Behaviour Couple therapy for Alcoholics and substance abuse

Presenter: Ms.Shruti SharmaGuide : Ms.T.Shivata Behaviour Couples Therapy for Alcoholism and Substance abuse1

CONTENTS Introduction Family based conceptualization of substance useRationale for Use of Couple TherapyFactors influencing recovery, couple functioning, and/or relationship longevityThe practice of Behaviour Couple TherapyProcess of Behaviour Couple Therapy Interventions techniquesConclusion

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IntroductionDrug/ alcohol abuse is a complex phenomenon, which has various social, cultural, biological, geographical, historical and economic aspects.

It is a global concern because of the impact on individuals health, familial and social consequences, criminal, legal problems and the effects on national productivity and economy.

The processes of industrialization, urbanization and migration have led to loosening of the traditional methods of social control rendering an individual vulnerable to the stresses and strains of modern life.

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These are the factors which may lead to alcohol abuse.The process of industrialization urbanization and migration have led to the loosening of traditional methods of social control..for eg how initially people used to sit for panchayat to solve the problems of an individual infront of all..taking suggestions from the elders or even sending the person to some spiritual place where they have to be abstinent all these traditional methods of social control have become weak and making an individual more vulnerable to stresses and strains of life. 3

Apart from affecting the financial stability, addiction increases conflicts and causes untold emotional pain for every member of the family.

(Nadeem et al., 2009)

Alcohol use disorders (AUDs) are best thought of as family disorders and many families are affected by AUDs.

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For example, 23% of Americans report that they have a first-degree relative with an alcohol problem and 38% report any blood relative with a drinking problem.

Although the probability of getting married is about the same for those with and without AUDs, separation and divorce rates are about four times that of the general population.(McCrady, B. S., 2012)

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Physical violence is common in couples where one partner has an AUD, occurring in about two thirds of couples where either the woman or the man has an AUD.

It also affects the physical and psychological health of spouses and children, with spouses being more likely to be depressed or anxious or to have psychophysiological symptoms

and children being at higher risk for school problems, conduct disorder, and internalizing disorders.

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Individuals attitudes and patterns of alcohol and drug use are influenced heavily by the family.

In adulthood, individual drinking patterns are influenced by the drinking of the intimate partner, and many couples align their drinking patterns so that they become more similar over time. 7

Prevalence Epidemiological surveys in India indicated, alcohol was the commonest substance used (60-98%) followed by cannabis use (4-20%).

Research data also revealed that 20-40% of subjects above 15 years are current users of alcohol and 10% of them are regular or excessive users. (c.f. Ahmed et al., 2009)

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Family based conceptualizations of substance use9

Historically, alcoholism and drug abuse have been viewed as individual problems most effectively treated on an individual basis.

During the last three decades, awareness of family members potentially crucial roles in the etiology and maintenance of addictive behaviour has grown.

Since the mid-1970s, three theoretical perspectives have come to dominate family-based conceptualizations of substance use and are the foundation for the treatment strategies most often used with substance users

Family disease approachFamily systems approachBehavioural approach (OFarrell et al., 2003)

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The best known of these, the family disease approach, conceptualizes alcoholism and other drug abuse as a family illness of not only the substance user but also his or her family members (who are viewed as being co-dependent)

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Treatment drawn from this perspective involves the substance- abusing patient and his or her family members, addressing their respective disease processes individually; formal couple or family treatment is largely deemphasized. Family members PERSPECTIVE is also taken into consideration. Individual problems are takn into consi..11

The family systems approach applies the principles of general systems theory to families, paying particular attention to ways that families maintain a dynamic balance between substance use and family functioning, and whose interactional behaviour is organized around alcohol or drug use. (cf. Edwards & Steinglass, 1995)

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Accordingly, family therapy has the goal of modifying family dynamics and interactions to eliminate the familys need for the substance- abusing patient to drink or use drugs. A systems perspective does not merely focus on separate parts, but on how all the separate parts are connected, interdependent and interrelated. From a systems perspective, one will examine how any fluctuation in one part of the system can affect other components of the system, which, in turn, can affect the initial component. General systems theory thus suggests that a holistic view is necessary to fully understand all the dynamics involved in any situation (Von Bertalanffy, 1968).12

Behavioural approaches assume that family interactions serve to reinforce alcohol- and drug-using behaviour.

The goal of couple or family therapy from this perspective is to eliminate reinforcement for substance use and to promote behaviour that serves to reinforce abstinence.13

Acc to the behaviour approach the pattern of interaction in the family serves to reinforce the behaviour of the patient. So those behaviours that reinforce substance use are eliminated and behaviors that promote abstinence are promoted.13

The disease model of addiction is the dominant view held by the vast majority of treatment providers in the substance abuse treatment community.

It should be noted that the behaviourally oriented treatment approach broadly assumes a problems perspective, in which problem behaviours presented by couples seeking help are modified to promote sobriety.

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So all those behaviours that promote substance abuse and alcohol are modified to promote sobriety.14

Behaviour Couple Therapy15Behavioural couple therapy (BCT), was launched by the work of Stuart (1969, 1980) and Jacobson (Jacobson & Margolin, 1979; Jacobson & Martin, 1976)

Based on social exchange theory (Thibaut & Kelley, 1959), Stuart hypothesized that successful marriages could be distinguished from unsuccessful ones by the frequency and range of positive acts exchanged reciprocally by the partners.

