Behaviour Couples Therapy for

Alcoholism and Substance abuse

Presenter: Ms.Shruti Sharma
Guide : Ms.T.Shivata

CONTENTS
Introduction
Family based conceptualization of substance use
Rationale for Use of Couple Therapy
Factors influencing recovery, couple functioning, and/or

relationship longevity
The practice of Behaviour Couple Therapy
Process of Behaviour Couple Therapy
Interventions techniques
Conclusion
2

Introduction
Drug/ alcohol abuse is a complex phenomenon, which has

various social, cultural, biological, geographical, historical and

economic aspects.
It is a global concern because of the impact on individuals

health, familial and social consequences, criminal, legal

problems and the effects on national productivity and economy.
The processes of industrialization, urbanization and migration

have led to loosening of the traditional methods of social

control rendering an individual vulnerable to the stresses and
strains of modern life.
3

Apart from affecting the financial stability, addiction

increases conflicts and causes untold emotional pain

for every member of the family.
(Nadeem et al., 2009)
Alcohol use disorders (AUDs) are best thought of as

family disorders and many families are affected by

AUDs.

For example, 23% of Americans report that they have

a first-degree relative with an alcohol problem and

38% report any blood relative with a drinking
problem.
Although the probability of getting married is about

the same for those with and without AUDs, separation

and divorce rates are about four times that of the
general population.
(McCrady, B. S., 2012)

Physical violence is common in couples where one

partner has an AUD, occurring in about two thirds of

couples where either the woman or the man has an
AUD.
It also affects the physical and psychological health

of spouses and children, with spouses being more

likely to be depressed or anxious or to have
psychophysiological symptoms
and children being at higher risk for school problems,

conduct disorder, and internalizing disorders.

6

Individuals attitudes and patterns of alcohol and drug

use are influenced heavily by the family.

In adulthood, individual drinking patterns are

influenced by the drinking of the intimate partner, and

many couples align their drinking patterns so that they
become more similar over time.

Prevalence
Epidemiological surveys in India indicated, alcohol

was the commonest substance used (60-98%)

followed by cannabis use (4-20%).

Research data also revealed that 20-40% of subjects

above 15 years are current users of alcohol and 10%

of them are regular or excessive users.
(c.f. Ahmed et al., 2009)
8

Family based conceptualizations of

substance use
Historically, alcoholism and drug abuse have been

viewed as individual problems most effectively

treated on an individual basis.
During the last three decades, awareness of family

members potentially crucial roles in the etiology and

maintenance of addictive behaviour has grown.

Since the mid-1970s, three theoretical perspectives

have come to dominate family-based

conceptualizations of substance use and are the
foundation for the treatment strategies most often
used with substance users
1. Family disease approach
2. Family systems approach
3. Behavioural approach

(OFarrell et al., 2003)

10

The best known of these, the family disease

approach, conceptualizes alcoholism and other drug

abuse as a family illness of not only the substance
user but also his or her family members (who are
viewed as being co-dependent)

11

The family systems approach applies the principles

of general systems theory to families, paying

particular attention to ways that families maintain a
dynamic balance between substance use and family
functioning, and whose interactional behaviour is
organized around alcohol or drug use.
(cf. Edwards & Steinglass, 1995)

12

Behavioural approaches assume that family

interactions serve to reinforce alcohol- and drugusing behaviour.

The goal of couple or family therapy from this

perspective is to eliminate reinforcement for

substance use and to promote behaviour that serves
to reinforce abstinence.

13

The disease model of addiction is the dominant view

held by the vast majority of treatment providers in the

substance abuse treatment community.

It should be noted that the behaviourally oriented

treatment approach broadly assumes a problems

perspective, in which problem behaviours presented
by couples seeking help are modified to promote
sobriety.

