Treating Alcohol Problems With Couple Therapy

Barbara S. McCrady
University of New Mexico
Couple therapy for treating alcohol use disorders (AUDs) results in less drinking and greater relation-
ship stability and satisfaction in both men and women with AUDs. The theoretical tenets, treatment
methods, and research evidence for Alcohol Behavioral Couple Therapy (ABCT) are summarized. The
application of ABCT is illustrated through the treatment of a 42-year-old woman with an AUD and
her 56-year-old husband. During 12 sessions over a 6-month period, the woman attained abstinence
from alcohol and learned cognitive and behavioral coping skills to deal with drinking antecedents.
Her husband learned to support her abstinence by stopping drinking himself, helping her cope with
drinking urges, and reinforcing her successes. The couple increased positive pleasurable activities
that did not involve alcohol and improved their communication skills. Challenges in the treatment in-
cluded her ambivalence about abstaining, their complicated work and travel schedules, and other life
stressors. C 2012 Wiley Periodicals, Inc. J. Clin. Psychol: In Session 68:514–525, 2012.

Keywords: alcohol abuse; couple therapy; cognitive-behavior therapy; women; Alcohol Behavioral
Couple Therapy

Most people in the United States (83%) consume alcohol at some point during their lives,
and about two thirds of teenagers and adults have consumed alcohol in the past year. Most
people drink without problems, but about 4% meet criteria for alcohol dependence and 4.5%
meet criteria for alcohol abuse (Fenton, Aivadyan, & Hasin, in press). Larger groups of people
engage in risky drinking at times, but do not meet criteria for an alcohol use disorder (AUD).
However, in mental health settings, anywhere from 30%–70% of patients will have an alcohol
or other substance use disorder (SUD) along with their presenting psychological disorders.
Given the prevalence of alcohol problems, it is important that mental health practitioners have
efficacious treatments available to them.
AUDs are best thought of as family disorders and many families are affected by AUDs. For
example, 23% of Americans report that they have a first-degree relative with an alcohol problem
and 38% report any blood relative with a drinking problem (Fenton et al., in press). Although the
probability of getting married is about the same for those with and without AUDs, separation and
divorce rates are about four times that of the general population. Physical violence is common
in couples where one partner has an AUD, occurring in about two thirds of couples where either
the woman or the man has an AUD. AUDs also affect the physical and psychological health
of spouses and children, with spouses being more likely to be depressed or anxious or to have
psychophysiological symptoms, and children being at higher risk for school problems, conduct
disorder, and internalizing disorders.
Individuals’ attitudes and patterns of alcohol and drug use are influenced heavily by the
family. Genetic vulnerabilities to developing AUDs, family attitudes about alcohol, and family
drinking patterns have a direct effect on drinking. Specific parenting behaviors and styles,
parental monitoring, and family rituals also have indirect effects on adolescents’ drinking. In
adulthood, individual drinking patterns are influenced by the drinking of the intimate partner,
and many couples align their drinking patterns so that they become more similar over time.
Problems related to drinking also develop within a social network, and having a heavier drinking
social network is associated with more drinking problems. Clearly there is an interaction: Heavier

The research that forms the basis for this article was funded by NIAAA Grant No. R37 AA07070.
Please address correspondence to: Barbara S. McCrady, Center on Alcoholism, Substance Abuse, and Addic-
tions, University of New Mexico, 2650 Yale Blvd. SE, Albuquerque, NM 87122; e-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 68(5), 514–525 (2012) 

C 2012 Wiley Periodicals, Inc.

Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21854

 Couple Therapy for Alcohol Problems 515

drinkers seek out and socialize with other heavy drinkers; the positive experiences in these social
interactions in turn reinforce continued heavy drinking.
At the same time, the family and others in the social network are central to the initiation,
resolution, and maintenance of change in AUDs. Family members often are the first to notice and
comment on a loved one’s behavior when drinking, suggest change, and encourage help seeking.
Families also provide important support to the individual who is trying to stop drinking, and
family support is often cited as one of the most important contributors to a person’s successful
sobriety.
We have developed and evaluated an integrated therapy for AUDs that includes both partners
in the treatment and that addresses individual change in both partners as well as couple level
change (McCrady & Epstein, 2009a, 2009b). We have established the efficacy of ABCT through
a series of clinical trials. O’Farrell and colleagues have evaluated a similar model of couple-
involved treatment, with similar positive results (O’Farrell, Cutter, Choquette, Floyd, & Bayog,
1992).

