Growing Together, Not Apart: Couples Therapy in Alcohol Addiction Recovery

Couples therapy, as defined by the American Psychological Association, describes when both members in a relationship are treated simultaneously by the same therapist.1 Couples therapy treats many different relationship obstacles, including mental and physical health.2

What Is Couples Therapy?

Couples therapy is also known as couples counseling, marriage counseling, or relationship therapy. In couples therapy, the term “couple” refers to two people who are united romantically.

Research shows that couples influence each other. When one partner changes a behavior, the other often does so as well. The behaviors may mirror each other, such as spouses starting or stopping a diet at the same time.2 The behaviors may also oppose each other, such as one person doing more around the house in response to their partner’s absenteeism or reduced ability to fulfill family responsibilities due to substance misuse.

Based on this theory, positive relationship experiences can influence healthy or desirable behaviors, including harm reduction, alcohol use moderation, or abstinence when one member of the couple struggles with alcohol misuse or has alcohol use disorder (AUD).

While an individual is responsible for their own actions and must find their own motivation for recovery, how their partner responds to their alcohol use and their steps in recovery can affect their behavior. For example, if their partner:

  • Purchases and uses alcohol, this may create continuous exposure to triggers
  • Reacts with anger, frustration, or aggression, this may enhance negative internal feelings and undermine the relationship
  • Sets clear, empathetic boundaries, this may empower recovery-focused choices
  • Learns how to avoid enabling behaviors, this may reduce the risk of relapse in the home environment

Couples therapy is one way to create positive relationship experiences in recovery. Studies indicate that for couples experiencing relationship distress, couples therapy improved:3

  • Intimacy
  • Communication skills
  • Problem-solving skills
  • Anxiety or depression symptoms

How Is Couples Therapy Different From Family Therapy?

Couples therapy is not family therapy, but they are interrelated. Marriage and family therapy recognizes that all members of a family are affected by the disorders of one member. Family therapy focuses on healing each member of the family separately and as a group.4

Couples therapy focuses only on improving the relationship between two intimate partners. Counseling that extends beyond the couple—such as by including the couple’s children in the therapeutic process—is considered family therapy.

The goals and achievements in couples counseling and family therapy have similarities, such as:4

  • Identifying strengths of the family unit being treated
  • Improving communication and listening skills in the family unit
  • Developing empathy within the family unit
  • Setting and prioritizing joint goals
  • Meeting the needs of all people involved in treatment
  • Building support systems for your relationship with someone who misuses alcohol

What Can I Expect in Couples Therapy?

Therapists working with couples may use more than one modality throughout treatment. No specific treatment necessarily will work for both individuals. Therapists collect information to determine which combination of modalities will offer you and your spouse the most benefits. Typically, there are three stages of couples therapy.5

1. Engagement and Building a Foundation

There are many types of couples therapy in alcohol addiction treatment.

The first stage involves collecting data and getting to know one another. A therapist helps you and your significant other set relationship goals and the steps to reach those goals. You discuss your relationship risk factors, which lead to the potential of damaging the relationship. Then, determine protective relationship factors or factors that lead to the preservation of your partnership.

Therapists use this time to motivate you by showing you the benefits of specific changes.

2. Initiate Behavior Changes

Skill-building takes place in the second phase. The skills you learn assist in meeting the identified needs of your relationship. Common skill-building activities include sessions focused on communication, stress management, trust-building, self-care, and anger management. Your therapist will likely give homework assignments to help you work on these skills between counseling sessions.

3. Maintenance and Closure

The final stage is when the therapist evaluates the changes you have made as a couple to see if you have achieved a sense of stabilization and if your relationship is improving.

You learn ways to maintain healthy changes and create a plan for future problems. Your therapist connects you with community resources to help you continue striving towards your goals. Community resources often include support groups—such as Alcoholics Anonymous (AA) and Alcoholics Anonymous Family Groups (Al-Anon)—and education that focus on your specific relationship issues.

How Is Couples Therapy Used for Alcohol Use Disorder?

When you, your partner, or both have alcohol use disorder, managing the physical and mental health issues associated with alcohol misuse is the priority. To make your relationship a priority, alcohol misuse must stop.