16 As such, distressed relationships were characterized by a scarcity of positive outcomes available for each member, particularly in relation to the frequency of negative outcomes.

Social exchange theory predicted that individuals satisfaction with their relationships would be based on the ratio of benefits to costs received in the form of positive and negative behaviours from their partners.

Ratio of benefits to costs means how much efforts they put in the relationship and what they receive in return. 16

17The forerunner of the Behavioural Couple Therapy (BCT) approach to the treatment of alcoholism and drug abuse was a social learning theory approach to the treatment of marital distress.

Originally called Behavioural Marital Therapy (BMT). BMT originated in the late 1960s and early 1970s, and has continued to the present as one of very few empirically validated approaches for the treatment of couple distress.

BMT has featured a functional analysis of distressed and non-distressed couples antecedents and consequences of partners social exchanges (i.e., relationship rewarding and non-rewarding behaviours),

and their positive and negative communication and problem-solving behaviours.

These elements constitute the very foundation of BCT for substance abuse.

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Why use BCT?Substance use problems and family problems often coexist

These sets of problems are often interwined

Addressing both problems at the same time results in the best outcomes.

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Rationale for use of BCT

The relationship between substance use and couple dysfunction is complex and appears to constitute a type of reciprocal causality.

Compared to well- functioning dyads , couples in which one partner abuses drugs or alcohol usually have extensive relationship problems, often characterized by comparatively high levels of relationship dissatisfaction,

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instability (i.e., partners taking significant steps toward separation or divorce),

high prevalence and frequency of verbal and physical aggression (e.g., Fals Stewart, Birchler, & OFarrell, 1999),

significant sexual problems (OFarrell, Choquette, Cutter, & Birchler, 1997), and often

significant levels of psychological distress in both partners and other family members, such as children

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Sexual dysfunction and dissatisfaction are also common in alcoholic relation- ships. Male alcoholics and their partners have less sexual satisfaction, less frequent intercourse, and more disagreements about sex than nonconicted couples (OFar- rell, Choquette, & Birchler, 1991). In general, their sexual problems are similar to couples with other types of marital conict but impotence is a more common problem with alcoholic men (OFarrell, Choquette, Cutter, & Birchler, 1997). Noel, McCrady, Stout, and Nelson (1991) found that frequency of sexual relationships decreased as the severity of womens alcohol problems increased.21

Although chronic substance use is correlated with reduced marital satisfaction for both spouses,

relationship dysfunction also is associated with increased problematic substance use and is related to relapse among alcoholics and drug abusers after treatment. ( OFarrell, & Pelcovitz, 1988)

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The relationship between substance use and marital problems is not unidirectional, with one consistently causing the other;

Rather, each can serve as a precursor to the other, creating a vicious cycle from which couples that include a partner who abuses drugs or alcohol often have difficulty escaping.

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There are several relationship-based antecedent conditions and reinforcing consequences of substance use.

Marital and family problems often serve as precursors to excessive drinking or drug use,

unfortunately, resulting family interactions can inadvertently facilitate continued drinking or drug use once these behaviours have developed.

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Eg relationship based antecedents may be argument with wife and reinforcing consequences could be wife taking care of the husband when he has a hangover.

2. (e.g., poor communication and problem solving, arguing, financial stressors)25

For example, substance abuse often provides more subtle adaptive consequences for the couple, such as facilitating the expression of emotion and affection (e.g., caretaking when a partner has a hangover).

Finally, even when recovery from the alcohol or drug problem has begun, marital and family conflicts can, and very often do, precipitate relapses.26

Factors influencing recovery, couple functioning, and/or relationship longevity

Alcohol and drug abuse are maintained by their consequences at the physiological, individual, and interpersonal levels ,

a number of risk factors seem to influence the prognosis for successful substance abuse treatment and relationship satisfaction outcomes.

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The probability of success for a given couple can be diminished ifthe partners alcohol or substance abuse is very severe and debilitating,

both partners are involved with substance abuse,

there is severe partner violence or chronic and highly conflicted couple interactions, or 28

4. there is in one or both partners the presence of psychiatric comorbidity, such as clinical levels of anxiety, depression, anti- social personality disorder, or psychosis.

Additional threats to maintaining sobriety include high- risk occupational or social contact situations.

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Interviews of alcoholic wives suggested that they very often drink-

to function within their marriages,

to be able to be more assertive,

to manage the sexual demands of their husbands

(Lammers et al.,1995)

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There is emerging evidence that BCT works about as well with both alcoholic and drug abusing women and their non-substance abusing male partners

as it does with alcoholic and drug- abusing men, in terms of maintaining sobriety and improving the couple relationship (Kelley et al., 2006)

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Practice of BCTStructure of the therapy process:BCT is not a suitable intervention for all substance- abusing individuals involved in intimate relationships.

Because BCT attempts to harness the influence of the dyadic system to promote abstinence, it is important that potential participants indicate some evidence of relationship commitment to be successful.

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And because BCT helps the couples to harness or develop their relationship better, and promotes abstinence, it is important that the couple shud also show some evidence of their relationship commitment to be successful.32

Thus, one general criterion is: the partners be married or cohabiting in a stable relationship for at least 1 year or

separated but attempting to reconcile.

accept at least temporary abstinence

both willing to work on the problem

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The reason for encouraging at least temporary abstinence in the course of the program is so that the user, and the couple, can experience a period of abstinence and better relationship functioning as a basis for considering future substance use.33

A second criterion, is that neither partner can have conditions, such as gross cognitive impairment or

psychosis, that would significantly interfere with learning new information, practicing skills, or completing assigned tasks.

