Behavioural Couples Therapy

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And the spouse expresses support for the patient’s efforts to stay abstinent. For patients taking a recovery-related medication (e.g., disulfiram, naltrexone), daily medication ingestion witnessed and verbally reinforced by the spouse also is part of the contract. The spouse records the performance of the daily contract on a calendar you give him or her. Both partners agree not to discuss past drinking or fears about future drinking at home to prevent substance-related conflicts which can trigger relapse, reserving these discussions for the therapy sessions.

At the start of each BCT session, review the Sobriety Contract calendar to see how well each spouse has done their part. Have the couple practice their trust discussion (and medication taking if applicable) in each session to highlight its importance and to let you see how they do it. Twelve-step or other self-help meetings are a routine part of BCT for all patients who are willing. If the Sobriety Contract includes 12-step meetings or urine drug screens, these are also marked on the calendar and reviewed. The calendar provides an ongoing record of progress that are rewarded verbally at each session.

Sobriety Contract Case Example.

The table below presents the Sobriety Contract and calendar for Mary Smith and her husband Jack. Mary was a 34-year old teacher’s aide in an elementary school who had a serious drinking problem and also smoked marijuana daily. She was admitted to a detoxification unit at a community hospital after being caught drinking at work and being suspended from her job. Her husband Jack worked in a local warehouse and was a light drinker with no drug

involvement. Mary and Jack had been married 8 years, and Jack was considering leaving the marriage, when the staff at the detoxification unit referred them to the behavioural couples therapy program.

In this example the therapist developed a contract in which Mary agreed to a daily “trust discussion” in which she stated to Jack her intent to stay “clean and sober” for the next 24 hours and Jack thanked her for her commitment to sobriety. The couple practiced this ritual in the therapist’s office until it felt comfortable, and then also performed the discussion at each weekly therapy session on Wednesday evening. As the calendar in the table shows, they did this part of the contract nearly every day, missing only on an occasional Saturday because their schedule was different that day and sometimes they forgot.

Mary agreed to at least two AA meetings each week and actually attended 3 meetings per week for the first two months. Jack was pleased to see Mary not drinking and going to AA. However, he was upset that weekly drug urine screens were positive for marijuana for the first few weeks, taking this as evidence that his wife was still smoking marijuana even though she denied it. The therapist explained that marijuana could stay in the system for some time

particularly in someone who had been a daily pot smoker. The therapist suggested Jack go to Al-Anon to help him deal with his distress over his wife’s suspected drug use. After a few weeks, the drug screens were negative for marijuana and stayed that way lending further credence to Mary’s daily statement of intent. Jack found Al-Anon helpful and the couple added to their contract that one night a week they would go together to a local church where Mary could attend an AA meeting and Jack could go to an Al-Anon meeting.

Relationship-Focused Interventions in BCT

Once the Sobriety Contract is going smoothly, the substance abuser has been abstinent and the couple has been keeping scheduled appointments for a month or so, the therapist can start to focus on improving couple and family relationships. Family members often experience resentment about past substance abuse and fear and distrust about the possible return of substance abuse in the future. The substance abuser often experiences guilt and a desire for recognition of current improved behaviour. These feelings experienced by the substance abuser and the family often lead to an atmosphere of tension and unhappiness in couple and family relationships. There are problems caused by substance use (e.g. bills, legal charges, embarrassing incidents) that still need to be resolved. There is often a backlog of other unresolved couple and family problems that the substance use obscured.

The couple frequently lacks the mutual positive feelings and communication skills needed to resolve these problems. As a result, many marriages and families are dissolved during the first 1 or 2 years of the substance abuser's recovery. In other cases, couple and family conflicts trigger relapse and a return to substance abuse. Even in cases where the substance abuser has a basically sound marriage and family life when he or she is not abusing substances, the initiation of abstinence can produce temporary tension and role readjustment and provide the opportunity for stabilizing and enriching couple and family relationships. For these reasons, many alcohol abusers can benefit from assistance to improve their couple and family relationships.

Two major goals of interventions focused on the drinker's couple/family relationship are:

(a) to increase positive feeling, goodwill, and commitment to the relationship; and

(b) to teach communication skills to resolve conflicts, problems, and desires for change.