Alcohol Behavioral Couple Therapy

ABCT draws upon cognitive-behavioral methods for the treatment of alcohol use disorders
(Epstein & McCrady, 2009) and behavioral couple therapy (Epstein & Baucom, 2003) for the
treatment of distressed relationships. Although we see AUDs as multiply determined, complex
behaviors, ABCT focuses on current factors maintaining drinking. Excessive drinking is treated
as an over-learned behavior.
ABCT is grounded in the assumption that drinking occurs in an interactional context, is
maintained in part by interactions between the drinker and partner, and is changed most ef-
fectively by teaching each partner new individual coping skills and also changing interactions
between partners. Drinkers learn skills to attain and maintain abstinence; partners learn skills
to reinforce positive changes in drinkers’ behavior and decrease behaviors that might cue or
reinforce drinking. Changes in the couple’s interactions are intended to decrease couple-level
cues for drinking and increase the reinforcement value of the relationship. Throughout, ABCT
maintains a dual focus on individual and interactional change. Partner behaviors and couple
interactions are viewed as potential triggers for drinking. The partner’s actions or the couple’s
interactions consequent to drinking may serve to reinforce the drinking, either by providing
positive consequences for the drinking or by shielding the drinker from negative consequences
of drinking that otherwise would occur. Treatment is based on the assumption that couples
affected by AUDs lack the skills to deal effectively with drinking-related situations.
ABCT is designed as an outpatient, stand-alone treatment for couples in which one or both
partners is affected by an AUD. Both partners are present for all sessions, which are 90 minutes
in length. Treatment is manual-guided and has been tested in versions ranging from 12 to 24
sessions. We reduced the length of the treatment because most change occurred in the first
12 sessions and because of the ongoing pressures from third-party payers to provide briefer
treatments. Our published treatment manual and client workbook (McCrady & Epstein, 2009a,
2009b) present our current 12-session version of the treatment. The case I will present in this
article was treated using the 20-session version of ABCT.
Research dating back to the early 1970s suggested that involving the spouse in treatment
resulted in better outcomes for the individual with an AUD. Given that several other studies had
found spouse involvement promising, our first study of ABCT examined the relative contribu-
tions to outcome of spouse presence, modifying spouse behaviors and the couple’s relationship
(McCrady, Noel, Stout, Abrams, & Nelson, 1991). Over the 18 months of posttreatment follow-
up, we found that couples receiving the treatment focused on both individual coping and the
couple’s relationship had better treatment retention, marital stability and satisfaction, and better
drinking outcomes than the comparison treatments that provided no intervention to improve
couples’ relationships.
Although our early results were promising, the majority of participants drank after treatment,
and in a later clinical trial, we assessed whether adding either relapse prevention (RP) interven-
tions or Alcoholics Anonymous (AA) and Alanon involvement would improve the outcomes
516 Journal of Clinical Psychology: In Session, May 2012

of ABCT. Participants generally showed significant decreases in the frequency of their drinking
through the 18-month follow-up period (McCrady, Epstein, & Hirsch, 1999; McCrady, Epstein,
& Kahler, 2004). The length of drinking episodes was shorter in the RP condition, but neither
the RP nor the AA/Alanon add-ons improved overall drinking outcomes over basic ABCT.
Early research on ABCT used all or mostly male samples; more recently we have conducted
studies of ABCT with women with AUDs and their male partners. In a randomized clinical trial
comparing individual CBT to ABCT, we found that women who received ABCT showed greater
improvements in abstinence and greater decreases in heavy drinking over time than women
receiving individual treatment (McCrady, Epstein, Cook, Jensen, & Hildebrandt, 2009). These
findings are very similar to findings for ABCT for men.
Our research is part of a larger body of research on conjoint treatment for persons with alcohol
and other substance use disorders. Results are consistent across research groups in finding that
despite some differences in the way the treatments are provided, conjoint therapies result in better
drinking and drug outcomes and improved relationship functioning after treatment. O’Farrell’s
research also has shown that conjoint models of treatment for AUDs lead to greater decreases
in intimate partner violence than individual treatment.

ABCT Treatment Goals and Elements

The principal goals of treatment are to (a) help drinkers decrease or stop drinking; (b) enhance
both partners’ motivation to change; (c) help the drinker develop individual behavioral, cognitive,
and interpersonal coping skills to stay abstinent; (d) help the partner develop better contingent
responses to drinking and abstinence, including decreasing behaviors that cue use, increasing
support for positive change, and decreasing attention to negative behavior; and (e) improve the
couple’s relationship as an incentive to maintain change.

Stopping Drinking
Treating AUDs always requires the therapist to consider the degree to which the drinker is phys-
iologically dependent on alcohol and to assess the potential for complicated alcohol withdrawal
(see McCrady & Epstein, 2009, for guidelines for determining withdrawal risk). Clients with high
levels of physiological dependence are referred for an inpatient or ambulatory detoxification.
Clients with low levels of dependence are helped to set goals to step down from their current
drinking level to abstinence over several weeks.

