BEHAVIORAL COUPLES THERAPY FOR SUBSTANCE USE DISORDERS

Resources:

O'Farrell, T. (1993). Treating alcohol problems: Marital and family interventions. New York: Guilford.

Ruff S, McComb JL, Coker CJ, Sprenkle DH (2010). Behavioral couples therapy for the treatment of substance abuse: a substantive and methodological review of O'Farrell, Fals-Stewart, and colleagues' program of research. Family Process, 49 (4), 439-56.

National Registry of Evidence-based Programs and Practices(NREPP): a searchable online database of mental health andsubstance abuse interventions. BCT review online at:

http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=134

FAMILY-FOCUSED TREATMENT APPROACHESFAMILY-FOCUSED TREATMENT APPROACHES

Engaging client /couple / family

Deciding on therapy parameters & goals -assessment

“Intervention” approach

Working with spouses/partners without IP, with intent of helping IP or drawing IP into treatment

Working with spouses/partners without IP

Self-help group referrals

FAMILY-FOCUSED TREATMENT APPROACHESFAMILY-FOCUSED TREATMENT APPROACHES

• Family Models

• family disease - a parallel process

• family systems- substance seen as “organizing principle”- symptom may not be the problem- interconnectedness, reciprocity, homeostasis

• behavioral couples / family- substance use viewed as problem behavior- focus on both recovery and relationships

- The Counseling for Alcoholics’ Marriages (CALM) Project --- example of BCT

Background & Introduction

Substance-Focused Methods

Relationship-Focused Methods

Relapse Prevention

Behavioral Couples Therapy for Alcoholism and Drug Abuse

Behavioral Couples Therapy for Alcoholism and Drug AbusePurpose of BCT is to increase relationship factors

conducive to abstinence

Daily Sobriety Contract supports abstinence

Behavioral therapy increases positive activities and constructive communication

Plan for relapse prevention

12-20 couple sessions over 3-6months

BCT fits well with self-help groups, medications, and other counseling

BCT gives more abstinence, happier re-lationships & fewer separations than IND

Benefit to cost ratio greater than 5:1

Domestic violence is greatly reduced

Children helped more by BCT than IND

BCT improves medication compliance

BCT works with family members other than spouses

Studies of BCT for Alcoholism and Drug Abuse Show

Married or living together relationship

Reside together or reconcile

Not psychotic past 90 days

Not high risk of injurious/lethal violence

? if both are substance abusers

Start after detox, rehab, or no prior Tx

Suitable Cases for BCT

THE FOUR PHASES OF PROJECT CALM

1. Engaging Alcoholic and Partner

• providing a rationale … and hope

2. 8 - 10 Weekly Couple Sessions

3. 10 Weekly Couples Group Sessions(group modality optional but better)

4. Quarterly Follow-up Visits for 24 Months

Weekly Couple Sessions

– developing a sobriety contract

– use of Antabuse or other recovery meds

– CALM Promises – no threats of separation, focus on present, and commit to action via hmwk. exercises

STRUCTURE OF CALM COUPLES GROUPS

4-5 couples

- stabilized and appropriate for group

male and female co-therapist team

- observer for training purposes

10 weekly two-hour sessions with 10-15 minute break for refreshments

PROCESS OF CALM COUPLES GROUPS

Report on homework in first half of each session

Focus on recovery:

- Sobriety Contract & check of urges to drink or drug; Crisis intervention PRN

Skills training and practice

End with review of homework assignments for coming week - eliciting commitments

Building Support

for

Abstinence

Substance-Focused Methods

BCT Sobriety Contract

Helps the CoupleReward abstinence

Reduce distrust and conflict

Refrain from punishing sobriety

BCT Sobriety Contract

Sobriety Trust DiscussionAlcohol/drug abuser states

intention to stay abstinent that day

Spouse thanks alcohol/drug abuser for efforts to stay abstinent

BCT Sobriety ContractDaily Sobriety Trust Discussion

Medication (Antabuse, Naltrexone) to aid

recovery

Self-help involvement

Weekly drug urine screens

Calendar to record progress

Other Support for AbstinenceReviewing urges to drink or use drugs

Helps identify cues for alcohol or drug use

Resisting urges builds confidence

Crisis intervention for substance useGet substance use stopped ASAP

Use as a learning experience

Discuss exposure to substances, including alcohol at home

Increasing

Positive Activities

Relationship-Focused Methods

Increasing Positive Activities

Catch Your Partner Doing Something Nice

Caring Day Assignment

Shared Rewarding Activities

CATCH YOUR PARTNER DOING SOMETHING NICE

NAME: Mike PARTNER’S NAME: Nancy

DAY DATE PLEASING BEHAVIOR NOTICED

MON 4/6 Waited to have dinner with me whenI had to stay late at work

TUES 4/7 Told me she loved me

WED 4/8 Cooked a delicious dinner

THUR 4/9 Was patient with me when I camehome tired and moody from work

FRI 4/10 Enjoyed a walk together

SAT 4/11 Woke me gently and rubbed my back

SUN 4/12 Helped plan a picnic with f riends

Increasing Positive Activities

Shared Rewarding ActivitiesEach partner lists possible activities

Plan one activity each week

Activity can be “date at home”, out with other couples or families, simple or large

Such activities linked with recovery

Teaching

Communication Skills

Relationship-Focused Methods

Teaching Communication Skills

Listening Skills

Expressing Feelings Directly

Communication Sessions

Negotiating for Requests

Maintenance and Relapse Prevention

Continuing Recovery Plan

Specifies activities to do to

maintain abstinence and

relationship recovery after weekly

couple sessions end

Maintenance and Relapse Prevention

Relapse Prevention PlanIdentify high risk situations

and early warning signs

Formulate and rehearse plan to

Prevent relapse

Minimize duration and negative consequences of substance use if it occurs

RELATED CLINICAL ISSUES

• Screening for Enabling

• Working with partners to:

focus on coping responses, eliminate enabling

- drank / used drugs with, or in presence of, client95%

- lied or made excuses to family/friends 90%

- gave client money to buy alcohol or drugs 71%

- purchased alcohol or drugs for client 55%

Dealing with Domestic Violence in Couples Counseling

Assess Domestic Violence

– Interview as Couple and Separately– Conflict Tactics Scale

Assess Current Risk of Lethal/Injurious Violence

– History and Nature of Violence (e.g., verbal, physical, weapons used?)

– Fear of Recurrence– Recent Threats of Violence– Has violence occurred only or mostly when alcoholic is/was

drinking?

Dealing with Domestic Violence

If Risk of Lethal/Injurious Violence is High:

– Provide Separate Treatment for Alcoholic and Spouse

– Make a Safety Plan

If Risk of Lethal/Injurious Violence is NOT High:

– Treat with Caution and Address Violence

Dealing with Domestic Violence

Address Violence in Couples Counseling:

– Commitment to nonviolence (“No angry touching.” “No threats.”)

– Review at each session successes and challenges to keeping nonviolence commitment

– “Time Out” to reduce escalating conflict– Communication Skills Training– Written agreement for at least temporary separation if

violence occurs– Address risk of violence if relapse occurs