Process and Technical Aspects of Couple Therapy
According to Gurman (2008), the main goal of BCT is to improve sobriety, deal with relative levels of comorbid individual psychological issues, and rehabilitate the distressed couple relationships. The prognosis for many couples is improved to the extent that the couple is better functioning at the outset of treatment. Gurman provides many substance abuse interventions that might be used in BCT. These interventions are described below:
Interventions Focused on Substance Abuse
Limiting exposure and risky situations- The couple comes to an agreement about how to deal with the substance abuse and each person’s role in achieving this goal. The couple will decide if there should be alcohol kept in the home for the person who doesn’t have a substance abuse problem or if the couple will go to gatherings that serve alcohol. It is very important for the couple to discuss all type of situations that may detour the abuser from maintaining his/her sobriety or that may cause stressful situations.
2). Behavioral contracting- The couple agrees on a specific goal and write in detail how they will accomplish this goal. The couple agree on what should and what should not be in the contract. Most therapists recommend the “sobriety trust discussion” contract. In addition to goals and steps, the abuser reports his/her sobriety during the past 24 hours and his/her intent not to drink or use drugs. The contract can state that the abuser attend self help groups, provide urine screening or take medications if needed. The therapist gives the couple a daily calendar to record their progress in which they discuss at the beginning of each session. The therapist verbally praises the couple for all progress made within the contract.
3). Attendance at self-help meetings- BCT recommends the substance abuser attend regular meetings although, there is very little empirical evidence that states the effectiveness of self help groups.
4). Medication to help maintain sobriety- There are many different medications that a substance abuser might use to maintain his/her sobriety. Antabuse (disulfiram) is a drug that makes you nausea and/or sick when consumed with alcohol. Naltrexone is a medication prescribed to people who abuse opioid because it inhibits the subjective high and methadone is used to ease the symptoms of heroin or opiate withdrawals.
Relationship-Focused Interventions
Adjustment to therapy:
Behavioral Couple Therapy (BCT) first focuses on the substance abuse within the couple. Once the substance abuser has decided to deal with his/her abuse, the couple can now focus on relationship building. Gurman (2008) states that family members often experience resentment, mistrust and anger towards the substance abuser. In turn, the substance abuser feels guilt and the desire for praise towards his/her new improved behaviors. There may be other problems that the substance abuser may have caused while abusing such as financial debt, substantial amounts of bills they have endured, embarrassment to the family, loss of employment and so on. Many of the emotions described above can lead to a tense and stressful atmosphere. It is hard for many couples to deal with the aftermath of a substance abuser actions. According to Gurman (2008), many marriages and families are dissolved during 1 or 2 years of the substance abusers recovery. In other cases, the stress of marital and family conflicts can cause a relapse in the abusers recovery.
Relationship promises during treatment:
This particular intervention asks the couple to agree to four different promises while participating in individualized or group programs. The four promises are as follows:
The two major goals of relationship interventions are (1) to increase positive feelings, goodwill, and commitment to the relationship and (2) to resolve conflicts and problems, and promote a desire for change (Gurman, 2008). The four steps taken to achieve the above goals are:
Increasing positive exchanges:
This intervention helps the couple to acknowledge the positive behaviors that exchange within the relationship. By completing this intervention it can help the couple see the “good” in the relationship. The couple is informed that caring behaviors are “behaviors that show you care for the other person”. The couple then has a homework assignment called, “Catch Your Partner Doing Something Nice”. As partners begin to notice and acknowledge daily caring behaviors, each begins initiating more caring behaviors (Gurman, 2008).
Shared Rewarding activities:
Shared reward activities (SRAs) helps increase a positive relationship within the family and couple. Gurman states, that in the past the abuser probably engaged in activities that pertained to substance abuse causing conflict within the family. Therefore, reversing this behavior and having the family and/or couple plan activities together will produce positive outcomes. The couple is also informed not to discuss any problems or conflicts during the planned SRAs.
Communication skills training:
Therapists use a variety of skills to teach couples how to communicate effectively. Such skills are instructions, modeling, prompting, behavioral rehearsal, and feedback. Learning communication skills, listening skills and speaking skills helps the couple to problem solve and change their old behaviors of communicating.
Communication sessions-are planned, structured discussions in which spouses talk privately, face-to-face, without distractions, and take turns expressing their points of view, without interrupting one another (Gurman, 2008). Couples pick times and places where they would like to have the communication sessions. At these sessions they can discuss feelings, events and any other problems that might be occurring within the relationship.
