Behavioral Couples Therapy for the Treatment of Substance Abuse

Behavioral Couples Therapy for the Treatmentof Substance Abuse: A Substantive andMethodological Review of O’Farrell, Fals-Stewart,and Colleagues’ Program of Research

SARALYNRUFF,M.ED. n,1

JENNIFERL.MCCOMB,PH.D. n,1

CASEYJ.COKER,M.A. n

DOUGLASH.SPRENKLE,PH.D. n

All abstracts are available in Spanish and Mandarin Chinese on Wiley Online Library (http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1545-5300). Please pass this information on toyour international colleagues and students.

Behavioral couples therapy (BCT) is an evidence-based couple therapy interventionfor married or cohabitating substance abusers and their partners. This paper providesreaders with a substantive and methodological review of Fals-Stewart, O’Farrell, andcolleagues’ program of research on BCT. The 23 studies included in this review providesupport for the efficacy of BCT for improving substance use behavior, dyadic adjust-ment, child psychosocial outcomes, and reducing partner violence. This reviewincludes a description of BCT, summaries of primary and secondary outcomes, high-lights methodological strengths and weaknesses, notes barriers to dissemination,suggests future research directions, and provides clinical implications for couple andfamily therapists. Although there are several versions of BCT developed for the treat-ment of substance abuse this paper focuses on the version developed by O’Farrell, Fals-Stewart, and colleagues.

Keywords: Behavioral Couples Therapy; Substance Abuse; Couples Treatment

Fam Proc 49:439–456, 2010

O’Farrell, Fals-Stewart, and colleagues’ program of research on the use of behav-ioral couples therapy (BCT) for the treatment of alcohol and drug abuse has ex-

tended more than three decades and provides extensive support for the efficacy of BCTwith this population. With the exception of one review article published in the Journalof Marriage and the Family (O’Farrell & Fals-Stewart, 2003), the authors’ work hasrarely appeared in couple and family therapy journals. As a result, few couple and

Family Process, Vol. 49, No. 4, 2010 r FPI, Inc.

439

PROCESS

Correspondence concerning this article should be addressed to Saralyn C. Ruff, Child Develop-ment & Family Studies, Purdue University, Fowler Memorial House, 1200 W. State St., WestLafayette, IN 47907. E-mail: [email protected]

nPurdue University, West Lafayette, IN.1Joint first Authors.

http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1545-5300



mailto:[email protected]

family therapists may be aware of BCT, despite the fact that it is perhaps the mostevidence-based relational approach to the treatment of substance abuse.

The purpose of this paper is to provide one of the first independent, critical sub-stantive, and methodological reviews of BCT for the treatment of alcohol and drugabuse. This paper includes a description of BCT, summaries of the primary and sec-ondary outcomes, a methodological critique of the program of research, a review ofdissemination research, and the clinical implications associated with these findings.

BCT

Historically, the substance abuse community viewed addiction as an individual dis-ease, treated with monitored detoxification, individual therapy, and referral to self-helporganizations such as Alcoholics or Narcotics Anonymous (O’Farrell & Fals-Stewart,2006). In the early 1970s, the National Institute on Alcohol Abuse and Alcoholism issueda report to the U.S. Congress identifying couple and family therapy as ‘‘one of the mostoutstanding current advances in the area of psychotherapy of alcoholism’’ (Keller, 1974,p. 161). Researchers recognized alcohol abuse as a systemic problem, impacting couplerelationships, children, family, friends, and society. O’Farrell, Fals-Stewart, and col-leagues developed BCT in response to this movement.

BCT originated from the Harvard Counseling for Alcoholics Marriages Project(Project CALM). Project CALM was developed in the 1980s as one of the first manu-alized behavioral couple treatments for alcohol abuse. The model focused on relationalinterventions to enhance relationship stability and support sobriety. Two funda-mental assumptions of BCT are that partners can reward abstinence and reduction inmarital distress decreases the likelihood of substance abuse and relapse (O’Farrell &Fals-Stewart, 2006). The primary objective of BCT is to help couples modify sub-stance-related interactions to support changing substance-abusing behaviors.

Description of the Model

BCT is typically delivered in a substance abuse treatment center and involves 12–20weekly couple sessions wherein the focus is on couple engagement, supporting ab-stinence, relational-focus, and continuing recovery. Although BCT was initially de-livered in a group context, it is now delivered in a conjoint couple session format. BCTis typically provided in conjunction with other treatments, including 12-step groups(Alcoholics and Narcotics Anonymous) and individual therapy. A detailed descriptionof the BCT intervention is provided in O’Farrell and Fals-Stewart (2006).

Couple engagement

The initial goal of the BCT therapist is to engage the non-substance-abusingpartner in the therapy process. The therapist gains permission from the substance-abusing client to contact the partner and encourages them to come in for a conjointinterview. During this initial session, the therapist asks the couple to make a com-mitment to therapy, and to not threaten separation for the duration of treatment.

