1. BEHAVIORAL COUPLES THERAPY FOR SUBSTANCE USE DISORDERS ROB J. ROTUNDA, Ph.D. DEPARTMENT OF PSYCHOLOGY UNIVERSITY OF WEST FLORIDA, PENSACOLA

2. WHY USE COUPLE AND FAMILY THERAPY APPROACHES TO TREAT SUBSTANCE USE DISORDERS? Innovation from individual tx methods JCAHO Most importantly: Family members affected, not just IP Many family members still do care & want to help Family conflict common trigger for relapse Solid relationships important in Relapse Prevention

3. HOW ALCOHOL ABUSE AFFECTS THE FAMILY I. Basic Family Processes Disrupted  Problem-Solving: roles/duties, achieving goals, daily living disrupted  Communication:emotional needs unmet; expression of feelings difficult  Control:chaotic; influence should be firm / constructive, yet flexible II.Other Negative Consequences Affecting Family  Indirect e.g., Loss of job, poor job performance  Directhigher rates of verbal/physical abuse:

5. ALCOHOL AND THE FAMILY RESEARCH SUMMARY ALCOHOLIC FAMILIES MORE DYSFUNCTIONAL THAN CONTROLS BUT SIMILAR TO FAMILIES STRUGGLING WITH OTHER PROBLEMS OR DISORDERS ( final common pathway to family dysfunction ) WET vs. DRY FAMILIES

6. 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

7. FAMILY-FOCUSED TREATMENT APPROACHES Engaging client /couple / family Deciding on therapy parameters & tx goals “ Intervention” approach Working with spouses/partners without IP, with intent of helping IP or drawing IP into treatment Working with spouses/partners without IP: Focus on partners Self-help group referrals

9. 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

10. Suitable Clients for BCT  married or cohabitating (usually 1 year+)  reside together or willing to work on reconciling  not psychotic  not high risk of serious violence  can begin tx after detox or rehab, or no prior treatment

11. 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

12. 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

13. 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

14. GOALS OF PROJECT CALM COUPLES GROUPS 1. Promote sobriety:Sobriety Contract 2. Increase positive activities:Catch Your Partner… SRAs, Caring Day 3. Teach communication skills:Listening; using “I” etc. 4. Negotiate desired changes: Positive Specific Requests 5. Plan for maintenance Relapse prevention of change:skills

15. RELATED CLINICAL ISSUES Screening for domestic violence Working with partners: focus on coping responses, enabling etc. - drank / used drugs with, or in presence of, client95% - lied or made excuses to family/friends90% - gave client money to buy alcohol or drugs71% - purchased alcohol or drugs for client55%

16. BCT OUTCOMES  compared to individual treatment  with added relapse prevention sessions  with women and minority IPs  effects on violence  effects on children  social cost outcomes  with dual-diagnosed clients: - ETOH dependence & PTSD

17. Dealing with Domestic Violence in Couples Counseling Assess Domestic ViolenceAssess Domestic Violence –Interview as Couple and Separately –Conflict Tactics Scale Assess Current Risk of Lethal/Injurious ViolenceAssess 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?

18. Dealing with Domestic Violence If Risk of Lethal/Injurious Violence is High: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:If Risk of Lethal/Injurious Violence is NOT High: –Treat with Caution and Address Violence

19. Dealing with Domestic Violence Address Violence in Couples Counseling: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