Behavioral Couples Therapy for Alcoholism and Drug Abuse: Where We've Been, Where We Are, and Where We're Going

Abstract

Among the various types of couple and family therapies used to treat substance abuse, Behavioral Couples Therapy (BCT) has the strongest empirical support for its effectiveness. During the last 3 decades, multiple studies have consistently found participation in BCT by married or cohabiting substance-abusing patients results in significant reductions in substance use, decreased problems related to substance use (e.g., job loss, hospitalization), and improved relationship satisfaction. Recently, investigations exploring other outcomes have found that, compared to traditional individual-based treatments, participation in BCT results in significantly (a) higher reductions in partner violence, (b) greater improvements in psychosocial functioning of children who live with parents who receive the intervention, and (c) better cost-benefit and cost-effectiveness. In addition to providing an overview of the theoretical underpinnings of BCT, methods used with this intervention, and the literature supporting its use, this article also examines the future directions of BCT research for substance abuse. Keywords: couples therapy; drug abuse; alcoholism; intimate partner violence Although alcoholism and drug abuse have been historically viewed as individual problems best treated on an individual basis (e.g., Jellinek, 1960), there has been a growing recognition over the last 3 decades that the family often plays a crucial role in the etiology and maintenance of substance misuse. In turn, increased emphasis has gradually been placed on treating the family, as either a primary or ancillary intervention, to reduce or eliminate abusive drinking or drug use, with the substance-abusing patient's behavior conceptualized and understood as occurring within a family system. In a special report given to the U.S. Congress in the early 1970s, the National Institute on Alcohol Abuse and Alcoholism described 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 the effectiveness of these promising methods (Keller, 1974, p. 161). Since that time, the call to examine family-based treatment approaches for substance abuse has been answered by many different research groups; initially with small-scale studies and, as evidence of effectiveness accumulated, followed by large-scale randomized clinical trials. Taken as a whole, the results of the investigations indicate that the early promise of family treatment for alcoholism and drug abuse has, to a large degree, been realized. As a case in point, meta-analytic reviews of randomized clinical trials have concluded that, compared to individual-based interventions that focus exclusively on the substance-abusing patient, familyinvolved treatments result in higher levels of abstinence, for both alcoholism (O'Farrell & Fals-Stewart, 2001) and drug abuse (Stanton & Shadish, 1997). Although many different types of couple- and family-based interventions are available and have been used with alcoholic and drug-abusing patients, Behavioral Couples Therapy (BCT) has, to date, the strongest empirical support for its effectiveness (O'Farrell & Fals-Stewart, 2003). In this review, we provide a brief discussion of (a) the theoretical rationale for the use and effectiveness of BCT with substance-abusing patients, (b) typical treatment methods used as part of the BCT intervention with substance-abusing patients and their partners, (c) past and ongoing research findings supporting the effectiveness of BCT in terms of the targeted primary outcome domains (i.e., substance use and dyadic adjustment), and (d) the results of recently completed investigations exploring the effects of BCT on secondary outcomes (i.e., outcomes not primarily targeted by BCT, but deemed to be of considerable importance, such as intimate partner violence, children's emotional and behavioral functioning, and cost outcomes, such as cost-benefit and cost-effectiveness). …