14

Behaviour Couple Therapy

Behavioural couple therapy (BCT), was launched by

the work of Stuart (1969, 1980) and Jacobson

(Jacobson & Margolin, 1979; Jacobson & Martin,
1976)
Based on social exchange theory (Thibaut & Kelley,

1959), Stuart hypothesized that successful marriages

could be distinguished from unsuccessful ones by the
frequency and range of positive acts exchanged
reciprocally by the partners.
15

 As such, distressed relationships were characterized

by a scarcity of positive outcomes available for each

member, particularly in relation to the frequency of
negative outcomes.

Social exchange theory predicted that individuals

satisfaction with their relationships would be based on

the ratio of benefits to costs received in the form of
positive and negative behaviours from their partners.

16

The forerunner of the Behavioural Couple Therapy

(BCT) approach to the treatment of alcoholism and

drug abuse was a social learning theory approach to the
treatment of marital distress.
Originally called Behavioural Marital Therapy (BMT).
BMT originated in the late 1960s and early 1970s, and

has continued to the present as one of very few

empirically validated approaches for the treatment of
couple distress.
17

BMT has featured a functional analysis of distressed

and non-distressed couples antecedents and

consequences of partners social exchanges (i.e.,
relationship rewarding and non-rewarding
behaviours),
and their positive and negative communication and
problem-solving behaviours.
These elements constitute the very foundation of BCT

for substance abuse.

18

Why use BCT?

Substance use problems and family problems often

coexist
These sets of problems are often interwined
Addressing both problems at the same time results

in the best outcomes.

19

Rationale for use of BCT

The relationship between substance use and couple

dysfunction is complex and appears to constitute a type

of reciprocal causality.
Compared to well- functioning dyads , couples in which

one partner abuses drugs or alcohol usually have

extensive relationship problems, often characterized by
comparatively high levels of relationship

dissatisfaction,
20

instability (i.e., partners taking significant steps

toward separation or divorce),

high prevalence and frequency of verbal and

physical aggression (e.g., Fals Stewart, Birchler, &

OFarrell, 1999),
significant sexual problems (OFarrell, Choquette,

Cutter, & Birchler, 1997), and often

significant levels of psychological distress in both

partners and other family members, such as children

21

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.
( OFarrell, & Pelcovitz, 1988)

22

The relationship between substance use and marital

problems is not unidirectional, with one consistently

causing the other;
Rather, each can serve as a precursor to the other,

creating a vicious cycle from which couples that

include a partner who abuses drugs or alcohol often
have difficulty escaping.

23

24

There

are several relationship-based antecedent

conditions and reinforcing consequences of substance
use.
Marital and family problems often serve as
precursors to excessive drinking or drug use,

unfortunately, resulting family interactions can

inadvertently facilitate continued drinking or drug use

once these behaviours have developed.

25

For example, substance abuse often provides more

subtle adaptive consequences for the couple, such as

facilitating the expression of emotion and affection
(e.g., caretaking when a partner has a hangover).

Finally, even when recovery from the alcohol or drug

problem has begun, marital and family conflicts can,

and very often do, precipitate relapses.

26

Factors influencing recovery, couple

functioning, and/or relationship longevity
Alcohol and drug abuse are maintained by their

consequences at the physiological, individual, and

interpersonal levels ,

a number of risk factors seem to influence the

prognosis for successful substance abuse treatment and

relationship satisfaction outcomes.
27

The probability of success for a given couple can be

diminished if
1. the partners alcohol or substance abuse is very
severe and debilitating,
2.

both partners are involved with substance abuse,

3. there is severe partner violence or chronic and highly

conflicted couple interactions, or

28

4. there is in one or both partners the presence of

psychiatric comorbidity, such as clinical levels of
anxiety,
depression,
anti- social personality disorder,
or psychosis.
Additional threats to maintaining sobriety include

high- risk occupational or social contact situations.

