Elizabeth E. Epstein

BEHAVIORAL COUPLES TREATMENT OF ALCOHOL AND DRUG USE DISORDERS: CURRENT STATUS AND INNOVATIONS

Research suggests that Behavioral Couples Therapy (BCT), tailored to treat alcohol problems, produces significant reduction in alcohol consumption and improvement in marital functioning. Having established basic clinical protocols for Alcohol Behavioral Couples Therapy (ABCT) and provided support for their efficacy, clinical researchers around the country continue to develop and study new applications of the basic ABCT treatment models, such as adding relapse prevention or Alcoholics Anonymous components. Recent research supporting the heterogeneity in the population of individuals with alcohol problems has prompted some researchers on ABCT to consider additional adaptations of the treatment models for specific subgroups of alcoholics, and for particular individual and couples characteristics. Adaptation of ABCT to treat new populations such as drug abusers, female alcoholics, and problem drinkers is under investigation. The current article provides an overview of theoretical and clinical aspects of ABCT, and research on efficacy of the basic model and on areas of innovation and adaptation to new populations. Directions for future research on ABCT are suggested.

A randomized trial of individual and couple behavioral alcohol treatment for women.

Although alcohol use disorders (AUDs) adversely affect women, research on efficacious treatments for women is limited. In this randomized efficacy trial of 102 heterosexual women with AUDs, the authors compared alcohol behavioral couple therapy (ABCT) and alcohol behavioral individual therapy (ABIT) on percentage of days abstinent (PDA) and percentage of days of heavy drinking (PDH) over 6 months of treatment and 12 months of posttreatment follow-up. Baseline relationship functioning and comorbid disorders were tested as moderators of outcome. Piecewise linear growth models were used to model outcomes. During treatment, women increased their PDA and decreased their PDH, with significantly greater improvements in ABCT than in ABIT (d = 0.59 for PDA; d = 0.79 for PDH). Differences favoring ABCT were maintained during follow-up. Women with poorer baseline relationship functioning improved more on PDA during treatment with ABCT than with ABIT. For PDH, results during treatment and follow-up favored ABCT for women with better baseline relationship functioning. ABCT resulted in better outcomes than ABIT for women with Axis I disorders at the end of follow-up (PDA), and for women with Axis II disorders at the end of treatment (PDA) and at the end of follow-up (PDH).

Women, Aging, and Alcohol Use Disorders

SUMMARY The increase in prevalence rates of alcohol use disorders in younger versus older cohorts of female drinkers is many times higher than the corresponding increase in prevalence rates for male drinkers. Thus, the number and impact of older female drinkers is expected to increase over the next 20 years as the disparity between mens and womens drinking rates decrease. Due to differences in metabolism of alcohol, women of all ages compared to men are at higher risk for negative physical, medical, social, and psychological consequences associated with at-risk and higher levels of alcohol consumption. Aging women face new sets of antecedents related to challenges in the middle and older adult phases of life, such as menopause, retirement, “empty nest,” limited mobility, and illness. As women age, they are subject to an even greater physiological susceptibility to alcohols effect, as well as to a risk of synergistic effects of alcohol in combination with prescription drugs. On the other hand, there is mixed research indicating that older women may benefit from the buffering effect of low levels of alcohol on hormonal declines associated with menopause, perhaps serving as a protective factor against Coronary Heart Disease and osteoporosis. However, with heavier drinking, these benefits are either reversed or eclipsed. In addition, any alcohol consumption increases the risk for breast cancer in older women. The possible beneficial effects of alcohol must be weighed with the fact that the research does not typically establish causality, that low-risk drinking equates to one standard drink per day, that there is a risk of progression towards alcohol dependence, and that there are alternate methods to gain the same benefits without the associated risks. Older women also experience unique barriers to detection of and treatment for alcohol problems. Current treatment options specifically for older women are limited, though researchers are beginning to address differential treatment response of older women, as well as development of elder women-specific treatment approaches. Treatment options include self-help/mutual peer support, which provides ancillary advantages, brief interventions in primary care settings, which have been demonstrated to be effective in reducing drinking levels, and cognitive behavioral techniques, which have been demonstrated to be useful; but more studies and larger samples are needed. Elder-specific treatments need to be appropriate in terms of content, to address the challenges associated with life stage, such as the loss of the parental role and widowhood, and in terms of process, such as delivery in a respectful therapeutic style and at a slower pace. Future directions in research should address the lack of assessment instruments, the risks of simultaneous use of alcohol and prescription medications, and the under-representation of older women in randomized trials of alcohol treatments.