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BCT is most effective with couples in which only one partner has a problem with drugs or alcohol.

The relationships of dyads in which both partners abuse drugs, sometimes referred to as dually addicted couples, are often not supportive of abstinence.

If substance use is a shared recreational activity of the partners, the relationship may serve to promote continued drinking or drug use, and may be antagonistic to its cessation. (OFarrell et al., 1999)

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BCT is most effective with couples in which only one partner has a problem with drugs or alcohol. The relation- ships of dyads in which both partners abuse drugs, sometimes referred to as dually addicted couples, are often not supportive of abstinence; in fact, if substance use is a shared recreational activity of the partners, the relationship may serve to promote continued drinking or drug use, and may be antagonistic to its cessation (e.g., Fals- Stewart, Birchler, & OFarrell, 1999).35

36Children are not included in conjoint sessions; however, BCT has been offered in formats that include parent training elements of intervention.

This pilot study examined preliminary effects of Parent Skills Training with Behavioural Couples Therapy on children's behavioural functioning. Participants were men (N=30) entering outpatient alcohol treatment, their female partners, and a custodial child between 8 and 12 years of age. Couples were randomly assigned to one of three equally intensive conditions: (a) Parent Skills with Behavioural Couples Therapy (PSBCT), (b) BCT (without parent training), and (c) Individual-Based Treatment (IBT; without couples-based or parent skills interventions). Parents completed measures of child externalizing and internalizing behaviours at pretreatment,posttreatment, 6- and 12-month follow up; children completed self-reports of internalizing symptoms at each assessment. Only PSBCT participants reported significant effects on all child measures throughout the 12-month follow up. PSBCT showed medium to large effects in child functioning relative to IBT, and small to medium effects relative to BCT from baseline through follow up. Effect sizes suggest clinically meaningful differences between PSBCT and both BCT and IBT that warrant further empirical evaluation of BCT with parent training for alcohol abusing men and their partners

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37Pilot study examined preliminary effects of Parent Skills Training with Behavioural Couples Therapy on children's behavioural functioning.

Couples were randomly assigned to one of three equally intensive conditions: (a) Parent Skills with Behavioural Couples Therapy (PSBCT),(b) BCT (without parent training), and(c) Individual-Based Treatment (IBT; without couples-based or parent skills interventions).

38PSBCT showed medium to large effects in child functioning relative to IBT, and small to medium effects relative to BCT from baseline through follow up. (Lam et al., 2008)

39The substance abusing patient and the spouse, are seen together in BCT, typically for 12-20 weekly outpatient couple sessions over a 3-6 month period.

BCT can be an adjunct to individual counselling or it can be the only substance abuse counselling the patient receives.

Individual conjoint sessions usually last 5060 minutes; group sessions range from 60 to 90 minutes in length.

Generally, within the organized substance abuse treatment programs the number of sessions is manualised and therefore time- limited.

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Purpose of BCTTo build support for abstinence

To improve relationship functioning among married or cohabiting individuals seeking help for alcoholism or drug abuse.

BCT works directly to increase relationship factors conducive to abstinence.

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Assessments The best practice assessment methods include :Clinical interviewing with partners, together and separately;

Paper-and-pencil assessment measures pertaining to substance abuse and relationship quality; and

Behavioural observation of the couples communication and problem- solving skills.

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Interview assessmenT of subsTanCe use The assessment of substance use involves inquiries about recent types, quantities, and frequencies of substances used, whether the extent of physical dependence on alcohol or other drugs requires detoxification, what led the couple to seek therapy at this time, outcomes of prior efforts to seek help, and goals of the substance abuser and the family member (e.g., reduction of substance use, tempo- rary or permanent abstinence). Along with alcohol and drug use severity, it is strongly recommended that assessment include an evaluation of problem areas likely influenced by substance use, including (1) medical problems, (2) legal entanglements, (3) financial difficulties, (4) psychological distress, and (5) social/family problems (McLellan et al., 1985). If helping couples with any of these issues falls within the professional skills and scope of the therapist and also fits within any time- limited as- pects of the particular BCT program, these prob- lems are addressed in BCT. Certain issues that af- fect the couple (e.g., legal difficulties, significant medical problems) also may require referral to the appropriate professionals for assistance.

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Questionnaires Drinking pattern questionnaire (DPQ) Zitter & McCrady, (1993)This is an inventory that both spouses complete to identify items that they believe may be associated with alcohol consumption, assigning a rank of importance to each set of items.Ten major areas are involved, including work,environment, financial factors, physiological states, interpersonal situations,

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44marital problems, relationship with parents, problems with children, emotional factors, and recent major life events

This inventory also focuses on major positive and negative consequences of alcohol consumption in order to pin point the reinforcing agents that can contribute to alcohol consumption and backslide.

Spouse Behaviour Questionnaire (SBQ); Orford et al., 1975)This questionnaire lists various behaviours that individuals might use to control or cope with alcohol consumption by a spouse.

There are separate forms given to spouses that relate to type and frequency of each non abusing spouses behaviour in the last 12 months.

These items, again, centre on specific behaviours that nonabusing spouses may engage in that trigger or reinforce drinking, or contribute to relapse.45

The Coping Questionnaire (CQ) Originally designed for wives of men with drinking problems.