The general sequence in teaching couples and families skills to increase positive activities and improve communication is:

(a) therapists instruction and modelling,

(b) the couple practicing under therapists supervision,

(d) review of homework with further practice.

Increasing Positive Activities

Catch Your Partner Doing Something Nice.

A series of procedures can increase a couple's awareness of benefits from the relationship and the frequency with

which spouses notice, acknowledge, and initiates pleasing or caring behaviours on a daily basis. The therapist tells the couple that caring behaviours are "behaviours showing that you care for the other person," and assigns homework called "Catch Your Partner Doing Something Nice" to assist couples in noticing daily caring behaviours.

This requires each spouse to record one caring behaviour performed by their partner each day on sheets the therapist provides.(see table opposite). The couple reads the caring behaviours recorded during the previous week at the subsequent session.

The therapist models acknowledging caring behaviours ("I liked it when you ….. It made me feel …….."), Noting the importance of eye contact; a smile; a sincere, pleasant tone of voice; and only positive feelings.

Each spouse then practices acknowledging caring behaviours from his or her daily list for the previous week. After the couple practices the new behaviour in the therapy session, homework is assigned in the form of a 2-5 minute daily communication session at home in which each partner acknowledges one pleasing behaviour noticed that day.

As couples begin to notice and acknowledge daily caring behaviours, each partner begins initiating more caring behaviours. Often the weekly reports of daily caring behaviours show that one or both spouses are fulfilling requests for desired change voiced before the therapy. In addition, many couples report that the 2-5 minute communication sessions result in more extensive conversations.

Caring Day. A final assignment is that each partner give the other a "Caring Day" during the coming week by performing special acts to show caring for the spouse. Each partner is encouraged to take risks and to act lovingly toward the spouse rather than wait for the other to make the first move. Finally, spouses are reminded that at the start of therapy they agreed to act differently (e.g., more lovingly) and then assess changes in feelings, rather than wait to feel more positively toward their partner before instituting changes in their own behaviour.

Planning Shared Rewarding Activities. Many substance abusers' families stop shared recreational and leisure activities due to strained relationships and embarrassing substance-related incidents. Reversing this trend is important because participation by the couple and family in social and recreational activities improves substance abuse treatment outcomes. Planning and engaging in shared rewarding activities are started by each spouse making a separate list of possible activities. Each activity must involve both spouses, either by themselves or with their children or other adults and can be at or away from home. Before the couple receive the homework of planning a shared activity, the therapist models planning an activity to illustrate solutions to common pitfalls (e.g., waiting until the last

minute so that necessary preparations cannot be made, getting sidetracked on trivial practical arrangements). The couple are asked to refrain from discussing problems or conflicts during their planned activity.

Teaching Communication Skills

Work on training in communication skills is generally begun by the therapist defining effective communication as "message intended (by speaker) equals message received (by listener)" and by emphasising the need to learn both "listening" and "speaking" skills. There are traits in each person that can impede communication. Teaching couples the communication skills of listening and speaking and how to use planned communication sessions are essential prerequisites for negotiating desired behaviour changes. The training is started with non-problem areas that are positive or neutral and move to problem areas and emotionally charged issues only after each skill has been practiced on easier topics.

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Listening Skills.

Good listening helps each spouse to feel understood and supported and to slow down couple interactions to prevent quick escalation of aversive exchanges. The therapist instructs the spouses to repeat both the words and the feelings of the speaker's message and to check to see if the message they received was the message intended by their partner ("What I heard you say was . . .. Is that right?"). When the listener has understood the speaker's message, roles change and the first listener then speaks. Teaching a partner to communicate support and understanding by summarising the spouse's message and checking the accuracy of the received message before stating his or her own position is often a major accomplishment that has to be achieved gradually. A partner's failure to separate understanding the spouse's position from agreement with it often is an obstacle that must be overcome.

Expressing Feelings Directly.

Expressing both positive and negative feelings directly is an alternative to the blaming, hostile, and indirect responsibility-avoiding communication behaviours that characterise many substance abusers' relationships.

