National Institute of Justice National Institute of Justice. Research. Development. Evaluation. Office of Justice Programs
Crime Solutions.gov
skip navigationHome  |  Help  |  Contact Us  |  Site Map   |  Glossary
Reliable Research. Real Results. skip navigation
skip navigation Additional Resources:

skip navigation

Program Profile

Behavioral Couples Therapy for Substance Abuse

Evidence Rating: Effective - More than one study Effective - More than one study

Program Description

Program Goals

Behavioral Couples Therapy for Substance Abuse (BCT) is a family-based treatment approach for substance- and alcohol-abusing couples and their families. The assumption underlying BCT is that therapeutic interventions that are designed to address substance abuse problems while concurrently dealing with a patient's family and relationship issues may provide a significant benefit because family and relationship factors appear to play a critical role in a patient’s abstinence from substance abuse and relapse after treatment. Involvement of intimate partners in the therapeutic process could increase the success of treatment and reduce the risk of relapse.

 

Patients are required to remain abstinent from drugs and alcohol through a sobriety contract, which is verbally agreed to and is reinforced with the help of the patient’s significant other. Patients are taught communication skills such as active listening and expressing feelings directly. They are also taught Cognitive Behavioral Therapy skills to: cope with exposure to drugs, identify high-risk situations, deal with cravings, and confront thoughts of use. Couples are encouraged to find positive behaviors and enjoyable activities that can be shared together to increase relationship satisfaction.

 

Program Components

Meetings usually last 60 to 90 minutes and include individual, group, and couples sessions. BCT consists of three phases: orientation, primary treatment, and discharge.

 

During the 4-week orientation phase, basic medical information and history are collected. Patients attend the individual and group therapy sessions during this phase.

 

The primary treatment phase lasts 12 weeks. Couples therapy sessions are added to the ongoing individual and group sessions. Couples are also asked to complete a Marriage Happiness Scale each week to measure the general happiness of partners in the relationship.

 

During the 8-week discharge phase, patients attend only individual therapy sessions.

 

Throughout treatment, patients are required to submit urine or blood–alcohol breath samples at each session, though only one urine sample is tested a week.

Evaluation Outcomes

top border

Study 1

Substance Use

The study by Fals–Stewart and colleagues (2000) found that at pretreatment and immediately following posttreatment both intervention groups had no significant difference in percentage of days abstinent (PDA). But at the 3- and 6-month follow-up periods the Behavioral Couples Therapy for Substance Abuse (BCT) group showed a significantly greater PDA than the individual-based treatment (IBT) group showed. Over the entire follow-up period, the BCT group showed a significantly larger proportion of patients reporting significant reductions in substance use, when compared to those in the IBT group.

 

Relationship Adjustment

Relationship adjustment scores at pretreatment were not different. But immediately posttreatment and at the 3-month follow-up, the BCT group had significantly higher scores. Compared over time, the BCT group showed significant improvements on their Marital Adjustment Test (MAT) scores, when compared with couples in the IBT group. Couples in the IBT group showed significant deterioration of scores over time.

 

Study 2

Relationship Satisfaction

The study by Winters and colleagues (2002) showed that couples in the BCT intervention reported significantly higher Marital Happiness Scale (MHS) scores during weeks 5–12 of treatment than couples in the IBT group reported. Relationship adjustment from the DAS scores was significantly higher for the BCT group during the 3- and 6-month follow-ups but not at any other time.

 

Substance Use

At the 3-, 6-, and 9-month follow-ups, BCT patients showed a significantly higher PDA than the IBT group, but no significant difference was found at any other point in time. The BCT group relapsed at a significantly slower rate than the IBT group over time.

 

Study 3

Alcohol Use

There was no significant difference between interventions for PDA at pretreatment and posttreatment or rate of change during treatment in the Fals–Stewart, Birchler, and Kelley (2006) study. Over the 12-month follow-up period, however, BCT patients increased their drinking at a significantly slower rate than patients in IBT or psychoeducational attention control treatment (PACT).

 

Relationship Satisfaction

During treatment, BCT couples had a faster rate of improvement in relationship satisfaction than couples in IBT or PACT. Immediately posttreatment, BCT couples had higher Dyadic Adjustment Scale (DAS) scores and declined at a slower rate during the 12-month follow-up period.