68-item Coping Questionnaire

Each taking the form of a statement, in the past tense, about a way of coping.

Each is followed by four response options: no; once or twice; sometimes; often (subsequently coded as 0,1,2,3, respectively, with not applicable also coded as 0)(Orford et al., 1975)46

Process of Couple Therapy The initial BCT session involves assessing substance abuse and relationship functioning and gaining commitment to and starting BCT (OFarrell, 1993) Start first with substance-focused interventions that continue throughout BCT to promote abstinence.

When abstinence and attendance at BCT sessions have stabilized for a month or so, add relationship-focused interventions to increase positive activities and teach communication.47

Early in treatment, for most couples, emphasis is first placed on achieving and maintaining sobriety,

strengthening the relationship, and finally

a dedicated program for relapse prevention is developed.

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Then therapeutic efforts shift to..48

49 All components receive several sessions of work.

However, in some cases, the relative emphasis placed on these three areas or the sequence may be altered to meet special needs of a given couple.

Intervention Techniques (BCT) 50Substance focused interventions

Relationship focused interventions

Substance-Focused Interventions in BCTLimiting exposure and risky situations

Behavioural Recovery Contract: Daily Sobriety Contract

Alcohol/drug abuser states intention to stay abstinent that day

Spouse thanks alcohol/drug abuser for efforts to stay abstinent51

BCT sees the substance abusing patient with the spouse or live-in partner to arrange a daily sobriety contract in which the patient states his or her intent not to drink or use drugs and the spouse expresses support for the patients efforts to stay abstinent.

For patients taking a recovery-related medication (e.g., disulfiram, naltrexone), daily medication ingestion witnessed and verbally reinforced by the spouse also is part of the contract. Self-help meetings and drug urine screens are part of the contract for most patients. BCT also increases positive activities and teaches communication skills.

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Attendance at self-help meetingWeekly drug urine screensCalendar to record progressSobriety Contract with a Recovery Medication

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Attendance at self help meeting:Accordingly, whenever possible, regular attendance at such meetings is recommended. We encourage that at least the substance abuser participate regularly, and that the partner attend appropriate meetings, if he or she so desires. As noted earlier, the attendance plan and performance records are usually a part of the Sobriety Contract established between partners engaged in BCT.

Weekly drug urine screens:Urine drug screens taken at each BCT session are included in BCT for all patients with a current drug problem. If the Sobriety Contract includes 12-step meetings or urine drug screens, these are also marked on the calendar and reviewed. The calendar provides an ongoing record ofprogress that you reward verbally at each session.

Sobriety contract with a recovery medication:A medication to aid recovery is often part of BCT. Medications include Naltrexone for heroin-addicted or alcoholic patients and Antabuse (disulfiram) for alcoholic patients. Antabuse is a drug that produces extreme nausea and sickness when the person taking it drinks. As such it is an option for drinkers with a goal of abstinence. Traditional Antabuse therapy often is not effective because the drinker stops taking it. The Antabuse Contract,also part of the Community Reinforcement Approach, significantly improves compliance in taking the medication and increases abstinence rates. In the Antabuse Contract, the drinker agrees to take Antabuse each day while the spouse observes. The spouse, in turn, agrees to positively reinforce the drinker for taking the Antabuse, to record the observation on a calendar you provide them, and not to mention past drinking or any fears about futuredrinking. Each spouse should view the agreement as a cooperative method for rebuilding lost trust and not as a coercive checking-up operation. Before negotiating such a contract, make sure that the drinker is willing and medically cleared to take Antabuse and that both the drinker and spouse have been fully informed and educated about the effects of the drug. This is done by the prescribing physician but double check their level of understanding about it.52

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Other support for abstinence Review substance use or urges to useDecrease exposure to alcohol and drugsAddress stressful life problemsDecrease behaviours that reward abuse 55

Reviewing urges to drink or use drugs#Helps identify substance use triggers#Resisting urges builds confidenceCrisis intervetion for substance use#Get substance use stopped quickly#Use as a learning experience

Other Support for AbstinenceReviewing urges to drink or use drugs experienced in the past week is part of each BCT session. This includes thoughts and temptations that are less intense than an urge or a craving. Discussing situations, thoughts and feeling associated with urges helps identify potential triggers or cues for alcoholor drug use. It can help alert you to the possible risk of a relapse. It also identifies successful coping strategies (e.g., distraction, calling a sponsor)the patient used to resist an urge and builds confidence for the future.Crisis interventionCrisis intervention for substance use is an important part of BCT. Drinking or drug use episodes occur duringBCT as with any other treatment. BCT works best if you intervene before the substance use goes on for too long a period. In an early BCT session, negotiate an agreement that either member of the couple should call you if substance use occurs or if they fear it isimminent. Once substance use has occurred, try to get it stopped and to see the couple as soon as possible to use the relapse as a learning experience. At the couple session, you must be extremely active in defusing hostile or depressive reactions to the substance use.Stress that drinking or drug use does not constitute total failure, that inconsistent progress is the rule rather than the exception. Help the couple decide what they need to do to feel sure that the substance use is over and will not continue in the coming week (e.g., restarting recovery medication, going to AA and Al-Anon together, reinstituting a daily Sobriety Contract, entering a detoxification unit). Finally, try to help the couple identify what trigger led up to the relapse and generate alternative solutions other than substance use for similar future situations.55

Relationship-focused interventionsAdjustments To recovery: Once the Sobriety Contract is going smoothly, the substance abuser has been abstinent and the couple has been keeping scheduled appointments for a month or so, you can start to focus on improving couple and family relationships.