Supporting abstinence

Once both partners are engaged in therapy, the clinician provides the couple withdaily sobriety contracts. These require that the couple commits to maintainingsobriety on a daily basis, attending a 12-step program, and having trust discussions

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wherein the substance-abusing partner expresses an intent to remain abstinent whilethe non-substance-abusing partner offers support. To augment the daily contract,some clients take medication, such as Antabuse (disulfiram), which causes aversivesymptoms when taken with alcohol.

Relational focus

The primary relational goals of BCT are to improve couple communication andincrease positivity and commitment. To achieve these goals, the therapist teacheseffective listening, conflict resolution, and problem-solving skills. Homework assign-ments are used throughout treatment to facilitate goal achievement. For example,caring day is a homework assignment encouraging each partner to initiate affec-tionate interactions.

Continuing recovery stage

During this stage, couples develop a continuing recovery plan that details how theyare going to promote sobriety posttreatment. The BCT clinician helps couples foreseefuture hurdles regarding relapse and practice talking about what to do if relapseoccurs. The therapist may schedule posttermination appointments with the couple forup to 5 years.

ARTICLE SELECTIONCRITERIA

The 23 studies included in this review met the following criteria: (1) published inpeer-reviewed journals; (2) written in English; (3) examined Fals-Stewart, O’Farrell,and colleagues’ version of BCT; (4) examined primary and/or secondary outcomesof BCT; and/or (5) were directly related to the dissemination or cost effectivenessof BCT.

PsychINFO, Medline, ERIC, PubMed, and the BCT website were searched for ar-ticles that fulfilled the inclusion criteria. Search terms included ‘‘BCT’’ ‘‘behavioralcouples therapy’’ ‘‘Fals-Stewart’’ ‘‘O’Farrell’’ AND ‘‘substance abuse’’ ‘‘drug abuse’’‘‘alcohol abuse’’ AND ‘‘family’’ ‘‘couples’’ ‘‘partners.’’ Manual searches of referencelists and treatment manuals were used to identify any articles that were not identifiedin the computer-based search. The search strategies resulted in the identification of 23studies that met the inclusion criteria (see Table 1).

SUBSTANTIVEREVIEW

This substantive review of the literature on the use of BCT for the treatment ofsubstance abuse will provide a summary of the efficacy of BCT on primary and sec-ondary outcome areas, cost-effectiveness of BCT, and dissemination-related research.

Primary Outcomes

Marital adjustment

BCT has consistently yielded significant improvements in marital adjustment andbetter outcomes than individual- and couple-based comparison groups (Fals-Stewart,Birchler, & Kelley, 2006; Kelley & Fals-Stewart, 2008). Pre- to post-effect sizes rangefrom d¼ 0.31 to 1.55 with an average effect size of d¼ 0.77 (a list of all effect sizes isavailable from the authors). There is evidence that the gains in marital adjustmentfollowing BCT are evident at 1- and 2-year follow-ups with effect sizes ranging from

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Fam. Proc., Vol. 49, December, 2010

d¼ 0.05 to 1.07 with an average effect size of d¼ 0.45 (Kelley & Fals-Stewart, 2008;O’Farrell, Choquette, & Cutter, 1998). For some couples, especially those with moresevere marital and substance abuse problems before treatment, the gains in maritaladjustment immediately following BCT decrease or disappear over time (Fals-Stewart, Birchler, & O’Farrell, 1996; Winters, Fals-Stewart, O’Farrell, Birchler, &Kelley, 2002). For example, a 2-year follow-up study found that the BCT group was nolonger superior to the interactional couple therapy (ICT) comparison group d¼ .05,but remained superior to the individual counseling comparison group d¼ .27(O’Farrell, Cutter, Choquette, Floyd, & Bayog, 1992).

In an attempt to sustain improvements in marital adjustment over time, O’Farrell,Choquette, Cutter, Brown, and McCourt (1993) added relapse prevention (RP) ses-sions to the BCT intervention. A comparison of the efficacy of BCT-only versus BCTplus RP (15 additional sessions in the 12 months posttreatment) found that coupleswho received the BCT plus RP intervention maintained improvements in marital

TABLE 1

List of Articles Included in Substantive Review

Primary Secondary Other

Author/year AA DA RA CP IPV CA DISS FU

O’Farrell et al. (1985) X XO’Farrell et al. (1992) X X 2, 6, 12,

18, 24O’Farrell et al. (1993) X X 3, 6, 12O’Farrell and Murphy (1995) X X 12O’Farrell, Choquette, Cutter, Floyd,Bayog, and Brown (1996)

X X

O’Farrell, Choquette, Cutter, Brownet al. (1996)

X X

Fals-Stewart et al. (1996) X X 3, 6, 9, 12Fals-Stewart et al. (1997) X X 3, 6, 9, 12O’Farrell et al. (1998) X X 3, 6, 12,

