The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 3
3 - Somewhat Usable
The intervention has operationalised principles and values and core components that are measurable and observable but does not have a fidelity resource; modifiable components are not identified
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.
Supports - Rating: 3
3 - Somewhat Supported
Some resources are available to support competency development or organisational development but not both
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/).
Evidence - Rating: 5
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
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)
Need
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).
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).
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
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.
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.
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
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.
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.
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).
Financial Support
Training in this therapy typically incurs costs through private providers. Does your organisation have the financial support to provide this?
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
