Couple Therapy Treatments for Substance Use Disorders: A Systematic Review
27
This article was downloaded by: [McGill University Library] On: 25 November 2013, At: 09:37 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Journal of Social Work Practice in the Addictions Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wswp20 Couple Therapy Treatments for Substance Use Disorders: A Systematic Review Kara Fletcher MSW a a School of Social Work , McGill University , Montreal , Quebec , Canada Published online: 13 Nov 2013. To cite this article: Kara Fletcher MSW (2013) Couple Therapy Treatments for Substance Use Disorders: A Systematic Review, Journal of Social Work Practice in the Addictions, 13:4, 327-352, DOI: 10.1080/1533256X.2013.840213 To link to this article: http://dx.doi.org/10.1080/1533256X.2013.840213 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms- and-conditions
Transcript of Couple Therapy Treatments for Substance Use Disorders: A Systematic Review
This article was downloaded by: [McGill University Library]On: 25 November 2013, At: 09:37Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Social Work Practice in theAddictionsPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/wswp20
Couple Therapy Treatments forSubstance Use Disorders: A SystematicReviewKara Fletcher MSW aa School of Social Work , McGill University , Montreal , Quebec ,CanadaPublished online: 13 Nov 2013.
To cite this article: Kara Fletcher MSW (2013) Couple Therapy Treatments for Substance UseDisorders: A Systematic Review, Journal of Social Work Practice in the Addictions, 13:4, 327-352, DOI:10.1080/1533256X.2013.840213
To link to this article: http://dx.doi.org/10.1080/1533256X.2013.840213
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.
This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Journal of Social Work Practice in the Addictions, 13:327–352, 2013Copyright © Taylor & Francis Group, LLCISSN: 1533-256X print/1533-2578 onlineDOI: 10.1080/1533256X.2013.840213
ARTICLES
Couple Therapy Treatments for Substance UseDisorders: A Systematic Review
KARA FLETCHER, MSWPhD Candidate, School of Social Work, McGill University, Montreal, Quebec, Canada
Social workers inevitably encounter couples suffering as a resultof one partner’s substance use disorder. Couples might want toaddress the impact of the addiction on their couple relationship.Certain models of couple therapy have been well studied as inter-vention tools in this particular context. This article synthesizes whatis known about couple therapy in the context of substance usedisorders, through employing a systematic review of existing litera-ture published in the past 20 years (1992–2012). Limitations andidentified gaps in the existing literature are discussed, and recom-mendations are offered for future research on treating couples inthe context of substance use disorders.
KEYWORDS addiction, behavioral couples therapy, couple ther-apy, substance abuse, substance dependence, systematic review
Addiction is a chronic relapsing disorder that can have a deleterious impacton couple relationships. Partners living with individuals with substancedependence issues present with as many psychosocial difficulties as thesubstance-dependent person (Dethier, Counerotte, & Blairy, 2011). Primarily,substance dependence can impede couple intimacy and the development oftrust within the relationship, as substance-dependent individuals often lie
Received July 23, 2013; revised August 20, 2013; accepted August 20, 2013.Editor’s Note: This article makes reference to many studies conducted by the late Dr.
William Fals-Stewart. Readers should be aware that some of his research has been called intoquestion on ethical grounds.
Address correspondence to Kara Fletcher, McGill University, School of Social Work,3506 University Street, Room 300, Montreal, QC H3A2A7, Canada. E-mail: [email protected]
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about their substance use, and will continue to use these substances despitetheir negative impact on the couple relationship (Stanton, 2005). There is alsoevidence for the cooccurrence of substance dependence and intimate part-ner violence (McCollum, Stith, Miller, & Ratcliffe, 2011). Studies have foundthat drug and alcohol use are both independent predictors of intimate part-ner violence (Moore & Stuart, 2004; Stuart, Moore, Kahler, & Ramsey, 2003).A couple’s experience of distress can be both a precursor to and a risk forcontinued substance abuse within a relationship (Kirby, Dugosh, Benishek,& Harrington, 2005). Even when an individual within a couple has startedrecovery from alcohol or drug dependence, couple conflict can precipitate arelapse (Stanton, 2005).
Within the family system, substance use disorders can become thefocus of many interactions and relations among members (Saatcioglu,Erim, & Cakmak, 2006). Numerous studies demonstrate the family needsto be involved in treatment as much as the substance-abusing individual(Benishek, Kirby, & Dugosh, 2011; Fischer & Wiersma, 2012; Saatcioglu et al.,2006). Relatedly, research has found that including the partner in therapy ispredictive of successful treatment (Heinz, Wu, Witkiewitz, Epstein, & Preston,2009; Nelson & Sullivan, 2007). As early as the 1970s, the National Instituteon Alcohol Abuse and Alcoholism identified couple and family therapy asa prominent treatment advance in the psychotherapy of alcoholism (Ruff,McComb, Coker, & Sprenkle, 2010).
Despite the impact of substance use disorders on the family system andthe couple relationship more specifically, treatment often occurs separately(Stanton, 2005). That said, research is increasingly considering the couplerelationship in substance-dependence treatment and the potential for coupletherapy as a modality within this context (Bischoff, 2008). More and morein the past 20 years, couple therapy has been studied as a treatment forsubstance-dependent persons and their partners. This review assesses theclinical effectiveness of couple therapy for substance use disorders.
TERMINOLOGY
The definitional boundaries of what addiction is have been changed multipletimes (Reinarman, 2005). Addiction was relabeled dependence in 1964 by theWorld Health Organization, as it was thought that the word addiction wastoo closely linked to opiate use (Edwards, 2012). Recently, the fifth edition ofthe Diagnostic and Statistical Manual of Mental Disorders (DSM–5; AmericanPsychiatric Association, 2013) was released, and combined the diagnosticcategories for substance abuse and substance dependence. These diagnoseshave been replaced with the term substance use disorders (O’Brien, 2011).The substance abuse category has been removed as the committee arguesthat there is not enough evidence of an intermediate state between substance
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Couple Therapy Treatments for Substance Use Disorders 329
use and substance dependence (O’Brien, 2011; Saunders, 2007). For thepurposes of this article, the DSM–5 definition of substance use disorder,which is “a cluster of cognitive, behavioral, and physiological symptomsindicating that the individual continues using the substance despite signif-icant substance-related problems” (American Psychiatric Association, 2013,p. 483) is used to refer to substance addiction. Addiction, substance usedisorder, and dependence all refer to a compulsive drug-taking condition(O’Brien, Volkow, & Li, 2006), and for the purpose of this review, theseterms are used with that intended definition. Substance abuse is only usedin reference to research specific to that phenomenon.
METHOD
Sample
This comprehensive and systematic literature review assessed the clinicaleffectiveness of couple therapy for substance use disorders. A detailed searchstrategy examined potentially relevant randomized control studies of coupletherapy in the context of addiction published between 1992 and 2012.
Search Strategy
The search strategy involved two steps. First, the following electronicresources were searched: ProQuest Central, OVID, PsychInfo, PubMed,Science Direct, and Medline. Electronic databases were searched individu-ally. The search terms alcohol, drug, substance, addiction, alcoholic, couple,marital, conjoint, dyadic, therapy, and intervention were integrated intodatabase-specific search strings. Combined, the initial database search identi-fied 1,552 hits, many of which were repetitive across databases. All identifiedtitles and abstracts were screened, and the quality and eligibility of the stud-ies was assessed. Titles and abstracts in the initial search unrelated to thetopic of couple therapy or substance use were excluded.
Second, reference lists taken from existing reviews on couple-basedinterventions and addiction (n = 6) identified by the first step were reviewedin an effort to locate references not found through the database-specificsearch. In total, 136 relevant articles were found among the database searchand by examining the existing reviews. Eighteen articles and 16 uniquestudies met the final inclusion criteria and were included in the review.
Inclusion Criteria
Studies with a focus on couple therapy or couple interventions in the contextof addiction or substance dependence from the past 20 years (dating from1992) were included. A large time frame was used in an effort to gain anaccurate picture of what is currently understood about couple therapy within
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this context and how it has been studied. Studies needed to meet the follow-ing criteria: included one or more treatment groups in which partners of asubstance-addicted adult were involved in couples treatment to (a) improvethe couple relationship (couple adjustment, individual adjustment of the per-son living with the addiction and individual adjustment for the romanticpartner) or (b) aid in the recovery of the individual living with the addiction(outcome data on alcohol or drug use by the person with the substance-dependence issue or drug or alcohol treatment or attendance); comparedcouple therapy to one or more comparison conditions; participants wererandomized to groups; assessed at least one outcome that was relevant tothe couple (e.g., couple adjustment); and involved quantitative analysis.
Exclusion Criteria
Studies were excluded if they were descriptive studies, did not include alco-hol or drugs, and did not focus on couple therapy. Studies without controlgroups were also excluded to focus on more rigorous randomized controltrial (RCT) studies. Studies in which partners were given individual treat-ment were excluded, unless this occurred within a control group. Studiesthat only considered family therapy were excluded. Studies that were not inEnglish were also excluded (n = 2). Other articles on couple therapy andaddiction (Epstein et al., 2007; Kelly, Epstein, & McCrady, 2004; McCollum,Nelson, Lewis, & Trepper, 2005; McCrady, Epstein, & Hirsch, 1999; Meyers,Miller, Smith, & Tonigan, 2002; Nattala, Leung, Nagarajaiah, & Murthy, 2010;Rotunda, O’Farrell, Murphy, & Babey, 2008) were excluded because theyeither did not have a control group, were not randomized, were not inter-vention studies, or included family members other than romantic partners.Qualitative studies were excluded because no substantial qualitative studies(other than exploratory case studies) on couple therapy and addiction werefound using the outlined search strategy.