18, 24, 30O’Farrell et al. (1999) X X 24Fals-Stewart et al. (2000) X X 3, 6, 9, 12Fals-Stewart et al. (2001) X XFals-Stewart and Birchler (2001) XFals-Stewart and Birchler (2002) X X X 3, 6, 9, 12Fals-Stewart et al. (2002) X X X 3, 6, 9, 12Kelley and Fals-Stewart (2002) X X X X 3, 6, 9, 12Winters et al. (2002) X X 3, 6, 9, 12Fals-Stewart et al. (2004) XO’Farrell et al. (2004) X X X 6, 12, 18,

24Fals-Stewart et al. (2005) X X X 3, 6, 9, 12Fals-Stewart et al. (2006) X X X 3, 6, 9, 12Kelley and Fals-Stewart (2007) X X X 3, 6, 9, 12Kelley and Fals-Stewart (2008) X X X 3, 6, 9, 12

Note. Primary¼primary outcome; Secondary¼ secondary outcome; AA¼ alcohol abuse; DA¼drugabuse; RA¼ relationship adjustment; CP¼ children’s psychosocial functioning; IPV¼ intimatepartner violence; CA¼ cost analysis; DISS¼dissertation related research; FU¼ follow-up (reportedin months posttreatment).

FAMILY PROCESS442 /


adjustment through a 24-month follow-up (for male partners d¼ .57, for femalepartners d¼ .39) (O’Farrell et al., 1998). Couples who received the BCT-only inter-vention did not maintain improvements. To date, the inclusion of RP sessions in thetreatment of drug abuse has not been evaluated.

Substance use outcomes

Substance use is the second primary outcome used to evaluate BCT’s efficacy. Al-though the majority of the empirical studies of BCT are focused on alcohol use as theprimary outcome, there is evidence for BCT’s efficacy with drug abuse (Fals-Stewart,O’Farrell, & Birchler, 2001; Kelley & Fals-Stewart, 2007; Winters et al., 2002).

BCT has consistently resulted in improvements in drinking (Fals-Stewart et al.,2006; Fals-Stewart, Klosterman, Yates, O’Farrell, & Birchler, 2005) and drug useoutcomes (Fals-Stewart et al., 2000, 2001; Kelley & Fals-Stewart, 2007). There isevidence that BCT is more effective at improving substance use outcomes than otherindividual and couple (couple education only control groups, ICT groups) comparisontreatments (Fals-Stewart et al., 2005, 2006). Specifically, effect sizes range fromd¼ 0.01 to 1.65 posttreatment (average d¼ 0.55) and from d¼ 0.20 to 0.83 at12-month follow-up (average d¼ 0.45).

Similar to marital adjustment outcomes, there is evidence that improvements indrinking and drug use following BCT are not sustained over time (O’Farrell et al.,1992, 1998; Winters et al., 2002). Winters et al. (2002) found that female drug-abusingclients who received BCT reported more days abstinent compared with participants inindividual-based treatment (IBT). These results dissipated at 12-month follow-up,and between group differences (BCT vs. IBT) in days abstinent were no longer sig-nificant (d¼ .37). However, other studies, examining the use of BCT with female al-cohol-abusing clients, noted small to large effect sizes (d¼ 0.37–0.75) for BCT at 12-month follow-up compared with individual treatment and psychoeducation compari-son groups (Fals-Stewart et al., 2006; Winters et al., 2002).

Moreover, research shows that the inclusion of RP sessions improves drinkingoutcomes (O’Farrell et al., 1998). Effect sizes of BCT compared with BCT plus RP ared¼ 0.60 at 12-month follow-up and d¼ 0.53 at 18-month follow-up (O’Farrell et al.,1998). The beneficial effect of the inclusion of RP sessions begins to dissipate by 24-month follow-up d¼ .15.

Secondary Outcomes

Intimate partner violence (IPV)

Approximately two thirds of married or cohabitating men seeking treatment foralcohol abuse, or their partners, report at least one incident of male-to-female violencein the past year (O’Farrell, Fals-Stewart, Murphy, & Murphy, 2003). O’Farrell andMurphy (1995) examined how involvement in BCT influenced IPV among alcoholabusers. Despite a significant decrease in the prevalence and frequency of violence inthe year after BCT, the rates of violence among the sample remained significantlyhigher than the matched comparison group (a demographically matched sample ofnonalcoholic married couples from the National Violence Re-survey). Additionalanalysis revealed that the prevalence and frequency of violence following BCTwas significantly related to drinking outcomes. Men classified as remitted alcoholics(those who reported some alcohol use but did not meet criteria for substance abuse)



did not have higher incidences of violence than the comparison sample; but relapsedalcoholics did. A 2-year follow-up of O’Farrell and Murphy’s study (1995) found thatthe alcoholic sample (as a whole) was not significantly more violent than the com-parison group, d¼ .31 (husband-to-wife violence) (O’Farrell, Van Hutton, & Murphy,1999).