29

Interviews of alcoholic wives suggested that they very

often drink

to function within their marriages,

to be able to be more assertive,

to manage the sexual demands of their husbands

(Lammers et al.,1995)
30

There is emerging evidence that BCT works about as

well with both alcoholic and drug abusing women

and their non-substance abusing male partners
as it does with alcoholic and drug- abusing men, in
terms of maintaining sobriety and improving the
couple relationship
(Kelley
et al., 2006)

31

Practice of BCT
Structure of the therapy process:
BCT is not a suitable intervention for all substanceabusing individuals involved in intimate relationships.

Because BCT attempts to harness the influence of the

dyadic system to promote abstinence, it is important that

potential participants indicate some evidence of
relationship commitment to be successful.
32

Thus, one general criterion is:

the

partners be married or cohabiting in a stable

relationship for at least 1 year or

separated but attempting to reconcile.

accept at least temporary abstinence
both willing to work on the problem

33

 A second criterion, is that neither partner can have

conditions, such as
gross cognitive impairment or
psychosis, that would significantly interfere with
learning new information,
practicing skills, or
completing assigned tasks.

34

 BCT is most effective with couples in which only one

partner has a problem with drugs or alcohol.

The relationships of dyads in which both partners

abuse drugs, sometimes referred to as dually addicted

couples, are often not supportive of abstinence.
If substance use is a shared recreational activity of the

partners, the relationship may serve to promote

continued drinking or drug use, and may be
antagonistic to its cessation.
(OFarrell et al., 1999)
35

Children are not included in conjoint sessions;

however, BCT has been offered in formats that include

parent training elements of intervention.

36

Pilot study examined preliminary effects of Parent

Skills Training with Behavioural Couples Therapy on

children's behavioural functioning.
Couples were randomly assigned to one of three

equally intensive conditions:

(a) Parent Skills with Behavioural Couples Therapy
(PSBCT),
(b) BCT (without parent training), and
(c) Individual-Based Treatment (IBT; without
couples-based or parent skills interventions).
37

PSBCT showed medium to large effects in child

functioning relative to IBT, and small to medium

effects relative to BCT from baseline through follow
up.
(Lam et al., 2008)

38

The substance abusing patient and the spouse, are seen

together in BCT, typically for 12-20 weekly outpatient

couple sessions over a 3-6 month period.
BCT can be an adjunct to individual counselling or it

can be the only substance abuse counselling the patient

receives.

39

 Individual conjoint sessions usually last 5060

minutes; group sessions range from 60 to 90 minutes

in length.
Generally, within the organized substance abuse

treatment programs the number of sessions is

manualised and therefore time- limited.

40

Purpose of BCT
To build support for abstinence
To improve relationship functioning among married or

cohabiting individuals seeking help for alcoholism or

drug abuse.
BCT works directly to increase relationship factors

conducive to abstinence.

41

Assessments
The best practice assessment methods include :
1. Clinical interviewing with partners, together and

separately;
2. Paper-and-pencil assessment measures pertaining

to substance abuse and relationship quality; and

3. Behavioural observation of the couples

communication and problem- solving skills.

42

Questionnaires
Drinking pattern questionnaire (DPQ) Zitter & McCrady,
(1993)
This is an inventory that both spouses complete to identify

items that they believe may be associated with alcohol

consumption, assigning a rank of importance to each set of
items.
Ten major areas are involved, including
work,
environment,
financial factors,
physiological states,
interpersonal situations,
43

marital problems,
relationship with parents,
problems with children,
emotional factors, and
recent major life events
This inventory also focuses on major positive and

negative consequences of alcohol consumption in

order to pin point the reinforcing agents that can
contribute to alcohol consumption and backslide.

44

 Spouse Behaviour Questionnaire (SBQ); Orford et al.,

1975)
This questionnaire lists various behaviours that

individuals might use to control or cope with alcohol

consumption by a spouse.
There are separate forms given to spouses that relate

to type and frequency of each non abusing spouses

behaviour in the last 12 months.
These items, again, centre on specific behaviours

that nonabusing spouses may engage in that trigger

or reinforce drinking, or contribute to relapse.
45

The Coping Questionnaire (CQ)

Originally designed for wives of men with drinking

problems.
68-item Coping Questionnaire
Each taking the form of a statement, in the past tense,

about a way of coping.