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57Relationship promises during Treatment:Attend Therapy Sessions and Do Homework as Assigned.

No Threats of Divorce or Separation.

Focus on the Present, Not the Past or the Future.

No Angry Touching.

Two major goals of interventions focused on the drinker's couple/family relationship are:

(a) to increase positive feeling, goodwill, and commitment to the relationship;

(b) to teach communication skills to resolve conflicts, problems, and desires for change. 58

59 The general sequence in teaching couples and families skills to increase positive activities and improve communication is :therapist instruction and modelling,

the couple practicing under your supervision,

assignment for homework, and

review of homework with further practice.

Increasing positive activitiesCatch you partner in doing something nice

Caring day

Planning shared rewarding activity60

Catch Your Partner Doing Something NiceTell the couple that caring behaviours are "behaviours showing that you care for the other person," and assign homework called "Catch Your Partner Doing Something Nice" to assist couples in noticing daily caring behaviours. 61

This requires each spouse to record one caring behaviour performed by the partner each day on sheets you provide them.

The couple reads the caring behaviours recorded during the previous week at the subsequent session.

Then the therapist models acknowledging caring behaviours.

Eg. "I liked it when you.... It made me feel ....",

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emphasizing the importance of:

eye contact;

a smile;

a sincere, pleasant tone of voice, and

only positive feelings.

Each spouse then practices acknowledging caring behaviours from his or her daily list for the previous week

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Homework is assigned for a 5-minute daily communication session at home, in which each partner acknowledges one pleasing behaviour he or she noticed that day. 65

After the partners practice the new behavior in the therapy session, 65

Caring DayA final assignment is that each partner give the other a "Caring Day during the coming week by performing special acts to show caring for the spouse.

Encourage each partner to take risks and to act lovingly toward the spouse rather than wait for the other to make the first move.66

Finally, remind spouses that at the start of therapy they agreed to act differently (e.g., more lovingly) and then assess changes in feelings, rather than wait to feel more positively toward their partner before instituting changes in their own behaviour.

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Planning Shared Rewarding ActivitiesMany substance abusers' families stop shared recreational and leisure activities due to strained relationships and embarrassing substance-related incidents.

Reversing this trend is important because participation by the couple and family in social and recreational activities improves substance abuse treatment outcomes. (Moos, Finney & Cronkite, 1990)68

Planning and engaging in shared rewarding activities can be started by simply having each spouse make a separate list of possible activities.

Each activity must involve both spouses, either by themselves or with their children or other adults and can be at or away from home.

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Before giving the couple homework of planning a shared activity, model planning an activity to illustrate solutions to common pitfalls.

Finally, instruct the couple to refrain from discussing problems or conflicts during their planned activity70

(e.g., waiting until the last minute so that necessary preparations cannot be made, getting sidetracked on trivial practical arrangements)Eg: the couple has to go and buy vegetables and something happens or husband has to go out immidiately.. Ie if some practical difficulty arises in between how to manage is modelled by the therapist.

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Communication skill trainingInadequate communication is a major problem for substance abusers and their spouses. (OFarrell & Birchler, 1987)

Inability to resolve conflicts and problems can cause abusive drinking or drugging and severe marital/family tension to recur. (Maisto, McKay, & OFarrell, 1995)71

Communication skills deficits is also a major prob in these couples. There are difficulties in expressive and receptive communication skills.Expressive skills include the speaker identifying his or her thoughts feelings and emtions, and then expressing them in the first person that i using i in a specific and clear manner.

Receptive skills include non verbal listening and attending, empathizing, paraphrasing and other epressions of good listening and understanding. 71

Definition:Effective communication as "message intended (by speaker) equals message received (by listener)." .

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The message should be clear and direct.73

Expressive and receptive skills are also called the building blocks for the problem solving.

Learning basic communication skills of listening and speaking are prerequisites for problem solving and negotiating desired behaviour changes.

This training begins with non problem areas that are positive or neutral and moves to problem areas and emotionally charged issues only after the couple has mastered basic skills. 74

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Communication sessions are planned, structured discussions in which spouses talk privately,

face-to-face,

without distractions, and

take turns expressing their points of view, without interrupting one another.

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So when one spouse is speaking the other spouse will not ask questions and interrupt rather will listen first. 75

76Communication sessions can be introduced for 5 minutes daily when couples first practice acknowledgment of caring behaviours andin 10- to 15-minute sessions three to four times a week in later sessions, when the partners discuss current relationship concerns.

Partners are encouraged to ask each other for a communication session when they want to discuss a problem, keep- ing in mind the behavioral ground rules that characterize such sessions.76

Listening skills:help each spouse to feel understood and supported, and

slow down couple interactions to prevent the quick escalation of aversive exchanges.

Spouses are instructed to repeat both the words and the feelings of the speakers message and

to check to see whether the message received was the message intended by the partner (What I heard you say was..... Is that right?).

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So having a better listening skill helps the couples to avoid or prevent arguments.77

When the listener has understood the speakers message, they change roles, and the first listener then speaks.78

Speaking skills:

Expressing both positive and negative feelings directly are alternatives to the blaming, hostile, and indirect responsibility- avoiding communication behaviours that characterize many substance abusers relationships.

