male clients and their nonsubstance-abusing female partners, in a sample of female drug- 84

5 abusing clients, Winters and colleagues (2002) found female clients who received BCT had significantly fewer days of substance use, longer periods of continuous abstinence, and higher levels of relationship satisfaction. The results of this study were very similar to those found with male substance-abusing clients, indicating BCT may work equally well with both types of couples, although further study is needed. Although BCT research has focused primarily on substance use and relationship outcomes, investigators have found that clients in BCT have also experienced secondary benefits as a result of their participation in treatment. Consequently, investigators are now taking a wide angle view to examine the effect of BCT on related areas such as intimate partner violence (IPV), cost outcomes, the psychosocial adjustment of children living in homes with substance-abusing parents, and HIV risk behaviors. IPV. Recently, several studies have examined the effect of BCT on the occurrence of IPV. The results of multiple studies suggest that IPV is a highly prevalent problem among substance-abusing clients and their partners. In fact, studies conducted in the past decade typically have found roughly 50%-60% of substance-abusing men with intimate partners report one or more episodes of IPV during the year prior to program entry. Fals-Stewart (2003) examined the temporal relationship between alcohol use and episodes of IPV among partnerviolent men entering either an alcoholism treatment program (N = 135) or a batterers program (N = 137) and found that the likelihood of IPV on days of drinking was 8-11 times higher than on days of no drinking. Similar results were found with a sample of domestically-violent drugabusing men (N = 149) entering treatment for drug abuse, with use of cocaine and alcohol being temporally linked to increased likelihoods of IPV (Fals-Stewart et al., 2003). In a non-controlled study, O Farrell et al. (2004) replicated, with a large heterogeneous intent-to-treat sample, initial study findings of dramatically reduced male partner physical violence associated with abstinence after BCT (O Farrell, Van Hutton, & Murphy, 1999). This investigation examined levels of IPV before and after BCT for 303 married or cohabiting male alcoholic patients and used a demographically matched non-alcoholic comparison sample drawn from national survey data. In the year before BCT, 60% of alcoholic patients had been violent toward their female partners, five times the comparison sample rate of 12%. In the year after BCT, violence decreased significantly to 24% in the BCT group, but remained higher than the comparison group. Among remitted alcoholics after BCT, violence prevalence reduced to 12%, identical to the comparison sample and less than half the rate among relapsed patients (30%). Results for the second year after BCT yielded similar findings. Chase and colleagues (2003) reported similar findings with married or cohabiting alcoholic women and their nonsubstanceabusing male partners who engaged in BCT. Fals-Stewart, Kashdan, O Farrell, and Birchler (2002) examined changes in IPV among 80 married or cohabiting drug-abusing male patients (both partner-violent and nonviolent) and their nonsubstance-abusing partners randomly assigned to receive BCT or individual treatment. While nearly half of the couples in each condition reported male-to-female IPV during the year before treatment, the number reporting violence in the year after treatment was significantly lower for BCT (17%) than for individual treatment for the male partner only (42%). Mediation analyses indicated BCT led to greater reductions in IPV because participation in BCT reduced drug use, drinking, and relationship problems to a greater extent than individual treatment. Cost Outcomes. O Farrell and colleagues (1996b) presented cost outcomes comparing: (a) BCT plus individual counseling, (b) interactional couples therapy plus individual counseling, and (c) individual counseling only. Results of a cost-benefit analysis of BCT plus individual alcoholism counseling revealed that the average costs per case for alcohol-related hospital 85

