A randomized clinical trial of group versus standard behavioral couples therapy plus individually based treatment for patients with alcohol dependence

Dual-substance use disorder couples: An integrative review and proposed theoretical model

Committed romantic relationships between two individuals with Substance Use Disorder (or dual-SUD couples) are prevalent. Dual-SUD couples have poor treatment engagement and outcomes. Research has established a reciprocal link between relationship dynamics (e.g., conflict, intimacy) and substance use. Thus, the couple's relationship presents a distinct social context for both partner's substance use. Dual-SUD couples face unique challenges due to substance use being a shared behavior that may serve as a rewarding source of compatibility, closeness, and short-term relationship satisfaction despite it being at the cost of other alternative sources of substance-free reinforcement. Yet, treatment options for these couples are scarce. Dual-maladaptive health behaviors (e.g., dual-substance use) are challenging to treat; however, theory and preliminary research suggests that transformation of couple's joint motivation toward adaptive health behavior change may result in a more satisfying relationship and improved treatment outcomes for both individuals. The current paper reviews the extant literature on dual-SUD couples from theoretical, empirical, and treatment research and proposes an expanded paradigm regarding how we understand dual-SUD couples with the aim of informing basic research and treatment development.

Patient-Concerned Other Dyads' 12-Step Involvement and Patients' Substance Use: A Latent Class Growth Model Analysis

OBJECTIVE

This study aimed to inform clinical practice by identifying subgroups of patient-concerned other (CO) dyads. Patients with alcohol use disorders (AUDs) were characterized on Alcoholics Anonymous (AA) involvement and substance use together with COs' Al-Anon involvement. Predictors and recovery maintenance outcomes of subgroup membership were examined.

METHOD

Participants were 279 patient-CO dyads. Patients were in residential treatment for AUD. Parallel latent class growth model analysis characterized 12-step involvement and substance use at treatment entry and 3-, 6-, and 12-month follow-ups.

RESULTS

Three classes were as follows: 38% Low AA/Low Al-Anon (patients' low AA and COs' low Al-Anon involvement, and patients' high-to-moderate substance use), 10% High AA/High Al-Anon (patients' high AA and COs' high Al-Anon involvement, and patients' moderate-to-low substance use), and 52% High AA/Low Al-Anon (patients' high AA and COs' low Al-Anon involvement, and patients' moderate-to-low substance use). At follow-up, the Low AA/Low Al-Anon classes' patients were less likely to have spirituality as recovery support, confidence about staying abstinent, and satisfaction with recovery progress. The High AA classes' COs had less concern about patients' drinking and scored higher on positive aspects of relationships with patients.

CONCLUSIONS

Clinicians should encourage patients' and COs' 12-step group involvement (12-step practices' engagement). Among patients treated for AUD, AA involvement was related to better outcomes, and to COs' lessened concern about the patients' drinking. COs' Al-Anon involvement was associated with having a more positive view of their relationship with the patient. That more than one third of dyads had low 12-step group involvement suggests that treatment programs may need to facilitate involvement in non-12-step mutual-help groups.

Implementing Behavioral Couples Therapy for Substance Use Disorders in Real-World Clinical Practice

Behavioral couple therapy (BCT) is an evidence-based, manualized treatment that has been primarily developed to treat alcohol use disorder. The treatment model leverages the intimate partner relationship to support recovery. Although the efficacy of BCT is well-supported in randomized controlled trials, little attention has been given to the translation of BCT to everyday practice settings. This article presents recommendations for implementing BCT in such settings. We describe a stepwise approach for getting a couple into BCT and determining whether it is an appropriate treatment for the couple. In addition, we provide recommendations for broadening inclusion criteria for everyday practice settings, including the use of BCT with couples who have drug use disorders with couples where both members exhibit substance use disorders and with couples who choose controlled drinking or drug use versus abstinence. Whereas BCT has mostly been researched in speciality substance use disorder settings, we provide recommendations for its use in general couple therapy settings. Based upon the extant research, we suggest implementing BCT as a standalone treatment or as an add-on to individual counseling for substance use disorders. We provide guidance for delivering BCT through telehealth and encourage future research to investigate this delivery modality. Future research should prioritize investigating the effectiveness of various BCT dissemination strategies and seek to determine what dosage and components of BCT will result in the best outcomes.

