In the present study, we compared the efficacy of behavioral couple therapy and individual cognitive–behavioral therapy for women with AUDs. It is one of two randomized clinical trials of ABCT for women with AUDs and their male partners (Fals-Stewart et al., 2006
) and one of only a handful of randomized clinical trials with an all-female sample of individuals with AUDs (e.g., Dahlgren & Willander, 1989
). The women were self-referred (i.e., not mandated) to treatment, and analyses of their drinking prior to the first treatment session found that many of the women started to decrease their drinking as soon as they contacted the treatment study (Epstein et al., 2005
). Thus, treatment focused both on helping women maintain their initial gains and decreasing their drinking.
Both major hypotheses were supported, and moderator analyses found evidence of the differential efficacy of ABCT over ABIT on some client attributes. Women receiving ABCT improved more on both PDA and PDH during treatment. However, women in ABCT drank more frequently during the first 2 months of treatment, so part of the greater slope of improvement represented their “catching up” with the women in ABIT. By the end of treatment, though, women in ABCT had surpassed women in ABIT in PDA. During follow-up, the ABCT group continued to have better drinking outcomes. Women with poorer relationship functioning who received ABCT showed more improvement in PDA than women who received ABIT during treatment but not during follow-up. During and after treatment, women with poorer relationship functioning responded similarly to the two treatments in changes in PDH, but women with better relationship functioning had fewer heavy drinking days in the ABCT than the ABIT condition. There also was evidence of differential positive effects of ABCT for women with Axis I disorders who had substantially poorer outcomes at the end of follow-up if they received ABIT rather than ABCT. Women with Axis II disorders in ABIT had substantially less PDA at the end of treatment and more PDH at the end of follow-up, compared with women in ABCT.
Women receiving individual treatment were more likely to complete the full 20-session treatment protocol, and there was a trend for them to participate in more treatment sessions. A small number of couples in each treatment condition separated during the follow-up period; a small number of women also sought additional help after the study treatment. The two treatments did not differ significantly on either of these variables, in contrast to earlier research (e.g., McCrady et al., 1991
) that reported lower separation rates associated with ABCT.
Regardless of treatment condition, the women were drinking considerably less frequently and heavily during and after treatment than before contacting the study. Eighteen months after their baseline interview, women who received ABCT were abstinent 75% of the time; women in ABIT were abstinent about 63% of the time. Women in both treatment conditions also reduced their heavy drinking considerably from approximately 57% of the days prior to treatment to 12% (ABCT) and 22% (ABIT) of days by the end of follow-up. During follow-up, there were no reliable differences between conditions in continuous abstinence (<20%) or avoiding any heavy drinking (<30%). However, these data reflect mean outcomes, and there was considerable variation among women in PDH. Future studies will examine individual differences in outcomes.
Several individual variables seemed to contribute to positive treatment outcome. As is typical, pretreatment drinking, severity of the AUD, and comorbid psychopathology generally predicted more drinking during treatment. During follow-up, baseline PDA continued to predict PDA, as did baseline severity of the AUD. The presence of an Axis II disorder predicted PDH.
Results are consistent with the literature supporting the relatively greater efficacy of couple rather than individual treatment for men with alcohol or other SUDs (McCrady et al., 1991
; McKay, Longabaugh, Beattie, & Maisto, 1993
; O’Farrell, Choquette, & Cutter, 1998
) and more recent findings supporting couple therapy for women (Fals-Stewart et al., 2006
; Winters et al., 2002
). There are a number of important similarities and differences between the present study and the two other randomized trials of ABCT for women with AUDs or SUDs. Demographically, the women in Fals-Stewart et al.’s (2006)
and Winters et al.’s (2002)
samples were younger, less affluent, more ethnically diverse than the present sample; a substantial minority of women in Winters et al.’s study were mandated to attend treatment. Their studies excluded male partners with AUDs or SUDs, resulting in the exclusion of one third to more than two thirds of potentially eligible women, thus limiting the generalizability of their results to the population of women with AUDs or other SUDs. More research is needed to determine whether the treatment needs of couples in which both are alcohol dependent differ from those with only one alcohol dependent partner. A second key difference between the present study and the two other studies was the treatment setting and model. Our model is a stand-alone treatment model that addresses individual sobriety strategies and relationship functioning in an integrated treatment framework—the model tested in Fals-Stewart et al.’s and Winters et al.’s studies is designed to be delivered in the context of an on-going, more intensive addictions treatment program and therefore focuses on couple-level interventions rather than individual sobriety strategies. Our stand alone model can be used readily by solo practitioners without the need for an additional treatment program, which is an advantage in areas that are poor in treatment resources and for clients with limited resources. Treatment effect size estimates from Fals-Stewart et al.’s and Winters et al.’s models must be interpreted in the context of a larger treatment program (participants had an additional 20–44 sessions of treatment available to them); our effect sizes reflect the full impact of the treatment model. In addition to the differences in study populations and treatments, the present study is the first to consider specific moderators of outcome for ABCT treatment, particularly the interaction of individual and conjoint treatment with individual psychopathology. Thus, findings from these three complementary studies (a) suggest the efficacy of conjoint treatment models for women of heterogeneous backgrounds and ages, (b) support the efficacy of conjoint treatment alone and in the context of on-going addictions treatment, and (c) suggest the applicability of the treatment to couples in which both may have AUDs or in which the woman has an additional Axis I or Axis II disorder.
