Behavioral couples therapy (BCT) for alcohol and drug use disorders: a meta-analysis
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Behavioral couples therapy (BCT) for alcohol and drug use disorders: a meta-analysis.

Powers M.B., Vedel E., Emmelkamp P.M.G.
Clinical Psychology Review: 2008, 28(6), p. 952–962.
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For the minority of patients for whom it feasible, acceptable and safe, this meta-analytic review of behavioural couples therapy suggests it reduces substance use relative to other therapies, and the benefits are more likely to extend to the whole family.

Behavioural couples therapy assumes that substance use problems and intimate relationships are reciprocally related, such that substance use impairs relationship functioning, and severe relationship distress combined with attempts by partners to control substance use may prompt craving, reinforce substance use, or trigger relapse. To break this vicious circle and transform the relationship in to a positive force, the therapy aims to build support for abstinence and to improve relationship functioning. It features a 'recovery contract' which involves the couple in a daily ritual to reward abstinence, together with techniques for increasing positive activities and improving communication. A requirement for the therapy is that the partner of the problem substance user does not themselves have the same sort of problem.

Descriptive Also known as 'narrative' reviews, these do not attempt to combine findings to create an overall quantitative indicator of the strength of impact of a class or type of intervention. reviews (for example, 1 2) have concluded that behavioural couples therapy produces better outcomes than individual-based treatment for alcoholism and drug abuse problems. However, the strength and consistency of this effect has not been examined because a meta-analysis A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. of studies of the therapy has not been reported. This meta-analysis combines multiple, well controlled studies to help clarify the overall impact of behavioural couples therapy in the treatment of substance use disorders, and to determine whether this varies across different types of outcomes (such as relationship functioning and substance use) and/or with time after treatment.

A comprehensive search found 12 (eight dealing with drinking problems, four with other substances instead or as well) randomised controlled trials of behavioural couples therapy which could be included in the final analyses, involving altogether 754 couples in intimate relationships. In all but two, couples therapy supplemented other approaches. Eight of the studies compared couples therapy with cognitive-behavioural therapy.

A presentation from one of the originators of behavioural couples therapy offers a taste of how the therapy looks in practice and reference to a book including practice guidance.

Across the studies and amalgamating all outcomes and lengths of follow-up, there was a clear advantage for treatment including behavioural couples therapy versus solely individual-based treatment. At 0.54, the effect size A standard way of expressing the magnitude of a difference (eg, between outcomes in control and experimental groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of the variability in the outcome across both groups. The most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. indicated a medium-size impact. Effects were comparable for alcohol studies and for studies including other drugs, for studies which did or did not combine the therapy with medication, which featured more or less extended versions of the therapy, and (but slightly less strongly) when comparison treatments were limited to cognitive-behavioural therapy without a focus on relationships. Across all the studies, effects were slightly greater for measures of the adverse consequences of substance use and for satisfaction with the relationship (0.52 and 0.57 respectively), than for the frequency of substance use (0.36). However, this pattern varied with time. Immediately after treatment ended, couples therapy was superior to comparison treatments only in respect of satisfaction with the relationship. At later follow-ups, it was superior in respect of all three types of outcomes and to roughly the same medium degree of strength. Possibly substance use outcomes were so good immediately after treatment that it was difficult to improve on them, or perhaps relationship benefits from couples therapy took time to impact on substance use.

When the clients are married or cohabiting couples seeking help for substance dependence problems confined to one of the partners, the authors concluded that behavioural couples therapy results in better outcomes than more typical individual-based treatments. The benefits extend beyond substance use to related problems and the quality of the relationship. Immediate improvements in relationships seem to pave the way for later relative gains in substance use outcomes. Though these outcomes were not included in the analyses, studies have also shown that the therapy outperforms individual-based treatments in respect of child adjustment, cost-effectiveness, and reduced interpersonal violence.

Findings logo commentary Behavioural couples therapy was one of only two The other was contingency management. psychosocial therapies recommended by Britain's National Institute for Health and Clinical Excellence (NICE) for the treatment of problems related to illicit drug use. In particular, NICE said it should be considered for problem users of stimulants or opioids who are in close contact with a non-drug-misusing partner. Experts reached a similar conclusion after reviewing the alcohol treatment literature for England's National Treatment Agency for Substance Misuse.

Both reviews noted the therapy's limited applicability: the patient must share an intact, live-in relationship with a relative or partner not also experiencing substance use problems, and the relationship must be sufficiently supportive for both to productively engage with the therapy. This will be the case for many (especially male) drinkers, but usually not for long-term dependent users of cocaine or heroin. Care will also be needed to exclude the risk that such therapies, particularly when they engage women in the treatment of male substance users, might perpetuate or aggravate victimisation by abusive partners. Another major limitation is the availability of family therapy of any kind. The dominant paradigm sees addiction as a disorder of the individual and treats it accordingly. Few drug misuse professionals have been trained in family approaches and in the UK there is no appreciable national drive to widen their perspective. The recent emphasis on addressing not just substance use but also other recovery-relevant issues may alter this situation.

The analysis shares the limitations of many meta-analyses. These mean that it is best seen not as an indication of the generalised impact of the therapy, but of how it performed in this set of studies. One assumption underlying the analysis – that the studies were entirely independent of each other – was certainly violated because eight of the 12 involved one or both of the developers of the therapy. Among the remaining four were the three with the least convincing results overall, raising the issue of whether outcomes depend on who is organising the study. Research conducted by teams linked in some way to the intervention they are testing has been found (1 2) to produce more positive findings than fully independent research. In relation to psychosocial therapies for drinking problems, an analysis of relevant studies concluded that therapies were generally equivalent, and that where they were not, the researcher's allegiance to the therapy accounted for However, this analysis restricted itself to drinking outcomes assessed immediately after therapy ended; the featured analysis suggests that the benefits of behavioural couples therapy go beyond drinking itself, and in respect of substance use, emerge only several months later. Nevertheless, allegiance may have played a part in the outcomes of at least eight of the 12 studies. a significant portion of the differences.

What all this means is that it cannot be assumed that fresh applications of the therapy will produce the average advantages over other therapies noted in the featured analysis. Still the analysis offers more support to this therapy than most others can muster, especially since the usual comparator (cognitive-behavioural therapy) was itself a generally effective approach and one relatively hard to better. For the minority of patients for whom it feasible, acceptable and safe, behavioural couples therapy seems a good option relative to other therapies, and one whose benefits are more likely to extend to the whole family.

Last revised 19 March 2013. First uploaded 29 June 2009

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