Mechanisms and moderators of behavioural couples therapy for alcohol and substance use disorders: an updated review of the literature

INTRODUCTION

Behavioural couples therapy (BCT) and alcohol behavioural couples therapy (ABCT) are couples-based interventions for substance use disorders (SUDs) that have been deemed a 'gold standard' treatment. Despite the substantial amount of promising research, there is a lack of research on the active components of treatment and treatment mechanisms and moderators. Since the most recent meta-analysis, a number of studies have been conducted that advance our understanding of the efficacy of BCT and ABCT.

AIMS

The purpose of the present review was to provide an update on the current knowledge of these treatments and to investigate mediators and moderators of treatment.

METHOD

A systematic search strategy of relevant databases from 2008 to 2021 identified 20 relevant articles that were coded for relevant information including study design, treatment, outcomes, as well as mechanisms and moderators.

RESULTS

The results indicated that BCT and ABCT are successful in reducing alcohol and substance use for both male and female clients, dual problem couples, and for reducing post-traumatic stress symptoms and intimate partner violence. The reviewed studies discussed a number of treatment mechanisms, with the most studied mechanism being relationship functioning. Moderators included relationship functioning and patient gender.

CONCLUSIONS

The results point to the need for additional research on active treatment components, mechanisms and moderators, in order to provide a more efficient and cost-effective treatment.

Couple and family therapy for substance use disorders: Evidence-based update 2010-2019

This article updates the evidence-based on couple and family therapy interventions for substance use disorders (SUD) since publication of the previous JMFT reviews in 2012. It first summarizes previous reviews along with findings from more recent reviews and meta-analytic studies. It then presents study design and methods criteria used to select 13 studies of couple and family therapy for level of support evaluation. Cumulative level of support designations are then determined for identified treatment approaches. Findings indicate that systemic family therapy is well-established as a standalone treatment, and behavioral family therapy and behavioral couple therapy are probably efficacious as standalone treatments and well-established as part of a multicomponent treatment. The article then suggests practice guidelines with regard to treatment modality considerations and implementation challenges. It concludes with future directions for delivering couple and family interventions in routine systems of care for SUD.

Concerned others' help utilization and patients' alcohol treatment outcomes

BACKGROUND

This study of dyads composed of patients in treatment for alcohol use disorders (AUDs) and their Concerned Others (COs) examined (1) COs' attendance at three types of help (educational sessions, treatment sessions with the patient, and treatment sessions without the patient) during a 3-month period after patients' admission, and (2) whether COs' use of help was associated with better treatment outcomes reported by COs about patients, and patients about themselves.

METHODS

Dyads (n = 277) were assessed when patients entered AUD treatment and 3 months later (80 %). COs rated their patient's AUD, and patients rated their own AUD, on the Brief Addiction Monitor. At 3-month follow-up, COs answered three items about help (education, treatment with patient, treatment without patient) from their patient's treatment program. Main analyses were analyses of covariance to examine associations between COs' help use and patients' outcomes.

RESULTS

At 3-month follow-up, COs who had obtained one type of help were significantly more likely to have also obtained the other two types of help. However, relatively few COs (39 %) obtained any type of help. COs who obtained help rated their patient as having more protection against future substance use. And, when COs had obtained help, patients rated themselves as having less risk of future substance use, and had attended a greater number of AA meetings, than when COs had not obtained help.

CONCLUSIONS

Findings suggest that COs' use of help can benefit patients in AUD treatment. Clinicians and researchers should increase the availability and use of help among COs.