Speakers express and take responsibility for their own feelings and do not blame the other person for how he or she feels.79

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80This reduces listener defensiveness and makes it easier for the listener to receive the intended message.

The use of statements beginning with I rather than you is emphasized.

Developing Drinker Coping SkillsFunctional analysis is central to ABCT. The functional analysis provides a framework for the therapist and couple to identify situations that place the client at high risk for drinking, understand cognitive and affective responses to high-risk situations, and recognize the positive and negative consequences that ensue. The therapist systematically helps the client learn to modify high-risk situations, use different cognitive and behavioral strategies to cope, learn new ways to obtain similar positive reinforcers through means other than drinking, and learn how to anticipate negative consequences of drinking in high-risk situations. Coping skills include: self-recording of drinking and drinking urges to identify high-risk situations, completing behavior chains for specic high-risk situations, self-management planning, and cognitive and behavioral skills to manage high risk situations.Developing Partner Coping SkillsPartnerbehaviorsareconsideredateachstepinthefunctionalanalysisandspecicinterventions focusonpartnercoping.Thetherapisthelpsthepartneridentifyactionsthatmayserveastriggers for drinking. These may include behaviors intended to inuence the drinker to change (such as nagging), attempts to control the drinking or the drinkers behavior (such as restricting access to money), or the partners own drinking. The therapist works with the couple to help the partner develop alternative behaviors that are less likely to serve as cues for drinking. The therapist also helps the partner learn to provide positive reinforcement for positive behavior changes related to drinking, decrease reinforcers for drinking, and allow negative consequences to occur should the drinker drink.80

After presenting the rationale and instructions, the therapist models correct and incorrect ways of expressing feelings and elicits the partners reactions.

They then role-play a communication session in which they take turns being speaker and listener, with the speaker expressing feelings directly and the listener using the listening response.

Similar homework communication sessions that last 10 to 15 minutes each are assigned three to four times weekly. 81

For eg .The therapist models negative non verbal listening. That is while the speaker is speaking the therapist doesnt pay attention by looking here and there. Each spouse is then asked how they felt and what thoughts they had while they were talking and not being attended to.Then therapist makes the couple practice positive non verbal listening behaviours and ask each spouse how they felt when they were attended to or listened to while they were speaking.Like wise the therapist also models the negative verbal receptive skills eg. Interrupting, finishing sentences in between, cross complaining ect. 81

Partners are also helped to gain the ability to appreciate each others experience and point of view.82

83A study evaluated the effects of alcohol-focused spouse involvement and behavioural couple therapy (BCT) on couple communication in the context of group drinking reduction treatment for male problem drinkers.

The beneficial effect of spouse involvement on negative couple communication was partially mediated by a reduction in the frequency of clients' heavy drinking during treatment.

BCT reduced couples' negative communication and increased problem-solving communication(Walitzer et al.,2013)

That means reduction in the negative couple communication was not only bcz of spouse involvement but also mediated by a reduction in the frequency of clients heavy drinking during the treatment.

Partners frequency of drinking played an important role in the effects of spouse involvement in reducing negavtive couple communication.Sixty-four male clients and their female partners were randomly assigned to one of three conditions: (i) treatment for problem drinkers only (PDO), (ii) couple alcohol-focused treatment or (iii) couple alcohol-focused treatment combined with BCT. Couples whose partners participated in the treatment made fewer negative statements during a couple conflict communication task following treatment than PDO couples.McCradys alcohol behavioral couple therapy (ABCT) program uses a method called alcohol-focused spouse involvement (McCrady & Epstein, 2008; Noel & McCrady, 1993). It involves teaching the spouse specic skills to deal with alcohol-related situations. The spouse is taught how to reinforce abstinence, decrease behaviors that trigger drinking, decrease behaviors that protect the alcoholic from naturally occurring adverse consequences of drinking, assertively discuss concerns about drinking-related situations, and respond to help the drinker in drink refusal situations. 83

Problem solving skills In solving a problem, the couple should first define the problem and list a number of possible solutions.

Each solution is evaluated by four criteria:Is it absurd?

Would this solution help to solve the problem?

What are the pros for the solutions?

What are the cons for the solutions?

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That is they should brain storm and generate a list of potential solutions to the prob.84

85 Finally, the spouses rank the solutions from most- to least- preferred and agree to implement one or more of the solutions.

It avoids the Yes, but . . . trap, with one partner pointing out problems with the others solution

The ultimate agreement is likely to be the most helpful solution on the list that have fewest negative consequences. 85

Relapse PreventionThree methods are employed in BCT to ensure long-term maintenance of the changes in alcohol or drug abuse problems.Plans for maintenance occur before the termination of the active treatment phase.

Second, the therapist helps the couple anticipate high-risk situations for relapse to abusive drinking or drugging that may occur after treatment.

Discussion includes how to cope with a lapse or potential relapse, if and when it occurs.86

This involves helping the couple complete a Continuing Recovery Plan that specifies which of the behaviors from the previous BCT sessions they wish to continue in a planned activity program (daily sobriety trust discussion, a Sobriety contract , medications AA/NA meetings, SRAs, planned couple communication sessions, etc.) Possible coping strategies are discussed and rehearsed that the substance abuser, partner, and other family members can employ to prevent relapse when confronted with such situations A specific relapse episode plan, written and rehearsed prior to ending active treatment, can be particularly useful. Early intervention at the beginning of a lapse or relapse episode is essential, and the couple must be impressed with this point.