ANALYSIS
Given the heterogeneity of topics across existing studies, the included studieswere grouped by topic (cost-effectiveness, children, etc.) and outcomes werereviewed.
RESULTS
Eighteen articles using 16 unique studies were included in the review.Fourteen studies were conducted in the United States, one in Australia,and one in the Netherlands. All studies identified were counseling-basedinterventions. Five targeted substance-dependent individuals and their
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partners, and 11 targeted alcohol-dependent individuals and their partners.Studies that met inclusion criteria overwhelmingly came from researchgroups led by O’Farrell and his colleagues, and McCrady and her colleagues.Both groups use variations of behavioral couples therapy (BCT) and theirresearch typically employs three different treatment conditions. The 18 stud-ies were divided into categories based on what variables they studied.Table 1 provides a summary of all reviewed studies.
Behavioral Couples Therapy
O’Farrell, Fals-Stewart, and colleagues have conducted over three decades ofresearch on BCT in the context of drug and alcohol addiction. In this review,BCT studies outnumbered any other theoretical model and comprised themajority of studies. BCT theorists posit that family members’ interactionswith the person abusing substances can reinforce their substance-usingbehavior (Fals-Stewart, Lam, & Kelley, 2009). BCT developed out of theHarvard Counseling for Alcoholics Marriages Project (Project CALM). CALMwas developed in the 1980s as one of the first manualized behavioral treat-ment models for couples treatment and alcohol (Ruff et al., 2010). WithinProject CALM, the couple completes a daily “trust discussion,” also knownas a “sobriety contract” or “recovery contract,” where the individual withthe substance abuse issue contracts to stay abstinent that day (O’Farrell& Fals-Stewart, 2008). The CALM BCT protocol was created initially to beused in conjunction with individual treatment; however O’Farrell and Schein(2011) have since argued that BCT can be used as a stand-alone model.Only one study examined in this review (Vedel, Emmelkamp, & Schippers,2008) adapted BCT as a stand-alone model, whereas the rest used BCT inconjunction with individual behavioral therapy.
BCT has two overarching components: assessing and improvingbehavioral interactions between the substance-dependent person and hisor her partner, and improving communication skills within the couple(Copello, Templeton, & Velleman, 2006). This approach posits if couplesare happier and improve their communication, there will be a lower chanceof relapse (O’Farrell & Clements, 2012). From this perspective, relationshipfunctioning and substance dependence are reciprocal (Powers, Vedel, &Emmelkamp, 2008). The model typically involves 12 to 20 weekly couplesessions in conjunction with individual treatment (Ruff et al., 2010). Moststudies examined within this review have an individually based 4-weekorientation phase, 12 weeks of BCT and individual therapy, and an 8-weekindividual discharge phase. Throughout the 12 weeks, the focus of BCTshifts from recovery and abstinence to the couple relationship (O’Farrell &Fals-Stewart, 2008). The couple is encouraged to avoid discussion of pastsubstance abuse and fears about future substance use outside of therapysessions (O’Farrell & Schein, 2011).
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TAB
LE1
Sum
mar
yofIn
cluded
Artic
les
for
Rev
iew
Ref
eren
ceIn
terv
entio
n(N
o.of
Sess
ions)
Des
ign
Sam
ple
(n)
Res
ults
Follo
w-U
p(M
onth
s)
Fals
-Ste
war
t,O
’Far
rell,
etal
.(2
009)
32,60
-min
sess
ions
ove
ra
20-w
eek
per
iod
of
(a)
CA
LMB
CT
plu
sIB
Tor
(b)
IBT
only
RCT
Gay
(n=
52)
and
lesb
ian
(n=
48)
with
alco
holuse
dis
ord
eran
dnon-
subst
ance
-dep
enden
tpar
tner
s
For
both
gay
and
lesb
ian
par
ticip
ants
,B
CT
had
asi
gnifi
cantly
low
erper
centa
geof
hea
vydrinki
ng
day
sduring
year
afte
rtrea
tmen
tth
anIB
T-o
nly
group
3-,6-
,9-
,12
-month
follo
w-u
p
Gay
couple
BCT–I
BT
contras
t:z
=−2
.11,
p<
.05
Lesb
ian
couple
BCT–I
BT
contras
t:z
=2.
45,
p<
.05
All
couple
sw
ho
rece
ived
BCT
reported
hig
her
leve
lsofre
latio
nsh
ipad
just
men
tth
anIB
TG
ayco
uple
BCT–I
BT
contras
t:z
=2.
01,
p<
.05
Lesb
ian
couple
BCT–I
BT
contras
t:z
=1.
43,
p<
.05
Fals
-Ste
war
t,Birch
ler,
etal
.(2
006)
12se
ssio
ns
of(a
)CALM
BCT
plu
sIB
T,or
(b)
IBT,
or
(c)
PACT
32se
ssio
ns
into
tal
RCT
n=
138
mar
ried
or
cohab
iting
fem
ale
alco
holic
clie
nts
and
non-s
ubst
ance
-dep
enden
tpar
tner
s
No
diffe
rence
bet
wee
ngr
oups
on
drinki
ng
beh
avio
r;how
ever
,B
CT
group
had
sign
ifica
ntim
pro
vem
entin
couple
adju
stm
entco
mpar
edto
PACT
(z=
2.02
)or
IBT
(z=
2.15
,p
<.0
5)
3-,6-
,9-
,12
-month
follo
w-u
p
Few
erday
sofdrinki
ng
and
hig
her
dya
dic
adju
stm
entat
12-m
onth
follo
w-u
pD
AS
BCT:
z=
2.44
,p
<.0
5,an
d%
day
sab
stin
entB
CT:
z=
–3.3
2,p
<.0
01Fa
ls-S
tew
artet
al.
(200
5)(a
)B
RT,
or
(b)
shorten
edB
CT
(S–B
CT),
or
(c)
IBT,
or
(d)
PACT
RCT
n=
100
alco
holic
mal
epar
ticip
ants
and
non-s
ubst
ance
-abusi
ng
fem
ale
par
tner
s
BRT
and
S–BCT
par
ticip
ants
had
equiv
alen
tpost
trea
tmen
tan
d12
-month
follo
w-u
pin
reduci
ng
hea
vydrinki
ng
outc
om
es(n
ot
sign
ifica
nt)
.They
wer
eboth
super
ior
tooth
erco
nditi
ons
indrinki
ng
and
dya
dic
outc
om
es,
z=
0.95
,p
<.0
5.B
RT
more
cost
-effec
tive
than
S–BCT
(z=
2.74
,p
<
.01)
,IB
T(z
=2.
04,
p<
.05)
,an
dPA
CT
(z=
2.04
,p
<.0
5)co
nditi
ons
3-,6-
,9-
,12
-month
follo
w-u
p
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Fals
-Ste
war
tet
al.
(200
1)Tw
ice
wee
kly
for
12w
eeks
,(a
)IB
MM
serv
ices
or
(b)
BCT
plu
s1
hr
of
indiv
idual
IBM
M
RCT
n=
36het
erose
xual
mar
ried
or
cohab
iting
couple
sw
ithsu
bst
ance
-dep
enden
tm
enen
tering
met
had
one
mai
nte
nan
ce
Mal
epar
tner
sin
BCT
conditi
on
had
few
erposi
tive
urine
sam
ple
sduring
trea
tmen
tth
anco
nditi
on:
p<
.5.B
CT
group
reported
hig
her
leve
lsofre
latio
nsh
iphap
pin
ess
during
trea
tmen
t,F(1
1,35
2)=
1.71
,p
<.5
,an
dhig
her
dya
dic
adju
stm
entat
post
trea
tmen
tth
anco
nditi
on,
F(1
,33
)=
8.01
,p
<.0
1
Atro
ugh
ly4
month
s
Fals
-Ste
war
tet
al.
(200
0)4-
wee
korien
tatio
nphas
e,th
en12
wee
kly
sess
ions
of
(a)
IBT
or
(b)
BCT
plu
sIB
Tfo
llow
edby
8-w
eek
dis
char
gephas
e
RCT
(nota
uniq
ue
study)
N=
80m
ale
mar
ried
or
cohab
iting
subst
ance
-dep
enden
tcl
ients
,m
ost
refe
rred
thro
ugh
crim
inal
just
ice
syst
em(n
=68
,85
%)
More
mal
esin
BCT
conditi
on
reported
sign
ifica
ntre
duct
ions
insu
bst
ance
use
(33.
83%
)th
anth
ose
inIB
Tco
nditi
on
(24.
6%)
Effec
t=
4.92
,p
=.0
3
3-,6-
,9-
,12
-month
follo
w-u
p
More
couple
sin
BCT
conditi
on
had
impro
ved
dya
dic
adju
stm
ent(2
4.6%
)th
anIB
Tco
nditi
on
(14.
35%
)Effec
t=
5.01
,p
=.0
3Fa
ls-S
tew
artet
al.
(199
7)Cost
outc
om
esex
amin
edin
12-w
eeks
of(a
)B
CT
plu
sIB
Tor
(b)
IBT;in
tota
l,both
groups
rece
ived
56trea
tmen
tse
ssio
ns
RCT
(nota
uniq
ue
study)
n=
80m
arried
or
subst
ance
-dep
enden
tcl
ients
BCT
more
cost
-ben
efici
alth
anIB
T(a
vera
gere
duct
ion
inso
cial
cost
sfr
om
bas
elin
eto
follo
w-u
pan
dfo
rea
ch$1
00sp
enton
trea
tmen
t)Cost
:B
CT,
t=
3.99
,p
<.0
01;
IBT,
t=
0.85
3-,6-
,9-
,12
-month
follo
w-u
p
Fals
-Ste
war
tet
al.