Each is followed by four response options: no; once or

twice; sometimes; often (subsequently coded as 0,1,2,3,

respectively, with not applicable also coded as 0)
46

(Orford et al., 1975)

Process of Couple Therapy

The initial BCT session involves assessing substance

abuse and relationship functioning and gaining

commitment to and starting BCT
(OFarrell, 1993)
Start first with substance-focused interventions that

continue throughout BCT to promote abstinence.

When abstinence and attendance at BCT sessions have

stabilized for a month or so, add relationship-focused

interventions to increase positive activities and teach
communication.
47

 Early in treatment, for most couples, emphasis is first

placed on
achieving and maintaining sobriety,
strengthening the relationship, and finally
a dedicated program for relapse prevention is

developed.

48

 All components receive several sessions of work.

However, in some cases, the relative emphasis placed

on these three areas or the sequence may be altered to

meet special needs of a given couple.

49

Intervention Techniques (BCT)

Substance focused interventions
Relationship focused interventions

50

Substance-Focused Interventions in BCT

Limiting exposure and risky situations
Behavioural Recovery Contract:
Daily Sobriety Contract
Alcohol/drug abuser states intention to stay

abstinent that day

Spouse thanks alcohol/drug abuser for efforts to

stay abstinent
51

Attendance at self-help meeting

Weekly drug urine screens
Calendar to record progress
Sobriety Contract with a Recovery Medication

52

53

54

Other support for abstinence

Review substance use or urges to use
Decrease exposure to alcohol and drugs
Address stressful life problems
Decrease behaviours that reward abuse

55

Relationship-focused interventions
Adjustments To recovery:

Once the Sobriety Contract is going smoothly, the

substance abuser has been abstinent and the couple
has been keeping scheduled appointments for a month
or so, you can start to focus on improving couple and
family relationships.

56

Relationship promises during Treatment:

Attend Therapy Sessions and Do Homework as

Assigned.
No Threats of Divorce or Separation.
Focus on the Present, Not the Past or the Future.
No Angry Touching.

57

Two major goals of interventions focused on the

drinker's couple/family relationship are:

(a) to increase positive feeling, goodwill, and
commitment to the relationship;
(b) to teach communication skills to resolve conflicts,
problems, and desires for change.

58

The general sequence in teaching couples and families

skills to increase positive activities and improve
communication is :
(a) therapist instruction and modelling,
(b) the couple practicing under your supervision,
(c) assignment for homework, and
(d) review of homework with further practice.

59

Increasing positive activities

Catch you partner in doing something nice
Caring day
Planning shared rewarding activity

60

Catch Your Partner Doing Something Nice

Tell the couple that caring behaviours are "behaviours

showing that you care for the other person," and

assign homework called "Catch Your Partner Doing
Something Nice" to assist couples in noticing daily
caring behaviours.

61

This requires each spouse to record one caring

behaviour performed by the partner each day on

sheets you provide them.
The couple reads the caring behaviours recorded

during the previous week at the subsequent session.

Then the therapist models acknowledging caring

behaviours.
Eg. "I liked it when you.... It made me feel ....",
62

emphasizing the importance of:

eye contact;
a smile;
a sincere, pleasant tone of voice, and
only positive feelings.

Each spouse then practices acknowledging caring

behaviours from his or her daily list for the previous week
63

64

Homework

is assigned for a 5-minute daily

communication session at home, in which each
partner acknowledges one pleasing behaviour he or
she noticed that day.

65

Caring Day
A final assignment is that each partner give the other a

"Caring Day during the coming week by performing

special acts to show caring for the spouse.

Encourage each partner to take risks and to act

lovingly toward the spouse rather than wait for the

other to make the first move.

