Nearly 25 years ago, the National Institute on Alcohol Abuse and Alcoholism hailed couple and family therapy as "one of the most outstanding current advances in the area of psychotherapy of alcoholism" and called for controlled studies to test these promising methods (Keller, 1974). Currently behavioral couples therapy (BCT) is the family therapy method with the strongest research support for its effectiveness in substance abuse.
Purpose of BCT
BCT works directly to increase relationship factors conducive to abstinence. A behavioral approach assumes that family members can reward abstinence, and that alcohol- and drug-abusing patients in happier, more cohesive relationships with better communication have a lower risk of relapse. Typically, the substance-abusing patient and the spouse are seen together in BCT for 15 to 20 outpatient couple sessions over five to six months. Generally, couples are married or cohabiting for at least one year, without current psychosis, and one member of the couple has a current problem with alcoholism and/or drug abuse. The couple starts BCT soon after the substance user seeks help.
BCT Treatment Methods
BCT sees the substance-abusing patient with the spouse to build support for sobriety. The therapist arranges a daily "sobriety contract" in which the patient states his or her intent not to drink or use drugs that day (in the tradition of one day at a time), and the spouse expresses support for the patient's efforts to stay abstinent. For those alcoholic patients who are medically cleared and willing, daily Antabuse ingestion-witnessed and verbally reinforced by the spouse-also is part of the sobriety contract. The spouse records the performance of the daily contract on a calendar provided by the therapist. Both partners agree not to discuss past drinking or fears about future drinking at home to prevent substance-related conflicts that can trigger relapse. Instead, they reserve these discussions for the therapy sessions. At the start of each BCT couple session, the therapist reviews the sobriety contract calendar to see how well each spouse has done their part. If the sobriety contract includes 12-step meetings or urine drug screens, these are also marked on the calendar and reviewed. The calendar provides an ongoing record of progress that is rewarded verbally at each session. The couple performs the behaviors of their sobriety contract in each session to highlight its importance and to let the therapist observe how the couple does the contract.
Using a series of behavioral assignments, BCT increases positive feelings, shared activities and constructive communication because these relationship factors are conducive to sobriety. For instance, "Catch Your Partner Doing Something Nice" asks spouses to notice and acknowledge one pleasing behavior performed by their partner every day. In the caring day assignment, each person plans ahead to surprise their spouse with a day when they do some special things to show they care.
Planning and doing shared rewarding activities is important, because many substance abusers' families have stopped shared activities that are associated with positive recovery outcomes (Moos et al., 1990). Each activity must involve both spouses, as well as their children or other adults. In addition, the activities can take place at or away from home. Teaching communication skills can help the alcoholic and spouse deal with stressors in their relationship and in their lives, and this may reduce the risk of relapse.
Relapse prevention is the final activity of BCT. At the end of weekly BCT sessions, each couple completes a continuing recovery plan that is reviewed at quarterly follow-up visits for an additional two years.
This BCT overview describes methods used at the Counseling for Alcoholics' Marriages (CALM) Project in the Harvard Medical School department of psychiatry at the Veterans Affairs Medical Center in Brockton, Mass. More details can be found elsewhere (O'Farrell, 1993; Rotunda and O'Farrell, 1997).
Research on BCT With Alcoholism
Several studies have compared drinking and relationship outcomes for alcoholic patients treated with BCT or individual alcoholism counseling. Outcomes have been measured at six-month follow-ups in earlier studies and at 18 to 24 months after treatment in more recent studies. The studies show a fairly consistent pattern of more abstinence and fewer alcohol-related problems, happier relationships, and lower risk of marital separation for alcoholic patients who receive BCT than for patients who receive only individual treatment (Azrin et al., 1982; Bowers and al-Redha, 1990; McCrady et al., 1991; O'Farrell et al., 1992).
Domestic violence is the focus of recent BCT studies. Table 1 shows the percentage of male alcoholic patients who were violent toward their female partner at least once in the year before BCT and in the first and second year after BCT. Information from a control group, which consisted of demographically matched couples without alcohol problems drawn from a national survey of family violence in the United States population, was also reported (O'Farrell and Murphy, 1995; O'Farrell et al., in press; O'Farrell et al., 1998). Nearly two-thirds of the alcoholics had been violent toward their female partner in the year before BCT. This is significantly and substantially higher than in couples without alcoholism. Violence was significantly lower in the first and second year after BCT than it was before BCT, but it remained somewhat higher than among couples without alcohol problems.