(199
6)4-
wee
korien
tatio
nphas
e,th
en12
wee
kly
sess
ions
of
(a)
IBT
or
(b)
BCT
plu
sIB
T,fo
llow
edby
8-w
eek
dis
char
gephas
e
RCT
n=
80m
ale
mar
ried
or
cohab
iting
subst
ance
-dep
enden
tcl
ients
,m
ost
refe
rred
thro
ugh
crim
inal
just
ice
syst
em(n
=68
,85
%)
Couple
sin
BCT
conditi
on
had
bet
ter
rela
tionsh
ipoutc
om
esEffec
t=
13.6
2,p
<.0
01.M
enin
BCT
conditi
on
reported
few
erday
sofdru
guse
,lo
nge
rper
iods
ofab
stin
ence
,an
dso
on
Effec
t=
.96
3-,6-
,9-
,12
-month
follo
w-u
p
Diffe
rence
bet
wee
ngr
oups
dis
sipat
edby
the
12-m
onth
follo
w-u
p
(Con
tin
ued
)
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TAB
LE1
(Contin
ued
)
Ref
eren
ceIn
terv
entio
n(N
o.of
Sess
ions)
Des
ign
Sam
ple
(n)
Res
ults
Follo
w-U
p(M
onth
s)
Hal
ford
etal
.(2
001)
12se
ssio
ns
of(a
)su
pportiv
eco
unse
ling,
(b)
stre
ssm
anag
emen
t,or
(c)
CALM
BCT
alco
hol-fo
cuse
dco
uple
sth
erap
y
RCT
n=
61m
arried
wom
enw
hose
husb
ands
are
alco
holic
Few
diffe
rence
sbet
wee
ntrea
tmen
tco
nditi
ons
(r<
.3)
No
clin
ical
lysi
gnifi
cantre
duct
ion
indrinki
ng
6-m
onth
follo
w-u
p
Kel
ley
&Fa
ls-S
tew
art
(200
2)
32se
ssio
ns
of(a
)B
CT,
(b)
IBT,
or
(c)
PACT
RCT
n=
71ch
ildre
nofal
coholic
men
n=
64ch
ildre
nof
dru
g-dep
enden
tm
en
Fath
ers
who
par
ticip
ated
inBCT
had
hig
her
ratin
gsofch
ildre
n’s
psy
choso
cial
funct
ionin
gth
anfa
ther
sin
IBT
or
PACT
Alc
oholco
uple
s:pre
–post
effe
ct=
.29,
post
to6
month
s=
.44,
6–12
month
s=
.46,
p<
.01
6-an
d12
-month
follo
w-u
p
Dru
gco
uple
s:pre
–post
effe
ct=
.35,
post
to6
month
s=
.42,
6–12
month
s=
.39,
p<
.01
Lam
etal
.(2
009)
12w
eekl
yse
ssio
ns
of(a
)par
enttrai
nin
gw
ithB
CT,
(b)
BCT,
or
(c)
IBT;al
lco
nditi
ons
inco
mbin
atio
nw
ith12
wee
kly
CB
Tse
ssio
ns
RCT
n=
30fa
ther
s,th
eir
fem
ale
par
tner
s,an
da
cust
odia
lch
ild8–
12ye
ars
old
Only
par
enttrai
nin
gw
ithB
CT
had
sign
ifica
nt
effe
cts
on
allch
ildm
easu
res
thro
ugh
out
12-m
onth
follo
w-u
p,
r=
.33
(med
ium
effe
ct),
p<
.05
6-an
d12
-month
follo
w-u
p
McC
ollu
met
al.
(200
3)12
wee
kly
sess
ions
of(a
)SC
Tplu
sre
gula
rag
ency
trea
tmen
t,(b
)SI
Tplu
sre
gula
rag
ency
trea
tmen
t,(c
)TA
Uplu
s“b
oost
er”
sess
ions
atfo
llow
-up
dat
es
RCT
n=
122
wom
enan
dth
eir
par
tner
sG
roups
did
notdiffe
rat
1ye
arpost
trea
tmen
ton
alco
holuse
scal
e;how
ever
,SC
Tan
dSI
Tdid
bet
ter
atfo
llow
-up
indru
guse
scal
eth
anTA
UA
lcoholuse
during
trea
tmen
t:F
=3.
256,
p=
.004
(ns
at1
year
)D
rug
use
during
trea
tmen
t:F
=2.
548,
p=
.21
(at1
year
SIT
and
SCT
groups,
p<
.04)
3-,6-
,12
-month
follo
w-u
p
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McC
rady
etal
.(2
009)
20w
eekl
yse
ssio
ns
of
(a)
AB
CT
or
(b)
AB
ITRCT
n=
102
het
erose
xual
wom
enan
dth
eir
par
tner
sIn
crea
sein
per
centa
geofday
sab
stin
entfr
om
alco
holan
ddec
reas
ein
per
centa
geof
hea
vydrinki
ng
day
sA
BCT
still
favo
red
during
12-m
onth
follo
w-u
p(ß
=−.
309,
p<
.05)
3-,6-
,9-
,12
-,15
-,18
-month
follo
w-u
p
O’F
arre
ll,Choquet
te,
Cutter
,B
row
n,
etal
.(1
996)
Wee
kly
BCT
for
5–6
month
sfo
llow
edby
(a)
15ad
diti
onal
conjo
intre
lapse
pre
ventio
nse
ssio
ns
ove
r12
month
sor
(b)
no
further
trea
tmen
t
RCT
n=
59co
uple
sw
ithnew
lyab
stin
ental
coholic
husb
ands
Both
BCT
and
BCT
with
rela
pse
pre
ventio
nsh
ow
eddec
reas
ein
hea
lthca
rean
dle
gal
cost
s12
month
saf
ter
trea
tmen
tB
CT
only
,t(
28)
=4.
72,
p<
.001
BCT
plu
sre
lapse
pre
ventio
n,
t(29
)=
4.93
,p
<.0
01B
enefi
tsex
ceed
edco
stofdel
iver
ing
trea
tmen
tby
more
than
5×Rel
apse
pre
ventio
ndid
notle
adto
grea
ter
cost
savi
ngs
12m
onth
saf
ter
BCT
follo
w-u
p
O’F
arre
ll,Choquet
te,
Cutter
,Fl
oyd
,et
al.(1
996)
10w
eeks
of(a
)IB
T,(b
)B
CT
plu
sIB
T,(c
)in
tera
ctio
nal
couple
sgr
oup
(ICT)
plu
sIB
T
RCT
n=
36new
lyab
stin
ent
mar
ried
mal
eal
coholic
sD
ecre
ases
inhea
lthca
rean
dle
galco
sts
inth
e2
year
spost
trea
tmen
tas
com
par
edw
ithpre
trea
tmen
t
24-m
onth
follo
w-u
p
ICT
incr
ease
dpost
trea
tmen
tco
sts,
IBT
had
asi
gnifi
cantly
more
posi
tive
ben
efit-to
-cost
ratio
than
BCT
(p=
.053
)Se
rvic
eco
sts
low
erth
anbas
elin
eco
sts
for
BCT
group,
t(9)
=2.
27,
p=
.049
,an
dIB
T,t(
11)
=5.
56,
p<
.001
BCT
reduce
dsy
stem
cost
ssi
gnifi
cantly
more
than
ICT,
t (20
)=
2.12
,p
=.0
47O
’Far
rell
etal
.(1
992)
Follo
w-u
pre
sults
toa
1985
study;
10w
eekl
yse
ssio
ns
of(a
)IB
T,(b
)BCT
plu
sIB
T,(c
)IC
T
RCT
n=
34co
uple
s,w
her
ehusb
ands
wer
eal
coholic
sB
CT
couple
shad
bet
ter
mar
italoutc
om
esth
anIB
T,t(
32)
=2.
27,
p=
.031
Only
BCT
dim
inis
hed
ove
rtim
eaf
ter
trea
tmen
tAdva
nta
ges
ofB
CT
for
drinki
ng
outc
om
esno
longe
rap
par
ent2
year
saf
ter
trea
tmen
t,not
sign
ifica
nt
24-m
onth
follo
w-u
p
(Con
tin
ued
)
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TAB
LE1
(Contin
ued
)
Ref
eren
ceIn
terv
entio
n(N
o.of
Sess
ions)
Des
ign
Sam
ple
(n)
Res
ults
Follo
w-U
p(M
onth
s)
Ved
elet
al.(2
008)
10se
ssio
ns
of(a
)st
and-
alone
BCT
(90
min
)or
(b)
indiv
idual
CBT
(60
min
)
RCT
n=
64al
coholic
par
ticip
ants
(n=
30)
and
thei
rpar
tner
s(n
=34
)
BCT
and
CB
Tboth
effe
ctiv
ein
chan
ging
drinki
ng
beh
avio
raf
ter
trea
tmen
t.Effec
t:d
=0.
35,
p=
.238
.Post
trea
tmen
t,B
CT
more
effe
ctiv
ely
incr
ease
dco
uple
satis
fact
ion
than
CBT:pat
ient,
d=
0.24
,p
=.4
16;par
tner
,d
=0.
62,
p<
.05.
How
ever
,th
isdid
nothold
up
atfo
llow
-up:
pat
ient,
d=
0.06
,p
=.8
54;par
tner
,d
=0.
17,
p=
.577
6-m
onth
follo
w-u
p
Wal
itzer
&D
erm
en(2
004)
10w
eekl
y2-
hr
group
sess
ions
of(a
)IB
T,(b
)AFS
I,or
(c)
AFS
Iplu
sBCT
RCT
n=
64m
ale
“pro
ble
mdrinke
rs”
and
thei
rco
hab
iting
par
tner
s
BCT
group
had
few
erhea
vydrinki
ng
day
s(e
ffec
t=
5.76
,p
<.0
5)an
dm
ore
abst
inen
tan
dlig
htdrinki
ng
day
sin
the
year
follo
win
gtrea
tmen
t(1
2m
onth
s),
Fs
=4.