Enhancing Motivation to Change

Therapists use a motivational enhancement style, characterized by empathy, positive regard, and
“rolling with resistance” (e.g., Miller & Rollnick, 2002). Several specific aspects of the treatment
also address motivation to change. At the start of treatment, therapists provide feedback to the
couple on the drinker’s pretreatment drinking and the consequences of drinking, how the partner
has coped, and strengths and concerns in the couple’s relationship. Early in the treatment, the
therapist and couple together complete a decisional balance related to drinking. Additionally,
conducting a functional analysis highlights negative consequences from drinking in specific to
manage high risk situations.

Developing Drinker Coping Skills

Functional analysis is central to ABCT. The functional analysis provides a framework for the
therapist and couple to identify situations that place the client at high risk for drinking, un-
derstand cognitive and affective responses to high-risk situations, and recognize the positive
and negative consequences that ensue. The therapist systematically helps the client learn to
modify high-risk situations, use different cognitive and behavioral strategies to cope, learn new
ways to obtain similar positive reinforcers through means other than drinking, and learn how
to anticipate negative consequences of drinking in high-risk situations. Coping skills include:
 Couple Therapy for Alcohol Problems 517

self-recording of drinking and drinking urges to identify high-risk situations, completing be-
havior chains for specific high-risk situations, self-management planning, and cognitive and
behavioral skills to manage high risk situations.

Developing Partner Coping Skills

Partner behaviors are considered at each step in the functional analysis and specific interventions
focus on partner coping. The therapist helps the partner identify actions that may serve as triggers
for drinking. These may include behaviors intended to influence the drinker to change (such as
nagging), attempts to control the drinking or the drinker’s behavior (such as restricting access to
money), or the partner’s own drinking. The therapist works with the couple to help the partner
develop alternative behaviors that are less likely to serve as cues for drinking. The therapist also
helps the partner learn to provide positive reinforcement for positive behavior changes related
to drinking, decrease reinforcers for drinking, and allow negative consequences to occur should
the drinker drink.

Improving the Couple’s Relationship

The goal of reciprocity enhancement is to increase positive exchanges between the partners so
that they experience more pleasure in being with each other, and so that the positive aspects
of the relationship may serve as an incentive for abstinence. Couples are helped to identify
positive behaviors from their partner and give each other feedback about these positive actions.
Later interventions focus on the development of shared enjoyable activities. Communication
and problem-solving skills are taught by helping couples identify positive and negative aspects
of their communication and then practicing more constructive communication skills. Problem-
solving skills are introduced toward the end of treatment.

Case Illustration
Presenting Problem and Client Description
Terri was a 42-year-old woman in her second marriage who sought treatment for her drinking
problem in one of our clinical trials for women with AUDs. Treatment included two assessment
sessions with Terri and her husband, Steve, which totaled about 4 hours, and 12 sessions of
treatment over 6 months.
Terri had a master’s degree in business administration and worked as an international man-
agement consultant; her annual income was about $175,000 per year. Her job required her to
travel about 2 weeks per month. She devoted at least 60 hours a week to her job, and said that
she had no friends. Her only social outlet was her involvement with church. She came from a
large family and had five older brothers. Her father had died of cirrhosis of the liver when Terri
was in college; her mother was suffering from advanced Parkinson’s disease. Steve was 55 years
old; this was his third marriage. Steve had two teen-aged daughters from his first marriage. He
also was college educated and had a small construction company. His annual income was about
$100,000/year.
Terri started drinking in high school, and by her senior year she started cutting school on
occasion to go drinking with her friends. She drank and drove frequently, although she had
never been arrested or charged with driving while intoxicated. By her senior year of college, she
was drinking heavily Thursdays through Sundays, describing herself as a “party girl,” and had
frequent arguments with her parents about her drinking. She continued to miss school, and said
that she “lost more than one boyfriend because I could drink more than they did.” She also had
experimented with cocaine during college, but had stopped using by her senior year of college.
She said she could drink large amounts of alcohol from the first time she drank, but began
to experience the physiological of tolerance and withdrawal in her early 30s. She made several
unsuccessful attempts to stop drinking on her own, which led her to decision to seek treatment.
She met criteria for Alcohol Dependence with Physiological Dependence.
518 Journal of Clinical Psychology: In Session, May 2012