The therapist emphasises that when the speaker expresses feelings directly, there is a greater chance that he or she will be heard because the speaker says these are his or her feelings, his or her point of view, and not some objective fact about the other person. The speaker takes responsibility for his or her own feelings and does not blame the other person for how he or she feels. This reduces listener defensiveness and makes it easier for the listener to receive the intended message. During the sessions the therapist will present examples of differences between direct expressions of feelings and indirect and ineffective or hurtful expressions. The use of statements beginning with "I" rather than "you" is emphasised. During the session the therapist presents the rationale and instructions, models correct and incorrect ways of expressing feelings and elicits the couple's reactions to these modelled scenes. Then has the couple role-play a communication session in which spouses take turns being speaker and listener, with the speaker expressing feelings directly and the listener using the listening response. During this role-playing, couples are coached as they practice reflecting the direct expressions of feelings. Assignments for homework similar to the communication sessions,is set, usually 10 to 15 minutes each, three to four times weekly. Subsequent therapy sessions involve more practice with role-playing, both during the sessions and for homework. Increasing the difficulty each week of the topics on which the couple practices.

Communication Sessions.

These are planned, structured discussions in which spouses talk privately, face-to-face, without distractions, and with each spouse taking turns expressing his or her point of view without interruptions. Communication sessions are introduced for 2-5 minutes daily when couples first practice acknowledging caring behaviours and in 10 to 15 minute sessions three to four times a week in later sessions when the couple discusses current relationship problems or concerns. The therapist discusses with the couple the time and place that they plan to have their assigned communication practice sessions. Assessment is made of the success of this plan at the next session, and suggestions for any needed changes. Just establishing a communication session as a method for discussing feelings, events, and problems can be very helpful for many couples.

Negotiating for Requests.

Many changes that spouses desire from their partners can be achieved through the aforementioned caring behaviours, rewarding activities, and communication and problem-solving skills. However, deeper, emotion-laden conflicts that have caused considerable hostility and coercive interaction for years are more resistant to change.

Learning to make positive specific requests and to negotiate and compromise can lead to agreements to resolve such issues. Positive specific requests are an alternative to the all too frequent practice of couples complaining in vague and unclear terms and trying to coerce, browbeat, and force the other partner to change. For homework each partner lists at least five requests. Negotiation and compromise comes next. Spouses share their lists of requests, starting with the most specific and positive items. The therapist gives feedback on the requests presented and helps rewrite items as needed. Explanations that negotiating and compromising can help couples reach an agreement in which each partner will do one thing requested by the other. The therapist gives examples and instructions and coaches a couple while they have a communication session in which requests are made in a positive specific form, heard by each partner, and translated into a mutually satisfactory, realistic agreement for the upcoming week. Finally, the agreement is recorded on a homework sheet that the couple knows the therapist will review with them during the next session. Such agreements can be a major focus of a number of BCT sessions.

Maintenance and Relapse Prevention

Three general methods are used during the maintenance phase of treatment, defined somewhat arbitrarily as the phase that begins after at least 3-6 consecutive months of abstinence have been achieved.

First, maintenance is planned prior to the termination of the active treatment phase. This involves helping the couple complete a Continuing Recovery Plan that specifies which

of the behaviours from the previous BCT sessions they wish to continue (e.g., daily Sobriety Contract, AA meetings, shared rewarding activities, communication sessions).

Second, high risk situations are anticipated which may cause relapse after treatment. Coping strategies are discussed and rehearsed so that the substance abuser and spouse can use these strategies to prevent relapse when confronted with such situations.

Third, therapist and couple discuss and rehearse how to cope with a relapse if it occurs. A specific relapse plan is written and rehearsed prior to ending active treatment. Early intervention at the beginning of a relapse episode is essential: the therapist will explain this to the couple. Often, individuals wait until the substance use has reached dangerous levels again before acting. By then, much additional damage has been done to couple and family relationships and to other aspects of the substance abuser’s life.

The therapist will suggest continued contact with the couple/family via planned in-person and telephone follow-up sessions, at regular and then gradually increasing intervals, preferably for 3 to 5 years after a stable pattern of recovery has been achieved. This ongoing contact is used to monitor progress, to assess compliance with the Continuing Recovery Plan, and to evaluate the need for additional therapy sessions. The therapist takes responsibility for scheduling and reminding the family of follow-up sessions and for placing agreed-upon phone calls so that continued contact can be maintained successfully. The couples are told the reason for continued contact is that substance abuse is a chronic health problem that requires active, aggressive, ongoing monitoring to prevent or to quickly treat relapses for at least 5 years after an initial stable pattern of recovery has been established. The follow-up contact also provides the opportunity to deal with couple and family issues that appear after a period of recovery.

