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2 DOCUIENT BESOMI ED CG AUTHOR O'Farrell Timothy J; Cutter Henry S G TITLE Behavioral Marital Therapy (BMT) for Alcoholids and Wives: Review of Literature and a ProposEd Research Program PUB DATE Sep 77 NOTE - 1p; Paper presented at the Annual Conference on ;Experimental and Behavioral Approachis tc Alcohclim (Bergen NORWAY AugUst 28-September ); Tables not available-due to poor filmingguality ES PRICE DESCRIPTORS MF-$083 HC-$1j67 Plus Postage *Alcoholism; issertiveneasi *Behavior Change; *Drinking; Family Life; Interaction; Interpersonal Belaonship; Literature Reviews; *Males; *Marriage Counseling: Reinforcement; *Socialization _ ^V- ABSTRACT After clescribing a sociallearniag formulation of the ---' male albohoiics marriage this paper reviews the few studies of behaiioral marital therapy (BMT) for alcoholics and their wives Although nose of these studies are as rigorous as one igbt Wish and many of them are merely case studies a review of the- iterature shows that behavio al marital therapy in ccmbinatiiion w 1 th social and vocational behavio sat alcoholism treatment produce's Letter results with State Hospital lcoholics than does a less intensive traditional alcoholism treatment! When intensity of treatment is held constant behavioral marital therapy for outpatient alcohclics is net only - superior to three alternativebehavicral treatments but clearly exceeds the outcome statistics in the nontehavitral lirature With the exception 'of a study treating cnly the xifee behavioral marital therapy hal had positive results in 29 of 31 cases treated A series of-issues and questions future studies should address are listed In addition i study to compare behaqiotal and non - behavioral couples groups-is proposed (Author) V 6 V ***************************************$******************************* * Reproductions supplied by EDRS ire thebeat that can be made from the original doeument *********************************************************************'

3 sit a BEHAVIORAL MARITAL-THERAPY (RMT) FORALCOHOLICS AND WIVES: itorwoi LITERATURE AND A PROPOSED RESEARCH PROGRAM 10 "PERMISSION TO REPRODUCE THIS MATERIAL HAS BEEN GRANTED BY TO THE EDUCATIONAL RESOURCES INFORMTIONI CENTER (ERIC) AND USERS OF TIE ERIC SYSTEM U S DEPARTMENT OF HEALTH EDUCATION I WELFARE 0' NATIONAL INSTITUTE OF E0i/CATION THIS DOCUMENT HAS BEEN REPRO- DUCED EXACTLY AS RECEIVED FROM THE PERSON OR ORGANIZTIONORIGIN MIND IT POINTS OF VIEW OR OPINIONS STATED DO NOT 'NECESSARILY REPRE SENT OFFICIAL NATIONAL INSTiTUTeOF EDUCATION POSITION OR POLICY -;?A Timothy J O'Farrell and Henrx;S G Cutter Veterans Administration Hospital Brockton Massachlaetts 0201 USA X Paper Presented 1 tla 1 at NATO INTERNATIONAL CONFERENCE on EXPERIMENTAL AND BEHAVIORAL APPROACHES TO ALCOHOLISM August 28 - September Bergen Norway LC

4 1 fte Today I would like to present a review of the literature and a preview' of a probosed researchprogram dealing with behavioralinarital thelapy (BIC) for alcoholics and their 'wives I had planned to lordsenethe first result% o of this-new research project but unforeseen delays'amake this iiposible is 'why I changed my title and why I am a bivemrrassed -ThOnetheless let start with a brief review of the literature which covers-the most f importaht features o past studies and the*eds they'reveal for future research; Mime limitations prevent detailed methodologa1 critique of each study Behavioral marital then yopinwforthe alco1061's marriage is based on a social-learning formulation "; / --- Xccording to-thpi'modt the marriages of male alcoholics and their wives mgenerally conflicted; the couple fight repeatedly about-drinking and poitivel reinforce each other at a low 'rate' Marital interaction under t ate condi ions-isahardly a'viable alternative to drinking % Inthis behavioral view certai antecedent and consequent events are assumed to maintain abusive drink(n An important antecedent to drinking A by married alcoholics mays their lack of assertiveness in IntexacURRWith their wives Wives who attend pr rily to awolic behaviors but virtually igiore'rositive nondrinking beha ors provide consequences likely increase drinkng Wiveslit furthermore often provide financial emotional and sexual $ support when alcoholidhusban are actively drinking A detailed consider- ) ation however of the evid e for and issues involved in this behavioral 'll'ormulation of the alaholi marriage is beyond the scope of my paper today li I want to tell:you boeflyabout the:few available reports of BMT for ' married male alcoholics I' able 1 of your handout summarizes these studies J Cheek Franks Laud updand Burtle (1971) tried toteach 2 wives and relatives of treated al oholics to apply operant principles to family \