We assessed her drinking pattern in the past 90 days using the TimeLine FollowBack Interview
(Sobell & Sobell, 1996), which we administered to Terri with Steve present to provide additional
information about Terri’s drinking as needed. They reported that Terri had drunk on about
half (48) of the past 90 days. She had two different drinking patterns: She typically drank 1-2
glasses wine a day during the week, and she and Steve shared three liters of wine each day on
the weekends over about a 3-hour period in the evenings. We estimated that she drank about 10
standard drinks per day on the weekends, with a resultant blood alcohol level of about .30.
Negative consequences of her drinking were assessed through a clinical interview and with
the unpublished Rutgers Consequences of Use (RCU). Major consequences of concern to Terri
included: acting in an embarrassing manner at work, weight gain, decreased energy, and concerns
about her health. On the RCU, she noted other concerns as well: arguments and other problems
in her relationship with Steve, feeling guilty about her drinking, a lack of other hobbies or
interests, being concerned that she was not following through on responsibilities at home, and
missing work. She also reported physical consequences of her drinking, such as having blackouts
and hangovers, getting sick, and feeling that her thinking was fuzzy. Although Terri had tried to
stop drinking on her own, this was her first attempt at alcohol treatment. She was on Paxil for
anxiety, prescribed by her general practitioner. Because she was seeking help for her drinking
problem, I did not assess her for a possible anxiety disorder, and anxiety issues did not arise in
the treatment.
Steve also was a regular drinker, and his drinking pattern was similar to Terri’s. On the
RCU he also reported that he and Terri had been arguing, that he experienced blackouts,
hangovers, and withdrawal symptoms, and that he got irritable and verbally violent at times
when drinking. Steve clearly had an alcohol problem as well, but the couple was presenting with
primary concerns about Terri’s drinking rather than Steve’s. Because they were presenting for
treatment in a clinical trial for women with AUDs, I thought it was appropriate to focus on
Terri’s drinking. In my clinical experience outside of clinical trials, I have treated a number of
couples with similar presentations and found that the spouse who is not identified as the patient
often makes substantial changes in his or her drinking even when not the main focus of the
treatment. Steve coped with Terri’s drinking by taking care of her when she had been drinking,
by trying to support her efforts toward abstinence by complimenting her and spending time with
her when she was not drinking, and by expressing his affection toward her.
Terri and Steve had been married for 3 years. Even though they argued often when they were
drinking, they both reported a very high level of marital satisfaction on the Dyadic Adjustment
Scale (DAS; Spanier, 1976). Terri’s DAS was 124; Steve’s was even higher at 133 (DAS scores
below 100 suggest a distressed relationship). On the DAS they reported that they used a mutual
approach to decision making. She was “extremely happy”; he rated their relationship as “per-
fect.” Both partners identified few areas of substantial concern. Steve was more concerned about
household chores than Terri, and reported that he would like more frequent sexual relations.
She also reported a desire for more frequent sexual relations and wanted them to spend more
time with her relatives.
To identify specific antecedents to drinking, Terri recorded drinking and drinking urges
throughout treatment. In addition, she completed the Drinking Patterns Questionnaire (DPQ:
Menges, McCrady, Epstein, & Beem, 2008), a self-report questionnaire listing a variety of po-
tential drinking antecedents. Steve also filled out the same measure to report his view of Terri’s
drinking. She said specific environments were the most important antecedents to her drinking,
including drinking at home, after work, at supper, during the evening, at bedtime, with her hus-
band, while smoking, while talking, while partying, when others drank, on Fridays/Saturdays,
and during the winter. Steve also noted that Terri drank at restaurants, while entertaining, and at
dinner. Work provided the second most important set of antecedents to drinking, and included
drinking after work to relieve job pressure and with business associates at meetings. Marital
antecedents (ranked #3) included Steve’s drinking, having a good time together, and celebrating.
Other antecedents included drinking when others were drinking, when others would buy her
drinks or offer her drinks, and when she felt guilty about not paying enough attention to her
mother or thought about her father’s early death.
 Couple Therapy for Alcohol Problems 519

Case Formulation
Terri had a positive family history of alcoholism and developed a drinking problem early,
suggesting that she may have been genetically vulnerable to alcohol dependence. Her social
environment in high school and college reinforced her heavier drinking pattern and her husband
reinforced her current drinking. They had clearly established a “drinking partnership” in which
alcohol was integral to the fabric of their relationship.
Terri’s work environment provided multiple cues for drinking and her frequent travel made
it difficult for her to establish a regular schedule that could support abstinence-based activities.
Her drinking had a strong habitual component and had generalized to multiple environments.
In addition to social reinforcement for her drinking, Terri’s drinking was maintained by several
individual factors, including anxiety relief, relaxation from work pressures, and temporary relief
from her high personal standards. Alcohol also provided temporary relief from her concerns
about her mother’s advancing illness and guilty feelings about not spending as much time with
her mother as she thought she should. Her high level of physiological dependence and her
positive family history suggested that abstinence was the most appropriate goal for her drinking.
Terri had several important strengths that she brought to the treatment: her intelligence, stable
job, and good income; a strong and positive relationship with her husband, who was willing to
support her efforts to change; and their strong religious faith.