6 treatments and jail stays decreased from about $7,800 in the year before treatment to about $1,100 in the two years after BCT; an approximate cost savings of almost $6,700 per case. In addition, the results of the cost-benefit analysis also showed a benefit-to-cost ratio of $8.64 in cost savings for every dollar spent to deliver BCT. Interestingly, none of the positive cost-benefit results observed for BCT were true for participants in the interactional couples therapy plus individual alcoholism counseling condition for which posttreatment utilization costs increased. O Farrell and colleagues (1996a) presented cost outcomes for a second study in which manualized BCT, plus couples relapse prevention (RP) sessions was compared with manualized BCT alone. Costs of treatment delivery and health and legal service utilization were measured 12 months prior to starting BCT and the 12 months after. While the results of the cost-benefit analysis results for both standard BCT and for the longer and more costly BCT-plus-RP showed decreases in costs (i.e., health care and legal) after treatment as compared to before treatment, the average cost savings per case was $5,053 for BCT, and $3,365 for BCT-plus-RP. Moreover, the benefit to cost ratios revealed that every dollar spent on BCT resulted in a cost savings of $5.97 and only $1.89 for BCT-plus-RP to deliver the treatment. The results of cost-effectiveness analyses indicated that BCT-only was also more cost effective than BCT plus RP in producing abstinence from drinking. Children s psychosocial adjustment. While it is widely recognized that substance abuse often has serious consequences for adults (e.g., emotional, economic, behavioral, physical, social), children living with alcoholic or drug-abusing parents may also be susceptible to the deleterious familial environments these caregivers often create. Research on Children of Alcoholics (COAs) tends to show these children display elevated rates of social, emotional, and behavioral problems compared to children of nonalcoholics. Despite the emotional and behavioral problems observed among children of alcoholics (COAs), surveys of clients entering substance abuse treatment who also have custodial children suggest that these parents are very reluctant to allow their children to engage in any type of mental health treatment (Fals-Stewart et al., 2003). Given the parent s unwillingness to allow their children to participate in treatment, the most readily available approach to improve the psychosocial functioning of these children may be by successfully treating their parents. Kelley and Fals-Stewart (2002) recruited couples in which male partners were entering substance abuse outpatient treatment. To be included, couples had to have at least one schoolaged child (i.e., between the ages of 6 and 16 years of age) living in their household. Couples were randomly assigned to one of three treatment conditions: (a) BCT, (b) Individual-Based Treatment only (IBT), or (c) Psychoeducational Attention Control Treatment (PACT). At baseline, at the completion of treatment, and every 3 months thereafter for 1 year, male and female partners were queried about the male partners' drug and alcohol use. Partners also completed questionnaires pertaining to dyadic adjustment as well as the Pediatric Symptom Checklist for 6-16 year old children in the household. In the year following treatment, results indicated that for both alcohol- and drug-abusing fathers, BCT improved children s functioning more than individual-based or couple psychoeducation. Moreover, of the three treatments, only BCT showed reductions in the number of children with clinically significant psychosocial impairment. HIV risk behaviors. In a clinical chart review of 163 married or cohabiting drugabusing men entering treatment at one of three substance abuse treatment clinics from 1994 to 1996, Fals-Stewart (1998) found that 24% (n = 39) reported that, over the prior 3 months, they had one or more episodes of unprotected vaginal or anal intercourse with their partners, plus one or more of the following: (a) unprotected vaginal intercourse with one or more individuals other 86

7 than their partners or (b) shared syringes with one or more individuals when injecting drugs. Additionally, 30 of these 39 men (77%) reported that their primary partners were not aware that they had engaged in these high-risk behaviors. More recently, Fals-Stewart and colleagues (2003) found that roughly 40% of married or cohabiting drug-abusing men engaged in some behavior that placed them at high risk for HIV exposure (e.g., risky needle practices, unprotected sexual intercourse with a partner other than their spouse). Yet, more than 70% of the wives of the men in this study were unaware of their husbands high-risk behaviors and reported having unprotected sexual intercourse with their husbands. Thus, these wives were unknowingly placed at high indirect risk for HIV exposure by their husbands. Thus, HIV risk behavior is a significant problem for both partners in these couples. In a study of