Listening skills- helps the couple to hear one another without interrupting each other or engaging in conflict. It gives each person a chance to talk and be heard without engaging in an argument. After the speaker has expressed his or her concerns then the listener responds by saying, (“What I hear you saying is. Was I right?”). Then the couple switches roles.
Speaking skills-helps the couple to express positive and negative feelings instead of blaming and engaging in a hostile environment as some substance abusers are used to doing. Learning how to speak to one another allows the couple to take responsibility for his or her own actions. This skill teaches the couple how to use “I” statements rather than “you” statements.
Problem-solving skills training:
After the couple learns communication skills as stated above, they are now ready to learn problem-solving skills. This skill teaches the couple how to cope with internal factors as well as external factors (job, extended family etc). Gurman states, when solving a problem the couple should first define the problem and make a list of possible solutions. Then the couple rank the solutions from most to least preferred and agree on which one they should work on. Overall, all interventions discussed are the basic skills of BCT for substance abuse rehabilitation and relationship improvement.
Relapse Prevention: Posttreatment Activities to maintain therapy gains:
Gurman (2008) states, there are three methods used in BCT to ensure long-term maintenance of the changes in alcohol or drug abuse problems. He also suggests that the therapist take responsibility for continuing contact via telephone and planned face-to-face encounters. Check-ups can last up to 5 years after an initial stable pattern of recovery has been established. The three methods are as follows:
Termination:
In many therapy sessions, a set number of sessions are offered. However, termination is applied on a time and session limited basis. When confidence, skills sets, and stability have been reached in regards to substance misuse and supportive relationship quality, termination is completed this is considered good termination (Gurman, 2008). Bad termination is determined when a couple drops out of therapy early and/or when there is no success in sobriety or relationship building.
According to Gurman (2008), the main goal of BCT is to improve sobriety, deal with relative levels of comorbid individual psychological issues, and rehabilitate the distressed couple relationships. The prognosis for many couples is improved to the extent that the couple is better functioning at the outset of treatment. Gurman provides many substance abuse interventions that might be used in BCT. These interventions are described below:
Interventions Focused on Substance Abuse
Limiting exposure and risky situations- The couple comes to an agreement about how to deal with the substance abuse and each person’s role in achieving this goal. The couple will decide if there should be alcohol kept in the home for the person who doesn’t have a substance abuse problem or if the couple will go to gatherings that serve alcohol. It is very important for the couple to discuss all type of situations that may detour the abuser from maintaining his/her sobriety or that may cause stressful situations.
2). Behavioral contracting- The couple agrees on a specific goal and write in detail how they will accomplish this goal. The couple agree on what should and what should not be in the contract. Most therapists recommend the “sobriety trust discussion” contract. In addition to goals and steps, the abuser reports his/her sobriety during the past 24 hours and his/her intent not to drink or use drugs. The contract can state that the abuser attend self help groups, provide urine screening or take medications if needed. The therapist gives the couple a daily calendar to record their progress in which they discuss at the beginning of each session. The therapist verbally praises the couple for all progress made within the contract.
3). Attendance at self-help meetings- BCT recommends the substance abuser attend regular meetings although, there is very little empirical evidence that states the effectiveness of self help groups.
4). Medication to help maintain sobriety- There are many different medications that a substance abuser might use to maintain his/her sobriety. Antabuse (disulfiram) is a drug that makes you nausea and/or sick when consumed with alcohol. Naltrexone is a medication prescribed to people who abuse opioid because it inhibits the subjective high and methadone is used to ease the symptoms of heroin or opiate withdrawals.
Relationship-Focused Interventions
Adjustment to therapy:
Behavioral Couple Therapy (BCT) first focuses on the substance abuse within the couple. Once the substance abuser has decided to deal with his/her abuse, the couple can now focus on relationship building. Gurman (2008) states that family members often experience resentment, mistrust and anger towards the substance abuser. In turn, the substance abuser feels guilt and the desire for praise towards his/her new improved behaviors. There may be other problems that the substance abuser may have caused while abusing such as financial debt, substantial amounts of bills they have endured, embarrassment to the family, loss of employment and so on. Many of the emotions described above can lead to a tense and stressful atmosphere. It is hard for many couples to deal with the aftermath of a substance abuser actions. According to Gurman (2008), many marriages and families are dissolved during 1 or 2 years of the substance abusers recovery. In other cases, the stress of marital and family conflicts can cause a relapse in the abusers recovery.
