Taken as a whole, the strong interrelationship between substance use and family interaction would suggest that interventions addressing the behavior of only one member of the family, in isolation from the family system, would be less than optimal. However, standard treatments for substance abuse, which focus largely on the individual substance-abusing patient, usually do just that. In contrast, BCT (and, for that matter, family-based treatments for substance abuse in general) have two primary objectives that evolve from a recognition of the interrelationship between substance use and family interaction: (a) eliminate abusive drinking and drug use and harness the support of the family to support positively the patients’ efforts to change and, relatedly, (b) alter dyadic and family interaction patterns to promote a family environment that is more conducive to long-term stable abstinence.

BCT Treatment Methods
The interventions used as part of BCT are designed to promote stable abstinence, enhance relationship satisfaction and promote a familial environment conducive to long-term sobriety, and relapse prevention/maintenance of gains. In many important respects, BCT attempts to address each of these areas simultaneously, using specific techniques and approaches to meet these ends.

Promoting Stable Abstinence. When using BCT to treat a married or cohabiting alcoholic or drug-abusing patient, the patient is seen with his or her intimate partner conjointly. BCT is designed to build support from within the dyadic system for abstinence. To meet this goal, the therapist, with extensive input from the couple, develops and has the partners enter into a daily Recovery Contract. As part of the contract, partners agree to engage in a daily Abstinence Trust Discussion, in which the substance-abusing partner states his or her intent not to drink or use drugs that day (in the tradition of one day at a time from Alcoholics Anonymous). In turn, the nonsubstance-abusing partner verbally expresses positive support for the patient’s efforts to remain clean and sober. For substance-abusing patients who are medically cleared and willing, daily ingestion of medications designed to support abstinence (e.g., naltrexone, disulfiram), witnessed and verbally reinforced by the nonsubstance-abusing partner, can also be a component of, and would occur during, the daily Abstinence Trust Discussion.

Also, as a condition of the Recovery Contract, both partners agree not to discuss past drinking or drug use or fears of future substance use when at home (i.e., between scheduled BCT sessions) during the course of couples treatment. This agreement is put in place to reduce the likelihood of substance-related and relapse-triggering conflicts occurring outside the confines of the therapy sessions. Partners are asked to reserve such discussions for the BCT therapy sessions, where the interaction can be monitored and facilitated by the therapist. Many contracts also include specific provisions for partners’ regular attendance at self-help meetings, such as Alcoholics Anonymous (AA) or Al-Anon.

At the start of each BCT session, the therapist reviews partners’ overall compliance with various components of the contract. When possible, the partners perform behaviors that are aspects of their Recovery Contract (e.g., Abstinence Trust Discussion) in each scheduled BCT session to allow the therapist to observe and provide corrective feedback regarding these behaviors.

Relationship Enhancement. Through the use of standard couple-based behavioral assignments, BCT also seeks to increase positive feelings, shared activities, and constructive communication; these relationship factors are viewed as conducive to sobriety. The exercise Catch Your Partner Doing Something Nice has each of the partners notice and acknowledge one pleasing behavior performed by his or her mate each day. In the Caring Day assignment, each partner plans ahead to surprise their significant other with a day when they do some special activities to show their caring. Planning and engaging in mutually agreed-upon Shared Rewarding Activities is important because many substance abusers’ families have ceased engaging in shared pleasing activities; participating in such activities has been associated with positive recovery outcomes. These activities must involve both partners, either as a couple only, with their children, or other adults -- and can be performed at or away from home. Teaching Communication Skills (e.g., paraphrasing, empathizing, validating) can help the substance-abusing patient and his or her partner better address the inevitable stressors in their relationship and in their lives as they arise, which also improves the chance for maintaining sobriety.

Relapse Prevention/Maintenance of Gains. Relapse prevention planning occurs in the final stage of BCT. At the end of weekly BCT sessions, each couple completes a Continuing Recovery Plan. This written plan provides an overview of the couples’ ongoing post-BCT activities that are designed to promote stable sobriety (e.g., continuation of a daily Abstinence Trust Discussion, attending self-help support meetings) and contingency plans to implement if relapses occur (e.g., re-contacting the therapist, re-engaging in self-help support meetings, contacting a sponsor).

During initial sessions, BCT therapists focus on decreasing partners’ negative feelings and interactions about past and possible future drinking or drug use and increasing their positive behavioral exchanges. During later sessions, partners are engaged in communication skills training, the development of problem-solving strategies, and learning to negotiate behavior change agreements. Traditionally, the substance-abusing patient and his or her partner is seen together in BCT, typically for 15-20 outpatient couple sessions over 5-6 months. BCT also can be delivered as a stand-alone intervention or as an adjunct to standard individual substance-abuse counseling.

Empirical Support for BCT
The findings of multiple studies conducted during the last three decades indicate that participation in Behavioral Couples Therapy (BCT) is associated with robust positive outcomes for couples in which one of the partners abuses alcohol or other drugs. More specifically, several investigations by members of our research team and other investigators) have demonstrated that, compared to patients who received other, more traditional forms of substance abuse treatment, those who participated in BCT reported significantly:

• fewer days of alcohol and drug use
• longer periods of abstinence
• fewer arrests
• fewer alcohol- or drug-related hospitalizations
• higher relationship satisfaction
• better emotional and behavioral adjustment of custodial children
• lower levels of intimate partner violence

Substance-Abusing Populations That Benefit from BCT
Initially, BCT was developed and evaluated with patient populations that were predominantly white, alcoholic men and their nonsubstance-abusing wives. However, BCT has proven itself effective with several different substance-abusing populations, including:

• alcoholic men
• alcoholic women
• polydrug-abusing men
• polydrug-abusing women
• methadone maintenance patients
• substance-abusing gay couples

Learning Sobriety Together Versus Behavioral Couples Therapy
As originally designed, Behavioral Couples Therapy was designed as an intervention for married or cohabiting alcoholic and drug-abusing patients and their partners, emphasizing change in the marital system to promote abstinence. However, as BCT has evolved, the focus has moved from an exclusive emphasis on the marital system to a broader family view. For example, more recent incarnations have integrated training in parent skills into BCT (PSBCT). Other versions of BCT have included family members other than intimate partners, such as parents or siblings. Thus, the label, Learning Sobriety Together, has been used to capture this broadening conceptualization of using the principles of BCT to treat the larger family systems.