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 1McCrady, 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.  Study 2McCrady, 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.
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. Study 3McCrady, 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.
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.
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.
Outcomes
| Outcome 1: Drinking behavior |
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Description of Measures
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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.
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Key Findings
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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.
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Studies Measuring Outcome
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Study 1, Study 2, Study 3
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Study Designs
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Experimental
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Quality of Research Rating
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3.2
(0.0-4.0 scale)
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| Outcome 2: Marital satisfaction |
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Description of Measures
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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.
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Key Findings
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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).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
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Quality of Research Rating
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3.0
(0.0-4.0 scale)
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| Outcome 3: Relapse |
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Description of Measures
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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.
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Key Findings
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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).
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Studies Measuring Outcome
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Study 2
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Study Designs
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Experimental
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Quality of Research Rating
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3.3
(0.0-4.0 scale)
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Study Populations
The following populations were identified in the studies reviewed for Quality of
Research.
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Study
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Age
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Gender
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Race/Ethnicity
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Study 1
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26-55 (Adult)
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73% Male
27% Female
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100% White
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Study 2
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26-55 (Adult)
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100% Male
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92.3% White
5.7% Black or African American
1% American Indian or Alaska Native
1% Hispanic or Latino
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Study 3
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26-55 (Adult)
55+ (Older adult)
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100% Female
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95% White
5% Black or African American
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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:
For more information about these criteria and the meaning of the ratings, see Quality of Research.
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Outcome
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Reliability
of Measures
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Validity
of Measures
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Fidelity
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Missing
Data/Attrition
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Confounding
Variables
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Data
Analysis
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Overall
Rating
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1: Drinking behavior
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3.3
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3.5
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3.0
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3.0
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3.1
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3.2
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3.2
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2: Marital satisfaction
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3.5
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3.5
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2.3
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2.5
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3.0
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3.0
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3.0
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3: Relapse
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3.5
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3.5
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3.0
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2.8
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3.3
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3.5
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3.3
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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.
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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:
- Availability of implementation materials
- Availability of training and support resources
- Availability of quality assurance procedures
For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.
Implementation
Materials
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Training and Support
Resources
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Quality Assurance
Procedures
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Overall
Rating
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3.0
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2.8
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3.3
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3.0
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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.
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