Alcoholics Anonymous and Relapse Prevention as Maintenance Strategies After Conjoint Behavioral Alcohol Treatment for Men: 18-Month Outcomes.

Ninety men with alcohol problems and their female partners were randomly assigned to 1 of 3 outpatient conjoint treatments: alcohol behavioral couples therapy (ABCT), ABCT with relapse prevention techniques (RP/ABCT), or ABCT with interventions encouraging Alcoholics Anonymous (AA) involvement (AA/ABCT). Couples were followed for 18 months after treatment. Across the 3 treatments, drinkers who provided follow-up data maintained abstinence on almost 80% of days during follow-up, with no differences in drinking or marital happiness outcomes between groups. AA/ABCT participants attended AA meetings more often than ABCT or RP/ABCT participants, and their drinking outcomes were more strongly related to concurrent AA attendance. For the entire sample, AA attendance was positively related to abstinence during follow-up in both concurrent and time-lagged analyses. In the RP/ABCT treatment, attendance at posttreatment booster sessions was related to posttreatment abstinence. Across treatment conditions, marital happiness was related positively to abstinence in concurrent but not time-lagged analyses.

Participation in alcoholics anonymous: intended and unintended change mechanisms.

This article is a compilation of the information presented at a symposium at the 2001 RSA Meeting in Montreal, Canada. The presentations were: (1) Maintaining change after conjoint behavioral alcohol treatment for men: the role of involvement with Alcoholics Anonymous, by Barbara S. McCrady and Elizabeth E. Epstein; (2) Changing AA practices and outcomes: Project MATCH 3-year follow-up, by J. Scott Tonigan; (3) Life events and patterns of recovery of AA-exposed adults and adolescents, by Patricia L. Owen and Valerie Slaymaker; (4) Social networks and AA involvement as mediators of change, by Lee Ann Kaskutas and Keith Humphreys; and (5) What do we know about Alcoholics Anonymous? by William R. Miller, discussant.

Sources of distress among women in treatment with their alcoholic partners

We examined sources of psychological and relationship distress among 90 nonalcoholic women with alcoholic male partners seeking outpatient, conjoint alcohol treatment. Results indicated that greater psychological distress among these women was most strongly associated with lower satisfaction with the marital relationship, presence of domestic violence, lower frequency of male partners drinking, lower perceived social support from family, and more frequent attempts to cope with the partners drinking. Controlling for psychological distress, greater marital satisfaction was associated most strongly with greater attempts to reinforce positively the partners abstinence and with less effort to detach from the partners drinking. Severity of partners alcohol problems was unexpectedly associated with greater marital satisfaction in multiple regression analyses, though not in bivariate analyses. Results highlight the close connection between psychological and relationship distress and potential relations between alcohol-related coping behaviors and both psychological and relationship distress.

Engagement and Retention in Outpatient Alcoholism Treatment for Women

Reviews of the dropout literature note significant attrition from addiction treatment. However, consistent predictors have not been identified and few studies have examined factors related to retention and engagement for women in gender-specific treatment. The current study consisted of 102 women and their partners randomized to individual or couples outpatient alcoholism treatment. Women attended more treatment sessions if they were assigned to individual treatment, older, had fewer symptoms of alcohol dependence, had more satisfying marital relationships, had spouses who drank, and had matched preference for treatment condition. Women were more engaged in treatment (ie, completed more assigned homework) if they had fewer children at home, fewer alcohol dependence symptoms, later age of onset of alcohol diagnosis, more satisfying marital relationships, and spouses who accepted or encouraged their drinking. Results highlight important associations of treatment and relationship variables with treatment retention and engagement.

