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Depression, anxiety, poor health and diminished self-esteem are among the myriad problems that loved ones experience as a result of a substance abuser's erratic and destructive behavior.

Mindful of this domino effect, psychologists began to build treatment models upon the principle that recovery is rarely sought or carried out alone. Among the approaches that have emerged is Behavioral Couples Therapy (BCT)--a team effort based upon cohesive, communicative relationships. BCT aims to rebuild and strengthen relationships on the premise that positive feelings, shared activities and constructive communication are conducive to sobriety.

Timothy O'Farrell, PhD, of Harvard Medical School and the VA Boston Healthcare System, in collaboration with William Fals-Stewart, PhD, of the Research Institute on Addictions in Buffalo, N.Y., has tested this theory for more than 20 years with substance abusers at the Harvard Families and Addiction Program. BCT works directly, he says, to increase relationship factors conducive to abstinence.

"A behavioral approach assumes that family members can reward abstinence and that substance abusers in happier, more cohesive relationships with better communication have a lower risk of relapse," he explains.

BCT is no panacea, O'Farrell cautions. "But relative to individual-based treatments, you get better substance abuse outcomes, better relationships and better long-term abstinence rates"--statistics that include lower divorce and separation rates in the two years after treatment and reduced anxiety and depression among children of the couples treated in BCT.

The tenets of BCT therapy

The typical BCT model entails about 20 sessions over five to six months, often followed by periodic maintenance sessions called Couples Relapse Prevention. O'Farrell concedes that briefer treatments would be more economical, but saving money is "a double-edged sword," he says. "While most patients show a similar pattern of positive outcomes after a shorter amount of time, more severe patients end up with relapses, and this is a false economy."

Each session is relatively structured, with the therapist setting the agenda at the outset of each meeting, explains O'Farrell. A typical session begins with an inquiry about any drinking or drug use or urges that have occurred since the last session. The therapist will also ask about compliance with the daily sobriety contract, in which the patient states his or her intention not to drink or use drugs that day (in the tradition of one day at a time) and the spouse expresses support for the patient's efforts to stay abstinent. Couples will then review any events from the week and report on "homework assignments," such as "Catch Your Partner Doing Something Nice Day," which are designed to create a home atmosphere of mutual support and caring. Then, the therapist identifies a specific concern from the past week related to recovery or relationships, with the goal of identifying steps that can be taken toward a solution.

The first few sessions are perhaps the most important, believes O'Farrell, because they "focus on decreasing negative feelings and interactions related to past or possible future substance abuse and on increasing positive exchanges," he says. "This decreases tension about substance use and builds good will--necessary ingredients for dealing with marital and family problems and desired relationship changes in later sessions."

Research to date

Studies over the past 20 years by O'Farrell and Fals-Stewart, and pioneering work by Barbara McCrady, PhD, of Rutgers University and Nathan Azrin, PhD, of Nova University, have produced data that bode well for BCT's future as a treatment for substance abuse.

In the first randomized study of BCT with drug abusers, for example, Fals-Stewart and O'Farrell assigned 80 married or cohabiting male patients, most of whom were cocaine or heroin users, to either BCT plus individual treatment or to individual treatment alone. After 56 therapy sessions over a six-month period, 12 of which were held with the female partner for BCT patients, the clinical outcomes for both drug use and relationship patterns favored BCT.

During the follow-up year, significantly fewer BCT patients relapsed. There were more cases of abstinence, fewer drug-related incidents such as arrests and hospitalizations, and fewer relationship conflicts and separations.

BCT reaps benefits not only for the substance abuser, but also brightens prospects for sober family members and friends. O'Farrell's work shows that alongside other treatment models, BCT demonstrates more reductions in domestic violence and family breakups. In addition, his data has interesting implications about the relationship between bad marriages and substance abuse. His before-and-after BCT comparisons of couples confirm that substance abuse problems make relationships worse, and that conversely "other aspects of life and other problems get better as one recovers and is no longer using substances," he says.

But perhaps O'Farrell's most salient findings--in light of the fact that a large percentage of all people in domestically violent situations are involved with some form of substance abuse-- is that domestic violence is substantially reduced after Behavioral Couples Therapy.

"In a study of BCT and domestic violence," he explains, "I found a great reduction in male to female partner violence." Before engaging in BCT, 65 percent of the alcoholics in O'Farrell's study exhibited violence. After treatment, he says, "for patients who stop drinking, the rate goes down to the national norm of 1 in 6 or lower."

The main outcomes of this study are important for families, O'Farrell notes, because both the substance abusers and relationships themselves improve. "Couples are not just staying together," he notes, "but are happier being together than if they underwent individual treatment."

In addition, he surmises that BCT reduces children's risk for subsequent mental health and substance abuse problems. He also plans to further study how to break cycles of substance abuse through greater familial involvement and communication.

When help is refused

Although many substance abusers enter programs like BCT of their own accord, others report that they would not have pursued treatment without the encouragement of concerned significant others. Community Reinforcement and Family Training (CRAFT) takes O'Farrell's therapy model one step further. CRAFT is built upon the analogous tenet that loved ones play a powerful role in effecting behavioral change, and fills a historical void of options for those who want to help resistant substance-abusers by training them in behavioral techniques.

A leader in CRAFT research is Robert Meyers, PhD, of the University of New Mexico. He was prompted to pursue what he calls an "enhanced version of reinforcement training" after participating in studies that showed that couples' therapy helped alcoholics reduce their alcohol consumption by more than half when only the concerned significant other was in treatment. This apparent benefit of therapy for partners "supports an at-home influence on drinking behavior," Meyers explains.

In his studies comparing CRAFT with models such as Al-Anon's 12-steps, the majority of loved ones displayed an improved outlook after entering therapy, but only the CRAFT group members were substantially more successful in convincing their substance abusing partners to get treatment, says Meyers.

Also, notes Meyers, "the patients who entered treatment had significantly higher abstinence rates at three and six months than those who did not enter treatment."

Closing the research and practice gap

Despite data from O'Farrell, Meyers and the National Institute on Alcohol Abuse and Alcoholism, BCT and CRAFT are not yet used widely by substance abuse practitioners and hospitals, which often rely only on individual treatment.

"Clearly more needs to be done to close the gap between research and practice," says O'Farrell. "Much of this research is recent and will take a while to catch on."

Now that a considerable number of studies are completed, O'Farrell says the next step is influencing the practice community with workshops and books. "There is not much out there now to show psychologists how to administer BCT," he notes.

He also plans to work with practitioners to find ways to make the BCT model fit into individually focused treatment programs. A compelling selling point for both practitioners and health insurers alike is the lower cost of BCT treatment when compared with individual therapy. In their studies, Fals-Stewart and O'Farrell found that social costs in the year before treatment--including health care, criminal justice fees and income from illegal sources and public assistance--averaged $11,000 per patient in both BCT and individual treatment groups. Yet a year after treatment, the BCT group had saved about $6,600 per case, as opposed to $1,900 per individual therapy patient.

BCT produces "a five times greater reduction in social cost than the cost of delivering the treatment because of its clinical effectiveness," he says. "Patients don't end up in front of a judge or in a hospital for treatment, because with BCT they simply abuse substances less."