66

Finally, remind spouses that at the start of therapy

they agreed to act differently (e.g., more lovingly) and

then assess changes in feelings,
rather than wait to feel more positively toward their
partner before instituting changes in their own
behaviour.

67

Planning Shared Rewarding Activities

Many substance abusers' families stop shared

recreational and leisure activities due to strained

relationships and embarrassing substance-related
incidents.

Reversing this trend is important because participation

by the couple and family in social and recreational

activities improves substance abuse treatment outcomes.
(Moos, Finney & Cronkite, 1990)
68

Planning and engaging in shared rewarding activities

can be started by simply having each spouse make a

separate list of possible activities.

Each activity must involve both spouses, either by

themselves or with their children or other adults and

can be at or away from home.

69

 Before giving the couple homework of planning a

shared activity, model planning an activity to illustrate

solutions to common pitfalls.

Finally, instruct the couple to refrain from discussing

problems or conflicts during their planned activity

70

Communication skill training

Inadequate communication is a major problem for

substance abusers and their spouses.

(OFarrell & Birchler, 1987)

Inability to resolve conflicts and problems can cause

abusive drinking or drugging and severe

marital/family tension to recur.
(Maisto, McKay, & OFarrell, 1995)
71

Definition:

Effective communication as "message intended (by

speaker) equals message received (by listener)." .

72

73

Expressive and receptive skills are also called the

building blocks for the problem solving.

Learning basic communication skills of listening and

speaking are prerequisites for problem solving and

negotiating desired behaviour changes.
This training begins with non problem areas that are

positive or neutral and moves to problem areas and

emotionally charged issues only after the couple has
mastered basic skills.
74

Communication sessions are planned, structured

discussions in which spouses talk

privately,
face-to-face,
without distractions, and
take turns expressing their points of view, without

interrupting one another.

75

Communication sessions can be introduced for 5

minutes daily when couples first

acknowledgment of caring behaviours and

practice

in 10- to 15-minute sessions three to four times a

week in later sessions, when the partners discuss
current relationship concerns.

76

Listening skills:
help each spouse to feel understood and supported, and
slow down couple interactions to prevent the quick

escalation of aversive exchanges.

Spouses are instructed to repeat both the words and

the feelings of the speakers message and

to check to see whether the message received was the

message intended by the partner (What I heard you

say was..... Is that right?).
77

 When the listener has understood the speakers

message, they change roles, and the first listener then

speaks.

78

Speaking skills:
Expressing both positive and negative feelings

directly are alternatives to the blaming, hostile, and

indirect responsibility- avoiding communication
behaviours that characterize many substance abusers
relationships.
Speakers express and take responsibility for their

own feelings and do not blame the other person for

how he or she feels.
79

This reduces listener defensiveness and makes it

easier for the listener to receive the intended

message.
The use of statements beginning with I rather

than you is emphasized.

80

After presenting the rationale and instructions, the

therapist models correct and incorrect ways of

expressing feelings and elicits the partners reactions.
They then role-play a communication session in

which they take turns being speaker and listener, with

the speaker expressing feelings directly and the
listener using the listening response.
Similar homework communication sessions that last

10 to 15 minutes each are assigned three to four times

weekly.
81

Partners are also helped to gain the ability to

appreciate each others experience and point of view.

82

A study evaluated the effects of alcohol-focused spouse

involvement and behavioural couple therapy (BCT) on

couple communication in the context of group drinking
reduction treatment for male problem drinkers.
The beneficial effect of spouse involvement on negative

couple communication was partially mediated by a

reduction in the frequency of clients' heavy drinking during
treatment.
BCT reduced couples' negative communication and

increased problem-solving communication

(Walitzer et al.,2013)
83

Problem solving skills

In solving a problem, the couple should first define the

problem and list a number of possible solutions.