These results are more dramatic when violence is examined in relation to drinking outcome status after BCT. Table 2 shows that domestic violence was nearly eliminated among patients who were remitted (i.e., about half of the sample who remained abstinent) after BCT (O'Farrell and Murphy, 1995; O'Farrell et al., in press). Thus, these studies showed that husband-to-wife violence was significantly reduced in the first and second year after BCT alcoholism treatment and was nearly eliminated with abstinence.
From studies of cost outcomes after BCT, Table 3 shows the average costs per case for alcohol-related hospital treatments and jail stays for male alcoholics in two of our Project CALM studies (O'Farrell et al., 1996a and 1996b). Costs for the year before BCT were about $7,800 in the first study and $6,100 in the second study. Costs were significantly lower after BCT, averaging about $1,100 for the two years after BCT in the first study and for the 18 months after BCT in the second study. Therefore, cost savings averaged
between $5,000 and $6,700 per case. The benefit-to-cost ratios show $8.64 in the first study and $5.97 in the second study in cost savings for every dollar spent to deliver BCT. Taken together, the data from these two studies show that reduced hospital and jail days after BCT save more than five times the cost of delivering BCT for alcoholism.
Research on BCT With Drug Abuse
The first randomized study of BCT with drug-abusing patients compared BCT plus individual treatment to individual treatment alone. Eighty married or cohabiting male patients with a primary drug abuse diagnosis (most frequently cocaine or heroin) in a substance abuse outpatient clinic were randomly assigned to one of the two treatments. The individual treatment was a behavioral coping skills program to help the patients resist using drugs. BCT used treatment methods described above. Both treatments had 56 therapy sessions over a six-month period. Individual treatment had all sessions with the patient alone; BCT had 12 of the sessions with the patient and female partner together.
Clinical outcomes in the year after treatment favored the group that received BCT for both drug use and relationship outcomes (Fals-Stewart et al., 1996a). Compared to individual treatment, BCT had significantly fewer cases that relapsed, fewer days of drug use, fewer drug-related arrests and hospitalizations, and longer time to relapse. Couples in BCT also had more positive relationship adjustment on multiple measures and fewer days separated due to relationship discord.
Cost-benefit outcomes in this same study favored BCT over individual treatment (Fals-Stewart et al., 1997). Table 4 shows social costs for the male drug abusers during the year before and the year after treatment. These social costs included costs for drug abuse-related health care, criminal justice system use for drug-related crimes, and income from illegal sources and public assistance. Social costs in the year before treatment averaged about $11,000 per case for both treatment groups. In the year after treatment, for the BCT group, social costs decreased significantly to about $4,900 per case with an average cost savings of about $6,600 per patient. In contrast, for the individual treatment only group, the average cost savings was $1,900 per patient. The benefit-to-cost ratio was significantly more favorable for BCT than for individual treatment, even though the cost to deliver the two treatments was nearly identical. There was $5.01 in social cost savings for every dollar spent to deliver BCT, and $1.37 in social cost savings for every dollar spent to deliver individual treatment.
Results of cost-effectiveness analyses also favored the BCT group. BCT produced greater clinical improvements (e.g., fewer days of substance use) per dollar spent to deliver BCT than did individual treatment. Therefore, this study showed that, in treating drug abuse, BCT as part of individual-based treatment is significantly more cost-effective and cost-beneficial than individual treatment alone.
In a second randomized study of BCT with drug-abusing patients (Fals-Stewart et al., 1996b), 30 married or cohabiting male patients in a methadone (Dolophine) maintenance program were randomly assigned to individual treatment only or to BCT plus individual treatment. The individual treatment was standard outpatient drug abuse counseling. Both treatments had 56 therapy sessions over a six-month period. Individual treatment had all sessions with the patient alone; BCT had 24 of the sessions with the patient and female partner together. Results during the six months of treatment favored the group that received BCT on both drug use and relationship outcomes. In comparison with individual treatment, BCT had significantly fewer drug urine screens that were positive for opiates, fewer drug urine screens that were positive for any of the nine drugs tested, and more positive relationship adjustment measured with a standard questionnaire.