Subsequently, Fals-Stewart, Kashdan, O’Farrell, and Birchler (2002) examined theefficacy of BCT for reducing IPV among drug-abusing clients. At 12-month follow-up,BCT couples reported a significant reduction in male-to-female physical aggression(18% vs. 43%), when compared with couples in the IBT group (unchanged at 43%).Further analysis showed that dyadic adjustment, frequency of heavy drinking, andfrequency of drug use posttreatment mediated the relationship between the treatmentcondition and reduced IPV at follow-up. Subsequent studies provide evidence thatBCT is associated with a decline in the frequency of IPV among female alcohol abusersand their non-substance-abusing male partners at 12-month follow-up, d¼ .38 (male-to-female) and d¼ .57 (female-to-male) (Fals-Stewart et al., 2006). Further, the use oftargeted behaviors is related to decreases in violence; this association is mediated byimprovements in drinking and marital outcomes (O’Farrell, Murphy, Stephan, Fals-Stewart, & Murphy, 2004).

Children’s psychosocial functioning

Children living with a parent who abuses substances are at risk for a range ofbehavioral, emotional, and social problems (Johnson & Leff, 1999). Kelley andFals-Stewart (2002) compared the efficacy of BCT, an equally intensive IBT, and apsychoeducation attention control treatment (PACT) for the treatment of paternalsubstance abuse. The BCT treatment group had better drinking and relationshipoutcomes than the comparison groups from posttreatment through the 12-monthfollow-up (effect sizes ranged from d¼ 0.63 to 0.90 for marital adjustment and d¼ 0.17to 0.63 for percent days abstinent [PDA]). Furthermore, children of fathers whoparticipated in BCT had higher levels of psychosocial functioning (as measured bymothers) than children whose fathers participated in the other two treatment con-ditions (IBT and PACT). For both alcohol and drug-abusing couples, the effect oftreatment group on children’s psychosocial adjustment was mediated by PDA andparents’ dyadic adjustment score. More recently, Kelley and Fals-Stewart (2007, 2008)found that BCT for the treatment of paternal substance abuse significantly reducedexternalizing symptoms but that developmental stage moderated this effect. Therewas a stronger association between parental substance abuse and externalizingsymptoms for children and preadolescents compared with adolescents.

Cost-Effectiveness and Cost-Benefit Analyses

Owing to the extensive social and legal costs associated with alcohol and drug abuse,cost analyses that highlight the economic benefits of relational interventions for thetreatment of substance abuse are an important component of the development, andimplementation, of systemically based treatment models. O’Farrell, Choquette, Cut-ter, Brown et al. (1996) explored the cost-benefit and cost-effectiveness of (1) indi-vidual counseling, (2) individual counseling plus BCT, and (3) individual counselingplus ICT for the treatment of alcohol abuse. Individual treatment plus group BCTresulted in decreases in health care and legal costs (average savings of US$6,700 per

FAMILY PROCESS444 /


person), a positive cost offset, and a benefit-to-cost ratio 41, indicating that the cost ofsavings exceeds the cost of treatment delivery (US$8.64 savings for each dollar spenton treatment delivery). The cost-effectiveness analyses indicated that the individualplus group BCT intervention was less cost-effective than individual treatment (due tolower costs associated with treatment delivery), only slightly more cost-effective thanindividual plus ICT on producing abstinence, and all three treatments were equallycost-effective for marital adjustment.

O’Farrell, Choquette, Cutter, Brown et al. (1996) compared group BCT to groupBCT plus RP sessions for the treatment of alcoholism. Cost-benefit analysis measuredcosts of treatment delivery and health and legal service utilization for 12 months priorand after treatment. They found that both treatments resulted in cost savings(US$5,053.00 per case for BCT and US$3,365 for BCT plus RP) and a benefit-to-costratio of US$5.97 for BCT-only and US$1.89 for BCT plus RP. Adding RP sessionsimproved drinking and relationship outcomes, but did not result in cost savings due tothe additional cost incurred by delivering RP sessions. BCT-only was more cost ef-fective at producing abstinence but both interventions were equally cost-effective onoutcomes of marital adjustment.

Fals-Stewart, O’Farrell, and Birchler (1997) conducted a cost outcome analysis ofBCT compared with an IBT for drug abuse. Results showed that, following treatment,male substance abusers in the BCT treatment condition experienced notable reduc-tions in costs related to substance abuse-related health case, criminal justice systemutilization, income from illegal sources, and public assistance (US$1.00 spent on BCTresulted in US$5.00 in cost savings). The total cost savings in the 12-month follow-upfor participants in the BCT treatment group was almost US$5,000.00 greater than forthose who received IBT only.

More recently, Fals-Stewart et al. (2005) evaluated the cost-effectiveness of a briefversion of BCT (6 BCT sessions and 12, 12-step group sessions) compared withstandard BCT (12 BCT sessions and 12, 12-step group sessions), IBT, and PACT forthe treatment of alcohol abuse. The brief version of BCT (BRT) was significantly morecost-effective than the standard BCT, IBT, or PACT. In this study, researchers de-livered the brief and standard versions of the BCT intervention conjointly rather thanin a group context.