5 S interactions likely to threaten sobriety' Their rather meager findings Indicated that wives were unable consistently to apply this new learn g at home The authors speculated that the ayes were so sensitized to t eir alcoholic husbands' behavior that the'tensiou7and anger they felt when dealing with reinforcers this study the joint tr their husbands t{nhibited the wives from changing Oieir emitted It may also be significant that only the wives/were treated in _ * Recent reviews of the marital therapy literature Suggest'that tment of husbands and wives is more likely to sucoeedthan dividual treatment -/ The effects of assertive training have been reported in a case study by Eisler Miller Hersen and Alford 1197) I The results showed'that the husband was more assertive in post'treatment videotaped interactions with his / wiieand apparently as a consequence weeklyibreath alcohol levels (taken of a random baiis fot 6 weeks before and after therapy) deoreaied This imaginative case study is noteworthy because it applied behavioral procedures and demonstrated changes on object ive measures of marital and drinking!? c' behavibr - Ao Miller (1972); in another case study found that ihe husband'? drinking dropped to and remained at agreed-on limits following the establishment' of a contingency contract between Spouses At six monthe-follow-0the couple also reported an improved Marital relstionship This study iathe firsi in the literature to apply contracting to the:5relationship between analcohdlic o and his wife oe Wilson and -Rosen= <(1976)< in <a ease study- -alao -employed :ebont riot <_ : I '(specifying the amountand stimulus conditions for controlled deinking) as part of a multifaceted behavioral treatinentprograsi thataiabineiuded BAp t discrimition training thought stopping an: assertive training The wife 0

6 1 / 'I I k observed treatment and provided feedback to the husband "and to the therapists 3 during therapy Sessions The couple initially teeteringon the brink of divorce reunited with both reporting 'greater happiness The husband was 0 contiolling'his drinking at 6 months fiollow-up Miller and HerSen (1975)in an as yet unpublished case report provide a model example of treatment-relevant assessment and the effectiveuse of a 1 more comprehensive marital treatment package Ahsessment'contistedof direct observation of the couple during' interviews together Videotaped-con= versations in which the couple discussed various problem and non-problem areas of their life and audiotape recordings of mealtimeinteracti6 at home '' on two occasions In some of these a % essmeat sessions the counsel6rs were absent to allow for more :'natural" in raction On the basis of these assee- =ants specific behavioral goals were set and achieved by means of social' skills trainipa assertive trairktigand contracting: 'Follow -up_at 9 months indicated that the husband had taken Antabuseeach'day and was completely i abstinent Improvements also were noted in the interactions of the couple (videotaped An theiclinic) and in their day-to-day behavior at hqme Hunt'and Azrin (1973) and Azrin'(1976) includeda behavioral marital i counseling procedure as part of their commnnity-reinforcement program for -t ) State Hosiital alcoholics 'Rigorous evaluation of the treatment program of which the marital counseling procedures were a part Showed it to be clearly superior to a less intendive moe*traditional hospital This is the first study in which marit 1 counseling was 'treatment package previously used witinon-alcoholics ptogram for alcoholics based on a behavioral Hftework dssignments and various structured tasks taught couples to pinpoint pleasing and displeasing spouse behaviors and to request desired changes Lastructipn in negotiation compromise;anainformal contracting was used to facilitate K behavior change at home 5 a e