Course of Treatment
Session 1 (Week 1). Terri came in saying that she had been trying to drink less since her
initial evaluation. After providing the rationale for treatment, I gave the couple feedback about
Terri’s drinking, Steve’s role in her drinking, and strengths and problems in their relationship.
Despite their high scores on the DAS, Terri said that she was unhappy in her relationship
with Steve, noting in particular that their ability to communicate had eroded. Steve stated that
although he knew he also needed to stop drinking, he did not want to discuss his drinking
yet. I introduced self-recording, asking her to record her drinking, drinking urges, and marital
satisfaction (on a 1–7 scale, where 7 was high satisfaction) on a daily basis, and to note when
she had her menstrual period. I asked him to record a daily estimate of her drinking as none,
light, moderate, or heavy; his estimate of the intensity of her urges to drink; and a daily marital
satisfaction rating. At the end of the session, we discussed situations that were coming up during
the week that might be particularly high-risk for her to drink. She was feeling guilty about her
mother and was concerned about having strong urges to drink after visiting with her. Steve
thought that her mother was manipulative of Terri because of her illness, and thought that she
“shouldn’t” feel guilty.

Session 2 (Week 2). Terri drank less on the weekend, but still drank on Friday and
Saturday evening (6 and 7.5 glasses of wine, respectively). I began graphs of her drinking,
drinking urges, and their relationship satisfaction (see Figure 1). Each week, I updated the
graphs and showed them to the couple. The visual representation provided feedback to them on
change that might not have been as apparent simply from a verbal discussion and review of their
weekly self-recording. Their relationship satisfaction ratings remained very high throughout
treatment and thus are not shown in the figure. We spent a fair amount of time reviewing high-
risk situations for her to drink (as described above). We also talked more about her “anxiety
attacks” and use of Paxil. She said she was ambivalent about taking medication and that she
did not get her prescription refilled consistently. However, she also reported intense anxiety
symptoms when she was off her medication for a few days. Terri also reported that about twice
a year she’d experience a few days of “intense” depression and low energy, but without suicidal
thoughts or hopelessness.
In this session, I introduced functional analysis to the couple. We worked through two be-
havior chains, one related to work and one related to visits to her mother, to show them the
functional and temporal relations among environmental triggers, cognitive appraisals, drinking,
and positive and negative consequences. They both grasped the concepts easily, and I asked her
520 Journal of Clinical Psychology: In Session, May 2012

Figure 1. Terri’s weekly drinking and drinking urges during treatment.

to work two more behavior chains on her own for other situations. At the end of the session, we
discussed an upcoming high-risk situation—a business reception—and how to avoid drinking
there. We identified simple strategies, such as getting a nonalcoholic beverage as soon as she got
there, spending more time with light than heavy drinkers, and perhaps leaving early if necessary.
Terri and Steve also noted an upcoming trip to the Caribbean, which was prepaid and all-
inclusive, including alcohol. Both of them said that they intended to drink during the trip. I
raised the possibility of using the trip as a way to enjoy each other without alcohol, but they
were not moved by my suggestion.

Session 3 (Week 4). Steve was held up at a business meeting so Terri came to the session
alone. However, our research trial required that both partners attend each session, so she and I
talked for 10-15 minutes and then rescheduled.
When Terri and Steve came in a week later, Terri had been in Spain for 4 days for business,
and the couple had been in the Caribbean for their extended weekend vacation. Terri reported
that she had been trying to limit her drinking, but she was still drinking a lot, as was Steve.
They said that the drinks at the resort were watered down, so they drank their usual number
of drinks but believed that they had effectively drunk less than was typical for them. Terri and
Steve continued to be ambivalent about making any substantial changes in their drinking, and
we started to work on a decisional balance sheet as a way to enhance their motivation. Although
we were focusing on Terri’s drinking, Steve was an active participant in this part of the session
and mentioned pros and cons of drinking that were personally relevant to him. Terri listed many
reasons not to drink, similar to the negative consequences she had reported at intake, and she
saw significant benefits of abstinence. A major reason for her to continue to drink, however,
was her feeling of being “terrified” of how she’d feel if she weren’t drinking. I talked with them
about behavioral sampling, suggesting that she’d know better how she felt when abstinent if she
tried. Because she said that she did want to stop drinking, and Steve supported that desire, we
 Couple Therapy for Alcohol Problems 521

worked on a schedule to help her reduce her drinking by about 10% every 2 days to work down
to abstinence.
Terri and Steve also talked about Terri’s high expectations for herself. She felt that she should
“always” be a good daughter, sister, aunt, wife, professional, etc. Steve challenged her “shoulds,”
saying that she “shouldn’t” let people bother her so much.