Many approaches to couples therapy are successfully adapted to treat AUD.5

Couples therapy may be used during inpatient rehab or outpatient alcohol addiction treatment programs. Couples therapy is often adapted to treat alcohol use disorder within a relationship, including addressing issues like:

  • The interconnectivity of alcohol and sex life
  • Alcohol and infidelity in the past
  • Issues related to alcohol and sharing of household responsibilities
  • Issues related to alcohol and sharing of parenting responsibilities
  • The effect of alcohol misuse on finances

Couples therapy is comprehensive, addressing and intervening in all areas of a person’s life affected by alcohol, not just the relationship. Examples include:5

  • Co-occurring mental health disorders
  • Employment issues
  • Legal problems
  • Medical conditions

Couples therapy seeks to educate you about alcohol as a brain disease, build support systems, and connect with family recovery groups in the community.5

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Which Couples Therapy Modalities Are Used for Alcohol Use Disorder?

There are several treatment approaches commonly adapted for alcohol use disorder.

Behavioral Couples Therapy

Behavioral couples therapy (BCT) is a type of counseling provided when one member of the couple has alcohol use disorder.6

Behavioral couples therapy is a treatment model that recognizes that a person with AUD’s intimate partner can positively or negatively affect drinking behaviors. Reports indicate that couples participating in BCT experience longer periods of sobriety. Couples also report fewer emotional problems in their children and a decrease in domestic violence incidences where intimate partner violence was previously an issue in the household.6

The benefits of alcohol-focused BCT include:7

  • Increased positive activities to enhance the relationship with someone who misuses alcohol
  • Support for abstinence through interpersonal contracts and other methods
  • Improvement of skills through education and homework activities
  • A multi-level approach that incorporates medication, self-help groups, and other resources
  • Introduction of relapse prevention skills

Community Reinforcement and Family Training

If your partner is currently resistant to addiction treatment, community reinforcement and family training (CRAFT) may be an appropriate choice. Your therapist helps the partner who has alcohol use disorder prepare to engage with treatment and continue to engage.

CRAFT focuses on the following 8 components:8

  1. Identifying the function alcohol misuse has served
  2. Contingency management training, which rewards recovery-focused behavior
  3. Allowing negative consequences to occur
  4. Improving communication skills
  5. Entering treatment
  6. Caring for yourself
  7. Motivating compliance with a treatment program
  8. Training for safety based on identified needs of each individual, the couple, and any other member of the household

In studies comparing CRAFT to a control group, CRAFT increased treatment entry, typically before the sixth session.8

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Emotion-Focused Couples Therapy

Theories exist that problems in a relationship with an alcoholic are due to issues with the emotional bonds between the couple. The misuse of alcohol can lead to either partner—or both partners—living with unmet needs and desires. Negative emotions can alcohol occur when the person who does not have alcohol use disorder experiences neglect, abuse, or the effects of alcohol and infidelity.

Emotion-focused couples therapy can help resolve negative emotions like:9

  • Anger
  • Emotional injuries
  • Hurt from betrayal
  • Feelings of abandonment
  • Trust issues
  • The need for forgiveness

Cognitive-Behavioral Couples Therapy

Cognitive-behavioral therapy (CBT) is a common treatment approach in alcohol addiction treatment. CBT is also commonly used in talk therapy for both individuals and couples to address other mental health conditions. In couples therapy, therapists help couples change thoughts and feelings that may lead to negative behaviors and consequences.10

A therapist can use a wide range of cognitive-behavioral couples therapy (CBCT) sub-approaches to treat various stressors outside and within the relationship, such as the following:10

  • Mental health co-occurring disorders such as depression and anxiety
  • Physical health conditions, including those directly related to alcohol misuse and those unrelated to alcohol use disorder
  • External stressors such as finances, employment, and pressure from family members
  • Severe relationship interaction problems
  • Internal stressors such as insecurities or codependency

Emerging Approaches

Less common treatment modalities for couples exist. They can be adapted to combine treatment for various conditions and alcohol use disorder. They include: 11, 12, 13

  • Cognitive-behavioral conjoint therapy—This type of CBT is for couples where one has post-traumatic stress disorder (PTSD). Because AUD is often co-occurring with PTSD, a therapist can help couples identify and move past the trauma that caused PTSD and may have contributed to the AUD and learn new coping skills that do not involve alcohol.
  • Congruence couples therapy—Congruence therapy is recommended when one person in a couple has a gambling problem or disorder. Gambling and other “behavioral addictions” share many of the same factors as alcohol use disorder, and some people may have a problem with both.
  • Couple dialectical behavior therapyDialectical behavior therapy (DBT) is another type of behavioral therapy used to improve interactions between a couple, including both verbal and nonverbal communication.

How Effective Is Couples Therapy for Alcohol Use Disorder?