Attrition from conjoint alcoholism treatment: Do dropouts differ from completers?

This study addresses patient attrition in order to identify variables associated with retention in conjoint treatment for alcohol abuse and dependence. Subjects were 105 male alcoholics and their partners who participated in a randomized clinical trial of three approaches to conjoint treatment of alcoholism: (a) alcohol and behavioral marital therapy (ABMT); (b) ABMT plus Alcoholics Anonymous and Alanon (AA/ABMT); and (c) ABMT plus relapse prevention (RP/ABMT). Completers (n = 45) attended two assessment and 15-17 treatment sessions. Partial completers (n = 23) left treatment between the 5th and 15th treatment session. Thirty-seven dropouts left treatment between the first assessment session and the 5th treatment session; of these, 22 dropouts completed at least one treatment session (called early treatment dropouts). Of subjects who entered treatment, dropouts from early treatment were least compliant with treatment requirements in the first few sessions, less educated, and less committed to their relationship. Data indicate that therapists with more clinical experience were more likely to retain clients in treatment, regardless of treatment condition. The data do not reflect a linear relationship between most variables studied and a continuum of attrition status from assessment to completion of the program.

What Do Women Want? Alcohol Treatment Choices, Treatment Entry and Retention

Study aims were to assess preferences for individual or conjoint treatment, differences between women with alcohol use disorders (AUDs) selecting each modality, and the impact on treatment entry and retention of providing a choice of treatments. During initial screening, women with AUDs in an intimate relationship with a male partner were given the choice of individual or conjoint treatment. After choosing a treatment modality and completing all assessments they entered one of two randomized trials testing different approaches to each treatment modality. Standardized measures were used to assess drinking quantity, frequency, and problems; motivation to change; and relationship satisfaction. Womens reasons for choice of treatment modality were coded using an iterative coding process. Results showed that women were more likely to select and follow through with individual than conjoint treatment. Women cited a desire to work on individual problems, lack of perceived support from their partner, and logistical issues as reasons for preferring individual treatment. Women in the two choice groups did not differ significantly on individual, partner, or relationship characteristics, but small to medium effect sizes suggested that women choosing individual treatment were more educated and less satisfied with their relationship, had fewer pretreatment heavy drinking days, and heavier drinking partners. Offering women a choice of treatment modality increased the probability of entering treatment, but not treatment attendance. Results suggest that barriers to couple therapy for women with AUDs need to be addressed to facilitate more widespread dissemination. Given womens preferences, it also is important to offer a range of treatments.

Changes in alcohol craving and consumption by phase of menstrual cycle in alcohol dependent women

The current study examines the menstrual cycle–alcohol relationship during 6 months of weekly outpatient sessions as part of a larger treatment outcome study for alcohol‐dependent females. Twelve premenopausal women in the clinical trial who were menstruating regularly and not on oral contraceptives kept a daily log of menstruation days, alcohol consumption and cravings. Three menstrual cycle phases were defined: menses, premenstrual, and “other.” Within subjects repeated measures analyses on the subsample of 12 women showed that, despite a lower average number of cravings, drinking frequency was higher in the premenstruum than the “other” phase in the first 3 months of treatment. In addition, according to a self‐report item on a measure given to 96 women in the larger study, 48 (69%) women under the age of 50 endorsed the premenstrual phase of the menstrual cycle as a drinking cue. Of these 48, 44% considered it a major drinking cue. These preliminary data support the value of continuing to investigate the relationship between phases of the menstrual cycle and alcohol consumption among female alcoholics.