Session 4 (Week 5). Terri drank heavily for the 3 days of the weekend (7.5 to 9 drinks
per day) including on Monday, which was a federal holiday. Steve was upset by her intoxicated
behavior and said that he realized that he also had to stop drinking for her to stop. Terri was
upset throughout the session, feeling overwhelmed at the prospect of not drinking but also
feeling even more that she needed to stop.
During the session, we reviewed the behavior chains she had completed and began to move
toward self-management for environmental triggers for her drinking. As a first step, we created
a list of her most important high-risk drinking situations, which were as follows: Friday nights
after work, Steve’s having a drink, dining in a restaurant, attending work/social functions,
entertaining at home, Saturday nights, job stress, socializing with friends, having alcohol in the
house, being offered a drink, holidays, trying to live up to her own standards (“shoulds”), dinner
time, sitting at the kitchen table for dinner and afterwards, sitting in their sunroom, celebrating
special events, feeling like she deserved a reward, when she and Steve were not “healthy” in
their relationship, and when she felt the need to “come down.” We worked on a specific self-
management plan around drinking at home, and after discussing several options, Terri and Steve
decided together to keep wine out of their house. They worked well together in discussing and
coming up with a plan that they agreed upon.
At the end of the session, I again asked her about upcoming high-risk situations. She was
planning to go out of town to visit family and anticipated drinking situations throughout the
visit because the family members she was visiting all were heavy drinkers. We discussed some
options, including telling her family that she had decided to stop drinking, or telling them that
she was on medication and could not drink, or giving some other excuse. Steve was impatient
in this discussion, and confronted her about “dancing around” the issue. She did not come up
with a plan that she felt comfortable with, and ended the session by saying, “I’ll be okay.”

Session 5 (Week 6). Terri cut down dramatically on her drinking the previous week.
She drank on only 2 days, consuming a total of eight drinks. Steve did not drink at all. They
attributed the change to their decision to keep alcohol out of the house and she emphasized the
importance of Steve’s not drinking. They both said they enjoyed each other during the week,
and found communication easier without drinking. During the session we continued to focus
on self-management planning, discussing ways that they could socialize without alcohol, and
how they would handle dining out. We also talked about ways to manage urges to drink and
practiced thinking about negative consequences of drinking as a strategy.
In addition, I introduced the concept of Steve’s providing positive reinforcement for Terri’s
sobriety. As first, he was somewhat uncomfortable with the idea, saying that he wanted to make
her happy whether or not she was drinking. However, she resonated with the idea of his giving
her extra support for not drinking, saying that she’d like him to give her positive feedback by
saying things such as, “I’m proud of what you’re doing.” We did a brief role-play and I asked him
to try this out during the week. Toward the end of the session, Terri returned to the discussion
of her “overachieving” style and her constant internal drive to do more and be more successful.
She said that she felt unable to relax or achieve any kind of balance in her life and wanted to
continue to discuss this issue in future sessions.

Session 6 (Week 8). Terri was returning from Portugal the day of our scheduled session.
Steve called to say they would have to reschedule the session because her plane had been delayed.
When the couple came in the next week, they reported that they had had a very good 2
weeks. She had 1.5 glasses of wine on one occasion and six 4-ounce glasses of wine on a second
occasion. I graphed her reported drinking and urges since our last session and she protested that
she was not getting “credit” for her success because some points on the graph covered 2 weeks
522 Journal of Clinical Psychology: In Session, May 2012

rather than 1. Given that she was eager to get positive feedback about changes she was making,
I agreed to redo all their graphs in 7-day chunks, regardless of when we held our treatment
sessions.
Terri had been using several strategies to deal with urges, particularly focusing on negative
consequences of drinking. The couple also had been spending more time with nondrinking
friends/acquaintances (primarily through their church) and she had been using other self-
management strategies, including keeping alcohol out of the house. Terri also had been telling
Steve when she was having urges to drink and he had been very helpful, mostly by telling her
about positive changes he had seen in her since she had almost stopped drinking. We discussed
additional ways that Steve could be supportive, such as making herbal tea for her after dinner,
or giving her a foot massage. Finally, we spent time on a self-management plan for an upcoming
visit with heavy drinking friends from high school.

Session 7 (Week 10). Once again, the couple had to reschedule their session, this time
because Steve had an unexpected business meeting.
The couple came in a week later. Terri had continued to drink intermittently. I was increasingly
concerned about her inability to abstain, even though she was making good progress in decreasing
her drinking. I asked Terri if she still saw abstinence as her ultimate goal, and when she said
“yes,” I asked when she thought she’d be ready to stop completely. Her answer was, “Not yet,
but I’m getting closer.” We spent the balance of the session talking about alternatives to drinking
and I helped the couple talk about ways to share positive times together. We identified several
things that were appealing to them, including lighting fragrant candles and soaking in the hot
tub and entertaining people from their church.