Conclusions and Directions
The findings presented here support three main conclusions. First, BCT for both alcoholism and drug abuse produces more abstinence, happier relationships, fewer couple separations and lower risk of divorce than does individual-based treatment. Second, domestic violence is substantially reduced after BCT for alcoholism. Third, cost outcomes after BCT are very favorable for both alcoholism and drug abuse and superior to individual-based treatment for drug abuse.
Additional research on BCT is warranted, especially for drug abuse where there are fewer studies. But even more important is technology transfer, enabling patients and their families to benefit from what has already been learned about BCT for alcoholism and drug abuse. The Institute of Medicine (1998) has documented a large gap between research and practice in substance abuse treatment. BCT is one example of this gap.
BCT has relatively strong research support, but it has not yet become widely used. Hopefully the next few years will see progress in closing this gap.
Azrin NH, Sisson RW, Meyers R, Godley M (1982), Alcoholism treatment by Disulfiram and community reinforcement therapy. J Behav Ther Exp Psychiatry 13(2):105-112.
Bowers TG, al-Redha MR (1990), A comparison of outcome with group/marital and standard/individual therapies with alcoholics. J Stud Alcohol 51(4):301-309.
Fals-Stewart W, Birchler GR, O'Farrell TJ (1996a), Behavioral couples therapy for male substance-abusing patients: effects on relationship adjustment and drug-using behavior. J Consult Clin Psychol 64(5):959-972.
Fals-Stewart W, O'Farrell TJ, Birchler GR (1997), Behavioral couples therapy for male substance-abusing patients: a cost outcomes analysis. J Consult Clin Psychol 65(5):789-802.
Fals-Stewart W, O'Farrell TJ, Finneran S, Birchler GR (1996b), The use of behavioral couples therapy with methadone maintenance patients: effects on drug use and dyadic adjustment. Paper presented at the Annual Meeting of the Association for the Advancement of Behavior Therapy, New York.
Institute of Medicine (1998), Bridging the gap between practice and research: forging partnerships with community-based drug and alcohol treatment. Lamb S, Greenlick MR, McCarty D, eds. Washington, D.C.: National Academy of Sciences Press.
Keller M, ed. (1974), Trends in treatment of alcoholism. In: Second special report to the U.S. Congress on alcohol and health. Washington, D.C.: Department of Health, Education, and Welfare.
McCrady B, Stout R, Noel N et al. (1991), Effectiveness of three types of spouse-involved alcohol treatment: outcomes 18 months after treatment. Br J Addict 86(11):1415-1424.
Moos RH, Finney JW, Cronkite RC (1990), Alcoholism treatment, context, process and outcome. New York: Oxford University Press.
O'Farrell TJ (1993), A behavioral marital therapy couples group program for alcoholics and their spouses. In: Treating Alcohol Problems: Marital and family interventions. TJ O'Farrell, ed. New York: Guilford Press.
O'Farrell TJ, Murphy CM (1995), Marital violence before and after alcoholism treatment. J Consult Clin Psychol 63(2):256-262.
O'Farrell TJ, Choquette KA, Cutter HSG et al. (1996a), Cost-benefit and cost-effectiveness analyses of behavioral marital therapy as an addition to outpatient alcoholism treatment. J Subst Abuse 8(2):145-166.
O'Farrell TJ, Choquette KA, Cutter HSG et al. (1996b), Cost-benefit and cost-effectiveness analyses of behavioral marital therapy with and without relapse prevention sessions for alcoholics and their spouses. Behavior Therapy 27(1):7-24.
O'Farrell TJ, Cutter HSG, Choquette KA et al. (1992), Behavioral marital therapy for male alcoholics: marital and drinking adjustment during the two years after treatment. Behavior Therapy 23:529-549.
O'Farrell TJ, Fals-Stewart W, Murphy C (1998), Domestic violence before and after couples therapy for male alcoholics. Paper presented at the International Conference on the Treatment of Addictive Behaviors, Santa Fe, N.M.
O'Farrell TJ, Van Hutton V, Murphy CM (in press), Domestic violence after alcoholism treatment: a two-year longitudinal study. J Stud Alcohol.
Rotunda RJ, O'Farrell TJ (1997), Marital and family therapy of alcohol use disorders: bridging the gap between research and practice. Professional Psychology 28(3):246-252.