June/July 2002 Article 1 Article 2

Couples- Versus Individual-based Therapy for Alcohol and Drug Abuse: Effects on Children’s Psychosocial Functioning Michelle L. Kelley, Ph.D. Old Dominion University William Fals-Stewart, Ph.D. Research Institute on Addictions, University at Buffalo, The State University of New York Abstracted from Journal of Consulting and Clinical Psychology, 70, 417-427, 2002. In the present investigation, Behavioral Couples Therapy (BCT), compared to individual-based therapy for male substance abusers, resulted in greater reductions in substance use, greater marital satisfaction, and, perhaps of greatest interest, greater improvements in their children’s psychosocial functioning. This investigation is the first to systematically examine the effect of BCT on children living in the home with a substance-abusing parent. BCT is a couples-based treatment that promotes marital satisfaction and the development of communication and negotiation skills. BCT is aimed at rebuilding and strengthening a couple’s relationship by helping them to express positive feelings, share positive activities, and encourage abstinence from alcohol and drug use. In this study, 135 couples were randomly assigned to receive one of three treatments: BCT, individual-based treatment (IBT), or a couples-based psychoeducational attention control treatment (PACT). Participants Heterosexual couples in which men were entering treatment for alcoholism or other drug abuse were recruited to participate in an investigation of the effects of couples-based treatment. To be included, the female partner of these men needed to agree to participate in the study, and if assigned to a couples-based treatment, to participate in the treatment. For study inclusion, the men needed to receive a diagnosis for a substance abuse disorder, whereas the women could not have had a substance abuse disorder of their own. In addition, couples had to have at least one child between the ages of six and 16 living in their household for whom one or both adults were the legal guardian. In total, 135 couples participated. The fathers and mothers participating were, on average, 37 years of age. They had lived together for about 11 years, and had two to three children. About 75 percent of the children lived with both biological parents, and slightly more than half were boys. The children were, on average, 10 years of age. Measures Each member of the couple was assessed prior to treatment, at the conclusion of treatment, and at 90-day intervals for one year following treatment. Assessments of the fathers and mothers were conducted separately. Relationship adjustment was measured using the Dyadic Adjustment Scale (Spanier, 1989). This 32-item self-report measure produces scores ranging from 0-151 with higher scores indicating higher levels of marital satisfaction. Substance use was examined using the Timeline Followback Interview (Fals-Stewart, O’Farrell, Freitas, McFarlin, & Rutigliano, 2000; Sobell & Sobell, 1996). The interview uses a calendar and memory aids to gather retrospective estimates of daily drinking and drug use. The percentage of abstinent days (i.e., the percentage of days the father did not use any alcohol or illicit drugs) was determined. Children’s psychosocial adjustment was determined by administering the Pediatric Symptom Checklist (Jellinek & Murphy, 1990) to both mothers and fathers. The 35-item questionnaire lists a broad range of questions that address emotional and behavioral problems in children and reflects parental impressions of their children’s psychosocial functioning. Treatment Alcohol-dependent or drug-abusing men and their partners were recruited from outpatient treatment sites in the community. Couples were then randomly assigned to one of three treatments for substance abuse: BCT, individual-based treatment (IBT), or couples-based psycho-educational attention control treatment (PACT). Each treatment method was comprised of 32 sessions conducted over 20 weeks. Twenty of the sessions were identical across all treatments; in these sessions, the male substance abuser (i.e., father) received individual cognitive-behavioral therapy sessions for substance abuse. The treatments differed, however with regard to the remaining 12 sessions. In BCT, the mother participated and the couple was taught relationship enhancement, communication, and negotiation skills. The 12 sessions were used to help male partners remain abstinent, encourage the partners to acknowledge pleasing behaviors and engage in shared recreational activities, and to eliminate verbal and physical conflict between them. In IBT, the mother did not participate and the father received 12 sessions covering coping skills training. In PACT, both partners attended sessions but did not receive couples-based intervention. They were passive participants in 12 lectures covering substance abuse topics. Results Similar to previous studies, men who received BCT reported less frequent substance use during follow-up than men who received IBT or PACT. Also, marital satisfaction was higher for those couples who received BCT. These findings support previous findings that BCT is superior to both IBT and PACT for its impact on substance use and couple functioning. The results of this new investigation also indicate that children of substance-abusing fathers who participated in BCT had higher levels of psychosocial functioning post-treatment than children whose fathers participated in the IBT or PACT conditions. Most importantly, BCT was found to be superior to both IBT and PACT for its impact on the children’s psychosocial adjustment at the close of treatment, as well as up to one year following treatment. A significant reduction (from pretreatment to the one year follow-up) in the number of children determined to have adjustment problems was found for children whose fathers received BCT (50% to 15% for children of drug abusing fathers; 32% to 5% for alcohol-abusing fathers). Such gains were not observed for children whose fathers received IBT or PACT. Thus, compared with the more traditionally used IBT or an attention control, BCT appears to be more beneficial in terms of its secondary effects on children. Results of this study suggest a dynamic interrelatedness of child, parent, couple, and family adjustment. Because both parental substance abuse and couple relationship problems are related to poor psychosocial adjustment in children, an intervention such as BCT that addresses both of these issues concurrently may be the treatment of choice for its impact on the substance abuser, the couple, and their children. Future Study It is unclear what components of BCT result in increased psychosocial adjustment for children. Skills taught in BCT may benefit the family environment by improving parental communication, reducing stress, and facilitating positive parent-child interactions. Perhaps the reduction or elimination of substance abuse reduces family distress. BCT may also allow couples to address conflict more constructively, thereby eliminating distress for the family as a whole. Each of these areas begs further investigation. It is important to note that none of the individual-based, couples-based, or psychoeducational modules were designed to address parenting skills, parent-child interactions, or child behavior. Improvement among children in the study appears to be a secondary effect of a treatment designed to facilitate couple functioning. Article 2

William R. Greiner, President

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