substance-abusing men and their female partners, Hoebbel and Fals-Stewart (2003) found that participation in BCT significantly reduced the proportion of male partners (N = 270) who engaged in high-risk behaviors during the year after treatment compared to an equally intensive individual-based, manualized 12-step facilitation treatment (Crits-Christoph et al., 1997) or a couples-based psychoeducational attention control condition. Although roughly 40% of the male partners in each of the conditions reported engaging in one or more high-risk behaviors during the year before entering treatment, significant differences between the groups emerged during the one-year follow-up phase of the study. Among male partners who received BCT with their wives, 19% reported they had engaged in one or more high-risk behaviors during the year after treatment, compared to 33% of the male partners in both the individual counseling condition and 34% of the male partners in the attention control treatment. Mediation analyses indicated that differential improvements in dyadic adjustment and reductions in substance use (both favoring BCT over individual-based treatment and the attention control) partially explained these posttreatment group differences. Future Directions Despite the impressive empirical evidence for BCT, important gaps in the BCT research exist and must be addressed. In particular, further research is needed in the following four areas: (a) examination of the effects of BCT with female substance-abusing clients and their nonsubstance-abusing partners and same-sex couples; (b) exploration of the effects of BCT with dual drug-abusing couples (i.e., dyads in which both partners have current drug and/or alcohol problems) and couples in which only female partners abuse alcohol or other drugs; (c) examination of mechanisms of action underlying the effects of BCT; and (d) addition of other intervention components to standard BCT specifically targeted to enhance important secondary outcomes (e.g., decreases in IPV, reductions in HIV risk behaviors, economic evaluations, and improvements in children s psychosocial adjustment). BCT with women substance abusers and their nonsubstance-abusing male partners and same sex couples. To date, BCT research has focused primarily on malesubstance abusing clients and their nonsubstance-abusing female partners. With the exception of the Winters and colleagues (2002) investigation, there is a paucity of research examining the effects of BCT on female substance-abusing clients and their nonsubstance-abusing male partners. Women s substance use is difficult to understand and complicated by many issues. More specifically, it is often very difficult to disentangle the effects of wife drinking independent of husband drinking because of the strong relationship between husband and wife drinking patterns. Regarding same sex couples, additional variables exclusive to these couples are likely to influence the treatment process (e.g., homonegativity, help-seeking behaviors; Potoczniak et al., 2003). Further study is required to determine if the results of participation in BCT for homosexual couples are similar to their heterosexual counterparts. 87

8 BCT for dual substance-abusing couples. Given that a primary tenant of BCT as a treatment for substance abuse is that there is support within the dyadic and family systems for abstinence (particularly from the nonsubstance-abusing partner), couples in which both partners have a diagnosis of an alcohol or other substance use disorder have typically been excluded from BCT clinical trials. In general, couples in which both partners abuse drugs or alcohol are almost always not supportive of abstinence. Yet, a significant proportion of married or cohabiting clients who enter substance abuse treatment are cohabitating with individuals who also have current problems with drugs or alcohol. This appears to be particularly true of women seeking treatment for substance abuse. For instance, in the Winters and colleagues (2002) study examining the effects of BCT on drugabusing women and their nonsubstance-abusing male partners, nearly 70% of married or cohabiting substance-abusing women entering treatment at the recruitment site were excluded from the investigation because their male partners met criteria for a substance use disorder. Although there is a paucity of research on these couples, from an anecdotal perspective, partners in these couples have fairly poor outcomes. Typically, one partner s success in eliminating his or her substance use changes the dynamics in the relationship, which eventually results in the dissolution of the relationship. In