Each solution is evaluated by four criteria:
Is it absurd?
Would this solution help to solve the problem?
What are the pros for the solutions?
What are the cons for the solutions?
84

 Finally, the spouses rank the solutions from most- to

least- preferred and agree to implement one or more

of the solutions.
It avoids the Yes, but . . . trap, with one partner

pointing out problems with the others solution

85

Relapse Prevention
Three methods are employed in BCT to ensure long-

term maintenance of the changes in alcohol or drug

abuse problems.
1. Plans for maintenance occur before the termination of
the active treatment phase.
2. Second, the therapist helps the couple anticipate high-

risk situations for relapse to abusive drinking or

drugging that may occur after treatment.
3. Discussion includes how to cope with a lapse or
86

potential relapse, if and when it occurs.

In a studt, results revealed BMT-plus-RP produced

more days abstinent and greater use of the Antabuse

Contract than BMT-only; and these superior drinking
outcomes for BMT-plus-RP lasted through 18-month
follow-up (i.e., 6 months after the end of RP).
BMT-plus-RP had better wives' marital adjustment

than BMT-only throughout the 30 months of followup, with the superiority of BMT-plus-RP over BMTonly being greatest for wives with poorer pretreatment marital adjustment during the later months
of follow-up.
87

BMT-plus-RP

also maintained their improved

marriages longer (through 24-month follow-up) than
BMT-only (through 12-month follow-up).
(O'Farrell et al., 1998)

88

In

another study married or cohabiting female

alcoholic patients (n = 138) and their non-substanceabusing male partners were randomly assigned to 1 of
3 (BCT, IBT, PACT) equally intensive interventions:

During

treatment, participants in BCT showed

significantly greater improvement in dyadic adjustment
than those in IBT or PACT; drinking frequency was not
significantly different among participants in the
different conditions.

89

During

the 1-year post-treatment follow-up,

participants who received BCT reported :

(a) fewer days of drinking,

(b) fewer drinking-related negative consequences,
(c) higher dyadic adjustment, and
(d) reduced partner violence.

(Stewart et al., 2006)

90

Multiple studies have consistently found married or

cohabiting substance-abusing patients who engage in

BCT, compared to traditional individual-based
counselling or partner-involved attention control
treatments, report significantly greater:
(1) Reductions in substance use,
(2) levels of relationship satisfaction, and
(3) greater improvements in other areas of
relationship and family adjustment
(Kelly et al., 2009)
91

CBT- BCT
Behavioural Couples Therapy (BCT) for alcohol

dependence, studied as an adjunct to individual

outpatient counselling, has shown to be effective in
decreasing alcohol consumption and enhancing
marital functioning,
but
no study has directly tested the comparative
effectiveness of stand-alone BCT versus an
individually focused cognitive-behavioural therapy
(CBT) in a clinical community sample.
92

Stand-alone BCT is as effective as CBT in terms of

reduced drinking and to some extent more effective in

terms of enhancing relationship satisfaction.
However, BCT is a more costly intervention, given that

treatment sessions lasted almost twice as long as

individual CBT sessions.
(Ellen et al., 2008)

93

Limitations
Although

most BCT studies have found that

participation in BCT results in improvements in
relationship adjustment and reductions in substance
use,

none has conducted a formal test of mediation to

determine whether 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 counselling, and attention control) and
substance use outcomes.
94

Although BCT has very strong research support for

its efficacy, it is not yet widely used in communitybased alcoholism and drug abuse treatment settings.

BCT was viewed as too costly to deliver, requiring

too many sessions in its standard form.

95

Conclusion
Understanding of how partner interaction influences

substance use and abuse has evolved, treatment

providers and researchers alike have placed increased
emphasis on conceptualizing drinking and drug use
from a systemic perspective and, in turn, on treating
the couple to address partners substance abuse.
BCT has been demonstrated to enhance the ability of

partners to achieve and maintain sobriety by improving

their primary relationship.
96

BCT have also found to be efficacious than other

therapies (IBT) in reducing partners violence and

higher dyadic adjustment.
BCT plus relapse prevention has proven to be more

effective in producing better marital outcomes than

BCT alone.

97

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215582/#
R24
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