Session 8 (Week 11). Although Terri continued to drink, she reported that she was
trying hard to use the abstinence strategies she was learning in treatment. The couple had been
spending enjoyable time together. They had talked about having church friends over but Terri
said that she would find that difficult. She felt that she was not a worthy member of her church
because of her drinking and having people to their home would heighten her feeling of not
belonging. We spent some time talking about cognitive strategies to address her high level of
self-criticism. The balance of the session focused on drink refusal skills, first doing role-plays
with Terri alone, and then with Terri and Steve together to develop ways that he could help her
in drinking situations.

Session 9 (Week 12). Terri reported having four glasses of wine during the week (two on
Friday and two on Saturday) and Steve also reported drinking on the same days. When asked,
they said they had not given up on their plan to not keep alcohol in the house but that Steve had
stopped to buy a couple of bottles of wine on his way home from work on Friday. Terri reported
no urges to drink on any other days. We talked about Steve’s decision to stop for wine and he
said that he just “felt like drinking” and thought since Terri had been doing better, it “wouldn’t
hurt.” Terri gave Steve feedback about her disappointment with his getting wine and asked that
he not do so without calling her first.
We spent much of session on the topic of assertiveness. Terri described herself as holding in her
feelings related to her family while Steve was overly blunt. He agreed with this characterization.
We then discussed how Terri could be more assertive with her siblings, who she felt were
not paying enough attention to their mother, and how Terri could be assertive in specific
situations with her stepdaughters and with Steve. The assertiveness discussion led naturally into
a more general discussion about communication between them. Although they saw themselves
as positive, supportive, and loving in their communication with each other, they felt they were
not skilled at discussing areas of disagreement. Steve described himself as impatient with “long
conversations about feelings” and Terri expressed a desire for him to listen to and acknowledge
her feelings, particularly when she was sharing her anxiety about his children.
In the last part of the session, we tried to build on the earlier positive, shared activities by
planning a love day, in which each of them would do a number of small, loving things for the
other throughout the day. At the end of the session, the couple noted that they had another
 Couple Therapy for Alcohol Problems 523

vacation planned and they expected they would drink more. We again talked about ways to
keep drinking low during the trip. Terri decided to set a quit date for 3 weeks thence. She had
a long-awaited job promotion that was going to be effective at that point and Steve’s younger
daughter was going to be moving in with them. Terri thought these two events would provide a
good point for change.

Session 10 (Week 14). We had a short session because Steve was caught in a traffic
jam, making them late. The couple had been on vacation for the past week and Terri reported
that she drank on three occasions in the past 2 weeks (two, two, and four drinks). They had
visited her brother at the start of the vacation. Terri said he was an active alcoholic and that he
was drinking heavily and behaving in ways that they found distressing (he was belligerent and
berating toward his wife and drank to the point of passing out). She spoke with him about his
drinking and gave him feedback about his behavior; he agreed to go to a detoxification program.
Although she found the situation with her brother upsetting, it also motivated her to make a
decision to stop drinking, at least for the next 30 days. Much of the rest of session focused on
reviewing their homework from the previous session. Terri had been trying assertiveness skills
in work situations and found them helpful. Both members of the couple had implemented the
love day and were positive about it. I then briefly introduced problem-solving skills before we
had to end the session.

Session 11 (Week 15). Steve again was a bit late because of his work schedule. Terri
reported that she did not drink at all during the week, and had just two urges. She said she was
successful because she had “made up her mind,” and then used several strategies to support her
decision. Although Terri and Steve said they were happy that Terri had successfully stopped
drinking, they were tired and tense during the session. Terri said that she was concerned about
having Steve’s daughter come to live with them and how this change would affect their lives
and their relationship. We focused on communication skills for the rest of the session and I
encouraged them to hear and validate the other’s concerns around the daughter. However, they
found it difficult to hear each other and to identify specific concerns that they could address
collaboratively.

