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BEHAVIORAL COUPLES THERAPY FOR SUBSTANCE USE DISORDERS Resources:

BEHAVIORAL COUPLES THERAPY FOR SUBSTANCE USE DISORDERS Resources: O'Farrell, T. (1993). Treating alcohol problems: Marital and family interventions. New York: Guilford.

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BEHAVIORAL COUPLES THERAPY FOR SUBSTANCE USE DISORDERS Resources:

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  1. 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 and substance abuse interventions. BCT review online at: http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=134

  2. FAMILY-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

  3. FAMILY-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

  4. Behavioral Couples Therapy for Alcoholism and Drug Abuse • Background & Introduction • Substance-Focused Methods • Relationship-Focused Methods • Relapse Prevention

  5. Behavioral Couples Therapy for Alcoholism and Drug Abuse • Purpose 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

  6. Studies of BCT for Alcoholism and Drug Abuse Show • 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

  7. Suitable Cases for BCT • 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

  8. 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

  9. 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

  10. STRUCTURE OF CALMCOUPLES 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

  11. PROCESS OF CALMCOUPLES 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

  12. Substance-Focused Methods Building Support for Abstinence

  13. BCT Sobriety Contract Helps the Couple • Reward abstinence • Reduce distrust and conflict • Refrain from punishing sobriety

  14. BCT Sobriety Contract Sobriety Trust Discussion • Alcohol/drug abuser states intention to stay abstinent that day • Spouse thanks alcohol/drug abuser for efforts to stay abstinent

  15. BCT Sobriety Contract • Daily Sobriety Trust Discussion • Medication (Antabuse, Naltrexone) to aid recovery • Self-help involvement • Weekly drug urine screens • Calendar to record progress

  16. Other Support for Abstinence • Reviewing urges to drink or use drugs • Helps identify cues for alcohol or drug use • Resisting urges builds confidence • Crisis intervention for substance use • Get substance use stopped ASAP • Use as a learning experience • Discuss exposure to substances, including alcohol at home

  17. Relationship-Focused Methods Increasing Positive Activities

  18. Increasing Positive Activities • Catch Your Partner Doing Something Nice • Caring Day Assignment • Shared Rewarding Activities

  19. Increasing Positive Activities Shared Rewarding Activities • Each 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

  20. Relationship-Focused Methods Teaching Communication Skills

  21. Teaching Communication Skills • Listening Skills • Expressing Feelings Directly • Communication Sessions • Negotiating for Requests

  22. Maintenance and Relapse Prevention • Continuing Recovery Plan Specifies activities to do to maintain abstinence and relationship recovery after weekly couple sessions end

  23. Maintenance and Relapse Prevention Relapse Prevention Plan • Identify 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

  24. RELATED CLINICAL ISSUES • Screening for Enabling • Working with partners to: focus on coping responses, eliminate enabling - drank / used drugs with, or in presence of, client 95% - lied or made excuses to family/friends 90% - gave client money to buy alcohol or drugs 71% - purchased alcohol or drugs for client 55%

  25. 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?

  26. 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

  27. 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

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