Couples Relapse Prevention Sessions after Behavioral Marital Therapy for Male Alcoholics: Outcomes during the Three Years after Starting TreatmentTimothy J. O'Farrell, Keith A. Choquette, Henry S.G. Cutter

Volume 59, 1998>Issue 4: July 1998Objective:This article provides a complete report of outcome data from a study of behavioral marital therapy (BMT) with and without additional couples relapse prevention (RP) sessions. (See J. Stud. Alcohol 54: 652-666, 1993, for an earlier partial report.)Method:Fifty-nine couples with an alcoholic husband, after receiving weekly BMT couples sessions for 5-6 months, were assigned randomly to get or not get 15 additional couples relapse prevention (RP) sessions over the next 12 months. Outcome measures were collected before and after BMT and at quarterly intervals for the 30 months after BMT.Results:BMT-plus-RP produced more days abstinent and greater use of the Antabuse Contract than BMT-only; and these superior drinking outcomes for BMT-plus-RP lasted through 18-month follow-up (i.e., 6 months after the end of RP). BMT-plus-RP had better wives' marital adjustment than BMT-only throughout the 30 months of follow-up, with the superiority of BMT-plus-RP over BMT-only being greatest for wives with poorer pretreatment marital adjustment during the later months of follow-up. BMT-plus-RP also maintained their improved marriages longer (through 24-month follow-up) than BMT-only (through 12-month follow-up). Irrespective of treatment condition, more use of BMT-targeted marital behaviors (e.g., shared recreational activities, constructive communication) was associated with better marital and drinking outcomes throughout the 30-month follow-up period whereas more use of the Antabuse contract was associated with better marital and drinking outcomes through 12-month follow-up. Alcoholics with more severe marital problems had more abstinent days and maintained relatively stable levels of abstinence if they received BMT-plus-RP, while their counterparts who received BMT-only had fewer abstinent days and showed a steep decline in abstinent days during the 30 months of follow-up. Furthermore, alcoholics with more severe alcohol problems used the Antabuse contract more and showed a less steep decline in use of the Antabuse contract in the 30 months of follow-up if they received BMT-plus-RP than if they received BMT-only.Conclusions:For the entire sample, BMT-plus-RP produced better marital outcomes throughout the 30 months of follow-up and better drinking outcomes during and for the 6 months following RP sessions, relative to BMT-only outcomes. For alcoholics with more severe marital and drinking problems, BMT-plus-RP produced better drinking outcomes than BMT-only throughout the 30-month follow-up period. (J. Stud. Alcohol 59: 357-370, 1998)

86

87In a studt, results revealed BMT-plus-RP produced more days abstinent and greater use of the Antabuse Contract than BMT-only; and these superior drinking outcomes for BMT-plus-RP lasted through 18-month follow-up (i.e., 6 months after the end of RP).

BMT-plus-RP had better wives' marital adjustment than BMT-only throughout the 30 months of follow-up, with the superiority of BMT-plus-RP over BMT-only being greatest for wives with poorer pre-treatment marital adjustment during the later months of follow-up.

88BMT-plus-RP also maintained their improved marriages longer (through 24-month follow-up) than BMT-only (through 12-month follow-up). (O'Farrell et al., 1998)

89In another study married or cohabiting female alcoholic patients (n = 138) and their non-substance-abusing male partners were randomly assigned to 1 of 3 (BCT, IBT, PACT) equally intensive interventions:

During treatment, participants in BCT showed significantly greater improvement in dyadic adjustment than those in IBT or PACT; drinking frequency was not significantly different among participants in the different conditions.

(a) behavioral couples therapy plus individual-based treatment (BCT; n = 46), (b) individual-based treatment only (IBT; n = 46), or (c) psychoeducational attention control treatment (PACT; n = 46). , compared with participants who received IBT or PACTThe Importance of Psychoeducation in Systemic Family Therapy Alcoholic Treatment ABSTRACT The main goal of the paper was to analyze the impact of psychoeducation in alcoholism therapy treatment on initial motivation and comprehension, change in attitudes to alcoholism, and beginning of creating a new value system. The sample consisted of 166 respondents (83 married couples) that had been involved in one-year systemic group family therapy alcoholic treatment (with the man being alcoholic). A questionnaire on knowledge about alcoholism was used. The respondents were tested three times at the beginning of the treatment, after 6 months, and after one year. The results showed that the level of education had increased through three phases of the treatment, that motivation changed from initial to substantial, that the comprehension had also changed, turning family system into a more functional model of living. Statistically significant difference in level of education between phase 1 and phase 3 of the family therapy was confirmed. In conclusion, the authors argue for the importance of psychoeducation as a method in treating alcoholism. 89

90During the 1-year post-treatment follow-up, participants who received BCT reported :

fewer days of drinking, fewer drinking-related negative consequences, higher dyadic adjustment, and reduced partner violence. (Stewart et al., 2006)

91Multiple studies have consistently found married or cohabiting substance-abusing patients who engage in BCT, compared to traditional individual-based counselling or partner-involved attention control treatments, report significantly greater:

(1) Reductions in substance use, (2) levels of relationship satisfaction, and (3) greater improvements in other areas of relationship and family adjustment(Kelly et al., 2009)

Among the various types of partner- and family-involved interventions used to treat adults with substance use disorders, Behavioural Couples Therapy (BCT) has garnered the strongest empirical support for its efficacy. In addition to discussing the theoretical rationale for BCT as a treatment of substance abuse, this article describes specific therapeutic techniques used as part of this intervention and summarizes the relevant evaluative empirical literature.