Summary

The purpose of Behavioural Couples Therapy is to build support for abstinence and to improve relationship functioning among married or cohabiting individuals seeking help for alcoholism or drug abuse. Research shows that BCT produces greater abstinence and better relationship functioning than typical individual-based treatment and reduces social costs, domestic violence, and emotional problems of the couple’s children.

BCT fits well with 12-step or other self-help groups, individual or group substance abuse counselling, and recovery medications.

For more information about relationships and couples counselling please view the Relationship problem Pages of this website.

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Behavioural Couples Therapy

Behavioural Couples Therapy for Substance Abuse (BCT) is a family-based treatment approach for substance- and alcohol-abusing couples and their families. The assumption underlying BCT is that therapeutic interventions that are designed to address substance abuse problems while concurrently dealing with a patient's family and relationship issues may provide a significant benefit because family and relationship factors appear to play a critical role in a patient’s abstinence from substance abuse and relapse after treatment. Involvement of intimate partners in the therapeutic process could increase the success of treatment and reduce the risk of relapse.

Patients are required to remain abstinent from drugs and alcohol through a sobriety contract, which is verbally agreed to and is reinforced with the help of the patient’s significant other. Patients are taught communication skills such as active listening and expressing feelings directly. They are also taught Cognitive Behavioural Therapy skills to: cope with exposure to drugs, identify high-risk situations, deal with cravings, and confront thoughts of use. Couples are encouraged to find positive behaviours and enjoyable activities that can be shared together to increase relationship satisfaction.

BCT Treatment Methods

Meetings usually last 60 minutes and include individual, group, and couples sessions. BCT consists of three phases: orientation, primary treatment, and discharge.

During the 4-week orientation phase, basic medical information and history are collected. Patients attend the individual and group therapy sessions during this phase.

The primary treatment phase lasts 12 weeks. Couples therapy sessions are added to the ongoing individual and group sessions.

During the 8-week discharge phase, patients attend only individual therapy sessions.

BCT sees the substance abusing patient with the spouse to build support for sobriety. The therapist arranges a daily "sobriety contract" in which the patient states his or her intent not to drink or use drugs that day (in the tradition of one day at a time), and the spouse expresses support for the patient's efforts to stay abstinent.

An option for those alcoholic patients who are medically cleared and willing, daily Antabuse ingestion, witnessed and verbally reinforced by the spouse, also is part of the sobriety contract. The spouse records the performance of the daily contract on a calendar provided by the therapist. Both partners agree not to discuss past drinking or fears about future drinking at home to prevent substance-related conflicts that can trigger relapse. Instead, they reserve these discussions for the therapy sessions.

At the start of each BCT couple session, the therapist reviews the sobriety contract calendar to see how well each spouse has done their part. If the sobriety contract includes 12-step meetings or urine drug screens, these are also marked on the calendar and reviewed. The calendar provides an ongoing record of progress that is rewarded verbally at each session. The couple performs the behaviours of their sobriety contract in each session to highlight its importance and to let the therapist observe how the couple does the contract.

Using a series of behavioural assignments, BCT increases positive feelings, shared activities and constructive communication because these relationship factors are conducive to sobriety. For instance, "Catch Your Partner Doing Something Nice" asks spouses to notice and acknowledge one pleasing behaviour performed by their partner every day. In the caring day assignment, each person plans ahead to surprise their spouse with a day when they do some special things to show they care.

Planning and doing shared rewarding activities is important, because research shows that many substance abusers' families have stopped shared activities that are associated with positive recovery outcomes. Each activity must involve both spouses, as well as their children or other adults. In addition, the activities can take place at or away from home. Teaching communication skills can help the alcoholic and spouse deal with stressors in their relationship and in their lives, and this may reduce the risk of relapse.

Relapse prevention is the final activity of BCT. At the end of weekly BCT sessions, each couple completes a continuing recovery plan that is reviewed at quarterly follow-up visits for an additional two years.

Daily Sobriety Contract

You can arrange what we call a daily Sobriety Contract or Recovery Contract. The first part of the contract is the “sobriety trust discussion”. In it, the patient states his or her intent not to drink or use drugs that day (in the tradition of one day at a time).