Many studies—including studies on specific couples therapy modalities—support the effectiveness of couples therapy when one partner is misusing alcohol. For example, alcohol behavioral couples therapy (BCT) has been shown to help someone with alcohol use disorder by reducing drinking, reducing the severity of drinking, and improving relationships and relationship satisfaction.14

Behavioral couples therapy research shows this approach is just as beneficial for couples in which both partners have alcohol use disorder. Traditionally, therapists use BCT when one person has alcohol use disorder. However, when studied, BCT offered significant and similar results for couples who both had an AUD diagnosis.15

Additional research shows that, because alcohol affects all family members, it’s important for each to learn how to help someone with alcoholism. Successful interventions include motivational enhancement like motivational interviewing, cognitive-behavioral therapy (CBT), and other multi-systemic approaches.16

If you, your partner, or both have AUD, couples counseling can help. Even if entering treatment is not something your loved one wants to do right now, that’s okay. Couples counseling can teach essential skills for building a stronger relationship. When implemented, the new skills may eventually motivate entry into alcohol treatment and recovery.

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Resources

  1. American Psychological Association. (2020). Couples Therapy. APA Dictionary of Psychology.
  2. Kiecolt-Glaser, J. K., & Wilson, S. J. (2017). Lovesick: How Couples’ Relationships Influence Health. Annual Review of Clinical Psychology, 13, 421-443.
  3. Canadian Agency for Drugs and Technologies in Health. (2014, October 17). Couples Therapy for Adults Experiencing Relationship Distress: A Review of the Clinical Evidence and Guidelines. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health.
  4. Tuerk, E. H., McCart, M. R., & Henggeler, S. W. (2012). Collaboration in Family Therapy. Journal of Clinical Psychology, 68(2), 168–178.
  5. Center for Substance Abuse Treatment. (2020). Substance Use Disorder Treatment and Family Therapy. Rockville (MD): Substance Abuse and Mental Health Services Administration (US).
  6. Dunlap, L. J., O’Farrell, T. J., Schumm, J. A., Orme, S. S., Murphy, M., & Murchowski, P. M. (2020, May 03). Group Versus Standard Behavioral Couples’ Therapy for Alcohol Use Disorder Patients: Cost-Effectiveness. Journal of Studies on Alcohol and Drugs, 81(2), 152-163.
  7. O’Farrell, T. J. & Fals-Stewart, W. (2000). Behavioral couples therapy for alcoholism and drug abuse. Journal of Substance Abuse Treatment, 18(1), 51-54.
  8. Kirby, K. C., Benishek, L. A., Kerwin, M. E., Dugosh, K. L., Carpenedo, C. M., Bresani, E., Haugh, J. A., Washio, Y., & Meyers, R. J. (2017, November 01). Analyzing components of Community Reinforcement and Family Training (CRAFT): Is treatment entry training sufficient? Psychology of Addictive Behaviors: Journal of the Society of Psychologists in Addictive Behaviors, 31(7), 818-827.
  9. Greenman, P.S. & Johnson, S.M. (2021, June 30). Emotionally focused therapy: Attachment, connection, and health. Current Opinion Psychology, 43, 146-150.
  10. Epstein, N.B. & Zheng, L. (2017). Cognitive-behavioral couple therapy. Current Opinion in Psychology, 13, 142-147.
  11. Monson, C.M., Fredman, S.J., Macdonald, A., Pukay-Martin, N.D., Resick, P.A. & Schnurr, P.P. (2012, August 15). Effect of cognitive-behavioral couple therapy for PTSD: a randomized controlled trial. JAMA, 308(7), 700-709.
  12. Lee, B.K. & Awosoga, O. (2015). Congruence Couple Therapy for Pathological Gambling: A Pilot Randomized Controlled Trial. Journal of Gambling Studies, 31(3), 1047-1068.
  13. Kirby, J.S. & Baucom, D.H. (2007). Treating emotion dysregulation in a couples context: a pilot study of a couples skills group intervention. Journal of Marital Family Therapy, 33(3), 375-391.
  14. McCrady, B. S., Wilson, A., Munoz, R., Fink, B., Fokas, K. & Borders, A. (2016). Alcohol-Focused Behavioral Couple Therapy. Family Process, 55(3), 443-459.
  15. Schumm, J. A., O’Farrel, T., Andreas, J.B. (2012, January 01). Behavioral Couples Therapy When Both Partners Have a Current Alcohol Use Disorder. Alcoholism treatment quarterly, 30(4), 407–421.
  16. McCrady, B. S., & Flanagan, J. C. (2021, May 06). The Role of the Family in Alcohol Use Disorder Recovery for Adults. Alcohol Research: Current Reviews, 41(1), 06.

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