Dissemination Research

Three of the studies included in this analysis focused on the dissemination of BCT.Fals-Stewart and Birchler (2001) conducted a national survey on the use of coupletherapy interventions in substance abuse treatment programs. They found thatamong the random sample of 398 program administrators in outpatient substanceabuse treatment centers in the United States, only 27% reported using couple-basedtreatments, o5% reported using behaviorally oriented couples therapy, and 0% usedBCT. Following survey completion, participants were sent a two-page summary ofresearch on BCT. Based on the information they received about BCT, investigatorsasked if participants would consider implementing the model. More than 70% saidthat they would not use BCT due to the number of sessions required, the intensity ofthe treatment, and the perception that therapists need postgraduate training inpsychotherapy.



In response to the barriers identified in the 2001 study, Fals-Stewart and Birchler(2002) evaluated whether bachelor’s level counselors could deliver BCT as effectivelyas master’s level counselors could. The findings confirmed that bachelor’s leveltherapists could deliver BCT equivalently as evaluated by couples’ satisfaction withtreatment, marital happiness during treatment, dyadic adjustment, and PDA. Al-though a blinded rater evaluated master’s level therapists as more competent becauseof their ability to diverge from the treatment manual when necessary, this did nottranslate into improved outcomes.

A more recent study by Fals-Stewart, Logsdon, and Birchler (2004) used a quali-tative methodology to explore the barriers and facilitators experienced by community-based substance abuse programs previously involved in BCT clinical trials. Numerousbarriers were identified at the client (i.e., fear of partner criticism and blame),counselor (i.e., turnover rates), supervisor (i.e., traditional philosophical beliefs thataddictions are best treated individually), and administration level (i.e., lack of thirdparty reimbursement). These barriers resulted in only one of the five agencies con-tinuing to use BCT after the completion of the clinical trials.

METHODOLOGICALREVIEW

The methodological review of this program of research includes a critical evaluationof methodologies used in the 21 outcome studies reviewed to facilitate interpretationof the substantive findings and inform research recommendations (see Table 2).Specifically, because the majority of articles included in this review are clinical trials,the focus will be on variables considered when evaluating randomized controlledtrials.

Sample Characteristics

The generalizability of the findings from a program of research are influenced bythe heterogeneity of the participants included in the evaluation of the intervention.The participants in the reviewed articles are primarily Caucasian, in their late thirtiesto early forties, married for approximately 7–10 years, heterosexual, and with no otherpsychopathology. Participants in the alcohol abuse studies are primarily middle orupper class, whereas participants in the drug use studies are primarily low or middleclass. Although the latter studies in this program of research show evidence of in-creasing variability in participant characteristics (i.e., increased percentages of mi-nority participants), they fall short of representing the heterogeneity of substanceabusers in the United States (U.S. Department of Health, 2005).

For the reviewed articles, the inclusion criteria consistently required participantsto: commit to their relationship and treatment; agree not to threaten separation forthe duration of treatment; be between 20 and 60 years of age; married for at least 1year, or living with a significant other in a common-law relationship for at least 2years; and commit to refrain from substance use. These criteria may have precludedcouples with heightened relational distress at baseline from participating (i.e., Fals-Stewart et al., 2005). Further, although not explicitly noted by the authors, the in-clusion criteria precluded same-sex couples from participating, as they were notincluded in any of the studies reviewed.

Participants were excluded if the husband or wife met the Diagnostic and Statis-tical Manual (DSM IV-TR) criteria for an organic mental disorder, schizophrenia,

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delusional disorder, or another psychotic disorder (American Psychiatric Association,2000), or if the partner had been diagnosed or received substance abuse treatmentwithin the previous 6 months. These criteria potentially limit the generalizability ofBCT’s findings due to the high prevalence of substance abuse among those withmental illness (Regier et al., 1990) and dual addiction. For example, Fals-Stewart et al.(2001) reported that 80% of the participants recruited were excluded because coupleswere dually addicted and/or partners met criteria for a psychotic disorder.

In reviewing how sample characteristics influence external validity, it is also nec-essary to examine the representation of gender and ethnicity. Only two of the outcomestudies included in this review examined the effects of BCT with female drug-abusingclients and their male partners (Fals-Stewart et al., 2006; Winters et al., 2002). Thesefemale samples may not represent the majority of female substance abusers sincemany women were excluded from these studies because they were not in a stablecommon law relationship/marriage, or because their partner also met the criteria forsubstance abuse. In Winters et al. (2002), 202 women were either excluded or chosenot to participate, resulting in a final sample size of 75. In Fals-Stewart et al. (2006),127 women were excluded (final sample N¼ 138). Individuals not included in thesestudies were significantly younger, had fewer days of abstinence in the year precedingtreatment, and reported greater relational conflict than those included in the study.

