Couples Therapy for Alcoholic Patients

Multiple studies indicate that participation in Behavioral Couples Therapy (BCT) is
associated with robust positive outcomes for alcoholic and drug-abusing patients, in terms
of reduced substance use and improved relationship functioning. Yet, community-based
treatment programs rarely offer BCT to incoming eligible patients. As reported by providers
and administrators in a national survey of treatment programs in the U.S., BCT was viewed as
prohibitively labor intensive, due in large measure to its standard conjoint
one-couple-at-a-time delivery format. Given the public policy climate that is now
emphasizing not only clinical effectiveness, but also economic accountability, an
intervention's efficiency (i.e., the ratio of effectiveness to program resources used to
provide the service) is a critical factor in decisions by treatment programs to adopt new
interventions. Although BCT has well-proven efficacy, the consensus of providers and
administrators is that BCT is not efficient.

To address these issues, we have studied couples group formats to deliver BCT. First, in
earlier work the PI developed a 10-week BCT group with a number of conjoint sessions added
before to prepare couples and afterwards to prevent relapse. While the outcomes were
favorable, the added conjoint sessions and the closed group that once begun did not add
additional members made it a hard sell for community agencies looking for briefer treatments
and typically running ongoing groups with new members added regularly. Second, to overcome
these problems, the PI and Co-PI developed a 10-session ongoing BCT group format that has
rotating content and rolling admissions in which couples join the group, complete 10
sessions, and "graduate". A major advantage of this ongoing group format for BCT is that it
fits with the way other types of groups generally are run in substance abuse programs. It
got favorable reviews in provider focus groups and showed promise in a pilot study.

The pilot study with married or cohabiting male drug-abusing patients examined the efficacy
of a multi-couple group therapy version of BCT (G-BCT) compared to standard conjoint BCT
(S-BCT), and individual-based treatment (group and individual counseling) for the patient
only. Results showed G-BCT yielded equivalent outcomes when compared to S-BCT, in terms of
reduction in substance use and improved relationship adjustment, but GBCT was less costly to
deliver and had superior cost-benefit and cost-effectiveness. Both G-BCT and S-BCT yielded
better clinical and cost-outcomes than individual-based treatment. Also, a small-scale
evaluation study indicated G-BCT was more likely to be used in community-based treatment
programs than S-BCT.

Thus, this proposed study will conduct a randomized clinical trial to examine the clinical
effectiveness, in terms of substance use, relationship functioning, and psychosocial
adjustment, of Group BCT (G-BCT) versus Standard BCT (S-BCT) for 160 alcoholic patients and
their nonsubtance-abusing partners. Given the likely differences in cost of treatment
delivery between the 2 interventions, we will also examine the comparative cost-benefit and
cost-effectiveness of the 2 intervention packages.

Inclusion Criteria:

(a) both members of the couple must be between 18 and 65 years of age; (b) patient must
meet Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric
Association, 1994) criteria for current (past 12 months) alcohol dependence and alcohol
must be the patient's primary substance of abuse as determined by a clinical algorithm
(Fals-Stewart, Stappenbeck et al, 2004); (c) be married to their current partner for at
least 1 year or be cohabiting in a stable common-law relationship for 2 years; (d) patient
agrees to a goal of abstinence from alcohol and drugs at least for the duration of the
12-week study-based treatment; (e) patient drank in past 60 days; (f) patient agrees to
forego other alcoholism counseling except for self-help meetings (e.g., AA) or treatment
required for a clinical emergency or clinical deterioration for the duration of the
12-week study-based treatment; (g) no more than 4 months living apart in past year; (h)
alcohol dependent patient and partner currently living with each other, i.e., not
separated or planning divorce; and (i) both alcohol dependent patient and the relationship
partner are willing to participate.

Exclusion Criteria:

a) partner meets DSM-IV criteria for a substance use disorder (other than nicotine) in the
last 12 months; (b) patient has dependence on alcohol or other drugs that requires
inpatient treatment or medical detoxification (as indicated by daily heavy use or use to
prevent or deal with withdrawal symptoms) - after patient has completed detoxification, he
or she may be eligible for the study; (c) patient or partner are at immediate risk for
suicide or homicide or either made a suicide attempt in past 30 days; and (d) patient or
partner meets DSM-IV criteria for a current organic mental disorder, schizophrenia,
delusional (paranoid) disorder, or any of the other psychotic disorders. The SCID-IV
(SCID; First, Spitzer, Gibbon, & Williams, 1995) will be used to screen out participants
with psychosis or thought disorder. Subjects with other disorders, however, will not be
excluded. Consistent with general AdCare Hospital services, the AdCare physician can
prescribe psychiatric medication (e.g., antidepressants) if necessary. Finally, we also
will exclude couples with a recent history (past 3 years) of severe partner violence on a
day when drinking or drug use did not occur or if either member of the couple expresses
fear that couples therapy may put him or her at risk of violence.