1. BEHAVIORAL COUPLES THERAPY FOR SUBSTANCE USE DISORDERS Resources: O'Farrell, T. (1993). Treating alcohol problems: Marital and family interventions. New York: Guilford. Ruff SRuff 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.McComb JLCoker CJSprenkle DH 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.  Background & Introduction  Substance-Focused Methods  Relationship-Focused Methods  Relapse Prevention Behavioral Couples Therapy for Alcoholism and Drug Abuse

5.  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.  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

7.  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

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 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

11. 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

12. Building Support for Abstinence Substance-Focused Methods

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

18. 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

19. Increasing Positive Activities Relationship-Focused Methods

20. Increasing Positive Activities  Catch Your Partner Doing Something Nice  Caring Day Assignment  Shared Rewarding Activities

22. 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

23. Teaching Communication Skills Relationship-Focused Methods

25. Teaching Communication Skills  Listening Skills  Expressing Feelings Directly  Communication Sessions  Negotiating for Requests

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

27. 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

28. 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/friends90% - gave client money to buy alcohol or drugs71% - purchased alcohol or drugs for client55%

29. 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?

30. 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

31. 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