Sample demographics related to ethnicity also influence the external validity of thefindings. Overall, sample statistics on ethnicity were relatively consistent across thereviewed BCT research. In general, samples were gathered from the northeasternUnited States and represented a Caucasian majority (see Table 2). Of note, re-searchers recruited participants from ethnically diverse areas of the country; how-ever, this diversity is not reflected in the sample demographics of BCT studies (U.S.Census Bureau, 2000). Among samples, researchers commonly identify three domi-nant ethnic groups: White, African American, and Hispanic. The articles reviewedinclude no representation of Asian Americans, or those who identify with two or moreethnicities, and minimal representation (0.4–2%) of Native Americans (Kelley & Fals-Stewart, 2007, 2008; O’Farrell et al., 2004). Overall, the lack of representation of et-hno-cultural groups in these studies is concerning since a disproportionate number ofminorities (e.g., Native Americans, Latinos, African Americans) struggle with sub-stance abuse (French, Finkbiner, & Duhamel, 2002; Grant et al., 2003; U.S. Depart-ment of Health, 2005).

Sample Size and Random Assignment

Although the initial investigation of BCT with alcohol-abusing clients includedsmall sample sizes, every study in this program of research included more than 30couples and, over time, the sample sizes have increased up to 303 couples (see Table 2).All of the outcome studies included in this review used random assignment to treat-ment condition. Despite limited reporting of the randomization process, researchersconsistently conducted statistical analyses to confirm that the treatment groups werenot significantly different. This is a methodological strength since random assignmentis intended to equally diffuse person characteristics across groups so that group dif-ferences can be attributed to the intervention (Light, Singer, & Willet, 1990).

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Comparison Groups

Thirteen of the reviewed outcome studies included at least one comparison groupwith dosages equivalent to the BCT condition (see Table 2). The eight studies that didnot include a dosage equivalent comparison group are those that examined RP,compared differential gains for children of substance-abusing parents, or examinedIPV using a matched comparison group. Comparison groups include, but are notlimited to: IBT, standard BCT (when evaluating the efficacy of a brief version of BCTand BCT plus RP sessions), ICT (used in either group or individual couple formats),and PACT.

ICT is a commonly used treatment for alcoholic clients involving group sessionsfocused on problem solving and communication. In comparison with BCT, this in-tervention does not use behavioral techniques (e.g., homework assignments, sobrietycontracts) or have treatment manuals. ICT emphasizes mutual support, problemsolving, and relational feedback from the therapist and group members (O’Farrell,Cutter, & Floyd, 1985). PACT, another frequently used comparison group, typicallyinvolves six individual therapy sessions alternating with six couple-based sessionsproviding psychoeducation on substance abuse. To control for treatment effects, cli-ents in all comparison groups are required to refrain from additional substance abusetreatments (with the exception of Alcoholics and Narcotics Anonymous).

With the exception of ICT and PACT, BCT has only been compared with IBTs.Moreover, because ICT and PACT are nonbehavioral groups and educational controlcomparison groups, respectively, current research findings do not provide evidencethat BCT is more effective than other equally well-developed and evidence-basedcouple-based treatment models.

Standardized Treatment

O’Farrell and colleagues have over 15 detailed treatment manuals to guide inter-vention (e.g., group BCT, 12-session BCT, 24-session BCT). BCT outcome researchconsistently cites use of these manuals. The use of these treatment manuals, pairedwith checklists completed by clinicians and supervisors, supports treatment fidelity.Moreover, all reviewed outcome studies provided adequate detail about use of themanuals as well as therapist supervision and training. Thirteen of the 21 outcomestudies reviewed measured adherence to treatment protocols. This included inde-pendent observers’ review of case notes and/or manipulation checks involving ob-servation of live, audio-taped, or video-recorded sessions (see Table 2).

OutcomeMeasures

BCT research consistently uses multiple outcome measures, with established reli-ability and validity, to evaluate each construct (i.e., marital adjustment, substanceuse). Measures of substance abuse include, but are not limited to: The Addiction Se-verity Index (McLellan, Luborsky, O’Brien, & Woody, 1980); The Timeline Follow-back (TLFB) Interview (Sobell & Sobell, 1996); and weekly urine and blood tests.Some relational adjustment measures include: The Locke-Wallace Marital Adjust-ment Test (Locke & Wallace, 1959); Areas of Change Questionnaire (Weiss, Hops, &Patterson, 1973); and The Responses to Conflict Scale (Birchler & Fals-Stewart,1994).



In addition to using multiple outcome measures, researchers included nonreactive-dependent variables that are less subject to measurement error and increaseconfidence in the validity of the treatment. These measures include substance-relatedincarcerations, hospitalizations, and days spent in halfway houses. To identify sec-ondary gains with children, BCT commonly utilizes mother-report on the PediatricSymptom Checklist, a 35-item well-validated questionnaire (Jellinek & Murphy,1990). In recent years, BCT has collected father and teacher report (Kelley & Fals-Stewart, 2007, 2008), but only with families with substance-abusing fathers.