05,
ps=
.046
AFS
Iplu
sB
CT
did
nothav
ebet
ter
outc
om
es
12-m
onth
follo
w-u
p
Win
ters
etal
.(2
002)
4-w
eek
orien
tatio
nphas
eplu
s12
wee
ksof(a
)B
CT
plu
sIB
Tan
dgr
oup
ther
apy
or
(b)
IBT
plu
sgr
oup
ther
apy
follo
wed
by
an8-
wee
kdis
char
gephas
e(5
6se
ssio
ns
into
tal)
RCT
n=
75m
arried
orco
hab
iting
dru
g-dep
enden
tfe
mal
esChan
ges
only
seen
thro
ugh
firs
t6
month
sof
follo
w-u
pM
artia
lhap
pin
ess,
F=
3.19
,p
<.0
5
3-,6-
,9-
,an
d12
-month
follo
w-u
pD
rug
use
,F
=1.
14,
ns,
they
wer
enot
sign
ifica
ntby
the
end
ofYea
r1
Not
e.CALM
=Counse
lling
forAlc
oholic
sM
arriag
esPro
ject
;BCT
=B
ehav
iora
lCouple
sTher
apy;
IBT
=in
div
idual
lybas
edtrea
tmen
t;RCT
=ra
ndom
ized
controltria
l;PA
CT
=psy
choed
uca
tional
atte
ntio
n-c
ontroltrea
tmen
t;D
AS
=D
yadic
Adju
stm
entSc
ale;
BRT
=brief
model
of
BCT;S–
BCT
=sh
orten
edB
CT;IB
MM
=in
div
idual
-bas
edm
ethad
one
mai
nte
nan
ce;CB
T=
cogn
itive
beh
avio
ralth
erap
y;SC
T=
syst
emic
couple
sth
erap
y;SI
T=
syst
emic
indiv
idual
ther
apy;
TAU
=trea
tmen
tas
usu
al;
AB
CT
=al
cohol
beh
avio
ral
couple
sth
erap
y;A
BIT
=al
cohol
beh
avio
ral
indiv
idual
ther
apy;
ICT
=in
tera
ctio
nco
uple
sth
erap
y;AFS
I=
alco
hol-fo
cuse
dsp
ouse
invo
lvem
ent.
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Couple Therapy Treatments for Substance Use Disorders 337
Alcohol Behavioral Couple Therapy Program
A variation of BCT, the alcohol behavioral couple therapy (ABCT) programwas developed by Epstein, McCrady, and their research team at RutgersUniversity. Integrating social learning theory with systems models, this modelassumes that problematic drinking occurs within an interactional context(McCrady, 2012). The structured program uses “alcohol-focused spouseinvolvement” where the nonaddicted spouse is taught skills to deal withalcohol-related situations (Epstein & McCrady, 1998). The spouse becomes asecondary therapist or coach for the addicted partner, helping them throughthe process of behavioral change (Walitzer & Dermen, 2004). Like theBCT model, ABCT uses cognitive-behavioral elements to help clients stopdrinking and maintain abstinence (McCrady et al., 1999). ABCT also usesbehavioral contracts between intimate partners to support abstinence and insome cases, the use of medication (e.g., Antabuse; Velleman, 2006). ABCThas since been expanded to include treatment for couples in which onepartner has a drug addiction.
Brief Couple Therapy and Systemic Couple Therapy
Only one study that used a therapeutic model other than BCT met criteriafor this review. This was McCollum, Lewis, Nelson, Trepper, and Wetchler’s(2003) study that examined the effectiveness of systemic couples therapy(SCT) in the context of female drug-dependent clients and their partners.SCT is an integrated model that uses structural, strategic, behavioral, andBowenian concepts of family therapy. It was developed to treat females whohave a substance use disorder and their partners, and focuses on patterns andthemes from the substance-dependent individual’s family of origin (Nelson,McCollum, Wetchler, Trepper, & Lewis, 1996). The goal of this therapy is tohelp the woman improve her primary relationship and in turn, foster herability to meet treatment goals. There are multiple phases within 12-weekSCT (assessment, goal setting, consolidation, etc.), but it is less structuredthan BCT (Nelson et al., 1996).
Participants in McCollum et al.’s (2003) study were randomized intothree treatment conditions: SCT, systemic individual therapy (SIT), and stan-dard treatment as usual (TAU). Although therapy only occurs with theindividual in SIT, like SCT, the focus of the therapy is altering nega-tive couple patterns. Using the Addiction Severity Index (ASI; McLellan,Luborsky, Woody, & O’Brien, 1980) to measure women’s drug use pre- andposttreatment, results found that women in SIT and SCT did better than theTAU group at 6 months and 1 year posttreatment (McCollum et al., 2003).The results of this study suggested the potential benefit of a systemic focuswith this particular population; however, replication is needed to examinethe benefit of this model over other couple therapy models.
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338 K. Fletcher
Behavioral Couples Therapy
BCT AS A TREATMENT FOR ALCOHOLISM
Studies on BCT and alcohol dependence outnumbered other studies in thisreview. Only one BCT study (Vedel et al., 2008) did not separate substance-dependent participants by gender. It was also the only reviewed studythat examined the effectiveness of a brief stand-alone BCT. Vedel et al.(2008) adapted the CALM protocol, described earlier, to use as a stand-alonemodel. Their study compared BCT to individual cognitive behavioral therapy(CBT). The outcome measures used in the study were couple functioningand alcohol consumption. BCT was equally effective in decreasing drink-ing as CBT, and although posttreatment effect size favored BCT, follow-upshowed only a small effect between conditions. BCT was more effectivethan CBT in decreasing couple satisfaction, but the effect size was mediumand there was not a significant change in marital satisfaction scores. Theauthors questioned whether decreasing couple dissatisfaction to a nondis-tressed level was too ambitious for a short-term treatment (10 sessions). BCTas a stand-alone model requires further research to better understand itseffectiveness.
BCT AND MALE ALCOHOLIC PARTICIPANTS
Results were varied for BCT studies conducted on male alcoholic participantsand their partners. The studies reviewed were Fals-Stewart, Klostermann,Yates, and Birchler (2005), Halford, Price, Kelly, Bouma, and Young (2001),O’Farrell, Cutter, Choquette, Floyd, and Bayog (1992), and Walitzer andDermen (2004). Primarily, these studies suggest that BCT ameliorates symp-toms for a specific subset of male alcoholics. For example, Fals-Stewart et al.’s(2005) study showed positive results for a brief model of BCT (BRT) for malealcoholic clients. BRT is a form of BCT that has been modified to last for onlysix sessions. In this study, BRT showed promise, with higher levels of rela-tionship satisfaction and positive drinking outcomes during the follow-upperiod than individual therapy or psychoeducational control groups. In con-trast, BCT participants in Walitzer and Dermen’s (2004) study identified as“problem drinkers” improved in their drinking, but not in their couple satis-faction. The authors posited this might be a result of their baseline of couplesatisfaction being less distressed in comparison with other samples (Walitzer& Dermen, 2004). A limitation of using this particular study is that we do nothave a good definitional understanding of “problem drinkers.” As a resultproblem drinkers might have a different treatment trajectory than alcoholics,which could invalidate a comparison.
These studies highlight that BCT interventions could vary substantiallyin practice. Although one can assume that treatment application is verysimilar within a research group (e.g., O’Farrell’s or McCrady’s studies),
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Couple Therapy Treatments for Substance Use Disorders 339
Walitzer and Dermen’s (2004) use of BCT was specific, focusing on therelationship-enhancement components of the therapy. They comparedthree groups: individual treatment, couples alcohol-focused treatment, andcouples alcohol-focused treatment with BCT. Using their application of BCT,they found that it did not enhance marital satisfaction compared with theother groups. This absence of effect in marital satisfaction is in contrast toother BCT studies (e.g., Fals-Stewart, Birchler, & Kelley, 2006). Clients whoparticipated with their partners (couples treatment with or without BCT)did, however, show reduction in drinking.
Halford et al. (2001) completed a couple therapy study with treatment-resistant clients. They recruited women whose husbands were alcoholics,but not currently in treatment. They compared the CALM BCT model (usingalcohol-focused couple therapy) with a supportive counseling group and astress management group (both for the female partners). All three treatmentsimproved emotional distress levels for the wives in the study; however,none of the treatments improved the husband’s drinking or the couplerelationship. Only 6 of the 21 husbands assigned to the CALM BCT con-dition completed treatment. The husbands’ resistance to treatment in thisstudy might account for these results. BCT participants have better treatmentresults when they are voluntary (e.g., Fals-Stewart et al., 2005; O’Farrell et al.,1992).
O’Farrell et al.’s (1992) study suggested that BCT can be effective inimproving couple functioning and drinking outcomes, but found that resultsmight not be sustainable over time. This article was included in the reviewalthough it presents posttreatment results from an earlier study completedin 1985. Married male alcoholics were randomly assigned to a condition ofa “no couple-treatment” control group, to 10 weekly sessions of BCT, orto an interactional couples therapy (ICT) treatment. ICT groups emphasizecatharsis, sharing feelings, problem solving through discussion, and ventila-tion, and they are not behaviorally focused (O’Farrell et al., 1992). Coupleadjustment and drinking outcomes were measured. Improved outcomes incouple adjustment and drinking found at 6 months posttreatment in BCTwere not sustained at the 24-month follow-up: There was no longer a sig-nificant difference in drinking or couple adjustment outcomes between theICT group and the BCT group. Drinking adjustment outcomes were notsignificant across the three groups. However, BCT and ICT maintained signifi-cance in couple adjustment over the individual “no couple-treatment” controlgroup.
