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QUESTION: In heterosexual couples in which men are entering outpatient treatment for alcoholism (AL) or other drug abuse (ODA), is behavioural couples therapy (BCT) more effective than individual based therapy (IBT) for improving the psychosocial functioning of their children?
4 sites in New York State, USA.
135 heterosexual couples (mean age 37 y) in which men were entering outpatient treatment for AL (71 couples) or ODA (64 couples). Inclusion criteria for men included DSM-III-R criteria for psychoactive substance abuse or dependence. Exclusion criteria included either partner being in a methadone maintenance programme or having a major mental disorder, or couples in which women had a recent psychoactive substance use disorder. Follow up was 82%.
Couples were allocated to 32 sessions of treatment over 20 weeks which included BCT (n=25 for AL and n=22 for ODA), IBT (n=22 for AL and n=21 for ODA), or psychoeducational attention control treatment (PACT) (n=24 for AL and n=21 for ODA). The 32 sessions consisted of 20 sessions of cognitive behaviour therapy for substance abuse, which was the same for all men, and 12 sessions that varied among the groups. The variations involved couples therapy aimed at improving abstinence and relationships (BCT group), individual coping skills for the men only (IBT group), and lectures about substance abuse attended by both partners (PACT group).
Main outcome measures
Children’s psychosocial adjustment (Pediatric Symptom Checklist), relationship adjustment (The Dyadic Adjustment Scale), and substance abuse (Timeline Followback Interview) assessed immediately after treatment, and at 6 and 12 months during follow up.
Analysis was by intention to treat. Improvement in psychosocial functioning of children whose fathers received treatment for either AL or ODA was greater in the BCT than in either of IBT and PACT groups throughout follow up (table). Improvements in the couples’ relationship and the men’s substance use were also greater in the BCT than in either of the IBT or PACT groups.
In heterosexual couples in which men are entering outpatient treatment for alcoholism or other drug abuse, behavioural couples therapy was more effective than individual based therapy for improving the psychosocial functioning of their children.
In the past decade, numerous studies have highlighted the significance of family or couples therapy over non-family therapy in the treatment of substance abuse. However, few systematic studies have directly examined the effect of parental substance abuse treatment on their children. Parental discord is a major consequence of substance abuse and a key factor in the poor psychosocial functioning of their children. The study by Kelly et al is one of the few studies that have used a well designed research protocol, including randomisation, clear inclusion and exclusion criteria, a comparison group, and the use of standardised instruments to assess relationship functioning in the parental dyads and psychosocial functioning in the children.
More specifically, this study provides evidence that BCT is more effective than IBT or PACT in improving substance use in the affected parent, the relationship with their spouse, as well as the psychosocial functioning of their children. This improvement in functioning was measured and maintained over a 12 month period. Moreover, the effects of treatment were observed whether the parent was an alcoholic or a drug abuser.
In terms of the generalisability of these findings, the majority of participants were Caucasian couples; and in the drug group the primary substances of abuse were cocaine or opioids. It remains to be determined whether the same effects would be observed in other racial/ethnic groups. It would also be of interest in future studies of family interventions to examine children using information from multiple informants and to use other indicators of change (eg, teacher ratings, child interviews).
The major clinical implications of these findings are the importance of BCT in improving not only the functioning of the substance abusing individual, but also the psychosocial functioning of his/her preadolescent/adolescent children. It would be interesting to follow these children over time to determine whether family interventions, such as BCT at pivotal points in adolescent development, might positively influence the familial “cycle” of substance abuse in the longer term.
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