7 c Hedberg and Campbell (197) in an 'experimental clinical study compared J among outpatients the therapeuticefficacy of behavioral mar I counseling systematic desensitization covert-sensitization andlaversion therapy At 6 months follow-up behavioral marital counseling was found to be the most ) egfec ive treatuent with 7i-;1-15 alcoholic patients achieving their goal (either abbtinence orcontrolled drinking); an additional'in'thowed "much I improvement'" For thosewho chose abdtinence as their goal behavforik marital counseling was by far superior to all other treatments Cammunica- tion training'instructions-inthe principles of'10arninge_contractingi and 0 Se assertive training were all partaif the marital treatment The sequencing frequency and-total number of treatment sessions was thesame for all f1 1 patients Irrespective of:the type of therapy received 10 Althoue none c of these studies are as rigotous as one might wish and s ---\ many of them are merely case studies we can see hop; orreview of the : literature that behavioral marital therapy in combination With social and A vocaelonal behavioral alcoholism treatment producei better results with' State Hospital alcoholios thandoes traditional alcoholism treatment although time in therapy was not equal for the two treatments) In addition when intensity of- treatment is held constant behavioral maritaltherapy (BMT) for outpatient alcoholics is not only superior to three alterndiive behav- / s% ioral iriprients but'clearly exceeds the outcome statistics in the' nonbe- C havioral-literature 'Finally BMT (with the erceptyon of a studyytreating only the wife) lids had positive results-iv 29of 31 rses treated BMT for alcoholics and their wivesone must conclude shows prombise and deserves the further terious'atiention of behavior therapists: We should develop and 'rigoiously evaluate-behaioral-parital treatment packages for alcoholics and 'their wives- Ocd such a package has been developed there are atnumber of questionsandisslies that should'beinvettigated A '6 1

8 -r 5 Now before cohdluaing with questions relevant to'future research I - would like to iell you about a research projec that my colleague Dr < - HenryoCutteri and / recehtly submitted far fundin L c undergoihg inpatient'ireatment for alcoholism in the rried alcoholics - sin'of this study 1 are randomly assigned-to (a no marital treatment cofitrol condition or to 12 weekly sessions of eithera behavioral couples gtoup ( Liberman Levine Wheeler Sanders E' Wallace 1976) or a nonbehaviora interabtion couples A group This latternonbehayioral treatment is included/in order to compare the behavioral methods of marital therapy with alternative!ike most frequently Used N ) Measures of marital drinking vodational'and emotional:adjust ment'taken pre'and post therapy (and at 2 6 and 12 month follow-ups)are / used to evaluate treatment outcome The marital measures include sampi escf couple interaction videbtaped in the clinic and at home and a variety self-report measures developed by 11MT researchers Drinking behavio is p measured by standardized self-yeport instruments collateral report and breath alcoholtysts in the community Table 2 of your handout describes the behayihral couples group in greeter _ detail; Table 3 lists the dependent vartablemeasureasi look forwartto cdmsmunicating the results of this proposed project to you'at a 'future date ''' There are a series of questions and issues that fptures esearch must address if this seemingly fertile field for treatment and research is bear fruit 'i'_ w /-- - 0e \ to 1 What does a RMT package add to-alcoholism treatment?' Rigorous studies which specifically evaluate marital treat- S ment using random aseignment; equartide-*treatment for experimental qnd control gr oups appropriate outcome measures and sufficient follow-up are needed 7 O r

9 I 6 2 How does-a BAT package compare in terms of effectiveness to li \ _ -7 other frequently used marital treatments foralcoholics and al their spouses? Thegreater structure andpresumablygreater cost in therapist and client time and effort needed for BHT as compareto alternative maritaltreatments'require theuse ofadditional appropriate treatmentcodparisons 3 For whom is BHT a sufficient treatment for alcoholism and for whom are additional nonrmarital treatments needed? What are these additional therapeuticinputs andwho needs them? -Job- # ' finding help for the unemployed awl specific training in controlled drinking for those with such a goal may be two such inputs 1 In addition alcoholics whose drinking istriggeredby uncomfortable thoughts and feelings related to events outside the marriage may benefit from relaxation training and stress inoculation training Individual differences in acceptance of and response to BHT should be studied 5 Afterriiorous evaluative studies demonstrate the efficacy of a BMT package then the importance-of specfficcomponentd of the package can be evaluaild for specific sub- groups of alcoholics and their wives- When the literature reachea'this: level of sophistication the following may be significant questions: a Is a treatment focused only on alcohol7related inter- "( adt pattrtts- vithant :intensive-therapy- -for-otire areas of the marital relationship sufficient for some alcoholics and their yives? k t

