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Behavioral Couples Therapy for Alcoholism and Drug Abuse

Behavioral Couples Therapy for Alcoholism and Drug Abuse (BCT) is a substance abuse treatment approach based on the assumptions that (1) intimate partners can reward abstinence and (2) reducing relationship distress lessens risk for relapse. In BCT, the therapist works with both the person who is abusing substances and his or her partner to build a relationship that supports abstinence. Program components include a recovery or sobriety contract between the partners and therapist; activities and assignments designed to increase positive feelings, shared activities, and constructive communication; and relapse prevention planning. Partners generally attend 15-20 hour-long sessions over 5-6 months. A typical session follows this sequence: (1) the therapist asks about any substance use since the last session; (2) the couple discusses compliance with the recovery contract; (3) the couple presents and discusses homework assigned at the last session; (4) the couple discusses any relationship problems since the last session; (5) the therapist presents new material; and (6) the therapist assigns new homework.

Descriptive Information

Areas of Interest	Mental health promotion Substance abuse treatment
Outcomes	Review Date: October 2006 1: Substance abuse 2: Quality of relationship with intimate partner 3: Treatment compliance 4: Intimate partner violence 5: Children's psychosocial functioning
Outcome Categories	Alcohol Drugs Family/relationships Mental health Social functioning Treatment/recovery Violence
Ages	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)
Genders	Male Female
Races/Ethnicities	American Indian or Alaska Native Black or African American Hispanic or Latino White Race/ethnicity unspecified
Settings	Outpatient
Geographic Locations	No geographic locations were identified by the developer.
Implementation History	BCT has been implemented at multiple outpatient facilities nationwide over nearly 30 years.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	Indicated

Quality of Research

Review Date: October 2006

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 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, 391-411.

Study 7

Fals-Stewart, W., O'Farrell, T. J., Feehan, M., Birchler, G. R., Tiller, S., & McFarlin, S. K. (2000). Behavioral couples therapy versus individual-based treatment for male substance-abusing patients. An evaluation of significant individual change and comparison of improvement rates. Journal of Substance Abuse Treatment, 18, 249-254.

Study 8

Kelley, M. L., & Fals-Stewart, W. (2002). Couples- versus individual-based therapy for alcohol and drug abuse: Effects on children's psychosocial functioning. Journal of Consulting and Clinical Psychology, 70, 417-427.

Study 9

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, 202-217.

Study 10

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, 344-355.

Supplementary Materials

Addiction and Family Research Group Web site, http://www.addictionandfamily.org

Fals-Stewart, W. (2001). National Institute on Alcohol Abuse and Alcoholism (NIAAA) grant application.

Fals-Stewart, W. (2006). Psychometric properties of primary measures used in BCT trials. Unpublished summary prepared for NREPP review.

Fals-Stewart, W., & Birchler, G. R. (2002). Behavioral couples therapy with alcoholic men and their intimate partners: The comparative effectiveness of bachelor's- and master's-level counselors. Behavior Therapy, 33, 123-147.

Fals-Stewart, W., Birchler, G. R., & Kelley, M. L. (2003). The Timeline Followback Spousal Violence Interview to assess physical aggression between intimate partners: Reliability and validity. Journal of Family Violence, 18, 131-142.

Fals-Stewart, W., O'Farrell, T. J., & Birchler, G. R. (1997). Behavioral couples therapy for male substance-abusing patients: A cost outcomes analysis. Journal of Consulting and Clinical Psychology, 65, 789-802.

Fals-Stewart, W., O'Farrell, T. J., Birchler, G. R., Cordova, J., & Kelley, M. L. (2005). Behavioral couples therapy for alcoholism and drug abuse: Where we've been, where we are, and where we're going. Journal of Psychotherapy: An International Quarterly, 19, 229-246.

Fals-Stewart, W., O'Farrell, T. J., Freitas, T. T., McFarlin, S. K., & Rutigliano, P. (2000). The Timeline Followback reports of psychoactive substance use by drug-abusing patients: Psychometric properties. Journal of Consulting and Clinical Psychology, 68, 134-144.

O'Farrell, T. J., & Fals-Stewart, W. (2006). Behavioral couples therapy for alcoholism and drug abuse. New York: Guilford Press.

Straus, M. A., Hamby, S. L., Boney-McCoy, S., & Sugarman, D. B. (1996). The Revised Conflict Tactics Scales (CTS2): Development and preliminary psychometric data. Journal of Family Issues, 17, 283-316.