Four of the five reviewed articles examining IPV used Straus’ (1990) ConflictTactics Scale, a widely used and well-validated scale that uses a 7-point scale to assessfrequency of IPV. The most recent article, Fals-Stewart et al. (2006), used the TLFB-Spousal Violence scale that has established validity and test-retest reliability (Fals-Stewart, Birchler, & Kelley, 2003). Across these five studies, only one measure wasused to assess IPV in the preceding 12 months and there were no measures of emo-tional or sexual violence. All of the studies that used alcoholic samples examined bothfemale- and male-perpetrated violence. The examination of IPV with drug-abusingclients only examined female report of male-to-female physical violence (Kelley et al.,2002).

Follow-Ups

Inclusion of follow-up data provides evidence for the efficacy of BCT over time.Aside from the initial outcome studies on the efficacy of BCT alcohol and drugtreatment, respectively (Fals-Stewart et al., 1996; O’Farrell et al., 1985), every out-come study included a follow-up (see Table 1).

Therapist and SettingVariables

To date, BCT has paid little attention to therapist or setting-related factors. Withthe exception of the study by Fals-Stewart and Birchler (2002) that compared thedifference between Bachelor and Master’s level therapists, none of the studies re-viewed examine differential therapist outcomes. Moreover, all reviewed outcomestudies were conducted at either community treatment centers or community-basedclinics. To date, the efficacy of BCT delivered in private practice settings is unknown.

Lastly, in the reviewed articles, there is no mention of empirical evaluation con-sidering external factors influencing participation. Although no studies offered in-centives to participate, many of the BCT studies with drug-abusing clients reportedthat parole officers referred clients. For example, Fals-Stewart et al. (1996) reportedthat 85% of their sample was referred to treatment by the criminal justice system,which might have influenced retention rates and motivation to change. Consequently,additional analyses are required regarding how such factors may have influencedmotivation and low attrition. With respect to attrition, this is of particular interestsince none of the reviewed articles reported significant attrition.

Research Recommendations

Attention to mechanisms of change

In the empirical literature there is increasing attention placed on studying un-derlying mechanisms and processes by which relationships between variables exist

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(MacKinnon & Luecken, 2008). Analyses that focus on identifying mediators (‘‘how’’and ‘‘why’’ treatment works) and moderators (‘‘when’’ or ‘‘for whom’’ treatmentworks) of treatment are an important component of a comprehensive program ofresearch.

Some preliminary findings have emerged about the mechanisms of change associ-ated with BCT. Mediation analyses have revealed that the association between greateruse of treatment-targeted behaviors and better outcomes was mediated by reduceddrinking and improved relationship adjustment (O’Farrell et al., 1998, 2004).Dyadic adjustment (Fals-Stewart et al., 2002; Kelley & Fals-Stewart, 2002; O’Farrellet al., 2004); frequency of heavy drinking and drinking in the year posttreatment(Fals-Stewart et al., 2002); PDA (Kelley & Fals-Stewart, 2002); and use of treatment-targeted behaviors (O’Farrell et al., 1993) have also been identified as mediators oftreatment outcomes.

Research on BCT has identified a number of moderators. For example, analyseshave revealed that children’s developmental stage moderates the association betweenparent’s functioning and children’s adjustment (Kelley & Fals-Stewart, 2007, 2008).More specifically, the association between parents’ functioning following treatmentand children’s adjustment was stronger for children than for their adolescent siblings.Marital problem severity and pretreatment drinking behavior (measured by numberof light drinking days in the year before treatment) also moderate treatment outcomes(O’Farrell et al., 1993, 1998). Participants with more severe marital problems andpretreatment drinking behavior have better outcomes if they receive the BCT plus RPintervention compared with standard BCT.

These findings highlight that a limited number of variables have been examined aspotential mediators or moderators of treatment. There is a need for future research toexpand the variables tested as mechanisms of change to include: family, patient,therapist, client-therapist relationship, and treatment characteristics. A better un-derstanding of the mechanisms of change will facilitate identifying the critical ele-ments of BCT and potential differential gains with specific populations, therebydifferentiating BCT from other treatment models.

Further analysis of secondary gains

BCT yields secondary gains including decreased IPV and improved child psycho-social functioning (Fals-Stewart & Birchler, 2002; Kelley & Fals-Stewart, 2002). Al-though there is some evidence of the factors associated with improved secondaryoutcomes (Kelley & Fals-Stewart, 2002), additional research is required to explorewhether the secondary effects of BCT are due to specific interventions, abstinencefrom substance use, and/or the relational focus of treatment. Further analysis is alsorequired to learn if IPV findings are generalizable to dually addicted couples, femaledrug-abusing clients, or female substance-abusers who perpetrate violence. Overall,further analysis may inform the development of clear guidelines for the use of BCTwith violent couples.

