BEHAVIORAL COUPLES THERAPY IN DRUG ABUSE TREATMENT
Behavioral Couples Therapy (BCT) is associated with positive outcomes for alcoholic couples, both in terms of reduced alcohol use and increased relationship functioning. In a recent investigation, we showed, for the first time, that married or cohabiting men who primarily abused drugs other than alcohol randomly assigned to participate in BCT (N = 40) reported fewer days of drug use, longer periods of abstinence, fewer drug-related arrests, and fewer drug-related hospitalizations through the 12-month posttreatment follow-up period than husbands randomly assigned to receive individual-based treatment (IBT) only (N = 40). Furthermore, couples who received BCT reported better relationship outcomes, in terms of relationship satisfaction and less time separated, than couples whose husbands received IBT. A cost outcomes analysis revealed BCT was more cost-beneficial and cost-effective than IBT. However, five factors limit the generalizability of these findings: (a) only substance-abusing men with nonsubstance-abusing partners were recruited for the study; (b) it is unclear if the effects observed were due to the BCT interventions or simply the result of attention provided to the spouses; (c) BCT and IBT were provided in the context of a very intensive outpatient program (56 sessions over a 6-month period); (d) a relatively high proportion of participants were mandated by the criminal justice system (i.e., over 80 percent) to engage in and complete treatment; and (e) the participants used in the study were fairly heterogeneous in terms of their substance use backgrounds, which may have added unnecessary sampling variance and thereby reducing statisical power for analyses. The PRIMARY OBJECTIVE of the proposed study is to conduct a randomized clinical trial with 180 married or cohabiting drug- abusing patients and their nonsubstance-abusing partners to examine the comparative clinical efficacy, in terms 1-year posttreatment of drug-using behavior, relationship adjustment (i.e., spousal violence, relationship satisfaction, and stability), and other psychosocial outcomes, of BCT versus (a) and equally intensive IBT for drug-abusing patients only, (b) an equally intensive Psychoeducational Attention Control Condition (PACT) for drug-abusing patients and their partners. The SECONDARY OBJECTIVE is to determine if BCT is more cost-beneficial and cost-effective than IBT or PACT. This Stage II study extends our previous work by (a) including substance-abusing women and their nonsubstance-abusing partners, (b) adding an attention control condition, (c) delivering all interventions in the context of a less intensive overall treatment regimen, and (d) recruiting more homogeneous participants of which a much smaller proportion are mandated to treatment by the legal system.

BRIEF COUPLES THERAPY IN DRUG ABUSE TREATMENT
Behavioral Couples Therapy (BCT) is associated with positive outcomes for couples in which one of the partners abuses drugs or alcohol, both in terms of reduced psychoactive substance use and improved relationship functioning. However, a major practical limitation of the use of BCT with substance-abusing patients is that it has been delivered either as an adjunct to an intensive outpatient treatment regimen, typically requiring 15-20 couples sessions along with individual sessions or group counseling, or is offered as the primary or only intervention. A recent survey of substance abuse treatment programs strongly suggests that, despite its effectiveness, a very small minority use BCT (or other couples-based treatments). Nearly all programs noted they would use a couples-based intervention as an adjunct to other services if it was brief, shown to be effective in reducing substance use and improving other psychosocial outcomes, and could be integrated into existing treatments (e.g., individual counseling, group counseling). Thus, the mandate for investigators is to develop an abbreviated version of BCT that retains the effectiveness of standard BCT and could therefore be more attractive and more widely implemented within the substance abuse treatment community. Thus, the PRIMARY OBJECTIVE of the proposed study is to conduct a randomized clinical trial with 214 married or cohabiting drug-abusing patients and their nonsubstance-abusing partners to examine the comparative clinical efficacy, in terms of 1-year posttreatment drug-using behavior, relationship functioning, and other psychosocial outcomes, or Abbreviated BCT (i.e., ABCT) versus (a) standard BCT, (b) Individual-Based Treatment, and (c) a Psychoeducational Attention Control Treatment. The SECONDARY OBJECTIVE is to compare the cost-benefit and cost-effectiveness of the treatment conditions. Pilot data indicate ABCT is as clinically effective as standard BCT, but is far less costly to deliver, primarily due to the significantly reduced number of sessions required to deliver ABCT. This Stage II study extends pilot studies conducted by the investigators with ABCT by (a) recruiting more participants, (b) including substance-abusing women and their nonsubstance-abusing partners, (c) recruiting a more homogeneous patient sample (i.e., primary cocaine-abusing patients) of which a smaller proportion are mandated to treatment by the legal system, and (d) using a longer posttreatment follow-up period.

