Introduction - Why Is There a Need for Brief Couples Treatment?

Brief Couples Therapy: Group and Individual Couple Treatment for Addiction and Related Mental Health Concerns

Brief Couples Therapy (BCT) is an eight-session, structured treatment for couples with substance abuse and related mental health concerns that can be delivered in either individual couple format with one therapist, or in a group format — of up to four couples — with two therapists. Over the course of eight weeks, couples learn to identify and reduce problems stemming from substance use, including problematic family interaction patterns, and communication styles. They will begin to establish concrete, attainable goals, build trust and intimacy, and establish relapse prevention strategies.

Couple Involvement

In both the areas of substance use and mental health treatment, there is a substantial literature supporting various types of family involvement and intervention as the main mode of intervention or as an adjunct to it (Stanton & Heath, 1997; Baucom et al., 1998). Health Canada’s Best Practices: Substance Abuse Treatment and Rehabilitation (1999) supports the effectiveness of marital behavioural therapy as well as group treatments. The effectiveness of couple involvement in the treatment of problem substance use has been widely documented in the past two decades (Kaufman, 1985; Zweben et al., 1988; Montag & Wilson, 1992; Shadish et al., 1993; Edwards & Steinglass, 1995; Pinsof & Wynne, 1995; Fals-Stewart et al., 1996; Stanton & Shadish, 1997; Epstein & McCrady, 1998; O’Farrell & Feehan, 1999; O’Farrell & Fals-Stewart, 2000). This research has shown that spousal involvement in treatment is effective in motivating people with alcohol problems to enter and continue treatment. Moreover, it has shown that different models of couple therapy have produced significant reduction in alcohol or drug use and improvement in marital functioning. However, despite the growing evidence that spousal involvement in treatment increases treatment retention and improves outcomes, addiction treatment continues to be focused on the substance-using individual in most settings.

As treatment resources become increasingly scarce and waiting lists grow, it is crucial to develop effective treatment interventions from both outcome and cost perspectives. It is also important to note that the majority of the treatment literature does not address issues related to cultural and sexual diversity. In order to address these gaps, CAMH is utilizing a number of brief treatment approaches for a diverse clientele, and the treatment protocol presented in this manual is one of a number of these brief treatment approaches.

Group Format

Treatment groups have a long history and are widely used in the addiction field, as they have been shown to result in decreased costs as well as improved outcomes (Roberts et al., 1999). In early studies of couples group therapy for alcoholism, couples groups were introduced mainly as an adjunct to inpatient programs. These studies provided some evidence for the efficacy of couples group treatment for alcohol problems. Today, the emerging research evaluating couples group therapy for outpatient treatment of alcohol problems suggests positive outcomes for couples treatment in the group format (Corder et al., 1972; Cadogan, 1973; McCrady et al., 1979; Hahlweg et al., 1982; Bowers & Al-Redha, 1990; Baucom et al., 1998; O’Farrell et al., 1998; O’Farrell & Fals-Stewart, 2000).

In view of the foregoing, some of the potential benefits of multiple couples therapy for addictions are: decreasing waiting lists; reducing treatment costs and increasing treatment retention; improving treatment outcomes (i.e., achieving substance use goals and improving couple satisfaction); providing a forum for demonstrating communication and problem-solving strategies; providing feedback and positive reinforcement from peers, which may also improve treatment retention and outcomes; modelling positive coping styles; and decreasing highly dysfunctional behaviours.

Concurrent Disorders

Estimates of lifetime drug-use disorders comorbid with alcohol dependence are as high as 80 per cent (Epstein & McCrady, 1998). Here at CAMH, over 50 per cent of clients presenting for treatment in the Addiction Programs reported drugs other than alcohol as their primary problem substance, and about 40 per cent reported more than one problem substance. About 50 per cent of these clients also screened positive on the Psychiatric Screener (a screening tool in development at CAMH) for mental disorders such as schizophrenia, mood, anxiety and eating disorders. Correspondingly high rates of comorbidity have also been published by large-scale studies in the United States.*

In addition, as the general and treatment populations become more diverse, it is important that treatment protocols and approaches address the severity and complexity of presenting problems, learning styles and ethno/sexual/racial/cultural dimensions. Where suitable, group interventions are preferable for the cost-benefit reasons outlined above. However, options for individual couple interventions and other individual and family interventions need to be available as well.

For 20 years, the members of our team of experienced clinicians have been offering couple treatment in the conjoint format for clients who present with substance use problems; and for the past five years, we have offered this treatment for clients with concurrent disorders. Drawing upon the clinicians’ experience, a BCT treatment program incorporating cognitive, behavioural and systems approaches is presently being researched and delivered. It is believed that this program will contribute to more efficient service delivery, lower treatment attrition rates and better treatment outcomes. We are hopeful that research utilizing the BCT model of therapy outlined in this manual will generate a broader conceptualization of the needs of couples and families with substance use and mental health issues and that, in turn, further refinement and extension of the treatment model will produce interventions that are germane to wider family constellations and to broader ethno/sexual/racial/cultural communities.

*See Daley & Moss (Chapter 1; 2002) for prevalence rates of dual disorders in the United States.

Brief Couples Therapy

Acknowledgments

Introduction

• Assessment Session
• Session 1: Introduction
• Session 2: Genogram/Family Tree
• Session 3: Miracle Question
• Session 4: Goal Setting
• Session 5: Communication
• Session 6: Trust/Intimacy
• Session 7: Relapse Prevention
• Session 8: Conclusion

References

Appendix A: The Background of the Integrative Model

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