BCT AND MALE SUBSTANCE-DEPENDENT PARTICIPANTS
Three articles and two unique studies were reviewed that examined maledrug dependence and couple therapy: Fals-Stewart et al. (2000), Fals-Stewart,Birchler, and O’Farrell (1996), and Fals-Stewart, O’Farrell, and Birchler, 2001.
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340 K. Fletcher
Fals-Stewart, Birchler, and O’Farrell’s (1996) study was the first random-ized clinical control trial to examine drug dependence and couple therapy.Married or cohabiting substance-dependent clients entering outpatient treat-ment were randomly assigned to a no couples-treatment control group or12 weekly sessions of BCT. Of the participants, 68.8% were referred by thecriminal justice system. This study had a lower dropout rate than many otherstudies, which might have resulted from legal coercion. Couples in the BCTcondition had better relationship outcomes (measured as dyadic adjustment)than couples in the no-couple treatment control group. Males in the BCT con-dition reported fewer days of drug use, fewer drug-related arrests, and fewerdrug-related hospitalizations throughout the 12-month follow-up period thanmen in the control group.
Fals-Stewart et al.’s (2000) article reanalyzed data from Fals-Stewart,Birchler, and O’Farrell’s (1996) study. Outcomes of the individually basedtreatment (IBT) and BCT group were compared in terms of individual changerates on primary outcome measures (significant reductions in substance use,improvement in dyadic adjustment, significant worsening in either of thesedomains, or no significant change from pretreatment functioning). Thesefindings enhanced Fals-Stewart, Birchler, and O’Farrell’s (1996) results thatBCT was more effective in reducing substance use and increasing dyadicadjustment than IBT alone. Due to small sample size, the authors could notexamine participant, therapist, or treatment factors that could discriminatewho improved, deteriorated, or showed no change.
Fals-Stewart et al. (2001) completed the first RCT to look at BCT in thecontext of substance-abusing men entering methadone maintenance (MM)treatment. Married or cohabiting men entering MM treatment were randomlyassigned to either an individual-based methadone maintenance (IBMM) pro-gram, or an intensive BCT treatment condition. IBMM is individually basedtreatment in addition to MM. Drug use and relationship satisfaction mea-sures were collected at baseline, during treatment (weekly), and at 4 monthsposttreatment follow-up. Males in the BCT condition had significantly fewerpositive drug tests than those in the IBMM condition, suggesting a reductionin drug use during treatment. Compared to the IBMM condition, couplesin the BCT group reported significantly higher levels of relationship satis-faction during treatment and higher relationship adjustment posttreatment.Finally, participants in the BCT condition reported greater reductions in druguse, family problems, and social problems from baseline to posttreatmentthan did IBMM participants. These findings might not be generalizable toother couple groups (e.g., heterosexual drug-dependent females on MM),and the follow-up period was relatively short, making it difficult to ascer-tain the sustainability of these interventions. Although there were only twounique studies to consider, BCT appears to offer a promising interventionfor couples in this context. Factors such as small sample size and dissipationof treatment effects over time encourage replication of these studies.
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Couple Therapy Treatments for Substance Use Disorders 341
BCT AND GAY AND LESBIAN ALCOHOLIC PARTICIPANTS
Relationship quality is equally impacted by alcohol use disorders (AUDs)for gay and lesbian couples as it is for heterosexual couples (Fals-Stewart,O’Farrell, & Lam, 2009). Only one study provided a perspective on the utilityof couple therapy in treating same-sex couples. Fals-Stewart, O’Farrell, andLam (2009) conducted two separate trials, one with gay participants and onewith lesbian participants, to examine the efficacy of BCT with gay and lesbianclients with AUDs and their non-substance-dependent partners. Outcomeswere compared between BCT and IBT throughout treatment and over a 12-month posttreatment follow-up period. For both gay and lesbian couples,those who received BCT reported significantly lower proportions of days ofheavy drinking in the year after treatment than did those couples in the IBTgroup. The BCT group also reported higher levels of relationship adjustmentthan the IBT group at the end of treatment and in the year after treatment.This study had a small sample size, and one study on the effect of BCTin treating gay and lesbian couples is insufficient to draw any substantiveconclusions, but these initial results recommend future studies.
BCT AND FEMALE ALCOHOLIC PARTICIPANTS
Despite evidence that women respond differently to alcohol and drug treat-ment, many approaches are designed to treat men (Winters, Fals-Stewart,O’Farrell, Birchler, & Kelley, 2002). Female alcoholics are seen to havemore personal problems than male alcoholics (Saatcioglu et al., 2006).Two unique studies examined female alcoholic participants and BCT: Fals-Stewart, Birchler, and Kelley (2006) and McCrady, Epstein, Cook, Jensen, &Hildebrandt (2009). These results are in contrast to some studies with maleparticipants (Fals-Stewart et al., 1996; O’Farrell et al., 1992).
Fals-Stewart, Birchler, and Kelley (2006) randomized married or cohab-iting female alcoholic clients and their non-substance-abusing male partnersto either a CALM BCT program, IBT only, or a psychoeducational attention-control treatment (PACT). During treatment there were no significantdifferences across groups in drinking frequency; however, couple adjust-ment significantly improved in the CALM BCT group. At 1-year follow-up,compared with IBT or PACT, the BCT group had fewer days of drinking,higher dyadic adjustment, and a reduction in partner violence.
McCrady et al. (2009) randomized heterosexual women participating inan alcohol behavioral couples therapy (ABCT) program compared to alcoholindividual behavioral therapy (ABIT). Compared with the ABIT group, duringthe 6 months of treatment, women in the ABCT group increased their per-centage of days abstinent and decreased their percentage of heavy drinkingdays significantly. At the 12-month follow-up, ABCT continued to be moreeffective than the ABIT condition. Of note, more than one quarter of thefemale sample had male partners who met criteria for a current or past AUD.
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BCT AND FEMALE SUBSTANCE-DEPENDENT PARTICIPANTS
Only one study that met inclusion criteria examined BCT and femalesubstance-dependent participants. Winters et al. (2002) conducted the firstRCT to examine the efficacy of BCT in treating drug-dependent femaleclients. Participants were randomly assigned to a BCT condition, which con-sisted of group, individual, and behavioral couple therapy sessions, or anequally intensive IBT condition, which involved both group and individualcounseling. During treatment, the BCT group had significantly higher levelsof relationship satisfaction than IBT, and both conditions were equally effec-tive in reducing substance abuse. During the 3-month and 6-month follow-upposttreatment, participants in the BCT condition reported fewer days of sub-stance use; longer periods of abstinence; lower levels of alcohol, drug, andfamily problems; and higher relationship satisfaction compared with the IBTcondition. Congruent with other BCT studies (e.g., Fals-Stewart et al., 1996),at 9-month and 1-year follow-up, differences in relationship satisfaction andnumber of days abstinent declined. This study had good results, but theywere not sustained over time.
BCT AND CHILDREN
Parental functioning impacts their child’s functioning (Saatcioglu et al., 2006).Children with substance-dependent parents have a high potential for expo-sure to emotional or psychological problems (Saatcioglu et al.). Two studiesmet criteria that examined child functioning and BCT: Kelley and Fals-Stewart(2002), and Lam, Fals-Stewart, and Kelley (2009). Kelley and Fals-Stewart’s(2002) study was the first to examine the effect of BCT on children withalcohol- or drug-dependent fathers. They separated couples into a drug treat-ment group (n = 64), and an alcohol treatment group (n = 71). Participantsin both groups were randomized into three treatment conditions: BCT, IBT,and PACT. Results from both treatment groups had the same patterns. BCTimproved children’s functioning after treatment, and during the follow-up at6 months and 12 months posttreatment, more than IBT and PACT conditions.The BCT condition had higher dyadic adjustment for both groups than theother conditions.
Lam et al. (2009) conducted a pilot study to evaluate the effect of parentskills training with BCT on children’s behavioral functioning. They investi-gated whether adding skills training to BCT with alcoholic fathers wouldhave more benefits for the couple’s children. The pilot study randomized30 alcoholic fathers to a parent training with BCT group, or BCT withoutparent training or IBT. Children did not attend therapy sessions; however,they completed self-reports of internalizing symptoms at each assessment.Parents completed measures about their own parenting and their child’sbehaviors at pre- and posttreatment and at 6- and 12-month follow-ups. Onlyparent training participants (with BCT) reported significant improvements
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on parenting practices and all child symptom measures throughout the 12-month follow-up. These results were positive and could benefit from beingreplicated with a larger sample size. Two studies are insufficient to drawconclusions about the impact of BCT on children living with alcohol- ordrug-dependent parents, but these initial studies offer promising family-wideresults for involving partners in substance treatment.
BCT AND COST-EFFECTIVENESS
When providing couple therapy in the context of addiction, questions ariseas to whether couple therapy is more cost-effective than individual therapy.As a result, RCT studies examining the cost-effectiveness of couple therapyin the context of addiction were reviewed to understand the economic com-parison of providing couple therapy as opposed to another treatment model(individual or group). Four studies on cost-effectiveness met criteria for thisreview: Fals-Stewart et al. (2005), Fals-Stewart, O’Farrell, and Birchler (1997),O’Farrell, Choquette, Cutter, Brown, et al. (1996), and O’Farrell, Choquette,Cutter, Floyd, et al. (1996). Both O’Farrell, Choquette, Cutter, Brown, et al.(1996) and O’Farrell, Choquette, Cutter, Floyd, et al. (1996) examinedcost-effectiveness by looking at newly abstinent male alcoholics.
