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Intervention Summary

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Alcohol Behavioral Couple Therapy

Alcohol Behavioral Couple Therapy (ABCT) is an outpatient treatment for individuals with alcohol use disorders and their intimate partners. ABCT is based on two assumptions: Intimate partner behaviors and couple interactions can be triggers for drinking, and a positive intimate relationship is a key source of motivation to change drinking behavior. Using cognitive-behavioral therapy, ABCT aims to identify and decrease the partner's behaviors that cue or reinforce the client's drinking; strengthen the partner's support of the client's efforts to change; increase positive couple interactions by improving interpersonal communication and problem-solving skills as a couple; and improve the client's coping skills and relapse prevention techniques to achieve and maintain abstinence.

The treatment program consists of 2-3 hours of assessment for treatment planning, followed by 12-20 weekly, 90-minute therapy sessions for the client with his or her partner. The number of treatment sessions may be increased if sessions of less than 90 minutes are desired. Treatment follows cognitive-behavioral principles applied to couples therapy and specific therapeutic interventions for alcohol use disorders. The optimal implementation of ABCT occurs in the context of an existing clinic or private practice with certified/licensed mental health or addictions professionals who have a background in treating alcohol use disorders and knowledge of cognitive-behavioral therapy.

Descriptive Information

Areas of Interest Substance abuse treatment
Co-occurring disorders
Outcomes Review Date: January 2009
1: Drinking behavior
2: Marital satisfaction
3: Relapse
Outcome Categories Alcohol
Family/relationships
Ages 26-55 (Adult)
55+ (Older adult)
Genders Male
Female
Races/Ethnicities American Indian or Alaska Native
Black or African American
Hispanic or Latino
White
Settings Outpatient
Geographic Locations Urban
Suburban
Implementation History Originally developed in 1979, ABCT has been used in seven States (Georgia, Illinois, Minnesota, New Jersey, New Mexico, Oregon, and Pennsylvania) and in five countries outside the United States (Canada, the Netherlands, New Zealand, Scotland, and Sweden). Approximately 300 couples have participated in evaluations of this intervention.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: January 2009

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

McCrady, B. S., Stout, R., Noel, N., Abrams, D., & Nelson, H. F. (1991). Effectiveness of three types of spouse-involved behavioral alcoholism treatment. British Journal of Addiction, 86(11), 1415-1424.  Pub Med icon

Study 2

McCrady, B. S., Epstein, E. E., & Hirsch, L. S. (1999). Maintaining change after conjoint behavioral alcohol treatment for men: Outcomes at 6 months. Addiction, 94(9), 1381-1396.  Pub Med icon

McCrady, B. S., Epstein, E. E., & Kahler, C. W. (2004). Alcoholics Anonymous and relapse prevention as maintenance strategies after conjoint behavioral alcohol treatment for men: 18-month outcomes. Journal of Consulting and Clinical Psychology, 72(5), 870-878.  Pub Med icon

Study 3

McCrady, B. S., Epstein, E. E., Cook, S., Jensen, N. K., & Hildebrandt, T. (2009). A randomized trial of individual and couple behavioral alcohol treatment for women. Journal of Consulting and Clinical Psychology, 77(2), 243-256.  Pub Med icon

Supplementary Materials

Epstein, E. E., & McCrady, B. S. (2002). Couple therapy in the treatment of alcohol problems. In A. S. Gurman & N. A. Jacobson (Eds.), Clinical handbook of marital therapy (3rd ed., pp. 597-628). New York: Guilford Press.

FRIENDS National Resource Center for Community-Based Child Abuse Prevention (CBCAP). (n.d.). Annotated description of the Marital Adjustment Scale (MAT). Available online at http://www.friendsnrc.org/download/outcomeresources/toolkit/annot/mat.pdf

Locke-Wallace Marital Adjustment Test (LWMAT). (2003). In Conceptualizing and measuring "healthy marriages" for empirical research and evaluation studies: A compendium of measures, Part 2 (pp. 201-202). Washington, DC: Child Trends.

Margolin, G., Talovic, S., & Weinstein, C. D. (1983). Areas of Change Questionnaire: A practical approach to marital assessment. Journal of Consulting and Clinical Psychology, 51(6), 920-931.