BCT FOR DRUG ABUSE: A GROUP THERAPY APPROACH
The results of multiple studies over the last 25 years indicate that, compared to traditional individual-based treatments, use of Behavioral Couples Therapy (BCT) for married or cohabiting alcoholic and drug-abusing patients results in superior outcomes across multiple domains of psychosocial functioning, including reduced substance use, increased relationship satisfaction, reduced levels of domestic violence, and improved family adjustment. However, despite its demonstrated efficacy, the results of a recent survey indicate BCT is rarely used in community-based substance abuse treatment programs. One of the barriers identified in the survey as interfering with the transfer of BCT from research settings into these programs was that BCT was perceived as costly to deliver, due largely to the staff resources required to provide BCT in the standard conjoint format (i.e., one or two therapists treating a patient and his or her partner for a clinical hour). The mandate for investigators is to develop a version of BCT that is less costly to deliver and yet retains the clinical effectiveness of standard BCT. A potential solution to the problem of the high treatment delivery costs for BCT is to develop a clinically effective version of BCT that can be conducted in a multi-couple group; such a format would allow for the more efficient use of limited staff resources. Thus, the proposed project has two primary aims which will be addressed in two sequential phases. In Phase I, we will develop and refine a 12-session treatment manual for conducting Behavioral Couples Therapy in a group therapy format (G-BCT) for married or cohabiting substance-abusing men and their nonsubstance-abusing intimate female partners. In Phase II of the project, we will conduct a small pilot study in which subjects participating in G-BCT plus Individual Drug Counseling (IDC) will be compared to subjects who participate in an equally intensive Standard BCT (S-BCT) plus IDC and those who receive treatment as usual (i.e., group-based drug abuse counseling [GDC plus IDC]) in terms of clinical outcomes (e.g., substance abuse, dyadic adjustment, family functioning), as well as cost outcomes (e.g., cost-benefit and cost-effectiveness). If the objectives of the proposed study are met, an efficacious variant of BCT would be available that community-based treatment programs could provide using a comparatively efficient delivery format.

PARENT TRAINING AND COUPLES THERAPY FOR DRUG ABUSE
A significant body of research indicates that preadolescent children who are raised by substance-abusing parents often manifest substantial emotional, behavioral, and social problems. Despite this, most custodial parents who enter treatment for substance abuse are very reluctant to allow their children to be involved in any type of psychosocial intervention, regardless of whether it be individual treatment for the child or as part of family therapy. Thus, interventions for substance-abusing parents that do not involve their children, which nonetheless serve to improve the family environment as a whole, may actually hold the most potential for improving the psychosocial adjustment of children who live in these homes. Moreover, such interventions may help prevent the poor outcomes often observed in these high-risk children as they enter adolescence and early adulthood. Results of a recent study conducted by our investigative team indicate children whose substance-abusing fathers and nonsubstance-abusing mothers participated in Behavioral Couples Therapy (BCT) displayed higher psychosocial adjustment at posttreatment and during an extended posttreatment follow-up period than children whose substance-abusing fathers participated in treatment-as-usual or whose parents participated in a couples-based attention control treatment. These encouraging findings suggest BCT has significant effects on the family that extend beyond the couple to their children, even though (a) the children themselves were not actively involved in treatment, (b) parent skills training was not a component of the treatment, and (c) parenting issues were not discussed during the course of BCT. It is plausible, however, that the effects of BCT for parents on their children may be enhanced further if parent training is integrated into the couples therapy intervention. Thus, the purpose of the Stage II investigation is to conduct a longitudinal randomized clinical trial to examine the clinical effects of a new, hybrid treatment, Parent Skills Training plus BCT (PSBCT) compared to (a) standard BCT; (b) Parent Training only (PT); and (c) Treatment-As-Usual (TAU). More specifically, married or cohabiting substance-abusing fathers and nonsubstance-abusing mothers (N = 216 couples) entering outpatient treatment who live with and parent one or more preadolescent children will be recruited for the study. Participants in the treatment conditions will be compared in terms of children's adjustment, fathers' substance use, and family and relationship functioning. Extensive cost, cost-benefit, and cost-effectiveness comparisons will also be conducted. As a new treatment targeted at substance-abusing patients and their children, PSBCT could potentially have broad and prolonged effects that extend beyond the patients seeking treatment for substance abuse to the children under their care.