O’Farrell, Choquette, Cutter, Brown, et al. (1996) studied couples whohad participated in and completed weekly BCT for 5 to 6 months. Coupleswere randomly assigned to receive or not receive an additional 15 sessionsof couples relapse prevention throughout the next 12 months. Measurementsfor cost–benefit analysis included baseline and follow-up costs incurredfrom alcohol-related health care and legal system use, the cost of deliver-ing both BCT and relapse prevention, monetary benefits of reduced healthand legal costs, and benefit-to-cost comparisons. The cost of treatment deliv-ery, and health and legal service use, were measured for the 12 monthsbefore and after BCT. Adding relapse prevention to BCT resulted in lessdrinking and improved couple adjustment; however, it did not have greatercost-effectiveness in health and legal service use. Treatments were equallycost-effective in couple adjustment, and BCT was more cost-effective in termsof abstinence.
O’Farrell, Choquette, Cutter, Floyd, et al. (1996) assigned newly absti-nent male alcoholics to a no BCT group, an interactional couples group(ICT), or to 10 weekly sessions of BCT. Measurements for cost–benefit analy-sis included the cost of delivering both BCT and relapse prevention, baselineand follow-up alcohol-related costs (health and legal), and benefit-to-costcomparisons. Like O’Farrell, Choquette, Cutter, Brown, et al. (1996), BCTwas more cost-effective in reducing alcohol-related costs. Both individualtreatment and BCT had equivalent couple adjustment outcomes.
Using data from Fals-Stewart et al.’s (1996) clinical outcome study,Fals-Stewart et al. (1997) examined cost outcomes for cohabitingsubstance-dependent male participants in a BCT or an IBT-only group.
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Estimating the social costs the year before and the year after treatment, theyfound BCT was more cost-effective than IBT with particular reductions ininpatient hospitalization, long-term residential care, and incarceration. Totalsavings for clients in collective social costs from baseline to follow-up wereabout $5,000 per client higher than the IBT control group. Clients in theIBT group relapsed more than clients in the BCT group, and relapses canincur large costs. This study was done with participants involved in the crim-inal justice system, so cost-effectiveness might look different with anotherpopulation of participants.
Fals-Stewart et al. (2005) also measured the cost-effectiveness of BCTand BRT. This study found that BRT was more cost-effective than other con-ditions (BCT, PACT, and IBT); however, the authors were cautionary withtheir results as their study did not complete a follow-up measure of cost-effectiveness (e.g., at 1 year following treatment). Although brief BCT mightappear to be more cost-effective, various factors could warrant or encouragethe use of standard BCT, such as couples with high levels of distress, or indi-viduals who continue to struggle with maintaining abstinence. Across studies,outcomes demonstrated that providing BCT in the context of substancedependence is cost-effective, particularly in terms of fewer relapses.
DISCUSSION
BCT is arguably the relational approach to treating substance dependencemost based on evidence (O’Farrell & Clements, 2012; Ruff et al., 2010;Shadish & Baldwin, 2005; Stanton & Shadish, 1997). This theoretical modelhas positive results with both heterosexual couples and same-sex couples.The action of BCT appears to be the ability to enhance satisfaction withinthe couple relationship, which, in turn, leads to a reduction in substance use(Fals-Stewart, Klostermann, & Yates, 2006; Powers et al., 2008). BCT is alsoproven to be cost-effective (e.g., Fals-Stewart et al., 2005).
Treatment effects of BCT are promising; however, there is evidence thatthey also dissipate over time. In their meta-analysis of BCT studies, Powerset al. (2008) also noted that the pattern of results varied as a function oftime. However, another meta-analysis of 30 randomized control BCT stud-ies indicated that an average couple receiving BCT has better outcomesthan those couples who receive no treatment (Shadish & Baldwin, 2005).Although this review found a variety of results for BCT, couples who aretreated together were seen to do better (at least when measured at short-termfollow-up) than couples treated separately. There is a potential for futurestudies to examine whether couple treatment improves couple functioningregardless of modality, or whether different treatment modalities produce dif-ferent results. With the exception of three studies—Fals-Stewart et al. (2005),O’Farrell et al. (1992), and Walitzer and Dermen (2004)—studies did not
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compare models of couple therapy (e.g., BCT and emotional-focused cou-ples therapy). Assessing whether there are differences in outcome betweenBCT and other couple therapy models is an important next step.
Regardless of modality (BCT, IBT, etc.), most clients entering addictiontreatment are not experiencing sustained treatment effects (Office of AppliedStudies, 2000). For example, of clients admitted to the U.S. public treatmentsystem in 1999, 60% were reentering treatment; 23% for the second time, 13%for the third time, 7% for the fourth time, 4% for the fifth time, and 13% forthe sixth time or more (Office of Applied Studies). Researchers have foundthat an individual’s relational and social stability is more predictive of thelonger term sustainability of treatment gains than the severity or chronicityof their addictive disease (e.g., Vaillant, 1988). More studies that focus onstrengthening an individual or a couple’s relational functioning in the contextof addiction are needed.
LIMITATIONS OF EXISTING LITERATURE
Clinician experience was not factored into these studies. A report by Raytek,McCrady, Epstein, and Hirsch (1999) argued that more experienced cliniciansdevelop stronger therapeutic alliances and are more competent when work-ing with couples in the context of addiction. Although their study examinedthe delivery of ABCT, one could argue that the experience of the cliniciancould impact outcome within all of these studies.
The studies reviewed also did not address comorbidity or multipleaddictions. They separated alcohol- and drug-dependent individuals withoutaddressing reasons for why that would be desirable, nor did they identifyhow many alcoholics also use drugs and vice versa. Individuals with sub-stance dependence might have an addiction to more than one substance(Teesson, Farrugia, Mills, Hall, & Baillie, 2012). The implications of this forexisting research on BCT could be that other variables (including other addic-tions or mental health comorbidities) affected the outcomes. Researchers’implemented BCT strategies of working with couples might be missingnecessary screening for comorbid mental health issues or addictions.
In terms of sample limitations, this review included studies with pri-marily White, married, English heterosexual samples. Some studies includedcohabiting partners (e.g., Walitzer & Dermen, 2004), but many had marriageas an inclusion criterion (Fals-Stewart et al., 2000; Halford et al., 2001). Onlyfive studies considered substance dependence, whereas the other studieswere focused on alcohol use. Separating alcohol and drug use in partici-pants was consistent across studies. All of the studies selected comparedcouple therapy treatment to an active control condition. With the exceptionof Vedel et al.’s, (2008) study, BCT was used as an adjunct treatment withindividual therapy, as opposed to a stand-alone condition.
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Studies focused on men with substance use disorders and their het-erosexual female partners outnumbered other studies. The studies revieweddid not state clear rationales for why they chose to focus on only menor women. Only one study grouped men and women with substance usedisorders together (Vedel et al., 2008), and only four studies focused onwomen with substance use disorders (Fals-Stewart, Birchler, & Kelley, 2006;McCollum et al., 2003; McCrady et al., 2009; Winters et al., 2002). Based onestimates in the United States, approximately one third of individuals with analcohol addiction, and slightly less than half of individuals with drug addic-tions, are women (Greenfield, Manwani, & Nargiso, 2003). These estimatesmight be low, as women are less likely to enter addiction treatment due toeconomic and family responsibilities (e.g., no child care; Brady & Ashley,2005). The high number of women with substance addictions needs to bebetter reflected in treatment research.
The reviewed studies had both gender normative and hetero-normativeinclusion criteria. Only one study addressed same-sex couples (Fals-Stewart,O’Farrell, & Lam, 2009). Given that the reported incidence of addiction forlesbian, gay, bisexual, and transgender individuals is higher than for hetero-sexuals (Cochran & Cauce, 2006; Marshal et al., 2008; McCabe, West, Hughes,& Boyd, 2013), the lack of research is unacceptable. Furthermore, no studiesincluded or mentioned transgendered clients. This absence is also glaring,and future research that is inclusive of these individuals and their partners isneeded.
Another limitation of the articles reviewed was a lack of focus on theimplications of couple therapy for the nonaddicted partner. Halford et al.(2001) was the only reviewed study that examined the partner’s distressspecifically. Similarly the language of “significant other” or “third party” notonly places the partner at the periphery of the treatment intervention, butalso narrows the lens of who the addiction is impacting. Similarly, the capac-ities of couples included in the BCT studies had to be very high, as partnerswere expected to support and coach their spouse with the addiction. Notall partners have that emotional capacity, and some might require their owncoaching and support. Perhaps future studies could examine the individualfunctioning (mood, stress level, attachment, etc.) of both partners to betterunderstand whether the partner of the addicted individual experiences anychange in functioning from pretreatment to posttreatment.
LIMITATIONS OF REVIEW
Although a rigorous search strategy was used, it is possible that the reviewdid not locate all relevant studies. Primarily, the time frame chosen forreviewed studies excluded early research on couple therapy and addic-tion. As a result, the review did not capture the complete evolution of
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the approaches examined. The selection criteria using randomized controlcouple therapy studies excluded almost all models of couple therapy withthe exception of BCT. Two research groups carried out the majority of theincluded research studies, and this could lead to a homogeneous researchagenda. There was little research found countering or questioning the use ofBCT in this context other than authors’ accounts of their own limitations.
Perhaps the greatest limitation within this review was studies addresseda diverse set of variables, making it difficult to draw firm conclusions aboutcouple therapy in the context of addiction. The heterogeneity of studies pro-vides insight into the widespread utility of models like BCT; however, muchmore needs to be known about each context and theoretical application.In describing what is currently known, this review highlights how muchmore remains to be learned.
There were gaps in the literature that are important to highlight.Primarily, there have been some theoretical pieces written that argue fornovel approaches to treating addiction using couple therapy. For exam-ple, McCollum et al. (2011) proposed a brief substance-abuse motivationalintervention treatment program for couples struggling with intimate partnerviolence. Reflective systemic therapy and emotionally focused couple ther-apy have also proposed clinical practice models to work with couples in thecontext of addiction (Flynn, 2010; Landau-North, Johnson, & Dalgeish, 2011).This review did not capture these theoretical models because they have yetto be studied using a randomized clinical trial; however, it is important toacknowledge their potential for the advancement of knowledge in coupletherapy and addiction.