The Role of the Family in Alcohol Use Disorder Recovery for Adults

Alcohol use disorder (AUD) and family functioning are inextricably bound, and families are impacted negatively by AUD, but families show substantial improvements with AUD recovery. Family members can successfully motivate a person with AUD to initiate changes in drinking or to seek AUD treatment. During recovery, family members can provide active support for recovery. Several couple- or family-involved treatments for AUD have been developed and tested in rigorous efficacy trials. Efficacious treatments based in family systems theory or cognitive behavioral approaches focus on the concerned family member alone, or they engage the couple or family as a unit in the treatment. However, most treatments have been studied in fairly homogeneous, heterosexual, White, non-Hispanic populations, limiting the potential generalizability of these treatments. Substantial gaps remain in our understanding of family processes associated with the initiation and maintenance of AUD recovery among adults. This review outlines the existing literature and describes opportunities for future research to address knowledge gaps in understanding the mechanisms by which these treatments are efficacious, use of family-based treatments with diverse populations, integration of pharmacotherapies with family-involved treatment, role of families in recovery-oriented systems of care, and how to improve treatment development and dissemination.

Psychosocial Interventions to Improve Psychological, Social and Physical Wellbeing in Family Members Affected by an Adult Relative's Substance Use: A Systematic Search and Review of the Evidence

It is estimated that over 100 million people worldwide are affected by the substance use of a close relative and often experience related adverse health and social outcomes. There is a growing body of literature evaluating psychosocial interventions intended to reduce these adverse outcomes. We searched the international literature, using rigorous systematic methods to search and review the evidence for effective interventions to improve the wellbeing of family members affected by the substance use of an adult relative. We synthesised the evidence narratively by intervention type, in line with the systematic search and review approach. Sixty-five papers (from 58 unique trials) meeting our inclusion criteria were identified. Behavioural interventions delivered conjointly with the substance user and the affected family members were found to be effective in improving the social wellbeing of family members (reducing intimate partner violence, enhancing relationship satisfaction and stability and family functioning). Affected adult family members may derive psychological benefit from an adjacent individually focused therapeutic intervention component. No interventions fully addressed the complex multidimensional adversities experienced by many families affected by substance use. Further research is needed to determine the effect of a multi-component psychosocial intervention, which seeks to support both the substance user and the affected family member.

More behavioral recommendations produce more change: A meta-analysis of efficacy of multibehavior recommendations to reduce nonmedical substance use

Death and morbidity associated with substance use have risen continuously over the last few decades, increasing the need for rigorous examination of promising programs. Interventions attempting to change multiple behaviors have been designed to address interconnected problems such as use of both alcohol and drugs. This meta-analysis aimed to examine the efficacy of multibehavior interventions to curb nonmedical substance use in relation to the theoretical relation among different substance use behaviors. Specifically, our synthesis aimed to estimate the optimal number of recommendations for intervention efficacy and evaluate the impact of different combinations of recommendations on intervention efficacy. A synthesis of multibehavior interventions addressing nonmedical substance use was conducted to measure behavioral changes between the pretest and the follow-up. These changes were then compared across different numbers of recommendations. Sixty-nine reports and 233 effect sizes (k of conditions = 155, n = 28,295) were included. A positive linear relation was found between the number of targeted behaviors and intervention efficacy, which was stronger for drug use than alcohol use. Furthermore, recommendations on drug use worked better when paired with recommendations targeting other behaviors, whereas recommendations on alcohol use worked more independently. Lastly, multibehavior interventions were especially efficacious when delivered by experts. Overall, our synthesis indicated that targeting multiple substances is beneficial for changing drug use outcomes, but less so for alcohol use outcomes. Therefore, in the current substance use epidemic, innovative multibehavior programs appear to hold promise, especially to combat nonmedical drug use. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Group Versus Standard Behavioral Couples' Therapy for Alcohol Use Disorder Patients: Cost-Effectiveness

OBJECTIVE

The purpose of this study was to evaluate the costs and cost-effectiveness of two treatments for 101 alcohol use disorder patients and their intimate partners--group behavioral couples' therapy plus individual-based treatment (G-BCT), or standard behavioral couples' therapy plus individual-based treatment (S-BCT).

METHOD

We estimated the per-patient cost of each intervention using a microcosting approach that allowed us to estimate costs of specific components in each intervention as well as the overall total costs. Using simple means analysis and multiple regression models, we estimated the incremental effectiveness of G-BCT relative to S-BCT. Immediately after treatment and 12 months after treatment, we computed incremental cost-effectiveness ratios (ICER) and cost-effectiveness acceptability curves for percentage days abstinent, adverse consequences of alcohol and drugs, and overall relationship functioning.