Outcomes

Outcome 1: Substance abuse
Description of Measures	Substance use was measured by urinalysis and structured interviews. Interview assessments included the Timeline Followback Interview (TLFB), which determines drinking and other drug use over a specified time period. Substance use also was measured with the substance use modules of the Structured Clinical Interview for DSM-IV (SCID). Some studies used the Drinker Inventory of Consequences (DrInC), a 45-item self-report measure. In some studies, researchers assessed substance use with the Addiction Severity Index (ASI), a 45-minute semistructured interview.
Key Findings	In evaluations using randomized controlled trials, male BCT clients improved significantly more than clients in individual-based therapy and/or attention control groups on measures of substance abuse. BCT clients who used opioids had more drug-free urine samples and self-reported days of alcohol and drug abstinence over the course of treatment and up to 1 year after completing treatment (p < .05). Among BCT clients on methadone maintenance, similar results at the end of treatment were obtained for cocaine and opiates, as measured by urine screens and by Addiction Severity Index scores (p < .05). Among women with alcoholism, BCT participants reported fewer days of drinking (p < .01) and fewer drinking-related consequences (p < .05) at 1-year follow-up, compared with those receiving alternative care. Among men in treatment for substance abuse, other benefits reported for BCT compared with alternative care included more days of abstinence at 6-month follow-up and fewer inpatient substance abuse treatment admissions and fewer alcohol-related arrests at 1-year follow-up. Among women, benefits reported for BCT included fewer substance-related problems at the end of treatment and fewer days of substance use and longer continuous abstinence 9 months after treatment. One evaluation found BCT is more cost-effective than individual-based therapy over the year following treatment for substance abuse.
Studies Measuring Outcome	Study 1, Study 2, Study 3, Study 4, Study 5, Study 6, Study 7, Study 8, Study 9, Study 10
Study Designs	Experimental, Quasi-experimental
Quality of Research Rating	3.4 (0.0-4.0 scale)

Outcome 2: Quality of relationship with intimate partner
Description of Measures	The quality of the relationship with the intimate partner was measured by standardized self-report measures. Some studies used the Dyadic Adjustment Scale (DAS), a 32-item self-report measure. Measures also included the 10-item Marital Happiness Scale (MHS); the Locke-Wallace Marital Adjustment Test (MAT), a 15-item self-report measure of general relationship satisfaction; the Areas of Change Questionnaire (ACQ), in which each partner notes on a 7-point scale how much partner change is desired in 34 common relationship behaviors; and the Responses to Conflict Scale (RTC), a 12-item scale of frequency of response occurrence.
Key Findings	In randomized controlled trials, BCT clients indicated better intimate partner relationship outcomes than clients in comparison conditions. In some studies, the benefits of BCT appeared to dissipate after 6 months; in others, BCT clients at 1-year follow-up showed a smaller decline in relationship satisfaction than recipients of alternative care.
Studies Measuring Outcome	Study 1, Study 2, Study 4, Study 6, Study 7, Study 8, Study 9, Study 10
Study Designs	Experimental, Quasi-experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

Outcome 3: Treatment compliance
Description of Measures	Treatment retention was measured by clinical records.
Key Findings	Among men receiving treatment for opiate use, BCT participants ingested more naltrexone (p < .01) and attended more scheduled treatment sessions (p < .05) than participants in individual-based treatment.
Studies Measuring Outcome	Study 5
Study Designs	Experimental
Quality of Research Rating	3.4 (0.0-4.0 scale)

Outcome 4: Intimate partner violence
Description of Measures	Intimate partner violence was measured by the Timeline Followback Interview on Spousal Violence, which assesses the percentage of days in a target interval when spousal violence occurred, and the Conflict Tactics Scale (CTS) verbal aggression and violence subscales, which assess prevalence and frequency of verbal aggression, overall violence, and severe violence over the past 12 months.
Key Findings	Two years posttreatment, indicators of verbal and physical aggression with intimate partners declined among male BCT clients with alcoholism. The rate of severe partner violence among the clients dropped to that of a matched sample of nonalcoholic men in the first year posttreatment; the rate of any violence dropped to that of the matched sample by the end of the second year. An evaluation of women with alcoholism who participated in BCT found lower rates of violence after 1 year than among participants in alternative care.
Studies Measuring Outcome	Study 1, Study 3, Study 9
Study Designs	Experimental, Quasi-experimental
Quality of Research Rating	3.7 (0.0-4.0 scale)