10 I 'NS - b' ror which married alcoholics should col:itrolled'dr'inking - be a goal? r How important is the wife's fullaccept- ti ance of such a goal? When should controlled drinking / bepursued through amarital agreement an when stiouid it be pursued through a ielf=control program (with or without wifeinvolvanent5 fopthe problem drinker c How doesa M dingle couplebmt intervention Compare to a couples group format and arg there differences'in O whb does best in which type of therapy? d) Do some wives need desensitiiatiou or some other r" r a intefvention/tohelp them adopt'a more positive attitude tadvard- the alcoholic lasband before BMT can be used? 'e Procedures need to be developed and evaluated to deal - i - with Cbmmon objections to marital therapy found among I some alcoholics 7indthei 1 spouses (Htylt& Azrin ) 1 i Now in closing I will return to some general points that d6 not refer to the specific components of a EMT treatment package 6 Investigators and therapists in this area should become and # remain familiar with the literature on behavioral approaches to marital conflict (cracobson & Martin 1976) sexual dysfunction (LoPiccolo & Lobitz 1-973) sexual enhancement (LoPiccolo &Miller 1975) Ulli parent-child problems (Patterson 197 These bodiesof literature may suggest useful assessment and treatment procedures for BMT with < alcoholics In addition university 'clinic investigators t 9-

11 0 in these other areas ckild benefit from the application of 7 their work to-the More problematicalaoholic population 8 Now BMT studiesphould usetheassessment and evaluation procedures Linda Sobell suggested yesterday (SobjelL 1977) with the marital measures being those suggested by leading BMTrbsea;\eHert (Weiss & Margolin 1977) However thes marital measures are`quite complex; time -cpnbuming and' of IN N L specifically tailored to marriages of problem drinkers I Thus we need to CleveloR simple inexpensive reliable and valid measures of marital adjustment for problem drinkers One such measurers Huntand Azrin's (1973) use of the number of weekends sprit in a stiuctured socialactivity outside the home during a dotow-up period; the behaviorally treaieck - F group with overall superior butcome also did muair?petter on this measu re In addition arecent retrospectivelalcoholism treatment outcbme evaluation found fa\mily participation 17n social and recreational activities to be one of the few OP family environment characteristics associated with positive tteafmen optcome (Moos Bromet Tsu & Moos 1977)(1 8" Finally II) we need extensive further study of the reationship between drinkirig behayior (controlled and uncontrolled) and marital and family behavior Oo t 10

12 V 9 NH 'References _ ImroVemenis'iti theconilunity-rdinforcebenspproach to f alcoholism Behavi Rd-search and Therapy Chek Franks; CH Laucius J & BUrtle V Behavior modificatio training for iwives of alcoholics Quarterly Journal of Studies on Alcohol Eisfer;'RM Miller PM Herven % M & Alford' H Effects of assertive j/ ' 7 f training onmarital interaction 'Archives-of Gelipral Psychiatry 197 a 30i It Hedberg AG p Camptell L A c9aparison of four behavioral treatments of alcoholism Journal OfBehavior Therapy And'Experimental Psychiatrp Hunt Gal & Azrin NH A community-reinforcement approach to alcoolism *Behavior Research and Therapy ' Jacobson NS & Maitin B Behavioralimarlage therapy t Bul tin; (1); lir Psycholoical ' Liberman RP Levine J Wheeler E Sanders N & CJ Marital therapy in groups: A comparative evaluation of behavioral and interactional formats Acta Psychiatrica Scandinavica 1916)Supplement 266 LoPiccolo & Lobitz WC Behavior therapy of sexual dysfunction In LA Miamerlynck LC Handy & EJ Mash (Edt) Behavior change: Methodology concepts anti practice ClIampaign lla:research Prss T LoPiccolo J & Miller V A program for enhancing the sexual relationship of normal -couples- The Counseling Kychologist 1975i5(1) 1-5

13 0 1 '1Q # Miller PM The use ofbehavioral contracting in the treatment of alcoholism: A case report Behavior Therapy f & A EillerPM & Hersen M tlbdification 'ormarital interaction patterns between an alcoholic and his wife Unputlished manuscript 1975 (Available frotlpeter Miller Weight Control Center; Hilton Head Hospitg 1tow1Head Island South Carolina) Moos tromet E Tsur V & MdosB Fawn nhaticteristics and the f outcome of treatment for alcoholism: Paper presented at the Eai*Lnir Psychological Association meeting New York April Patterson GR: Families: Applications of social learning to familylife Champaignl'Ill:: Research Press 1971 Sobell LC Alcohol treatment outcome evaluation: Conttibutions irom * behavioial'research Invited address presented at NATO International" I Conferehce on Experimental and Behavioral Approaches to Alcoholism fal Hergen Norway August Weiss RL & Margolin Marital canact and accord- In AR- Cimaro i -KS Calh HEAdams (Eds<)Hantikfor behavior /assessment - New York:'-'John Wiley &SonsInt*1917' f t : _ - Wilson GT tlosen RCo train : contrdlled I drinking in- an alcoholic i 1 through a multifieted behavior tr me 1 ogram: A case study In JD Krumboltz & GEThoresen (Eds) Couns i : -thods New York: f " a 1 - Holt; Rinehart & Winstpn 1976 Yet C- ^ - A at p 12 \

