September/October 2001 Article 1 Article 2

Behavioral Couples Therapy for Male Methadone Maintenance Patients: Effects on Drug-Using Behavior and Relationship Adjustment William Fals-Stewart, Ph.D. Research Institute on Addictions, University at Buffalo, The State University of New York Timothy J. O’Farrell, Ph.D. Harvard Medical School and Veterans Affairs Medical Center, Brockton, Massachusetts Gary R. Birchler, Ph.D. Veterans Affairs Medical Center and University of California, San Diego School of Medicine Abstracted from Behavior Therapy, 32, 391-411, 2001. Studies with patients from both alcohol and drug outpatient treatment programs suggest that use of Behavioral Couples Therapy (BCT) -- in addition to traditional individual counseling -- results in reduced substance use and improved relationship satisfaction among participants. The purpose of the present study was to determine if BCT had similar positive effects with married or cohabiting methadone maintenance (MM) patients. This study was led by William Fals-Stewart, RIA research scientist and UB research associate professor of psychology. About Behavioral Couples Therapy Briefly, BCT involves providing counseling to both the alcohol or drug-involved individual and his or her partner. It differs from standard treatment in which most or all of the focus is directed toward the individual seeking assistance. BCT consists of a series of treatment components designed to equip couples with a variety of skills and techniques that they can use to increase cohesion and the positive aspects of their marriage, enhance communication, and develop conflict resolution skills. O’Farrell and Fals-Stewart (1999) suggest that BCT may serve to reduce substance use by (a) training the spouse in the use of simple communication patterns which promote and encourage their partner’s sobriety from illicit drugs and alcohol and (b) reducing stressors in the couple’s relationship that may serve as antecedents to drug or alcohol use (e.g., unresolved disagreements, hostile conflict). In BCT, both partners participate in a series of exercises designed to (1) increase positive interactions between the partners, (2) improve communication skills, and (3) teach and practice negotiation skills. Positive couple interactions are encouraged by techniques such as “caring behaviors” where couples are asked to notice and acknowledge caring behaviors performed by their partner as well as to engage in “caring days.” “Shared rewarding activities” involve the couple identifying a mutually agreed-upon, drug-free activity that both partners would enjoy. The shared rewarding activity is planned in session. The couple follows through with their plans between sessions and during the ensuing session, describes how the activity proceeded (i.e., whether it was satisfactory, whether there were any problems, and so forth). Communication skills training teaches couples how to discuss and practice listening and expressing feelings directly. Finally, negotiation skills training gives couples the opportunity to discuss and practice methods for obtaining desired changes from their spouses (e.g., making positive specific requests, negotiating, compromise, and making and troubleshooting agreements). The specific communication and negotiation skills are first modeled by the therapist in session, and then role-played repeatedly by the couple. Another major component to BCT is the “sobriety trust discussion” – a daily, brief discussion between the couple on the status of the male patient’s sobriety. During the trust discussion, the male partner commits to remaining sober for the next 24 hours and the female partner acknowledges her partner’s sobriety in a positive fashion. The purpose of the sobriety trust discussion, which continues daily throughout treatment, is to reward abstinence from drugs and alcohol and provide a constructive communication ritual as an alternative to couple conflict about past drug-related problems or feared future relapse. BCT and MM Patients The BCT approach used in the present investigation was compared to a standard individual-based methadone maintenance (IBMM) treatment. Each treatment lasted 16 weeks, with participants receiving methadone plus two individual counseling sessions per week, over the initial four weeks. In the fifth week, participants receiving the BCT approach started attending one of the two weekly sessions with their partner. By comparison, participants in the standard treatment continued receiving two individual counseling sessions weekly for the duration of treatment. In order to participate in this study, the heterosexual couples had to include an intravenous opiate-using male partner and to have been married for at least one year, or living with a significant other for at least two years. In addition, couples were excluded if the female partner had her own current substance abuse problem. Results Compared to those who received traditional IBMM counsel- ing, clients who received the BCT component had a greater reduction of illicit drug use during treatment. Specifically, there was less use of opiates and cocaine for clients participating in BCT compared to clients participating in the IBMM treatment. Those who received BCT also reported greater reductions in drug use severity and family and social problems from pre- treatment to end-of-treatment, relative to patients receiving IBMM treatment. Clients who received BCT reported increased levels of relationship satisfaction with their partner compared to those receiving the IBMM treatment (see Figure, below). Mean Marital Happiness Scale (MHS) scores for couples in the BCT and IBMM conditions during each week of the primary treatment phase. Figure reprinted from Fals-Stewart, W., O’Farrell, T.J., & Birchler, G.R. (2001). Behavioral couples therapy for male methadone maintenance patients: Effects on drug-using behavior and relationship adjustment. Behavior Therapy, 32, 405. Copyright (2001) by the Association for Advancement of Behavior Therapy. Reprinted by permission of the publisher. Implications The current findings suggest that in conjunction with individual counseling, BCT may benefit MM patients who are married or cohabiting with nonsubstance-abusing partners. These findings are consistent with research examining the use of BCT for couples in which the male partner is an alcohol or other drug abuser. BCT as an adjunct to standard MM treatment not only seeks to enhance skills that are likely to improve overall relationship quality (e.g., problem-solving, conflict resolution), but also incorporates components that directly address substance use behavior. Last Word This study had some important strengths, including random assignment to treatment conditions; use of well-validated and widely used measures; and consistent monitoring of changes in drug use behavior and relationship satisfaction during the primary treatment phase. However, certain limitations should be highlighted. Findings may have been different if the study sample had included couples in which only the female, or both the male and the female, had a drug abuse problem. There was no assessment beyond end-of-treatment. There- fore it is unknown whether these improvements would have maintained, accelerated, or reversed. Most previous research suggests that there is some backsliding immediately following couples’ treatment. Findings from this investigation are based on data from a fairly small sample of MM patients, but the results are promising. Given the relatively few investigations that have examined the effects of psychosocial services on MM treat- ment, the results supporting the efficacy of BCT observed in this initial investigation merit further study. References O’Farrell, T. J., & Fals-Stewart, W. (1999). Treatment models and methods - Family models. In B.S. McCrady & E.E. Epstein (Eds.), Addictions: A comprehensive guidebook for practitioners (pp. 287-305). New York: Oxford University Press. This research was supported in part by the Department of Veterans Affairs and grants from the National Institute on Drug Abuse (R01DA12189) and the National Institute on Alcohol Abuse and Alcoholism (R01AA10356 and K02AA00234). Mean Marital Happiness Scale (MHS) scores for couples in the BCT and IBMM conditions during each week of the primary treatment phase. Figure reprinted from Fals-Stewart, W., O’Farrell, T.J., & Birchler, G.R. (2001). Behavioral couples therapy for male methadone maintenance patients: Effects on drug-using behavior and relationship adjustment. Behavior Therapy, 32, 405. Copyright (2001) by the Association for Advancement of Behavior Therapy. Reprinted by permission of the publisher. Article 2

William R. Greiner, President

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