Alcohol‐Focused Behavioral Couple Therapy

• Date: 01 September 2016
• Author: Kathryn Fokas,Brandi C. Fink,Barbara S. McCrady,Adrienne Borders,Adam D. Wilson,Rosa E. Muñoz
• DOI: http://doi.org/10.1111/famp.12231
• Published date: 01 September 2016

Alcohol-Focused Behavioral Couple Therapy

BARBARA S. MCCRADY*

ADAM D. WILSON*

ROSA E. MUN

˜OZ*

BRANDI C. FINK

†

KATHRYN FOKAS*

ADRIENNE BORDERS*

Alcohol Behavioral Couple Therapy (ABCT) has emerged over the last 30 years as a

highly efficacious treatment for those with alcohol use disorders. This review highlights

the historical and conceptual underpinnings of ABCT, as well as the specific treatment ele-

ments and structure. Proposed active ingredients, moderators, and mediators of treatment

outcome are discussed. Efficacy is evaluated for reductions in identified patient drinking,

improved relationship functioning, and reductions in intimate partner violence. Adapta-

tions of ABCT for substances other than alcohol are described. Other adaptations, includ-

ing brief interventions, interventions addressing PTSD and TBI along with alcohol use,

and interventions deliverable via technology platforms are described. Additional cost-bene-

fit and cost-effectiveness findings supporting the economic value of ABCT are noted. Future

directions for research in this area include possible adaptations for female identified

patients, nontraditional couples, LGBT partners and dyads involving nonintimate partner

relationships. The development of more flexible models and enhanced dissemination strate-

gies may improve clinical uptake and utility as well as increasing the feasibility of this

treatment for integrated healthcare settings.

Keywords: Alc ohol; Couple Therapy; Behavioral; Review

Fam Proc 55:443–459, 2016

DESCRIPTION OF ALCOHOL BEHAVIORAL COUPLE THERAPY

Historical Roots

Concerns about the impact of alcohol on families and the engagement of families in

alcohol treatment date back to the temperance movement in the 1800s (inspired in

large part by women’s concerns about the impact of male drinking in taverns on the fam-

ily) and efforts in the late 1800s to engage families in treatment in early residential treat-

ment programs for “dipsomania and inebriety” (McCrady, Owens, & Brovko, 2013). More

contemporary family focused treatment approaches began with efforts by caseworkers to

assist women married to men with drinking problems (e.g., Baldwin, 1947) and the devel-

opment of parallel therapy groups for husbands with alcohol use disorders (AUDs) and

their wives (e.g., Gliedman, Rosenthal, Frank, & Nash, 1956; Pattison, Courlas, Patti,

Mann, & Muller, 1965). Table 1 summarizes major characteristics of couple therapy

*Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico, Albuquerque, NM.

†

University of New Mexico School of Medicine, Albuquerque, NM.

Correspondence concerning this article should be addressed to Barbara S. McCrady, Center on

Alcoholism, Substance Abuse, and Addictions, University of New Mexico, 2650 Yale Blvd SE,

Albuquerque, NM 87106. E-mail: bmccrady@unm.edu.

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Family Process, Vol. 55, No. 3, 2016 ©2016 Family Process Institute

doi: 10.1111/famp.12231

studies for AUDs (see also Table S1 for a complete listing of early treatment studies).

Many of these early approaches drew on psychodynamic principles, positing that marriage

to a man with an AUD represented a neurotic resolution of psychological conflicts by these

wives, and that therapy, therefore, should focus on the woman’s own psychological issues.

The application of family systems and behavioral models to the treatment of AUDs

began in the late 1960s and early 1970s, when clinicians began to report the use of conjoint

therapy for AUDs (e.g., Burton & Kaplan, 1968a). The earliest studies described family

system-based models with some cognitive-behavioral elements, and many reported com-

parisons of conjoint therapy to other approaches using nonrandomized groups (e.g., com-

paring outcomes for men in treatment whose wives did or did not participate in sessions).

Follow-ups varied widely in duratio n, from 6 to 39 months, and typically reported sub-

stantially more positive drinking outcomes for men whose wives participated in the treat-

ment than those who did not, as well as improvements in relationship functioning (Burton

& Kaplan, 1968a, 1968b; Gallant, Rich, Bey, & Terranova, 1970; Smith, 1967, 1969). By

the mid-1970s, descriptions of behavioral approaches to conjoint therapy for AUDs began

to appear in the literature, and controlled outcome studies of cognitive-behavioral

approaches began in the late 1970s (e.g., McCrady et al., 1986; O’Farrell, Cutter, & Floyd,

1985).

Conceptual Model

Alcohol-focused Behavioral Couple Therapy (ABCT) is a cognitive-behavioral treatment

model based on the assumption that multiple factors maintain the identified patient’s

(IP’s) drinking, including individual, dyadic, familial, and other social/environmental vari-

ables. The ABCT model assumes a reciprocal relation between drinking and relationship

functioning, and that interventions focused on both will be most effective. The model

assumes that (a) external antecedents to drinking have a lawful relation to drinking,

developed through repeated pairings with positive or negative reinforcers; (b) internal

physiological, cognitive, and affective states mediate the association between external

antecedents and drinking behavior; (c) expectancies about the reinforcing value of alcohol

play an important role in determining subsequent drinking behavior; (d) drinking is main-

tained by its more immediate, positive consequences, which may be physiological, psycho-

logical, or interpersonal; and (e) negative consequences of drinking tend to be delayed and

therefore have less impact on drinking behavior (see McCrady & Epstein, 2015) .

Interventions in ABCT focus on familial antecedents and consequences of drink ing.

Familial antecedents may include typical family celebrations or daily rituals as well as

familial attempts to influence the IP’s drinking. Families in which alcohol problems are

present often have evolved poor patterns of communication and problem solving and have

TABLE 1

Major Characteristics of Couple Therapy Studies for Alcohol Use Disorders

Therapy type

Number of

studies

Number of

participants

Years

conducted

Relationship

outcome evaluated

and improved?

Yes No No diff.

Nonbehavioral couple treatment 12 565 1956–1982 4 7 1

Group treatment for wives only 4 159 1958–1969 4

Behavioral couples therapy 24 1,186 1985–present 15 3 6

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