(e.g. reductions in partner violence, improvements in custodial children's adjustment). 91

CBT- BCT92Behavioural Couples Therapy (BCT) for alcohol dependence, studied as an adjunct to individual outpatient counselling, has shown to be effective in decreasing alcohol consumption and enhancing marital functioning, but

no study has directly tested the comparative effectiveness of stand-alone BCT versus an individually focused cognitive-behavioural therapy (CBT) in a clinical community sample.

Background:Alcohol abuse serves as a chronic stressor between partners and has a deleterious effect on relationship functioning. 92

93Stand-alone BCT is as effective as CBT in terms of reduced drinking and to some extent more effective in terms of enhancing relationship satisfaction.

However, BCT is a more costly intervention, given that treatment sessions lasted almost twice as long as individual CBT sessions.(Ellen et al., 2008)

The present study is a randomized clinical trial evaluating the effectiveness of stand-alone BCT (n = 30) compared to individual CBT (n = 34) in the treatment of alcohol use disorders in community treatment centers in Dutch male and female alcoholics and their partners.Results:Results show both BCT and CBT to be effective in changing drinking behavior after treatment. BCT was not found to be superior to CBT. Marital satisfaction of the spouse increased significantly in the BCT condition but not in the CBT condition, the differences being significant at the post-test. Patients self-efficacy to withstand alcohol-related high-risk situations increased significantly in both treatment conditions, but more so in CBT than in BCT after treatment. Treatment involvement of the spouse did not increase retention.Conclusion:Regular practitioners in community treatment centers can effectively deliver both treatments. Stand-alone BCT is as effective as CBT in terms of reduced drinking and to some extent more effective in terms of enhancing relationship satisfaction. However, BCT is a more costly intervention, given that treatment sessions lasted almost twice as long as individual CBT sessions.(Ellen et al., 2008)

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Limitations94Although most BCT studies have found that participation in BCT results in improvements in relationship adjustment and reductions in substance use,

none has conducted a formal test of mediation to determine whether changes in relationship adjustment (i.e., either during treatment or after treatment completion) partially or fully mediate the relationship between type of treatment received (e.g., BCT, individual counselling, and attention control) and substance use outcomes.

That means whether relationship adjustment has improved because of BCT directly or reduction in alcohol/ substance use has improved it.94

95Although BCT has very strong research support for its efficacy, it is not yet widely used in community-based alcoholism and drug abuse treatment settings.

BCT was viewed as too costly to deliver, requiring too many sessions in its standard form.

Conclusion96Understanding of how partner interaction influences substance use and abuse has evolved, treatment providers and researchers alike have placed increased emphasis on conceptualizing drinking and drug use from a systemic perspective and, in turn, on treating the couple to address partners substance abuse.

BCT has been demonstrated to enhance the ability of partners to achieve and maintain sobriety by improving their primary relationship.

96

97BCT have also found to be efficacious than other therapies (IBT) in reducing partners violence and higher dyadic adjustment.

BCT plus relapse prevention has proven to be more effective in producing better marital outcomes than BCT alone.

97

ReferencesFarrell, O. T. J., & Stewart, F. W. (2006) Behavioral couples therapy for alcoholism and drug abuse. Guilford Press: New York.Farrell, T. J. O., & Schein, . Z. (2000) Behavioral couples therapy for alcoholism and drug abuse. Journal of Substance Abuse Treatment, 18, 51-54. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215582/#R24Gurman, A. S.(2008). Clinical Handbook of Couple Therapy Guilford Press: New York.

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99Kaur, R & Gulati, J.K. (2005). International Marketing Conference on Marketing & Society, 8-10 April 2007; India. Punjab: India Institute of Management Kozhikode. Lam, W. K., Stewart, W. F., & Kelley, M. L. (2008). Effects of parent skills training with behavioral couples therapy for alcoholism on children: a randomized clinical pilot trial. Journal of Addictive Behaviors, 33, 10761080.Nadeem, A., Rubeena, B., Piyush, K., & Agarwal, V.K. (2009).Substance abuse in india. Journal of Pravara Medical Review, 1, 1-6.

100Orford, J., Natera, G., Davies, J., Nava, A., Mora, J. A. N., Rigby, K., Bradbury, C., Bowie, N., Copello, A., & Velleman, R. (1988). Tolerate, engage or withdraw: a study of the structure of families coping with alcohol and drug problems in south west england and mexico city. Journal of Addiction, 93, 1799-1813. O'Farrell, T. J., Choquette, K. A., & Cutter, H. S. G. (1998). Couples Relapse Prevention Sessions after Behavioral Marital Therapy for Male Alcoholics: Outcomes during the Three Years after Starting Treatment. Journal on studies of Alcohol and Drugs, 59, 357-370.

Ray, R. & Chopra, A.(2012) Monitoring of Substance abuse in india initiating & experiences. Indian Journal of Medical Research, 135, 806-808.

101Walitzer, K., Dermen, K., Shyhalla., K & Kubiak, A.(2013). Couple communication among problemdrinking males and their spouses: a randomized controlledtrial. Journal of Family Therapy,35, 22-251