McCrady, B. S., Noel, N. E., Abrams, D. B., Stout, R. L., Nelson, H. F., & Hay, W. M. (1986). Comparative effectiveness of three types of spouse involvement in outpatient behavioral alcoholism treatment. Journal of Studies on Alcohol, 47(6), 459-467.  Pub Med icon

Powers, M. B., Vedel, E., & Emmelkamp, P. M. G. (2008). Behavioral couples therapy (BCT) for alcohol and drug use disorders: A meta-analysis. Clinical Psychology Review, 28(6), 952-962.  Pub Med icon

Outcomes

Outcome 1: Drinking behavior
Description of Measures Drinking behavior was measured using the Timeline Followback (TLFB) method, a semistructured, calendar-based interview that asks clients to retrospectively estimate their daily alcohol consumption over a specified time period. Clients reported the daily quantity of alcohol consumed, and partners reported the number of drinking days per week along with subjective estimates (abstinent, light, moderate, or heavy) of the client's drinking. In face-to-face interviews with both the client and partner, discrepancies between their drinking reports were resolved. For telephone follow-up interviews carried out separately with the client and partner, the analyses used the report reflecting the poorer drinking outcome or the partner report (if the client report was not available). The baseline TLFB interview gathered data about drinking 12 months, 6 months, or 3 months prior to study entry, depending on the study.

Drinking behavior reported using the TLFB was confirmed in one study by three other data sources: blood samples for liver function, breath samples for blood alcohol concentration (BAC), and driving records for reports of driving while intoxicated. In another study, daily drinking logs were used when TLFB data were not available.
Key Findings In a randomized clinical trial (RCT), men with an alcohol use disorder and their spouses were assigned to one of three outpatient treatment conditions that varied by level of the spouse's involvement in treatment: minimal, alcohol-focused, or alcohol-focused plus ABCT. Face-to-face assessments including both the client and spouse took place at baseline, posttreatment, and 6, 12, and 18 months posttreatment. In addition, monthly telephone assessments were conducted separately with each client and spouse throughout the 18 months of follow-up. Findings from this trial included the following:

  • All three treatment groups had an increase in reported days of abstinence (p < .001), an increase in reported days of abstinence or light drinking (p < .001), and a decrease in reported days of heavy drinking (p < .001) over the study period as a whole (baseline through 18-month follow-up). However, from the 12- to 18-month follow-up, the reported days abstinent increased for clients assigned to the ABCT condition but decreased sharply for clients assigned to either the minimal or alcohol-focused spouse involvement condition (p < .02).
In a second RCT, men with an alcohol use disorder and their female partners received ABCT, either alone or in combination with participation in Alcoholics Anonymous or Relapse Prevention treatment. Face-to-face assessments including both the client and partner took place at baseline and at 6, 12, and 18 months posttreatment. In addition, monthly follow-up telephone assessments were conducted separately for each client and partner for 18 months posttreatment. Findings from this trial included the following:

  • Clients in all three treatment groups had significant increases in the percentage of reported days abstinent from baseline to the 6-month follow-up (p < .0001), and these increases were sustained through the 18-month follow-up.
  • Clients in all three treatment groups had significant reductions in reported heavy drinking days that were sustained through the 18-month follow-up (p < .0001).
  • Clients in all three treatment groups who reported a higher percentage of days abstinent during the prestudy baseline period also reported a higher percentage of days abstinent across the 18 months of follow-up (p = .04).
In a third RCT, women with an alcohol use disorder and their male partners were assigned to 6 months of either ABCT or individual alcohol behavioral therapy. A face-to-face baseline assessment was conducted that included both the client and partner. Follow-up telephone assessments were conducted separately for each client and partner at midtreatment and 3 and 9 months posttreatment, and follow-up face-to-face assessments were conducted with both the client and partner at posttreatment and 6 and 12 months posttreatment. Findings from this trial included the following:

  • Clients in both treatment groups had increases in reported days abstinent during treatment (p < .01). During the 12 months of posttreatment follow-up, the number of reported days abstinent remained stable among clients who received ABCT and decreased among clients who received individual alcohol behavioral therapy (p < .05). The gain or loss in reported days abstinent achieved during treatment (whether ABCT or individual alcohol behavioral therapy) was maintained through the 12-month posttreatment follow-up (p < .01).
  • Clients who received ABCT reported a higher percentage of days abstinent during treatment (p < .05), at the end of treatment (p < .05), and at every follow-up point out to 12 months posttreatment (p < .05) than clients who received individual alcohol behavioral therapy. These differences were associated with a medium effect size (Cohen's d = 0.59).
  • Among clients with a DSM-IV Axis II personality disorder, those receiving ABCT reported a higher percentage of days abstinent across the treatment period than those receiving individual alcohol behavioral therapy (p < .05). Among clients with a DSM-IV Axis I clinical disorder, those receiving ABCT reported a higher percentage of days abstinent at the end of the follow-up period than those receiving individual alcohol behavioral therapy (p < .05).
  • Clients who received ABCT reported fewer heavy drinking days during treatment (p < .05) than clients who received individual behavioral alcohol therapy. This difference was associated with a medium effect size (Cohen's d = 0.79). Similarly, clients who received ABCT reported a lower percentage of heavy drinking days in the 6 months following treatment and at months 9-12 posttreatment than clients who received individual alcohol behavioral therapy (p < .05).
  • Among women with better baseline relationship functioning (p < .05) and/or a DSM-IV Axis II personality disorder (p < .01), women receiving ABCT reported fewer heavy drinking days across the 12-month follow-up than women receiving individual alcohol behavioral therapy.
Studies Measuring Outcome Study 1, Study 2, Study 3
Study Designs Experimental
Quality of Research Rating 3.2 (0.0-4.0 scale)
Outcome 2: Marital satisfaction
Description of Measures Marital satisfaction was measured using the Areas of Change Questionnaire (ACQ), a self-report instrument that measures each spouse's desire for change in a marital relationship, as well as each spouse's perception of his or her partner's desire for change. Each spouse rates whether he or she wants the partner to increase, decrease, or not change each of 34 specific behaviors along a 7-point Likert scale that ranges from -3 (much less) to +3 (much more), with 0 representing no change. Items begin "I want my partner to" and include "express emotions clearly," "show appreciation for things I do well," "start interesting conversations with me," "give me attention when I need it," and "pay attention to my sexual needs." Using the same list of 34 behaviors beginning with "It would please my partner if I," each spouse also rates whether an increase, decrease, or no change in his or her own behavior would be pleasing to the partner. The ACQ total change score ranges from 0 to 68, with lower scores indicating more marital satisfaction.
Key Findings In an RCT, men with an alcohol use disorder and their spouses were assigned to one of three outpatient treatment conditions that varied by level of the spouse's involvement in treatment: minimal, alcohol-focused, or alcohol-focused plus ABCT. Face-to-face assessments including both the client and spouse took place at baseline, posttreatment, and 6, 12, and 18 months posttreatment. In addition, monthly telephone assessments were conducted separately with each client and spouse throughout the 18 months of follow-up. Findings from this trial included the following:

  • Spouses assigned to the ABCT condition had improved marital satisfaction from baseline to the 18-month follow-up compared with spouses assigned to the minimal and alcohol-focused spouse involvement conditions (p < .02).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.0 (0.0-4.0 scale)
Outcome 3: Relapse
Description of Measures Alcohol use was assessed using the TLFB method, a semistructured, calendar-based interview that asks clients to retrospectively estimate their daily alcohol consumption over a specified time period. Relapse after treatment was measured in three ways: time to the first reported drink, time to the first reported heavy drinking day, and average duration of the reported drinking episode defined as the number of consecutive drinking days.
Key Findings In an RCT, men with an alcohol use disorder and their female partners received ABCT, either alone or in combination with participation in Alcoholics Anonymous or Relapse Prevention treatment. Face-to-face assessments including both the client and partner took place at baseline and at 6, 12, and 18 months posttreatment. In addition, monthly follow-up telephone assessments were conducted separately for each client and partner for 18 months posttreatment. Findings from this trial included the following:

  • There were no group differences in time to the first reported drink, but clients who received ABCT alone reported longer average periods of abstinence prior to their first reported heavy drinking day than did clients who received ABCT with Alcoholics Anonymous (p < .05). A similar difference was found between clients who received ABCT alone and in combination with Relapse Prevention, but this finding was not statistically significant.
  • Clients who received ABCT in combination with Relapse Prevention reported the shortest average relapse episodes in the first 6 months posttreatment (1.9 days), followed by clients who received ABCT alone (5.4 days) and ABCT with Alcoholics Anonymous (8.4 days; for 1.9 days vs. 8.4 days, p < .05).
Studies Measuring Outcome Study 2
Study Designs Experimental
Quality of Research Rating 3.3 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult) 73% Male
27% Female
100% White
Study 2 26-55 (Adult) 100% Male 92.3% White
5.7% Black or African American
1% American Indian or Alaska Native
1% Hispanic or Latino
Study 3 26-55 (Adult)
55+ (Older adult)
100% Female 95% White
5% Black or African American

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Drinking behavior 3.3 3.5 3.0 3.0 3.1 3.2 3.2
2: Marital satisfaction 3.5 3.5 2.3 2.5 3.0 3.0 3.0
3: Relapse 3.5 3.5 3.0 2.8 3.3 3.5 3.3

Study Strengths

All three studies used the Timeline Followback method, which has strong psychometric properties, and further used multiple sources to validate the self-reported data on alcohol use. All three studies also used randomization and collected data using trained research assistants. Two of the three studies had high follow-up rates and collected detailed data from both the client and partner across extended follow-up periods. The two later studies used sophisticated statistical strategies to model the outcome data and incorporate missing data into the models.