Attention to therapist factors

Assessing and reporting the relative outcomes of therapists would help ensure thatpossible therapist effects, independent of the treatment itself, are not primarily res-ponsible for therapeutic change. Furthermore, future research is required to elucidate



the influence of the client-therapist relationship on treatment outcomes, which issomething overlooked in current empirical literature.

It is also possible that allegiance effects significantly influenced the outcomes ofexisting clinical trials. Researchers not affiliated with O’Farrell and Fals-Stewartshould replicate these studies to evaluate the efficacy of BCT, using therapists,supervisors, and researchers without a strong allegiance to the treatment model.

Diversity and differential outcomes

Owing to the heterogeneity and the high rates of comorbidity among substance-abusing populations, we recommend future inclusion of a more diverse sample ofparticipants reflective of the complex couples that typically present for substanceabuse treatment (U.S. Department of Health, 2005). Specifically, future studiesshould focus on female clients, dually addicted couples, same-sex couples, and diverseethnic groups to highlight how these characteristics influence treatment outcomes. Itis imperative that samples be stratified and/or that studies be conducted to examinethe efficacy of BCT with specific ethnic populations. Otherwise, the findings from thisprogram of research will continue to have limited generalizability, which poses anotable barrier to the dissemination of BCT among diverse ethnic populations.Moreover, further assessment of moderation and meditational hypotheses examiningdifferential outcomes between clients addicted to drugs, alcohol, and/or both would beuseful in informing real-world treatment practices and in enabling direct links totreatment.

Evaluation of RP

The use of RP sessions helps sustain improvements in marital adjustment anddrinking outcomes following treatment for alcohol abuse (O’Farrell et al., 1998;O’Farrell & Fals-Stewart, 2003). The current authors found no BCT research on theefficacy of RP sessions for the treatment of drug abuse; additional research shouldfocus on RP with drug abuse.

Dissemination research

Dissemination appears to be one of the greatest challenges facing this program ofresearch (Fals-Stewart & Birchler, 2001; Fals-Stewart et al., 2004). There should beresearch conducted to further examine the barriers to dissemination and inform thedevelopment of strategies to address these barriers.

Comparison with group BCT

BCT was originally designed to be delivered in a group context, and this version ofBCT was evaluated in the early studies (O’Farrell et al., 1985). To date, BCT re-searchers have not compared the efficacy of group-based BCT versus the currentlyused conjoint design. This research could be useful in addressing cost and resourceallocations, as well as identifying barriers to implementation.

Comparison with other couple therapy treatments

Future research must compare BCT to other evidence-based couple therapytreatments, such as Epstein and McCrady’s (1998) model of BCT used for the treat-ment of substance abuse. If BCT emerges as more efficacious than other

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evidence-based couple therapy treatments, this would further support the efficacy ofthis model for the treatment of substance abuse.

CLINICAL IMPLICATIONSAND CONCLUSIONS

Owing to the prevalence of substance abuse and the impact that it has on families,we encourage therapists who work with couples to become familiar with evidence-based, systemic models for the treatment for substance abuse such as BCT. In anattempt to bridge this gap between research and practice, the authors will highlightthe key clinical implications derived from BCT’s program of research, which include:(1) the efficacy of couple-based treatment for substance abuse; (2) the broader sys-temic impact of couple-based treatment for substance abuse; and (3) enhanced out-comes associated with inclusion of RP sessions. It is important to note that due tolimitations imposed by the inclusion criteria, these clinical implications are derivedfrom studies with relatively homogeneous samples and therefore cannot be general-ized to all couples and families.

1. Efficacy of couple-based treatment for substance abuse: Couple-based treatmentfor alcohol and drug abuse were consistently more efficacious than equal doses ofindividual treatment (e.g., Fals-Stewart et al., 2005, 2006), providing support forthe use of couple therapy for the treatment of drug and alcohol abuse.

2. Broader systemic impact of couple-based treatment: BCT research has demon-strated positive outcomes for children (Kelley & Fals-Stewart, 2002) and is as-sociated with decreased IPV (O’Farrell et al., 1999). These secondary gainsprovide evidence for the larger systemic value of the BCT intervention.

3. Enhanced outcomes associated with inclusion of RP sessions: The use of RP ses-sions appears to help sustain improvements in marital adjustment and drinkingoutcomes following treatment for alcohol abuse (O’Farrell et al., 1993, 1998).Therefore, when working with this population we recommend including RP ses-sions to encourage the continued use of treatment-targeted behaviors.

This program of research has extended more than three decades and provides anexample of a comprehensive program of research. O’Farrell, Fals-Stewart, and col-leagues have established that couple-based interventions for substance abuse are notjust possible, but consistently prove to be more efficacious than IBT. Although thereare obvious strengths and limitations in any program of research, the research thathas emerged has consistently shown that BCT is efficacious at creating change on arange of outcome measures. Dissemination is one of the most significant challenges forthis program of research. Addressing the methodological limitations of this program ofresearch presents an opportunity to advance the field and bridge the gap betweenresearch and practice.

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