Relationship promises during treatment:
This particular intervention asks the couple to agree to four different promises while participating in individualized or group programs. The four promises are as follows:
- Attend therapy Sessions & do assigned homework from therapist
- NO threats of divorce or separation
- Focus on the present, not the past or the future
- No angry touching (both agree not to use any violence towards one another)
The two major goals of relationship interventions are (1) to increase positive feelings, goodwill, and commitment to the relationship and (2) to resolve conflicts and problems, and promote a desire for change (Gurman, 2008). The four steps taken to achieve the above goals are:
- therapist instruction and modeling
- couple practice with therapist supervision
- assignments for homework
- review of homework, with further practice
Increasing positive exchanges:
This intervention helps the couple to acknowledge the positive behaviors that exchange within the relationship. By completing this intervention it can help the couple see the “good” in the relationship. The couple is informed that caring behaviors are “behaviors that show you care for the other person”. The couple then has a homework assignment called, “Catch Your Partner Doing Something Nice”. As partners begin to notice and acknowledge daily caring behaviors, each begins initiating more caring behaviors (Gurman, 2008).
Shared Rewarding activities:
Shared reward activities (SRAs) helps increase a positive relationship within the family and couple. Gurman states, that in the past the abuser probably engaged in activities that pertained to substance abuse causing conflict within the family. Therefore, reversing this behavior and having the family and/or couple plan activities together will produce positive outcomes. The couple is also informed not to discuss any problems or conflicts during the planned SRAs.
Communication skills training:
Therapists use a variety of skills to teach couples how to communicate effectively. Such skills are instructions, modeling, prompting, behavioral rehearsal, and feedback. Learning communication skills, listening skills and speaking skills helps the couple to problem solve and change their old behaviors of communicating.
Communication sessions-are planned, structured discussions in which spouses talk privately, face-to-face, without distractions, and take turns expressing their points of view, without interrupting one another (Gurman, 2008). Couples pick times and places where they would like to have the communication sessions. At these sessions they can discuss feelings, events and any other problems that might be occurring within the relationship.
Listening skills- helps the couple to hear one another without interrupting each other or engaging in conflict. It gives each person a chance to talk and be heard without engaging in an argument. After the speaker has expressed his or her concerns then the listener responds by saying, (“What I hear you saying is. Was I right?”). Then the couple switches roles.
Speaking skills-helps the couple to express positive and negative feelings instead of blaming and engaging in a hostile environment as some substance abusers are used to doing. Learning how to speak to one another allows the couple to take responsibility for his or her own actions. This skill teaches the couple how to use “I” statements rather than “you” statements.
Problem-solving skills training:
After the couple learns communication skills as stated above, they are now ready to learn problem-solving skills. This skill teaches the couple how to cope with internal factors as well as external factors (job, extended family etc). Gurman states, when solving a problem the couple should first define the problem and make a list of possible solutions. Then the couple rank the solutions from most to least preferred and agree on which one they should work on. Overall, all interventions discussed are the basic skills of BCT for substance abuse rehabilitation and relationship improvement.
Relapse Prevention: Posttreatment Activities to maintain therapy gains:
Gurman (2008) states, there are three methods used in BCT to ensure long-term maintenance of the changes in alcohol or drug abuse problems. He also suggests that the therapist take responsibility for continuing contact via telephone and planned face-to-face encounters. Check-ups can last up to 5 years after an initial stable pattern of recovery has been established. The three methods are as follows:
- Helping the couple complete a Continuing Recovery Plan i.e., daily sobriety trust discussion or a Sobriety Contract.
- The therapist helps the couple anticipate high-risk situations for relapse to abusive drinking and/or drug abuse after treatment i.e., coping strategies.
- Discussion of how to cope with a potential relapse if and when it occurs.
Termination:
In many therapy sessions, a set number of sessions are offered. However, termination is applied on a time and session limited basis. When confidence, skills sets, and stability have been reached in regards to substance misuse and supportive relationship quality, termination is completed this is considered good termination (Gurman, 2008). Bad termination is determined when a couple drops out of therapy early and/or when there is no success in sobriety or relationship building.