 

Partner Violence

At pretreatment there were no differences between interventions on the Drinker Inventory of Consequences (DrInC) or the Conflict Tactics Scale of the Timeline Followback Interview–Spousal Violence (TLFB–SV). The 12-month follow-up revealed significantly greater reductions on the Interpersonal, Intrapersonal, and Social Responsibility subscales of the DrInC and in the Days Any Violence (Male to Female and Female to Male) subscales of the TLFB–SV for the BCT couples.

bottom border

Evaluation Methodology

top border

Study 1

Fals–Stewart and colleagues (2000) reanalyzed data from the Fals–Stewart, Birchler, and O’Farrell (1996) study to compare the change in substance use frequency and dyadic adjustment between intervention groups. The sample consisted of 86 couples randomly assigned to Behavioral Couples Therapy for Substance Abuse (BCT) or individual-based treatment (IBT). Of the 86 couples randomized, 3 from each intervention were excluded from this analysis for not completing at least half of the assigned sessions. The final sample consisted of 40 couples in BCT and 40 couples in IBT.

 

Couples were recruited when the husband or cohabiting male partner entered one of two community-based outpatient clinics for substance abuse. Male patients had to be a) between 20 and 60 years old, b) either married for at least 1 year or in a stable cohabitating relationship for at least 2, c) meet abuse or dependence criteria per the Diagnostic and Statistical Manual of Mental Disorders, Third Addition Revised (DSM–III–R) for at least one psychoactive drug, d) agree to abstain from drug use during treatment, and e) agree to refrain from seeking additional substance abuse treatment. Excluded couples were those in which the female met DSM–III–R criteria for abuse or dependence of a psychoactive drug, either partner met DSM–III–R criteria for an organic mental disorder, or if either partner participated in a methadone maintenance program and had sought additional outpatient support.

 

Male patients in the IBT group received two 60-minute individual therapy sessions and one 90-minute group therapy session each week. This intervention aimed to teach coping skills to help patients remain abstinent of drugs and alcohol. Urinalysis and blood alcohol breath samples were taken weekly.

 

Data was collected from each partner as couples entered the study, at treatment completion, and every 3 months thereafter for 1 year. Use of alcohol and drugs was measured with the Timeline Followback Interview (TLFB), using the percentage of days abstinent (PDA) index. Relationship adjustment was measured with the Locke–Wallace Marital Adjustment Test (MAT) by averaging scores from each partner.

 

Study 2

Winters and colleagues (2002) looked at females entering substance abuse treatment and their male partners to examine the effect BCT had on relationship satisfaction and substance use. Seventy-five patients were randomly assigned to either BCT (n= 37) or IBT (n= 38) interventions. Patients in the IBT intervention group received twice-weekly 60-minute individual therapy sessions and once-weekly 90-minute group therapy sessions. Both intervention groups were required to give weekly urine and blood–alcohol breath samples.

 

Females were included in the study if they a) were between the ages of 20 and 60, b) were married for at least a year or living with their male partner for at least 2, c) met abuse or dependence criteria for at least one psychoactive drug per the DSM–IV, d) agreed to refrain from substance use, and e) agreed to not seek additional treatment. A couple was excluded if the male partner met DSM–IV criteria for drug abuse or dependence in the past 6 months, if either partner met DSM–IV criteria for a mental or psychotic disorder, or if the female patient was in a methadone maintenance program.

 

Relationship satisfaction was measured using the Dyadic Adjustment Scale (DAS) and the Marital Happiness Scale (MHS). Substance use was measured using the TLFB and the Addiction Severity Index. Surveys were completed at pretreatment, at discharge, and at 3 months, 6 months, 9 months, and 1 year posttreatment. The MHS was also completed weekly during treatment.

 

Study 3

Fals–Stewart, Birchler, and Kelley (2006) used a randomized controlled trial to examine whether BCT participants would report lower frequency alcohol use and higher relationship satisfaction than the comparison groups. They also looked at the effect of BCT on partner violence. Participants were female alcoholics entering treatment and their non–substance abusing male partners. Couples were assigned to one of three interventions: BCT with IBT, IBT only, or psychoeducational attention control treatment (PACT). Each intervention was assigned 46 couples who met the study criteria and were not significantly different. Women in the IBT intervention participated in individual therapy without a couple’s component. Women in the PACT intervention attended individual therapy, while their partners attended lectures about substance abuse.

 

To be included in the study, females had to a) be between 20 and 60 years old, b) be married at least 1 year or live with a romantic partner for 2, c) meet alcohol abuse or dependency criteria according to the DSM–IV, d) have alcohol as their drug of choice, e) agree to remain abstinent of alcohol or other drugs during treatment, and f) agree to not seek other substance abuse treatment unless recommended by their counselors. A couple was excluded if the male partner met DSM–IV criteria for a substance use disorder or if either partner showed evidence of a psychotic disorder. All eligible couples gave informed consent to participate.