Outcome 5: Children's psychosocial functioning
Description of Measures	Children's psychosocial adjustment was measured by the Pediatric Symptom Checklist (PSC). The PSC is a 35-item questionnaire on emotional and behavioral problems.
Key Findings	Parents who participated in BCT reported higher psychosocial functioning in their children than recipients of alternative care at posttreatment and at 6- and 12-month follow-ups (p < .001). In addition, the percentage of children of couples in BCT with clinical impairment declined from 32% at baseline to 5% at 12-month follow-up (p < .001).
Studies Measuring Outcome	Study 8
Study Designs	Experimental
Quality of Research Rating	3.7 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	50% Female 50% Male	54.3% White 33% Black or African American 7.2% Hispanic or Latino 4% Race/ethnicity unspecified
Study 2	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	50% Female 50% Male	85% White 11.3% Black or African American 3.8% Hispanic or Latino
Study 3	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	50% Female 50% Male	85% White 11.3% Black or African American 3.8% Hispanic or Latino
Study 4	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	50% Female 50% Male	60% White 22% Black or African American 13% Hispanic or Latino 5% Race/ethnicity unspecified
Study 5	26-55 (Adult)	100% Male	65.5% White 25% Black or African American 5.5% Race/ethnicity unspecified 4% Hispanic or Latino
Study 6	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	50% Female 50% Male	52.8% White 40.3% Black or African American 6.9% Hispanic or Latino
Study 7	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	50% Female 50% Male	85% White 11.3% Black or African American 3.8% Hispanic or Latino
Study 8	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	50% Female 50% Male	68.3% White 23.2% Black or African American 8.5% Hispanic or Latino
Study 9	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	50% Female 50% Male	95.7% White 2.2% Black or African American 1.2% Hispanic or Latino 0.7% American Indian or Alaska Native 0.4% Race/ethnicity unspecified
Study 10	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	50% Female 50% Male	65.3% White 27.3% Black or African American 7.3% Hispanic or Latino

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

1. Reliability of measures	4. Missing data and attrition
2. Validity of measures	5. Potential confounding variables
3. Intervention fidelity	6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Substance abuse	4.0	4.0	3.3	2.9	3.0	3.0	3.4
2: Quality of relationship with intimate partner	4.0	4.0	2.8	3.0	3.5	4.0	3.5
3: Treatment compliance	4.0	3.0	4.0	3.0	3.0	3.5	3.4
4: Intimate partner violence	3.5	3.5	4.0	3.5	3.5	4.0	3.7
5: Children's psychosocial functioning	4.0	4.0	4.0	3.0	3.0	4.0	3.7

Study Strengths

Recent studies document treatment fidelity and employ sophisticated approaches to handling missing data and attrition. Studies generally used successful random assignments. Measures used were psychometrically sound and reflected the state of the science. Analytic plans were generally well described and justified, and exhaustive assessments minimized confounds. Intervention fidelity was well described and measured in several studies.

Study Weaknesses

Not all studies minimized confounds with randomized controlled trials. Some small data sets were analyzed more than once and may have been underpowered. Some studies lacked documentation of intervention fidelity or the approach to handling missing data and attrition.

Readiness for Dissemination

Review Date: October 2006

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Behavioral Couples Therapy in Alcohol and Drug Abuse Treatment [Online course]. Retrieved January 2007 from http://www.ireta.org/online/

Behavioral Couples Therapy Web site, http://www.addictionandfamily.org

Fals-Stewart, W., O'Farrell, T., Birchler, G., & Gorman, C. (2006). Behavioral couples therapy for drug abuse and alcoholism: A 12-session manual (2nd ed.). Buffalo, NY: Addiction and Family Research Group.

O'Farrell, T., & Fals-Stewart, W. (2006). Behavioral couples therapy for alcoholism and drug abuse. New York: Guilford Press.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
3.5	3.5	2.5	3.2

Dissemination Strengths

Manuals and workbooks are highly detailed, and the intervention Web site is user-friendly. One- and 2-day trainings are available online and in person; clinical supervision (up to 24 hours) is available for a small fee to those who participate in 2-day training. The Web site offers information on training content and cost and examples of letters/notifications used to document treatment, which could be helpful to new practitioners of this intervention. The session-by-session format provides opportunity for detailed feedback on therapist adherence and competence. Protocols to support fidelity of implementation are available.

Dissemination Weaknesses

Materials focus more on the various uses of the intervention than on actual implementation. Clinical supervision specific to BCT, while offered for a fee for those who participate in 2-day training, is not required. Training for therapists, supervisors, and trainers is not specifically addressed in the materials. It is not clear whether the use of fidelity assessments is required.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Behavioral Couples Therapy for Alcoholism and Drug Abuse guidebook	$38 each	Yes
1-day training	$3,000 plus travel expenses	No
2-day training	$2,750 plus travel expenses	No
2-day training and clinical supervision	$7,000 plus travel expenses for up to 100 participants; $500 per day for each 50 additional participants	No
Support and quality assurance information	Contact the developer	Contact the developer

Additional Information

The average per-couple cost to complete BCT was estimated in a 1997 study to be about $1,400; this included clinician training, staff salaries, overhead, workbooks, and services such as urine lab tests.

Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

The intervention developer has provided a list of citations for BCT replication studies in the following publications.

O'Farrell, T. J., & Fals-Stewart, W. (2006). Behavioral couples therapy for alcoholism and drug abuse. New York: Guilford Press.

Contact Information

To learn more about implementation or research, contact:
Timothy J. O'Farrell, Ph.D., ABPP
(508) 583-4500 ext 63493
timothy_ofarrell@hms.harvard.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.