14 / COMPREHENSIVE READING LIST ON BEHAVIORAL APPROACHES TO MARITAL THERAPY ior ALCOHOLICS AND WIVES s f Aztin NH Tmprovements in the community-reinfercement approach to alcoholism Behavior Research and Therapy ginger S Zu neueren therapeutischen Ansatzen bet Alkoholkranken (New therapeutic approaches to the treatment of alcoholics) f Zeitscriftfur Psychothiapie and Medizinishe Psychologie (6) PM& Hersen M Modification of marital interaction patterns between an alcoholic and his wife Unpublished manuscript 1975 (Available from Peter Miller Weight Control Center HiltaRead Hospital Hilton Head Island South Carolina) Miller PM &WAstria MA Sex counseling Chapter in P Miller' & MA Mastria Alternatives to alcohol abuse: A social learning model Chaipaign Illinois: Research Press (a) Cheek; FE Franks CE Laucius Hurtle V Behavior - modification training for wives of alcoholics Quarterly Journal of Studies on Plcohol' ' Eisler RM Mille? PM Hersen & Alford H' Effects of assertive training on marital interaction Archives of General Psychiatry L Hedberg CampbeY1 L A comparison Of fourbehavioral'trest - 1 ments'of alcoholism Journal of Ifehavlor Therapy and Experimental Psychiatry 197; ! thunt & Atrin WW community-reinforcement approach to \ alcoholism havior R search and Therapy Miller PM & Mastria MA Social and marital' skills training Chapter in PM Miller &MArMastria Alternatives to alcohol abuse: A social learninkisodel Champaign Illinois: Research Press Miller PM; Stanford AG & Hemphill DP A comprehensive social-learning approach to alcoholism treatment Social Casework 1971 Man OFarrelr'TJ Wanted: A behavioral couples- group model for ate - holica and their wives Pap& presented at the Eighth Annual Brockton Symposium on Behavior Therapi VA Hospital Brocktod Massachusetts May 1977 / Knox D Alcohol Chapt r in D inox'marriage- happiness: A behavioral approach to counseling Champaign Illinois: Research Press : O'Farrell TJ & Cutter HSG Behavioral and interactional couples group therapy for alcoholics Research-proix)se1 submitted to Veterans AdministrationrNovember 1976 Knox D When hard liquor or soft drugs are a problem Chapter in D Knox Dr Knox's marital exercise book New York: DaVid McKay Co Kranitz L Arealternatiie treatment ror alcoholism Rewslettertibr Researehin Psychology () 21 L'Abate L Behaeforal program for families of Micoholics In L L'Abate Manual of family enrichment/programs Atlanta: Social Research Laboratories Miller PR The use of behavioral contracting in the treaties* of alcoholism: A case reporte Behavior Thera O'Farrell TJ & Cutter HSG Behavioral marital therapy (BMT) for alcoholics and wives: Review of literature and a proposed research program Paperresentedat NATO International Conference on Experimental and Jehavioral Approaches to Alcoho}ism Bergen Norway September 1'1911 Psalm TJ & McCradyi BS Joint admission u a treatment modality for problem drinkers: A case report American Journal of Psychiatry (3) 222i22 & McCrady BS The alcoholic marriage: Psychoanalytic sociological learning and systems theori perspectives New Yorks Grune and Stratton in press 13 Miller PM Marital interaction* Chapte 'In P Miller; Behavioral treatment of alcoholism New York: Perg Press 'tither PM & Elkin T Marital assertiveness training'in-the treatment of alcoholism Presented at'the Association for the' Advancemen of Behavior Therapy Miami December ) r ; Weiesr RL & Birchler GR Adults with marital disfunction Unpublished manuscript University of Oregon 1977 Wilson GT & Rosen RC Training controlled drinking in an 0 alcoholic through a multifaceted behavior treatment programi A eagle etudy In JD Krumboltz & CL Thoresen (Eds) Counseling (A methods New York: Nolt Dinohert & Winstons1976 r P- t /

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