most instances, however, the treatment-seeking partner fails to stop drinking or using drugs and the relationship survives. The lack of support for abstinence within dual substance-abusing couples has resulted in BCT being largely ineffective with these types of couples. Couples in which both partners abuse substances may also not exhibit the degree of relationship distress or dysfunction as the other couple types because many shared recreational activities are built around alcohol use (Klostermann et al., 2005). Thus, treatment is likely to be very different for these couples. In turn, some modification to the standard BCT approach is clearly necessary since there is typically a lack of support for abstinence within the dyad. At present, contingency management approaches (i.e., providing voucher incentives for attendance and abstinence by both partners) are being used with these couples. Although the initial findings are encouraging, this research effort is in its infancy and more data is necessary before more definitive conclusions can be drawn. Mechanisms of Action. While the results of several randomized clinical trials demonstrate the effectiveness of BCT, the mechanisms of action that produce the observed outcomes have not been empirically tested. As previously mentioned, the theoretical rationale for the effects of BCT on substance abuse has been that certain dyadic interactions reinforce continued substance use or relapse and that relationship distress, in turn, is a trigger for substance use. Consequently, the BCT intervention package that has evolved from this conceptualization involves (a) teaching and promoting methods to reinforce abstinence from within the dyad (e.g., engaging in the Recovery Contract); (b) improving communication skills to address problems and conflict appropriately when it arises; and (c) encouraging participation in relationship enhancement exercises (e.g., Shared Rewarding Activities) to increase dyadic adjustment. However, it is not clear which, if any, of these aspects of the BCT intervention results in the observed improvements. As reasoned by the National Institute of Alcohol Abuse and Alcoholism (2001), it is difficult to translate treatments that are based on empirical research into routine clinical practice unless the active ingredients of the treatments are known (Longabaugh et al., 2005; p236). For example, although most BCT studies have found that participation in BCT results in improvements in relationship adjustment and reductions in substance use, none have conducted a formal test of mediation to determine if changes in relationship adjustment (i.e., either during treatment or after treatment completion) partially or fully mediate the relationship between type of treatment received (e.g., BCT, individual counseling, an attention control 88

9 condition) and substance use outcomes. Indeed, it is important to highlight that most studies have generally failed to find strong relationships between theoretical mechanisms of action and subsequent outcomes, both in general psychotherapy (e.g., Orlinski, Grawe, & Parks, 1994; Stiles & Shapiro, 1994) and in substance abuse treatment (e.g., Longabaugh & Wirtz, 2001). Thus, it is important for future studies to formally test the theoretical mechanisms thought to underlie the observed BCT effects. Additions to standard BCT targeted to enhance secondary outcomes. Future research needs to examine if the effects of BCT can be enhanced by specifically targeting secondary outcome domains. Preliminary research is currently being conducted to examine the effect of adding such circumscribed interventions to the standard BCT intervention package. In fact, a pilot study is currently underway to determine if components added to BCT designed to reduce IPV will also enhance the effects of standard BCT on this secondary outcome. Conclusion From the initial small-scale pilot studies conducted in the early 1970s to the large, wellfunded randomized clinical trials that are ongoing, research on BCT for substance abuse continues to evolve. More specifically, 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 of exploration. Thus, the goal for BCT investigators will be to continue to modify, refine, and re-evaluate the intervention to make what is already a very effective intervention even more so. Advertisement Behavior Analyst Online The Behavior Analyst Online organization (BAO) develops and deploys new resources for behavior analysts and makes them available on the internet free of charge to the public. These resources are dedicated to educating the public about behavior analysis as well as serving as a resource