Some articles that use BCT in interesting ways were also excludedbecause they did not meet criteria for review. For example, one studyexamined the impact of BCT on intimate partner violence in relationshipswith addiction (Schumm, O’Farrell, Murphy, & Fals-Stewart, 2009), andanother examined the impact of BCT on substance abuse and combat-relatedposttraumatic stress disorder (Rotunda et al., 2008).
CONCLUSION
Fals-Stewart, Birchler, and O’Farrell (1999) observed in an early study that32% of 892 applicants for two substance-dependence treatment programsmet the inclusion criteria for couple therapy. A large proportion of clientsentering addiction treatment are suitable for couple treatment; however,surveys report that well-studied approaches like BCT are not widely used(Fals-Stewart & Birchler, 2001). A lack of knowledge about models such asBCT, and missing links in knowledge translation between research findingsand practice could explain the underuse of couple therapy in addiction treat-ment centers. This review highlights that there are still numerous variables
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and theoretical modalities that merit investigation in the context of coupletherapy and addiction. Couples therapy clearly has an important role to playin addiction treatment, and continuing research provides important directionin terms of new avenues of treatment.
REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical manual ofmental disorders (5th ed.). Washington, DC: Author.
Benishek, L. A., Kirby, K. C., & Dugosh, K. L. (2011). Prevalence and fre-quency of problems of concerned family members with a substance-usingloved one. The American Journal of Drug and Alcohol Abuse, 37(2), 82–88.doi:10.3109/00952990.2010.540276
Bischoff, R. J. (2008). Couple therapy for substance abuse. Journal of Couple &Relationship Therapy, 7 , 175–179. doi:10.1080/15332690802107255
Brady, T. M., & Ashley, O. S. (Eds.). (2005). Women in substance abuse treatment:Results from the Alcohol and Drug Services Study (ADSS) (DHHS Publication No.SMA 04-3968, Analytic Series A-26). Rockville, MD: Substance Abuse and MentalHealth Services Administration, Office of Applied Studies.
Cochran, B. N., & Cauce, A. M. (2006). Characteristics of lesbian, gay, bisexual,and transgender individuals entering substance abuse treatment. Journal ofSubstance Abuse Treatment, 30, 135–146. doi:10.1016/j.jsat.2005.11.009
Copello, A. G., Templeton, L. J., & Velleman, R. (2006). Family interventions for drugand alcohol misuse: Is there a best practice? Current Opinion in Psychiatry, 19,271–276.
Dethier, M., Counerotte, C., & Blairy, S. (2011). Marital satisfaction in cou-ples with an alcoholic husband. Journal of Family Violence, 26 , 151–162.doi:10.1007/s10896-010-9355-z
Edwards, G. (2012). Correspondence: “The evil genius of the habit”: DSM–5 seen inhistorical context. Journal of Studies on Alcohol and Drugs, 73, 699–701.
Epstein, E. E., & McCrady, B. S. (1998). Behavioral couples treatment of alcohol anddrug use disorders: Current status and innovations. Clinical Psychology Review,18, 689–711. doi:10.1016/S0272-7358(98)00025-7
Epstein, E. E., McCrady, B. S., Morgan, T. J., Cook, S. M., Kugler, G., & Ziedonis,D. (2007). Couples treatment for drug-dependent males: Preliminary efficacy ofa stand alone outpatient model. Addictive Disorders & Their Treatment, 6(1),21–38.
Fals-Stewart, W., & Birchler, G. R. (2001). A national survey of the use of couplestherapy in substance abuse treatment. Journal of Substance Abuse Treatment,20, 277–283. doi:10.1016/S0740-5472(01)00165-9
Fals-Stewart, W., Birchler, G. R., & Kelley, M. L. (2006). Learning sobriety together: Arandomized clinical trial examining behavioral couples therapy with alcoholicfemale patients. Journal of Consulting and Clinical Psychology, 74, 579–591.
Fals-Stewart, W., Birchler, G. R., & O’Farrell, T. J. (1996). Behavioral couples ther-apy for male substance-abusing patients: Effects on relationship adjustmentand drug-using behavior. Journal of Consulting and Clinical Psychology, 64,959–972. doi:10.1037/0022-006X.64.5.959
Dow
nloa
ded
by [
McG
ill U
nive
rsity
Lib
rary
] at
09:
37 2
5 N
ovem
ber
2013
Couple Therapy Treatments for Substance Use Disorders 349
Fals-Stewart, W., Birchler, G. R., & O’Farrell, T. J. (1999). Drug-abusing patients andtheir intimate partners: Dyadic adjustment, relationship stability, and substanceuse. Journal of Abnormal Psychology, 108, 11–23.
Fals-Stewart, W., Klostermann, K., & Yates, B. T. (2006). Brief couples therapy effi-cacious for alcoholism. DATA: The Brown University Digest of Addiction Theory& Application, 5, 2–3.
Fals-Stewart, W., Klostermann, K., Yates, B. T., & Birchler, G. R. (2005). Brief rela-tionship therapy for alcoholism: A randomized clinical trial examining clinicalefficacy and cost-effectiveness. Psychology of Addictive Behaviors, 19, 363–371.
Fals-Stewart, W., Lam, W. K., & Kelley, M. L. (2009). Learning sobriety together:Behavioural couples therapy for alcoholism and drug abuse. Journal of FamilyTherapy, 31, 115–125. doi:10.1111/j.1467-6427.2009.00458.x
Fals-Stewart, W., O’Farrell, T. J., & Birchler, G. R. (1997). Behavioral couples ther-apy for male substance abusing patients: A cost outcome analysis. Journal ofConsulting and Clinical Psychology, 65, 789–802.
Fals-Stewart, W., O’Farrell, T. J., & Birchler, G. R. (2001). Behavioral couples ther-apy for male methadone maintenance patients: Effects on drug-using behaviorand relationship adjustment. Behavior Therapy, 32, 391–411. doi:10.1016/S0005-7894(01)80010-1
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 formale substance-abusing patients: An evaluation of significant individual changeand comparison of improvement rates. Journal of Substance Abuse Treatment,18, 249–254. doi:10.1016/S0740-5472(99)00059-8
Fals-Stewart, W., O’Farrell, T. J., & Lam, W. K. (2009). Behavioral couple therapy forgay and lesbian couples with alcohol use disorders. Journal of Substance AbuseTreatment, 37 , 379–387. doi:10.1016/j.jsat.2009.05.001
Fischer, J. L., & Wiersma, J. D. (2012). Romantic relationships and alcohol use.Current Drug Abuse Reviews, 5, 98–116. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22455505
Flynn, B. (2010). Using systemic reflective practice to treat couples and familieswith alcohol problems. Journal of Psychiatric and Mental Health Nursing, 17 ,583–593.
Greenfield, S. F., Manwani, S. G., & Nargiso, J. E. (2003). Epidemiology of substanceuse disorders in women. Obstetrics & Gynecology Clinics of North America, 30,413–446.
Halford, W. K., Price, J., Kelly, A. B., Bouma, R., & Young, R. M. (2001). Helpingthe female partners of men abusing alcohol: A comparison of three treatments.Addiction, 96 , 1497–1508. doi:10.1046/j.1360-0443.2001.9610149713.x
Heinz, A. J., Wu, J., Witkiewitz, K., Epstein, D. H., & Preston, K. L. (2009). Marriageand relationship closeness as predictors of cocaine and heroin use. AddictiveBehaviors, 34, 258–263. doi:10.1016/j.addbeh.2008.10.020
Kelley, M. L., & Fals-Stewart, W. (2002). Couple- versus individual-based therapy foralcohol and drug abuse: Effects on children’s psychosocial functioning. Journalof Consulting and Clinical Psychology, 70, 417–427.
Kelly, S., Epstein, E. E., & McCrady, B. S. (2004). Pretreatment attrition from cou-ple therapy for male drug abusers. The American Journal of Drug and AlcoholAbuse, 30(1), 1–19. doi:10.1081/ADA-120029861
Dow
nloa
ded
by [
McG
ill U
nive
rsity
Lib
rary
] at
09:
37 2
5 N
ovem
ber
2013
350 K. Fletcher
Kirby, K. C., Dugosh, K. L., Benishek, L. A., & Harrington, V. M. (2005). TheSignificant Other Checklist: Measuring the problems experienced by fam-ily members of drug users. Addictive Behaviors, 30, 29–47. doi:10.1016/
j.addbeh.2004.04.010Lam, W. K., Fals-Stewart, W., & Kelley, M. L. (2009). Parent training with behavioral
couples therapy for fathers’ alcohol abuse: Effects on substance use, parentalrelationship, parenting, and CPS involvement. Child Maltreatment, 14, 243–254.doi:10.1177/1077559509334091
Landau-North, M., Johnson, S. M., & Dalgeish, T. L. (2011). Emotional focused coupletherapy and addiction. In J. L. Furrow, S. M. Johnson, & B. A. Bradley (Eds.), Theemotionally focused casebook: New directions in treating couples (pp. 193–218).New York, NY: Routledge.
Marshal, M. P., Friedman, M. S., Stall, R., King, K. M., Miles, J., Gold, M. A., . . .
