Behavioural Couples Therapy (BCT) for Substance Use

Core Components

Behavioural Couples Therapy, as a treatment for alcohol and other drug use disorders, assumes the reciprocity between substance use and relationship functionality. It recognises the contribution of substance use to the relationship distress, and the reinforcing effect of relationship dysfunctionality on substance use and relapse. BCT therefore aims to address this ‘reciprocal causality’ by employing active partner involvement for the purpose of addressing specific relationship issues (that may predispose to substance use), or for improving general relationship functioning.

The rationale behind BCT is the better resolution of substance use problems when therapy is delivered to couples (as opposed to individuals), and the concomitant resolution of relationship dysfunction caused by these problems. To facilitate these, BCT is delivered to the individual seeking help from substance use problems and their partner. BCT teaches Cognitive Behavioural Therapy (CBT) skills to enhance coping and self-control strategies in order to promote abstinence from substance use. It also teaches skills to manage substance-use related situations, and strategies to enhance general relationship functioning (e.g. increasing positive activities, enhancing communication, expressing emotions, negotiating requests, and acts of kindness). BCT includes homework components and appreciation exercises, as these provide opportunities for couples to generalise the skills learnt to their everyday lives. One key feature of BCT is a “recovery contract” that includes a daily ritual to promote and reward abstinence (e.g. daily affirmations, completion of activities that support recovery). BCT can be delivered in 12-20 couples sessions, offered weekly over 50-60-minutes. Sessions can be delivered over 3 to 6 months, typically in outpatient settings. Following achievement of abstinence for about 3-6 months, periodic maintenance contacts are scheduled to facilitate continued recovery.

Fidelity

Fidelity is enhanced by ensuring adherence to treatment manual and providing on-going supervision to therapists. Recorded therapy sessions can be rated to assess treatment adherence.

Support for Organisation / Practice

Implementation Support

Implementation support is provided mainly by trained supervisors who support the application of BCT within practice. Support for implementing BCT is limited in NHS services in Scotland.

Start-up Costs

Training is typically provided by private organisations and costs apply.

Building Staff Competency

Qualifications Required

BCT is ideally delivered by mental health professionals (e.g. psychologists, social workers, psychiatrists, counsellors and mental health nurses) with a Masters degree in psychology, social work, or counselling who have existing skills in therapy and working with substance use.

Training Requirements

Practitioners can deliver BCT following supervised training. Training is provided in 5 days through some organisations (e.g., see https://tavistockrelationships.ac.uk/couples-alcohol-dependence) and can be shorter if practitioners have had previous training in working with couples.

Supervision Requirements

It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/).

Theory of Change

BCT is guided by social learning theory. It recognises the role of substance use in the deterioration of relationships and intensification of relationship distress/ interpersonal conflict, as well as the impact of these on substance use reinforcement and relapse. BCT therefore involves active partner participation in the resolution of substance use problems by addressing relationship dysfunction; teaching skills to facilitate and sustain substance use abstinence; and building support for abstinence. These are expected to translate to enhanced relationship function and substance use recovery.  

Research Design & Number of Studies

The best available evidence for BCT in substance use disorders includes two meta-analytic studies that compared BCT to individually-based treatments or interventions delivered without significant-other involvement.

Outcomes Achieved

Compared to control groups who did not receive BCT, the following outcomes were observed;

• Significantly increased abstinence days at posttreatment, short-term (up to 6 months post-treatment), and long-term follow-up (greater than 6 months post-treatment) (3)
• Significantly greater reduction in frequency of substance use and consequences of use at follow-up (from 3 months post-treatment to 1-year post-treatment) (4)
• Significantly improved relationship satisfaction at post-treatment and at follow-up (from 3 months post-treatment to 1-year post-treatment) (4)
• Significantly improved relationship adjustment at post-treatment, short-term (up to 6 months post-treatment), and long-term follow-up (greater than 6 months post-treatment) (3)

Values

Behavioural Couples Therapy, as a treatment for substance use disorder, assumes the reciprocity between substance use and relationship functionality. It recognises the contribution of substance use to the relationship distress, and the reinforcing effect of relationship dysfunctionality on substance use and relapse. BCT is based on social learning theory.

• Do the guiding principle and substance misuse focus of the intervention align with the requirements of your organisation?

Priorities

BCT involves active partner participation in the resolution of substance use problems by addressing relationship dysfunction; teaching skills to facilitate and sustain substance use abstinence; and building support for abstinence. These are expected to translate to enhanced relationship function and substance use recovery. BCT is delivered to couples.

• Is your organisation looking to deliver an intervention that focuses on substance use problems?
• Does the couple-centric focus of BCT align with the priorities of your organisation?

Existing Initiatives

• Does your service currently deliver interventions that address substance use disorders?
• Are existing initiatives practicable and effective?
• Do existing initiatives fit current and anticipated requirements?

Workforce

BCT is ideally delivered by mental health professionals (e.g. psychologists, social workers, psychiatrists) with a Masters degree in psychology, social work, or counselling. BCT can be delivered in 12-20 couples sessions, over 3-6 months. Sessions can be offered weekly, and last about 50-60-minutes. Following achievement of abstinence for about 3-6 months, periodic maintenance contacts are scheduled.

• Does your service have qualified practitioners who are available and interested in delivering BCT?

Technology Support

BCT can be delivered without technology. Availability of technology for recording sessions for fidelity monitoring will be useful, as is access to technology to receive feedback if provided remotely.

• Can your practitioners access technology to record sessions and receive feedback (if provided remotely)?

Administrative Support

BCT is typically delivered in outpatient settings over 12-20 weeks. BCT can be delivered as a stand-alone intervention, or can be used with the 12-step programme and other substance misuse interventions. Administrative support will be needed for scheduling appointments and for integrating BCT with other interventions (if required).

• Does your service have a venue to deliver BCT?
• Will BCT be delivered alone or as part of other treatment programmes?
• Can your service provide administrative support to deliver (BCT alone or as a part of other treatment programmes)?

Financial Support

Training in this therapy typically incurs costs through private providers. Does your organisation have the financial support to provide this?  

Comparable Population

BCT is traditionally delivered to couples in which one member has current alcohol or other drug use disorder, i.e. single problem couple. It has also been evaluated in dual problem couples (i.e. couples both presenting with current alcohol or other drug use disorders).

• Is this comparable to the population your organisation would like to serve?

Desired Outcome

BCT is associated with significant improvement across several outcomes including increased abstinence, reduction in substance use, improved relationship satisfaction, and improved relationship adjustment. Effects have been observed at post-treatment, short-term (up to 6 months post-treatment), and long-term follow-up (greater than 6 months post-treatment).

• Is delivering a couple-centred intervention for substance use disorder treatment a priority for your organisation?
• Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?