RESULTS

The average per-patient cost of delivering G-BCT was $674, significantly less than the cost of S-BCT ($831). However, 12 months after treatment, S-BCT participants performed better on all outcomes compared with those in G-BCT, and the calculated ICER moving from G-BCT to S-BCT ranged from $10 to $12 across these outcomes. The current findings indicated that, except at very low willingness-to-pay values, S-BCT is a cost-effective option relative to G-BCT when considering 12-month posttreatment outcomes.

CONCLUSIONS

As expected, G-BCT was delivered at a lower cost per patient than S-BCT; however, S-BCT performed better over time on the clinical outcomes studied. These economic findings indicate that alcohol use disorder treatment providers should seriously consider S-BCT over G-BCT when deciding what format to use in behavioral couples' therapy.

Group Versus Standard Behavioral Couples' Therapy for Alcohol Use Disorder Patients: Cost-Effectiveness

OBJECTIVE

The purpose of this study was to evaluate the costs and cost-effectiveness of two treatments for 101 alcohol use disorder patients and their intimate partners--group behavioral couples' therapy plus individual-based treatment (G-BCT), or standard behavioral couples' therapy plus individual-based treatment (S-BCT).

METHOD

We estimated the per-patient cost of each intervention using a microcosting approach that allowed us to estimate costs of specific components in each intervention as well as the overall total costs. Using simple means analysis and multiple regression models, we estimated the incremental effectiveness of G-BCT relative to S-BCT. Immediately after treatment and 12 months after treatment, we computed incremental cost-effectiveness ratios (ICER) and cost-effectiveness acceptability curves for percentage days abstinent, adverse consequences of alcohol and drugs, and overall relationship functioning.

RESULTS

The average per-patient cost of delivering G-BCT was $674, significantly less than the cost of S-BCT ($831). However, 12 months after treatment, S-BCT participants performed better on all outcomes compared with those in G-BCT, and the calculated ICER moving from G-BCT to S-BCT ranged from $10 to $12 across these outcomes. The current findings indicated that, except at very low willingness-to-pay values, S-BCT is a cost-effective option relative to G-BCT when considering 12-month posttreatment outcomes.

CONCLUSIONS

As expected, G-BCT was delivered at a lower cost per patient than S-BCT; however, S-BCT performed better over time on the clinical outcomes studied. These economic findings indicate that alcohol use disorder treatment providers should seriously consider S-BCT over G-BCT when deciding what format to use in behavioral couples' therapy.

Interventions for Couples

Because relationship discord and dissolution are common and costly, interventions are needed to treat distressed couples and to prevent distress among vulnerable couples. We review meta-analytic evidence showing that 60-80% of distressed couples benefit from behavioral and emotion-focused approaches to couple therapy, but we also note that treatment effects are weaker in actual clinical practice than in controlled studies, dissipate following treatment for about half of all couples, and may be explained by factors that are common across models. Meta-analyses of prevention programs reveal reliable but smaller effects, reflecting a need to know more about whether and how communication mediates effects, about how risk and diversity moderate effects, and about how technology-enabled interventions can reduce attrition in vulnerable populations. Interventions for couples are improving and expanding, but critical questions remain about how and for whom they work.

Group treatment for substance use disorder in adults: A systematic review and meta-analysis of randomized-controlled trials

BACKGROUND AND AIMS

From residential programs to outpatient services, group therapy permeates the clinical field of substance misuse. While several group interventions for substance use disorders (SUDs) have demonstrated effectiveness, the existing evidence on group therapy has not been systematically reviewed. The current meta-analysis aims to provide estimates of the efficacy of group therapy for SUDs in adults using rigorous methods.

METHODS

We included studies comparing group psychotherapy to no treatment control groups, individual psychotherapy, medication, self-help groups, and other active treatments applying no specific psychotherapeutic techniques for patients with substance use disorder. The primary outcome was abstinence, and the secondary outcomes were frequency of substance use and symptoms of substance use disorder, anxiety, depression, general psychopathology, and attrition. A comprehensive search was conducted in Medline, Web of Science, CENTRAL, and PsycINFO, complemented by a manual search. Random-effects meta-analyses were run separately for different types of control groups.