Morse, J. Q. (2008). Sexual orientation and adolescent substance use: A meta-analysis and methodological review. Addiction, 103, 546–556. doi:10.1111/
j.1360-0443.2008.02149.xMcCabe, S. E., West, B. T., Hughes, T. L., & Boyd, C. J. (2013). Sexual orienta-
tion and substance abuse treatment utilization in the United States: Resultsfrom a national survey. Journal of Substance Abuse Treatment, 44, 4–12.doi:10.1016/j.jsat.2012.01.007
McCollum, E. E., Lewis, R. A., Nelson, T. S., Trepper, T., & Wetchler, J. L. (2003).Couple treatment for drug abusing women: Effects on drug-use and need fortreatment. Journal of Couple & Relationship Therapy, 2(4), 1–18.
McCollum, E. E., Nelson, T. S., Lewis, R. A., & Trepper, T. (2005). Partner relation-ship quality and drug use as predictors of women’s substance abuse treatmentoutcome. The American Journal of Drug and Alcohol Abuse, 31(1), 111–127.doi:10.1081/ADA-200047906
McCollum, E. E., Stith, S. M., Miller, M. S., & Ratcliffe, G. C. (2011). Including abrief substance-abuse motivational intervention in a couples treatment programfor intimate partner violence. Journal of Family Psychotherapy, 22, 216–231.doi:10.1080/08975353.2011.602618
McCrady, B. S. (2012). Treating alcohol problems with couple therapy. Journal ofClinical Psychology, 68, 514–525. doi:10.1002/jclp.21854
McCrady, B. S., Epstein, E. E., Cook, S. M., Jensen, N., & Hildebrandt, T. (2009).A randomized trial of individual and couple behavioral alcohol treatment forwomen. Journal of Consulting and Clinical Psychology, 77 , 243–256.
McCrady, B. S., Epstein, E. E., & Hirsch, L. S. (1999). Maintaining change after con-joint behavioral alcohol treatment for men: Outcomes at 6 months. Addiction,94, 1381–1396. doi:10.1080/09652149932839
McLellan, A. T., Luborsky, L., Woody, G. E., & O’Brien, C. P. (1980). An improveddiagnostic evaluation instrument for substance abuse patients. The Journal ofNervous and Mental Disease, 168(1), 26–33.
Meyers, R. J., Miller, W. R., Smith, J. E., & Tonigan, J. S. (2002). A randomizedtrial of two methods for engaging treatment-refusing drug users through con-cerned significant others. Journal of Consulting and Clinical Psychology, 70,1182–1185.
Moore, T. M., & Stuart, G. L. (2004). Illicit substance use and intimate partner violenceamong men in batterers’ intervention. Psychology of Addictive Behaviors, 18,385–389.
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nloa
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Couple Therapy Treatments for Substance Use Disorders 351
Nattala, P., Leung, K. S., Nagarajaiah, & Murthy, P. (2010). Family memberinvolvement in relapse prevention improves alcohol dependence outcomes: Aprospective study at an addiction treatment facility in India. Journal of Studieson Alcohol and Drugs, 71, 581–587.
Nelson, T. S., McCollum, E. E., Wetchler, J. L., Trepper, T., & Lewis, R. A. (1996).Therapy with women substance abusers: A systemic couples approach. Journalof Feminist Family Therapy, 8(1), 5–27.
Nelson, T. S., & Sullivan, N. J. (2007). Couple therapy and addictions. Journal ofCouple & Relationship Therapy, 6(1/2), 45–56. doi:10.1300/J398v06n01_05
O’Brien, C. P. (2011). Addiction and dependence in DSM-V. Addiction, 106(5),866–867.
O’Brien, C. P., Volkow, N., & Li, T.-K. (2006). What’s in a word? Addiction versusdependence in DSM–V. American Journal of Psychiatry, 163, 764–765.
O’Farrell, T. J., Choquette, K. A., Cutter, H. S. G., Brown, E. D., Bayog, R.D., McCourt, W., . . . Deneault, P. (1996). Cost-benefit and cost-effectivenessanalyses of behavioral marital therapy with and without relapse preven-tion sessions for alcoholics and their spouses. Behavior Therapy, 27 , 7–24.doi:10.1016/S0005-7894(96)80032-3
O’Farrell, T. J., Choquette, K. A., Cutter, H. S. G., Floyd, F. J., Bayog, R. D., Brown,E. D., . . . Deneault, P. (1996). Cost-benefit and cost-effectiveness analyses ofbehavioral marital therapy as an addition to outpatient alcoholism treatment.Journal of Substance Abuse, 8, 145–166.
O’Farrell, T. J., & Clements, K. (2012). Review of outcome research on maritaland family therapy in treatment for alcoholism. Journal of Marital and FamilyTherapy, 38, 122–144.
O’Farrell, T. J., Cutter, H. S. G., Choquette, K. A., Floyd, F. J., & Bayog, R. D.(1992). Behavioral marital therapy for male alcoholics: Marital and drinkingadjustment during the two years after treatment. Behavior Therapy, 23, 529–549.doi:10.1016/S0005-7894(05)80220-5
O’Farrell, T. J., & Fals-Stewart, W. (2008). Behavioral couples therapy for alcoholismand other drug abuse. Alcoholism Treatment Quarterly, 26(1/2), 195–219.
O’Farrell, T. J., & Schein, A. Z. (2011). Behavioral couples therapy for alco-holism and drug abuse. Journal of Family Psychotherapy, 22, 193–215.doi:10.1080/08975353.2011.602615
Office of Applied Studies. (2000). National household survey on drug abuse: Mainfindings 1998. Rockville, MD: Substance Abuse and Mental Health ServicesAdministration.
Powers, M. B., Vedel, E., & Emmelkamp, P. M. G. (2008). Behavioral couples therapy(BCT) for alcohol and drug use disorders: A meta-analysis. Clinical PsychologyReview, 28, 952–962.
Raytek, H. S., McCrady, B. S., Epstein, E. E., & Hirsch, L. S. (1999). Therapeuticalliance and the retention of couples in conjoint alcoholism treatment. AddictiveBehaviors, 24, 317–330.
Reinarman, C. (2005). Addiction as accomplishment: The discursive construc-tion of disease. Addiction Research & Theory, 13, 307–320. doi:10.1080/
16066350500077728Rotunda, R. J., O’Farrell, T. J., Murphy, M., & Babey, S. H. (2008). Behavioral couples
therapy for comorbid substance use disorders and combat-related posttraumatic
Dow
nloa
ded
by [
McG
ill U
nive
rsity
Lib
rary
] at
09:
37 2
5 N
ovem
ber
2013
352 K. Fletcher
stress disorder among male veterans: An initial evaluation. Addictive Behaviors,33, 180–187.
Ruff, S., McComb, J. L., Coker, C. J., & Sprenkle, D. H. (2010). Behavioral couplestherapy for the treatment of substance abuse: A substantive and methodologicalreview of O’Farrell, Fals-Stewart, and colleagues’ program of research. FamilyProcess, 49, 439–456. doi:10.1111/j.1545-5300.2010.01333.x
Saatcioglu, O., Erim, R., & Cakmak, D. (2006). Role of family in alcoholand substance abuse. Psychiatry and Clinical Neurosciences, 60, 125–132.doi:10.1111/j.1440-1819.2006.01476.x
Saunders, J. B. (2007). Substance dependence and nondependence in DSM and theICD. In J. B. Saunders, M. D. Schuckit, P. J. Sirovatka, & D. A. Regier (Eds.),Diagnostic issues in substance use disorders: Refining the research agenda forDSM-V (pp. 75–92). Arlington, VA: American Psychiatric Association.
Schumm, J. A., O’Farrell, T. J., Murphy, C. M., & Fals-Stewart, W. (2009). Partnerviolence before and after couples-based alcoholism treatment for female alco-holic patients. Journal of Consulting and Clinical Psychology, 77 , 1136–1146.doi:10.1037/a0017389
Shadish, W. R., & Baldwin, S. A. (2005). Effects of behavioral marital therapy: Ameta-analysis of randomized control trials. Journal of Consulting and ClinicalPsychology, 73, 6–14.
Stanton, M. D. (2005). Couples and addiction. In M. Harway (Ed.), Handbook ofcouples therapy (pp. 313–336). Hoboken, NJ: Wiley.
Stanton, M. D., & Shadish, W. R. (1997). Outcome, attrition, and family-couples treat-ment for drug abuse: A meta-analysis and review of the controlled, comparativestudies. Psychological Bulletin, 122, 170–191. doi:10.1037/0033-2909.122.2.170
Stuart, G. L., Moore, T. M., Kahler, C. W., & Ramsey, S. E. (2003). Substance abuseand relationship violence among men court-referred to batterers’ interventionprograms. Substance Abuse, 24, 107–122.
Teesson, M., Farrugia, P., Mills, K., Hall, W., & Baillie, A. (2012). Alcohol, tobacco,and prescription drugs: The relationship with illicit drugs in the treatmentof substance users. Substance Use & Misuse, 47(8/9), 963–971. doi:10.3109/
10826084.2012.663283Vaillant, G. E. (1988). What can long-term follow-up teach us about relapse and
prevention of relapse in addiction? British Journal of Addiction, 83, 1147–1157.Vedel, E., Emmelkamp, P. M. G., & Schippers, G. M. (2008). Individual cognitive-
behavioral therapy and behavioral couples therapy in alcohol use disorder:A comparative evaluation in community-based addiction treatment centers.Psychotherapy and Psychosomatics, 77 , 280–288.
Velleman, R. (2006). The importance of family members in helping problem drinkersachieve their chosen goal. Addiction Research & Theory, 14, 73–85.
Walitzer, K. S., & Dermen, K. H. (2004). Alcohol-focused spouse involvement andbehavioral couples therapy: Evaluation of enhancements to drinking reduc-tion treatment for male problem drinkers. Journal of Consulting and ClinicalPsychology, 72, 944–955. doi:10.1037/0022-006X.72.6.944
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 onsubstance use and relationship adjustment. Journal of Consulting and ClinicalPsychology, 70, 344–355.
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by [
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] at
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