Findings in the present study held despite the fact that couples were less likely to complete the full treatment protocol than individuals. Even though we provided extensive evening hours, the logistics of scheduling 20 weekly treatment sessions with both partners were challenging, particularly because most of the men were employed full-time, and many commuted to jobs more than an hour from their homes. Also, exit interviews with some women who withdrew from the study revealed that a small number of women assigned to ABCT felt uncomfortable with their partner’s presence in the treatment sessions. Initially, the conjoint format appears to have been more difficult for the women, as reflected by the women in ABCT drinking more frequently in the first 2 months of couple treatment. In the first several conjoint sessions, the treatment focused on abstinence for the woman, but the male partner was in the room, and the couple was interacting. Also, because the male partners were not required to change their own drinking, their presence may have made early sessions more difficult for the women. The divided focus on drinking and the relationship may have contributed to the early poorer response in the couples condition. However, over time, the women in ABCT increased their abstinence and decreased their heavy drinking so that by the end of treatment they were on a more positive trajectory of change and drinking less frequently and heavily than women participating in individual treatment.
In terms of reducing their drinking during treatment, women seemed to benefit from the conjoint therapy format, particularly if they had poorer relationship functioning and more relationship-related drinking prior to treatment. For more distressed couples, the treatment may have provided needed skills to support each other, communicate, and solve problems. However, the couples therapy did not differentially benefit women in distressed relationships in terms of their heavy drinking. Rather, the couples therapy appeared to lead to less heavy drinking for the better functioning couples.
Women with other Axis I and Axis II disorders also responded more positively to ABCT than to ABIT. These findings seem counterintuitive, because it would seem that practitioners could more easily adapt individual rather than couple treatment to address or manage other psychopathology. However, the findings are consistent with the larger literature suggesting the efficacy of family-involved approaches to treatment of Axis I disorders. It may be that the men were learning a general set of skills to provide support to the women regardless of the problems that the women were coping with, and also may have learned better communication skills that may have decreased expressions of negative affect often associated with relapse in AUDs and other psychiatric disorders (e.g., O’Farrell, Hooley, Fals-Stewart, & Cutter, 1998
In general, in the study design we maximized internal validity by using treatment manuals to guide the delivery of the treatment conditions, well-trained therapists who delivered both treatments, valid and objective measures of treatment integrity, well-trained interviewers to collect follow-up data, and well-validated standardized measures. There were, however, some limitations in the study design. First, although we attempted to recruit from community treatment programs, most participants entered the study in response to direct advertising. Despite the potential limitations in such a recruitment strategy, the women were quite similar to reported samples of women in treatment (e.g., Rice et al., 2001
) in terms of quantity and frequency of drinking as well as levels of comorbid psychopathology. Second, follow-up interviewers could not be blinded to treatment condition. Third, the length of the sessions differed between the two treatment conditions. We designed the treatments this way to equate the conditions on time focused on the woman’s drinking, but as a consequence the total hours of treatment exposure differed between the two conditions.
There also are some limitations on the generalizability of the results. Participants were recruited to a university-based clinic, and most were recruited by direct advertising. Almost the entire sample was alcohol dependent and Caucasian, and mean income was higher than national and local means at the time. An unavoidable limitation of the design was the requirement that the male partners be willing to participate in the treatment. These men were a select subsample, given that about one third of potentially eligible callers did not enter the study because of reasons at least partly related to the male partner’s availability or willingness to participate in the study. The men differed from other reported samples of husbands of women with AUDs in that they had considerably lower rates of current AUDs (12.7% vs. 51%; Dahlgren, 1978
), lower rates of other psychopathology, and lower rates of interference with women’s help-seeking than reported in prior research (e.g., Beckman & Amaro, 1986
). The women also may have been a select group in that they were agreeable to couple rather than individual therapy, were older, and were more likely to be married than women who inquired about the study but did not enroll (but they also had longer drinking histories). The couples in the study also may have had more functional intimate relationships than typical samples of women with AUDs. Finally, the study design did not call for following women who were randomized but refused to start treatment. Somewhat more women dropped out after being assigned to couples rather than individual therapy, making results generalizable only to couples willing to participate in treatment together.
Despite the fairly robust literature on ABCT, little is known about the mechanisms underlying the effectiveness of the treatment. Three major mechanisms have been proposed: increases in the reinforcing qualities of the relationship that may provide greater incentives for continued abstinence, greater partner support for change efforts, and improved conjoint problem solving around alcohol-related and other life problems (Longabaugh et al., 2005
). Future research should directly test these hypothesized mechanisms of change. Future research also should examine the interconnections between relationship functioning and treatment outcomes for women when their male partner is not involved in treatment, and should test more flexible models of conjoint treatment that place less demands on the couple for conjoint participation. In advance of these studies, however, the current results support the value of involving male partners in the treatment of women with AUDs if the couple is willing to seek treatment together.