for professionals involved in the field of behavior analysis. The BAO organization is responsible to its membership to develop resources that the membership will find useful in everyday research, education, and application of the science of behavior analysis. The BAO organization offers may perks to its members, including a Web Forum and the ABA-PRO Mailing List. In addition, the organization publishes several major free e-journals of interest to the behavior analysis community: The Behavior Analyst Today International Journal of Behavioral Consultation and Therapy The Journal of Early and Intensive Behavior Intervention The Journal of Behavior Analysis in Health, Fitness and Medicine Journal of Behavior Analysis of Offender &Victim Treatment & Prevention The Journal of Speech - Language Pathology and Applied Behavior Analysis The Behavior Development Bulletin Membership in the BAO organization is free. For details, visit our website at 89

10 References Azrin, N. H., Sisson, R. W., Meyers, R., & Godley, M. (1982). Alcoholism treatment by disulfiram and community reinforcement therapy. Journal of Behavior Therapy and Experimental Psychiatry, 13, Bowers, T. G., & Al-Rehda, M. R. (1990). A comparison of outcome with group/marital and standard/individual therapies with alcoholics. Journal of Studies on Alcohol, 51, Chase, K. A., O Farrell, T. J., Murphy, C. M., Fals-Stewart, W., & Murphy, M. (2003). Factors associated with partner violence among female alcoholic patients and their male partners. Journal of Studies on Alcohol, 64(1), Crits-Christoph, P., Siqueland, L., Blaine, J., Frank, A., Luborsky, L., Onken, L. S., Muenz, L., Thase, M., Weiss, R. D., Gastfriend, D. R., Woody, G., Barber, J. P., Butler, S. F., Daley, D., Bishop, S., Najavits, L. M., Lis, J., Mercer, D., Griffin, M. L., Moras, K., & Beck, A. T. (1997). The NIDA Collaborative Cocaine Treatment Study: Rationale and Methods. Archives of General Psychiatry, 54, Fals-Stewart, W. (1998, February). Couples-based treatment for alcoholism and drug abuse. Paper presented at the Mid-Winter Convention of the American Psychological Association, San Diego, California. Fals-Stewart, W. (2003). The occurrence of interpartner violence on days of alcohol consumption: A longitudinal diary study. Journal of Consulting and Clinical Psychology, 71, Fals-Stewart, W., Birchler, G. R., Hoebbel, C., Kashdan, T. B., Golden, J., & Parks, K. (2003). An examination of the indirect risk of exposure to HIV among wives of substanceabusing men. Drug and Alcohol Dependence, 70 (1), Fals-Stewart, W., Birchler, G. R., & O'Farrell, T. J. (1996). Behavioral couples therapy for male substance-abusing patients: Effects on relationship adjustment and drug-using behavior. Journal of Consulting and Clinical Psychology, 64, Fals-Stewart, W., Birchler, G. R., & O'Farrell, T. J. (1999). Drug-abusing patients and their intimate partners: Dyadic adjustment, relationship stability, and substance use. Journal of Abnormal Psychology, 108(1), Fals-Stewart, W., Fincham, F., Vendetti, K., & Kelley, M. L. (2003). The effect of adding parent skills training to behavioral couples therapy. Poster presented at the 110 th Annual Convention of the American Psychological Association, Toronto, Ontario, Canada. Fals-Stewart, W., Kashdan, T. B., O Farrell, T. J., & Birchler, G. R. (2002). Behavioral couples therapy for drug-abusing patients: Effects on partner violence. Journal of Substance Abuse Treatment, 21, Fals-Stewart, W., Kelley, M. L., Cooke, C. G., & Golden, J. (2003). Predictors of the psychosocial adjustment of children living in households in which fathers abuse drugs: The effects of postnatal social exposure. Addictive Behaviors, 28(6), Fals-Stewart, W., O Farrell, T. J., & Birchler, G. R. (2001). Behavioral couples therapy for male methadone maintenance patients: Effects on drug-using behavior and relationship adjustment. Behavior Therapy, 32,

11 Hedberg, A. G., & Campbell, L. (1974). A comparison of four behavioral treatments of alcoholism. Journal of Behavior Therapy and Experimental Psychiatry, 5, Hoebbel, C., & Fals-Stewart, W. (2003, June). Changes in HIV risk behaviors of husbands who participate in behavioral couples therapy. Poster presented at the College on Problems of Drug Dependence, Boca Raton, Florida. Kelley, M. L., & Fals-Stewart, W. (2002). Couples-versus individual-based therapy for alcoholism and drug abuse: Effects on children s psychosocial functioning. Journal of Consulting and Clinical Psychology, 70, Klostermann, K., Fals-Stewart, W., Gorman, C., Kennedy, C., & Stappenbeck, C. (2005). Behavioral couples therapy for alcoholism and drug abuse: Rationale, methods, findings, and future directions. In C. Hilarski (Ed.), Assessment and Treatment with Adolescents, Adults, and Families (pp ). Binghamton, NY: Haworth Press. Longabaugh, R., Donovan, D. M., Karno, M. P., McCrady, B. S., Morgenstern, J., & Tonigan, S. (2005). Active ingredients: How and why evidence-based alcohol behavioral treatment interventions work. Alcoholism: Clinical and Experimental Research, 29(2), Longabaugh, R., & Wirtz, P. W. (2001). Project MATCH hypotheses: Results and causal chain analyses. Project MATCH Monograph Series, Vol. 8. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. Maisto, S. A., O Farrell, T. J., McKay, J., Connors, G. J., & Pelcovitz, M. A. (1988). Alcoholics attributions of factors affecting their relapse to drinking and reasons for terminating relapse events. Addictive Behaviors, 13, McCrady, B. S., Epstein, E. E., & Kahler, C. W. (2004). Alcoholics anonymous and relapse prevention as maintenance strategies after conjoint behavioral alcohol treatment for men: 18-month outcomes. Journal of Consulting and Clinical Psychology, 72, McCrady, B., Stout, R., Noel, N., Abrams, D., & Nelson, H. (1991). Comparative effectiveness of three types of spouse involved alcohol treatment: Outcomes 18 months after treatment. British Journal of Addiction, 86, Moos, R. H., & Billings, A. G. (1982). Children of alcoholics during the recovery phase. Alcoholic and matched control families. Addictive Behavior, 7, Moos, R. J., Finney, J. W., & Cronkite, R. C. (1990). Alcoholism treatment: Context, process and outcome. New York: Oxford University Press. Morgenstern, J., & McKay, J. R. (2007). Rethinking the paradigms that inform behavioral treatment research for substance use disorders. Addiction, 102, O'Farrell, T. J., Choquette, K. A., Cutter, H. S. G., Brown, E. D., Bayog, R., McCourt, W., Lowe, J., Chan, A., & Deneault, P. (1996a). Cost-benefit and cost-effectiveness analyses of behavioral marital therapy with and without relapse prevention sessions for alcoholics and their spouses. Behavior Therapy, 27, O'Farrell, T. J., Choquette, K. A., Cutter, H. S. G., Floyd, F. J., Bayog, R. D., Brown, E. D., Lowe, J., Chan, A., & Deneault, P. (1996b). Cost-benefit and cost-effectiveness analyses of behavioral marital therapy as an addition to outpatient alcoholism treatment. Journal of Substance Abuse, 8,

12 O Farrell, T. J., Choquette, K. A., Cutter, H. S. G., & Birchler, G. R. (1997). Sexual satisfaction and dysfunction in marriages of male alcoholics: Comparison with nonalcoholic maritally conflicted and nonconflicted couples. Journal of Studies on Alcohol, 58, O'Farrell, T. J., Cutter, H. S. G., Choquette, K. A., Floyd, F. J., & Bayog, R. D. (1992). Behavioral marital therapy for male alcoholics: Marital and drinking adjustment during the two years after treatment. Behavior Therapy, 23, O Farrell, T. J., & Fals-Stewart, W. (2003). Alcohol abuse. Journal of Marital and Family Therapy, 29, 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, O Farrell, T. J., Van Hutton, V., & Murphy, C. M. (1999). Domestic violence after alcoholism treatment: A two-year longitudinal study. Journal of Studies on Alcohol, 60, Orlinsky, D., Grawe, K., & Parks, B. (1994). Process and outcome in psychotherapy. In A. E. Bergin & S. R. Garfield (Eds.), Handbook of psychotherapy and behavior change (4 th ed., pp ). New York: Wiley. Potoczniak, M. J., Mourot, J. E., Crosbie-Burnett, M., & Potoczniak, D. J. (2003). Legal and psychological perspectives on same sex domestic violence: A multisystemic approach. Journal of Family Psychology, 17, Stanton, M. D., & Shadish, W. R. (1997). Outcome, attrition, and family-couple treatment for drug abuse: A meta-analysis and review of the controlled, comparative studies. Psychological Bulletin, 122(2), Stiles, W. B., & Shapiro, D. A. (1994). Disabuse of the drug metaphor: Psychotherapy processoutcome correlation. Journal of Consulting and Clinical Psychology, 62, Winters, J., Fals-Stewart, W., O Farrell, T. J., Birchler, G. R., & Kelley, M. L. (2002). Behavioral couples therapy for female substance-abusing patients: Effects on substance use and relationship adjustment. Journal of Consulting and Clinical Psychology, 70, This project was supported, in part, by grants from the National Institute on Drug Abuse (R01DA12189, R01DA014402, R01DA SUPL, R01DA015937, R01DA016236), the National Institute on Alcohol Abuse and Alcoholism (R21AA013690), and the Alpha Foundation. Author Contact Information: Keith Klostermann School of Nursing, University of Rochester 601 Elmwood Avenue, Box SON, Rochester, New York (585)

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