Session 12 (Week 26). The couple did not arrive for their scheduled session. Ten minutes
into the scheduled session time Terri called and said she had forgotten to check her calendar,
and that she was at work and Steve was away. We rescheduled for next the week.
The next week, Terri called to say they couldn’t make their appointment because Steve was
away. We again rescheduled for the following week.
The next week, Terri again called to say they couldn’t make appointment because Steve was
away. We then rescheduled for the next week. During our conversation, she noted that she now
had been abstinent for a month.
The next week, I called to reconfirm appointment. Steve called back to say that Terri was at
an offsite meeting and would be away the next week.
We finally met 21/2 months after the previous appointment. Terri had been virtually abstinent
since last session: She drank a half a beer on one occasion and one glass of wine on another
occasion. Factors that she said helped her included daily prayer, bible study class, Steve’s ab-
stinence, keeping busy at high-risk times, going to bed early, traveling for work, socializing less
with drinking friends, and spending time with her mother.
Steve’s younger daughter had moved in and they were finding the adjustment difficult, es-
pecially Terri, who tried to impose her high standards on the stepdaughter in terms of how
she dressed, how she kept her room, her schoolwork, and her friends. Steve felt that Terri was
placing him in the middle between her and his daughter and was upset with Terri. To deal with
these tensions, Steve and Terri had been trying to make time to talk and be together as a couple.
Although they felt that they were still finding their way, they were trying to use the communica-
tion skills we had discussed in sessions and said that not drinking made it much easier for both
of them to maintain their calm.
524 Journal of Clinical Psychology: In Session, May 2012

Figure 2. Terri’s monthly drinking.

Because Terri and Steve were part of a research study, there was a 6-month limit on the
treatment, and this session had to be their last. We spent the last part of the session discussing
relapse prevention, including warning signs, what they could do if warning signs for a relapse
were coming up, and how they could cope if a relapse occurred. We concluded with a review
of their progress through treatment. They both were pleased with the changes in their drinking
and felt that their relationship was stronger. They both, however, expressed uncertainty about
their commitment to longer term abstinence.

Outcome and Prognosis

We followed Terri and Steve’s progress for a year after treatment. The couple stayed together
and reported that they felt more comfortable with and happier with each other. At 12 months
posttreatment, Terri’s DAS had increased to 140; Steve’s DAS was essentially unchanged at 130.
Figure 2 shows Terri’s posttreatment abstinence and heavy drinking (defined as more than 3
drinks/day). Terri was abstinent most of the time during the year after treatment, and although
she drank occasionally, she never drank heavily.
Given that we tracked the couple’s progress for a year after treatment, their prognosis seemed
good. I capitalized on the strengths they brought to treatment, particularly their commitment
to each other, and tried to give Terri sufficient space to find her way to making a decision to
change. She developed individual behavioral and cognitive coping skills to maintain abstinence,
Steve made a commitment to abstinence and learned ways to support Terri’s abstinence, and the
couple developed better communication skills to deal with problems in their relationship.

Clinical Practices and Summary

This case illustrates several aspects of couple-involved treatment for AUDs. First, the treatment
had a dual focus on drinking and the relationship. For this couple, in particular, drinking was
multiply determined by Terri’s familial vulnerability, her current situation, and her coping skills.
By involving Steve in the treatment, I could change the social environment that reinforced
her drinking at the same time that I focused on her individual motivation and coping skills for
change. The improvements in the couple’s relationship should, in the long run, provide additional
incentives for maintaining the changes they initiated during treatment.
 Couple Therapy for Alcohol Problems 525

Although ABCT is a structured and directive treatment, the therapist respects the clients’
autonomy and need for self-determination. The optimal stance is one of collaboration in ex-
ploring their goals and means to achieve them. This stance was most challenged by Terri’s
ambivalence about abstinence. In several sessions, I simply asked if she was ready to change,
and when she’d say, “not quite yet,” we would talk about what would help her “get there.” The
fortuitous interaction with her brother was not something I orchestrated, but it did provide a
deeper motivation when she saw how devastating drinking could be and how strongly alcoholism
was manifested in her own family.
The couple did not complete the full 20-session ABCT in use at that time. The number of
sessions they attended was typical for ABCT; we found that only about one quarter of couples
actually attended the full 20 sessions. This observation was one reason why we reduced the total
length of the treatment to 12 sessions. My sense was that they both thought that successfully
achieving abstinence represented a good stopping point for treatment. Additionally, their life
circumstances had become more complicated with the addition of Steve’s daughter to their
household, and because they did not see a need for treatment to help them stay abstinent,
treatment became a lower priority. I would have liked additional sessions to reinforce their
abstinence and communication skills, but was glad to at least have a final session to consolidate
and reinforce key points.

Selected References and Recommended Reading

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use problems: Therapist guide. New York, NY: Oxford University Press.
Fenton, M.C., Aivadyan, C., & Hasin, D. (in press). Epidemiology and diagnosis. In: B.S. McCrady &
E.E. Epstein (Eds.), Addictions: A comprehensive guidebook, second edition. New York, NY: Oxford
University Press.
McCrady, B.S., & Epstein, E.E. (2009a). Overcoming alcohol problems: A couples-focused program. New
York, NY: Oxford University Press.
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Oxford University Press.
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