Transcript behavioral couples therapy for substance use disorders

BEHAVIORAL COUPLES THERAPY FOR
SUBSTANCE USE DISORDERS
Resources:
O'Farrell, T. (1993). Treating alcohol problems: Marital and family
interventions. New York: Guilford.
Ruff S, McComb JL, Coker CJ, Sprenkle DH (2010). Behavioral couples therapy
for the treatment of substance abuse: a substantive and methodological review of
O'Farrell, Fals-Stewart, and colleagues' program of research. Family Process, 49
(4), 439-56.
National Registry of Evidence-based Programs and Practices
(NREPP): a searchable online database of mental health and
substance abuse interventions.
BCT review online at:
http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=134
FAMILY-FOCUSED TREATMENT APPROACHES
Engaging client /couple / family
Deciding on therapy parameters & goals -assessment
“Intervention” approach
Working with spouses/partners without IP, with intent of
helping IP or drawing IP into treatment
Working with spouses/partners without IP
Self-help group referrals
FAMILY-FOCUSED TREATMENT APPROACHES
• Family Models
• family disease - a parallel process
• family systems
- substance seen as “organizing principle”
- symptom may not be the problem
- interconnectedness, reciprocity, homeostasis
• behavioral couples / family
- substance use viewed as problem behavior
- focus on both recovery and relationships
- The Counseling for Alcoholics’ Marriages
(CALM) Project --- example of BCT
Behavioral Couples Therapy for
Alcoholism and Drug Abuse
Background & Introduction
Substance-Focused Methods
Relationship-Focused Methods
Relapse Prevention
Behavioral Couples Therapy for
Alcoholism and Drug Abuse
Purpose of BCT is to increase relationship
factors conducive to abstinence
Daily Sobriety Contract supports abstinence
Behavioral therapy increases positive
activities and constructive communication
Plan for relapse prevention
12-20 couple sessions over 3-6months
BCT fits well with self-help groups,
medications, and other counseling
Studies of BCT for Alcoholism
and Drug Abuse Show
BCT gives more abstinence, happier relationships & fewer separations than IND
Benefit to cost ratio greater than 5:1
Domestic violence is greatly reduced
Children helped more by BCT than IND
BCT improves medication compliance
BCT works with family members
other than spouses
Suitable Cases for BCT
Married or living together relationship
Reside together or reconcile
Not psychotic past 90 days
Not high risk of injurious/lethal violence
? if both are substance abusers
Start after detox, rehab, or no prior Tx
THE FOUR PHASES OF PROJECT CALM
1.
Engaging Alcoholic and Partner
• providing a rationale … and hope
2.
8 - 10 Weekly Couple Sessions
3.
10 Weekly Couples Group Sessions
(group modality optional but better)
4.
Quarterly Follow-up Visits for 24 Months
Weekly Couple Sessions
– developing a sobriety contract
– use of Antabuse or other recovery
meds
– CALM Promises – no threats of
separation, focus on present, and
commit to action via hmwk.
exercises
STRUCTURE OF CALM COUPLES GROUPS
 4-5 couples
- stabilized and appropriate for group
 male and female co-therapist team
- observer for training purposes
 10 weekly two-hour sessions with 10-15 minute
break for refreshments
PROCESS OF CALM COUPLES GROUPS
 Report on homework in first half of each session
 Focus on recovery:
- Sobriety Contract & check of urges to drink or
drug; Crisis intervention PRN
 Skills training and practice
 End with review of homework assignments for
coming week - eliciting commitments
Substance-Focused Methods
Building Support
for
Abstinence
BCT Sobriety Contract
Helps the Couple
Reward abstinence
Reduce distrust and conflict
Refrain from punishing sobriety
BCT Sobriety Contract
Sobriety Trust Discussion
Alcohol/drug abuser states
intention to stay abstinent that day
Spouse thanks alcohol/drug abuser
for efforts to stay abstinent
BCT Sobriety Contract
Daily Sobriety Trust Discussion
Medication (Antabuse, Naltrexone)
to aid recovery
Self-help involvement
Weekly drug urine screens
Calendar to record progress
Other Support for Abstinence
Reviewing urges to drink or use drugs
 Helps identify cues for alcohol or drug use
 Resisting urges builds confidence
Crisis intervention for substance use
 Get substance use stopped ASAP
 Use as a learning experience
Discuss exposure to substances,
including alcohol at home
Relationship-Focused Methods
Increasing
Positive Activities
Increasing Positive Activities
Catch Your Partner Doing
Something Nice
Caring Day Assignment
Shared Rewarding Activities
CATCH YOUR PARTNER DOING SOMETHING NICE
NAME:
Mike
DAY
DATE
MON
4/6
PARTNER’S NAME:
Nancy
PLEASING BEHAVIOR NOTICED
Waited to have dinner with me when
I had to stay late at work
TUES
4/7
Told me she loved me
WED
4/8
Cooked a delicious dinner
THUR
4/9
Was patient with me when I came
home tired and moody from work
FRI
4/10
Enjoyed a walk together
SAT
4/11
Woke me gently and rubbed my back
SUN
4/12
Helped plan a picnic with friends
Increasing Positive Activities
Shared Rewarding Activities
Each partner lists possible activities
Plan one activity each week
Activity can be “date at home”, out with
other couples or families, simple or large
Such activities linked with recovery
Relationship-Focused Methods
Teaching
Communication Skills
Teaching Communication Skills
Listening Skills
Expressing Feelings Directly
Communication Sessions
Negotiating for Requests
Maintenance and
Relapse Prevention
Continuing Recovery Plan
Specifies activities to do to
maintain abstinence and
relationship recovery after
weekly couple sessions end
Maintenance and
Relapse Prevention
Relapse Prevention Plan
Identify high risk situations
and early warning signs
Formulate and rehearse plan to
 Prevent relapse
 Minimize duration and negative
consequences of substance use
if it occurs
RELATED CLINICAL ISSUES
• Screening for Enabling
• Working with partners to:
focus on coping responses, eliminate enabling
- drank / used drugs with, or in presence of, client 95%
- lied or made excuses to family/friends
90%
- gave client money to buy alcohol or drugs
71%
- purchased alcohol or drugs for client
55%
Dealing with Domestic Violence in
Couples Counseling
 Assess Domestic Violence
– Interview as Couple and Separately
– Conflict Tactics Scale
 Assess Current Risk of Lethal/Injurious Violence
– History and Nature of Violence (e.g., verbal, physical,
weapons used?)
– Fear of Recurrence
– Recent Threats of Violence
– Has violence occurred only or mostly when alcoholic is/was
drinking?
Dealing with Domestic Violence
 If Risk of Lethal/Injurious Violence is High:
– Provide Separate Treatment for Alcoholic and
Spouse
– Make a Safety Plan
 If Risk of Lethal/Injurious Violence is NOT High:
– Treat with Caution and Address Violence
Dealing with Domestic Violence
 Address Violence in Couples Counseling:
– Commitment to nonviolence (“No angry touching.”
“No threats.”)
– Review at each session successes and challenges
to keeping nonviolence commitment
– “Time Out” to reduce escalating conflict
– Communication Skills Training
– Written agreement for at least temporary separation
if violence occurs
– Address risk of violence if relapse occurs