 

Alcohol use was measured by a PDA index derived from the TLFB. Adverse drinking consequences were measured with the Drinker Inventory of Consequences (DrInC). Relationship satisfaction was measured by the DAS. Partner violence was measured by items taken from the Conflict Tactics Scale of the TLFB–Spousal Violence (TLFB–SV) method. Participants completed interviews as they entered the study, at the end of the discharge phase, and every 3 months thereafter for 12 months.

bottom border

Cost

top border
Fals-Stewart, O’Farrell and Birchler (1997) performed a cost–benefit analysis on married or cohabiting substance-abusing male patients who were assigned to Behavioral Couples Therapy (BCT) versus male patients assigned to Individual-Based Therapy (IBT). The benefit-to-cost ratio for men receiving BCT showed $5.00 in cost savings for every treatment dollar spent. The analyses showed that social costs for patients receiving BCT decreased significantly, with an average cost savings of nearly $7,000 per patient for BCT and a net benefit (after paying to deliver BCT) of nearly $5,000 per patient. In contrast, the average cost savings for IBT of nearly $2,000 per patient was not a statistically significant reduction in social costs, and the net benefit (after paying to deliver IBT) was only about $550 per patient.
bottom border

Evidence-Base (Studies Reviewed)

top border
These sources were used in the development of the program profile:

Study 1
Fals–Stewart, William, Timothy J. O’Farrell, Michael Feehan, Gary R. Birchler, Stephanie Tiller, and Susan K. McFarlin. 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 18:249–54.

Study 2
Winters, Jamie, William Fals–Stewart, Timothy J. O’Farrell, Gary R. Birchler, and Michelle L. Kelley. 2002. “Behavioral Couples Therapy for Female Substance-Abusing Patients: Effects on Substance Abuse Use and Relationship Adjustment.” Journal of Consulting and Clinical Psychology 70(2):344–55

Study 3
Fals–Stewart, William, Gary R. Birchler, and Michelle L. Kelley. 2006. “Learning Sobriety Together: A Randomized Clinical Trial Examining Behavioral Couples Therapy With Alcoholic Female Patients.” Journal of Consulting and Clinical Psychology 74(3):579–91.
bottom border

Additional References

top border
These sources were used in the development of the program profile:

Fals–Stewart, William, and Gary R. Birchler. 2001. “A National Survey of the Use of Couples Therapy in Substance Abuse Treatment.” Journal of Substance Abuse Treatment 20:277–83.

Fals–Stewart, William, Gary R. Birchler, and Timothy J. O’Farrell. 1996. “Behavioral Couples Therapy for Male Substance-Abusing Patients: Effects on Relationship Adjustment and Drug-Using Behavior.” Journal of Consulting and Clinical Psychology 64(4):959–72.

Fals–Stewart, William, Todd B. Kashdan, Timothy J. O’Farrell, and Gary R. Birchler. 2002. “Behavioral Couples Therapy for Drug-Abusing Patients: Effects on Partner Violence.” Journal of Substance Abuse Treatment 22:87–96.

Fals–Stewart, William, Keith Klostermann, Brian T. Yates, Timothy J. O’Farrell, and Gary R. Birchler. 2005. “Brief Relationship Therapy for Alcoholism: A Randomized Clinical Trial Examining Clinical Efficacy and Cost-Effectiveness.” Psychology of Addictive Behaviors 19(4):363–71.

Fals–Stewart, William, and Timothy J. O’Farrell. 2003. “Behavioral Family Counseling and Naltrexone for Male Opiod-Dependent Patients.” Journal of Consulting and Clinical Psychology 71(3):432–42.

Fals–Stewart, William, Timothy J. O’Farrell, and Gary R. Birchler. 1997. “Behavioral Couples Therapy for Male Substance-Abusing Patients: A Cost Outcomes Analysis.” Journal of Consulting and Clinical Psychology 65(5):789–802.

Fals–Stewart, William, Timothy J. O’Farrell, and Gary R. Birchler. 2001. “Behavioral Couples Therapy for Male Methadone Maintenance Patients: Effect on Drug-Using Behavior and Relationship Adjustment.” Behavior Therapy 32:391–411.

Fals–Stewart, William, Timothy J. O’Farrell, and Gary R. Birchler. 2004. “Behavioral Couples Therapy for Substance Abuse: Rationale, Methods, and Findings.” Science and Practice Perspectives 2(2):30–41.

Kelley, Michelle L., and William Fals–Stewart. 2002. “Couples- Versus Individual-Based Therapy for Alcohol and Drug Abuse: Effects on Children’s Psychosocial Functioning.” Journal of Consulting and Clinical Psychology 70(2):417–27.
bottom border


Program Snapshot

Age: 20 - 60

Gender: Both

Race/Ethnicity: Black, Hispanic, White, Other

Geography: Rural, Suburban, Urban

Setting (Delivery): Inpatient/Outpatient

Program Type: Alcohol and Drug Therapy/Treatment, Cognitive Behavioral Treatment, Group Therapy, Individual Therapy

Targeted Population: Alcohol and Other Drug (AOD) Offenders, Families

Current Program Status: Active

Listed by Other Directories: National Registry of Evidence-based Programs and Practices