Study Weaknesses

Different assessment methodologies were used within studies; researchers used face-to-face interviews with each couple at baseline and separate client and spouse telephone interviews throughout follow-up. The absence of an independent fidelity assessment or regular, audiotape-based supervision was an issue in the earliest study, in which the same therapists administered all three levels of spousal involvement being tested. Due to the small number of couples assigned to each condition, two of the three studies were most likely underpowered to detect group differences.

Readiness for Dissemination
Review Date: January 2009

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Barrick, C. (n.d.). Behavioral interventions with couples [PowerPoint slides]. Buffalo, NY: University at Buffalo.

Behavioral Interventions With Couples Database Web site, http://www.ria.buffalo.edu/ubbic/

Center of Alcohol Studies, Rutgers University. (2009). ABCT treatment integrity instructions. Piscataway, NJ: Author.

Center of Alcohol Studies, Rutgers University. (n.d.). Rutgers Women's Treatment Project II: Treatment integrity ratings. Piscataway, NJ: Author.

Center of Alcohol Studies, Rutgers University. (n.d.). Therapist checklist for couples treatment: Rutgers Women's Treatment Project II. Piscataway, NJ: Author.

Center of Alcohol Studies, Rutgers University. (n.d.). Timeline Followback: Periods of abstinence. Piscataway, NJ: Author.

Epstein, E. (2005). Enlisting and helping the spouse: A cognitive behavioral couples treatment model for alcohol use disorder [PowerPoint slides]. Piscataway, NJ: Center of Alcohol Studies, Rutgers University.

Epstein, E. (2005). Enlisting and helping the spouse: A cognitive behavioral couples treatment model for alcohol use disorder, workshop II [PowerPoint slides]. Piscataway, NJ: Center of Alcohol Studies, Rutgers University.

McCrady, B. S. (n.d.). Behavioral couples therapy for addiction [PowerPoint slides]. Albuquerque: Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico.

McCrady, B. S. (n.d.). Substance abuse and intimate relationships: Impact and intervention [PowerPoint slides]. Piscataway, NJ: Center of Alcohol Studies, Rutgers University.

McCrady, B. S., & Epstein, E. E. (2009). Overcoming alcohol problems: A couples-focused program. Therapist guide. New York: Oxford University Press.

McCrady, B. S., & Epstein, E. E. (2009). Overcoming alcohol problems: Workbook for couples. New York: Oxford University Press.

Psychotherapy.net (Producer). (2000). Couples therapy for addictions: A cognitive behavioral approach [DVD]. San Francisco: Author.

Spanier, G. B. (1976). Dyadic Adjustment Scale (DAS).

Weiss, R. L. (1975). Areas of Change Questionnaire.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.0 2.8 3.3 3.0

Dissemination Strengths

The therapist guide is clearly written and sequenced and contains useful information on addressing clinical barriers and facilitating client engagement and change. Implementer training is comprehensive and includes both group and individual exercises to practice key concepts. The quality assurance tools strengthen program implementation and support the development of therapists' treatment skills.

Dissemination Weaknesses

The materials do not supply any implementation information specifically for program administrators or specify what kinds of organizations are appropriate for implementing this intervention. The level of ongoing technical supervision or consultation provided by the developer is unclear. The outcome measures may be cumbersome for regular use outside a research-oriented implementation site.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Therapist guide $35 each Yes
Client workbook $254.95 each, one per client Yes
3- to 4-day, on-site training $2,000 per site plus travel expenses for one trainer No
Ongoing consultation for sites using train-the-trainer model $150 per hour No
Dyadic Adjustment Scale Varies depending on volume and format No
Areas of Change Questionnaire Free No
Treatment integrity materials Free No
Replications
Contact Information

To learn more about implementation, contact:
Barbara S. McCrady, Ph.D.
(505) 925-2388
bmccrady@unm.edu

To learn more about research, contact:
Barbara S. McCrady, Ph.D.
(505) 925-2388
bmccrady@unm.edu

Elizabeth E. Epstein, Ph.D.
(732) 445-0906
bepstein@rci.rutgers.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.