CHILDREN OF DRUG ABUSING FATHERS
Over the last century, an extensive empirical literature has evolved examining the psychosocial adjustment of Children of Alcoholics (i.e., COAs). In general, these investigations have concluded that COAs are at heightened risk for a host of emotional and behavioral problems compared to children of nonalcoholic parents. Conversely, research examining the psychosocial functioning of children whose parents primarily abuse drugs other than alcohol, often referred to as Children of Substance Abusers (i.e., COSAs), is far less evolved than the COA literature. Although results of available studies suggest COSAs are at heightened risk for psychological, social, and behavioral problems, it is far less clear what risk and protective factors may be associated with these observed adjustment problems. To date, the vast majority of investigations of COSAs have focused on children of drug-abusing mothers. Although many leading investigative teams have called for research examining psychosocial adjustment of children with drug-abusing fathers, they have noted consistently, efforts to obtain data from such families have been fraught with substantial logistic difficulties. Drug abuse by fathers, with its broad implications for the family environment (e.g., poor parenting, parental conflict, stressful home life) and for the child (e.g., genetic transmission of characteristics that may increase vulnerability), is likely to be an important risk factor for psychosocial maladjustment of their custodial children. Thus, recruitment and methodological barriers notwithstanding, the fact that the effects of paternal drug misuse on their children have been substantially understudied represents a serious gap in the empirical literature. The primary aim of the proposed 5-year study is to examine the psychosocial adjustment of preadolescent custodial children (i.e., 8-12 years of age) who live in two-parent homes with drug-abusing fathers and nonsubstance-abusing mothers (N = 150). To provide a comparative context, these children and their families will be compared to demographically matched children from homes with alcoholic fathers and nonsubstance-abusing mothers (N = 150) and from homes with nonsubstance-abusing parents (N = 150). Additionally, we will be examining several mediating risk factors (e.g., parenting behavior, child temperament, interparental conflict) and protective factors (e.g., children's cognitive ability, social support) that may partially or fully explain differences among the children from homes with either a drug-abusing, alcoholic, and nonsubstance-abusing father. Changes in risk and protective factors, as well as children's adjustment, will be evaluated during the course of three annual waves of data collection.

DOMESTIC VIOLENCE AND COUPLES ALCOHOLISM TREATMENT
Domestic violence has long been recognized as a highly prevalent problem among alcoholic patients and their intimate partners. Findings from several studies reveal that 40%-60% of couples in which a male partner is entering treatment for alcoholism report episodes of male-to-female physical aggression in the year prior to program entry. Unfortunately, little is known about the general effectiveness of different types of interventions for these patients (and couples) in terms of reducing or eliminating episodes of partner physical aggression. The purpose of the present project is to perform a secondary analysis on data available for alcoholic men and their wives who participated in a couples therapy intervention to examine changes in prevalence and frequency of partner violence during and after treatment. The project also will explore theoretically grounded factors that may be significantly related to the occurrence of frequency of partner violence among these patients.