RESULTS

Thirty-three studies were included. Significant small effects of group therapy were found on abstinence compared to no treatment, individual therapy, and other treatments. Effects on substance use frequency and SUD symptoms were not significant, but significant moderately sized effects emerged for mental state when group therapy was compared to no treatment. There were no differences in abstinence rates between group therapy and control groups. These results were robust in sensitivity analyses and there was no indication of publication bias.

CONCLUSIONS

The current findings represent the best available summary analysis of group therapy for SUDs in adults, however cautious interpretation is warranted given the limitations of the available data.

Designing a Pilot Study Protocol to Test a Male Alcohol Use and Intimate Partner Violence Reduction Intervention in India: Beautiful Home

Introduction: Evidence suggests alcohol consumption is correlated with intimate partner violence (IPV) making alcohol reduction interventions a promising method for reducing IPV. While both financial incentive and cognitive behavioral therapy (CBT) interventions in high-income countries, respectively, have effectively reduced alcohol consumption and IPV perpetration among men, little evidence exists demonstrating that these approaches can work in a low-resource setting. Methods: The objective of this study is to design and pilot test a low-cost, scalable intervention for reducing alcohol consumption and IPV in Bengaluru, India, where alcohol has been shown to be a key driver of high rates of IPV. A pilot randomized controlled trial (RCT) design will be used to examine the feasibility of testing a combined incentive and CBT based intervention among couples to stimulate immediate behavior change and to sustain positive behaviors pertaining to alcohol use and IPV. Sixty couples will be screened and enrolled into one of three study arms: an incentive-only, incentive plus counseling, or a control arm. Extensive procedures have been included to ensure participant safety, including staff training on global safety procedures for violence intervention research, careful messaging of study aims, screening procedures to exclude those at high risk of alcohol withdrawal or severe violence due to the study, and a referral and case management system. Male and female participants will complete surveys at baseline and immediately and 3-months post-intervention. Breathalyzers will be used to capture male participants' blood alcohol content daily for intervention arm participants and three times a week for control participants. A sub-sample of male and female members of couples will participate in qualitative in-depth interviews to further explore pathways to change. The results from this preliminary study will inform the development of a larger RCT study of male alcohol and IPV reduction.

The Experience of Couples in the Process of Treatment of Pathological Gambling: Couple vs. Individual Therapy

Context: Couple treatment for pathological gambling is an innovative strategy. There are some results supporting its potential effectiveness, but little is known about the subjective experiences of the participants. Objective: The aim of this article is to document the experiences of gamblers and their partners participating in one of two treatments, namely individual or couple. Method: In a study aiming to evaluate the efficacy of the Integrative Couple Treatment for Pathological Gambling (ICT-PG), couples who were entering specialized treatment for the addiction of one member who was a pathological gambler were randomly assigned to individual or ICT-PG. Nine months after their admission to treatment, gamblers and partners (n = 21 couples; n = 13 ICT-PG; n = 8 individual treatment) were interviewed in semi-structured interviews. A sequenced thematization method was used to extract the major themes. Results: This study highlighted five major themes in the therapeutic process noted by the gamblers and their partners mainly after the couple treatment but also partly through the individual therapy. These were: (1) the gamblers' anxiety about having to reveal their gambling problems in couple therapy; (2) the wish to develop a mutually beneficial understanding of gambling and its effects on the partners in the two types of treatments; (3) the transformation of negative attributions through a more effective intra-couple communication fostered by the couple therapy; (4) the partners' contribution to changes in gambling behavior and prevention of relapses, which were both better supported in couple therapy; and (5) the interpersonal nature of gambling and its connections with the couples' relationship. However, gamblers who were in individual treatment were more likely to mention that their partners' involvement was not necessary. Participants likewise made a few recommendations about the conditions underlying the choice of one treatment method or the other. Discussion: Participants reported satisfaction with both treatment models, but their experience was more positive in couple treatment. Complementary benefits emerged from each form of treatment, which points to future treatments involving both types. Future research should explore both the couple processes associated with attempts to stop pathological gambling and the various ways of involving partners in the gamblers' treatment.