COGNITIVE REHABILITATION FOR SUBSTANCE ABUSERS
There is now ample evidence from multiple lines of research that chronic ingestion of alcohol and other psychoactive substances is associated with measurable cognitive impairment. Typically, individuals with extensive histories of substance abuse have relatively preserved verbal skills, but have deficits in verbal problem-solving, conceptual shifting, perceptual-spatial skills, abstract reasoning, information-processing speed, and memory. The presence of cognitive deficits among substance-abusing patients has important clinical implications; these deficits are likely to interfere with patients' abilities to receive, encode, and integrate new information presented in the course of treatment. Moreover, findings from several investigations indicate the presence of cognitive impairment among patients is associated with poorer treatment engagement and outcomes. There is also evidence to suggest cognitive functioning improves with extended abstinence. However, from a treatment perspective, the natural rate of cognitive recovery (i.e., time-dependent recovery) is, practically speaking, relatively slow. Although cognitive performance shows signs of improvement after as little as one month of sobriety, full recovery takes several months (or more) of abstinence. Given the relative brevity of most interventions for substance abuse, patients may not be cognitively able to engage fully in treatment until long after participation has been completed. It is plausible that methods designed specifically to accelerate the rate of cognitive recovery (i.e., experience-dependent recovery) could have important benefits for substance-abusing patients. Findings from Stage IA/B pilot studies provide preliminary support for this hypothesis. More specifically, use of computer-assisted cognitive stimulation exercises, developed for patients who have suffered traumatic brain injury, can accelerate the cognitive recovery of substance-abusing patients and, importantly, lead to improvements on measures of treatment engagement and posttreatment outcome. Thus, the primary aim of the proposed Stage II trial is to examine the effects of Computer-Assisted Cognitive Rehabilitation (CACR) on treatment response and outcome compared to two control conditions: (a) an equally intensive Computer-Assisted Typing Tutorial (CATT) and (b) Treatment-As-Usual (TAU). Substance-abusing patients (N = 240) from one of two long-term residential treatment programs (i.e., LRTs) will be randomly assigned to the above treatment conditions and will be compared on measures of treatment engagement (during the course of treatment) and 12-month posttreatment outcomes (measured quarterly). It is hypothesized that participants who receive CACR will remain in treatment longer and will have better 1-year posttreatment substance use and other psychosocial outcomes compared to patients in the control conditions.

EFFECTS OF BEHAVIORAL COUPLES THERAPY ON INTIMATE PARTNER VIOLENCE
Intimate partner violence (IPV) is widely recognized as a significant public health concern in the U.S. population, with the results of a national survey revealing that 15%-20% of couples engage in acts of partner physical aggression each year. As alarming as these prevalence rates appear, they are dwarfed in comparison to rates reported in studies of substance-abusing couples entering treatment, in which it is estimated that 50%-60% of these couples engage in IPV. With the use of marital- and family-based assessments and interventions becoming more common as part of treatment for alcoholism and other drug disorders, providers are increasingly faced with addressing IPV, and its negative sequelae, among their patients and their intimate partners.

Unfortunately, effective options for treatment providers who confront this issue are extremely limited. Although the most common approach for providers is to refer these cases to agencies specializing in batterers treatment, three fundamental problems make this strategy largely untenable: (a) most of the agencies offering these services only accept individuals legally mandated to complete their programs; (b) among programs that do accept nonmandated patients, most substance-abusing patients do not accept such referrals or drop out very prematurely; and (c) available evidence suggests that these programs are ineffective in reducing IPV. Thus, it is imperative that substance abuse treatment programs develop and evaluate other intervention alternatives for IPV.

Findings from several studies suggest that Behavioral Couples Therapy (BCT) significantly reduced IPV among married or cohabiting alcoholic and drug-abusing patients. Although use of conjoint treatment for IPV is controversial, the reductions in IPV observed among patients and their partners who participate in BCT are substantial and are difficult to ignore. Thus, the promising findings for BCT as an intervention for IPV require further, more rigorous evaluation. Using the stage model described in NIAAA’s PA Behavioral Therapies Development Program, the objective of this exploratory/developmental investigation is to conduct a Stage IB (pilot) study, comparing the efficacy of BCT versus an individual-based treatment for alcohol dependence (i.e., Individual Drug Counseling [IDC]; Crits-Christoph et al., 1997) in terms of reducing IPV during and after treatment for domestically-violent married or cohabiting alcohol-dependent patients (N = 50) and their partners. Potential mediators of the effect (e.g., reduced alcohol use, reduced use of maladaptive methods of conflict) will also be examined. If the observed effects of this small-scale randomized clinical trial are promising, they will be used to inform the development of a larger efficacy trial (i.e., Stage II study).