(p. 469) Behavioral Couples Therapy for Substance-Abusing Parents
Parental substance use can affect children in many ways. First, exposure to maternal alcoholism and illicit drugs in utero may cause physical and central nervous system insult to the developing fetus that may result in long-term developmental consequences (e.g., Glantz & Chambers, 2006). Second, some behaviors such as alcohol abuse appear to be moderately heritable (e.g., see Boris, 2009). Finally, considerable research has shown that family contexts characterized by parental drug or alcohol use may lead to ineffective parenting practices (e.g., poor discipline: Barnard & McKeganey, 2004; Leonard et al., 2008; Suchman & Luthar, 2000; Young et al., 2007). In some cases, parental substance use may result in impaired parent behavior or discipline, and in other instances, inadequate child-monitoring (Widom & Hiller-Sturmhofel, 2001). Although not mutually exclusive, the focus of this chapter is on children who reside with one or more substance-abusing parents for part or all of their childhoods and who often experience concomitant family factors associated with parental substance abuse.
Children Residing with Caregivers who Abuse Alcohol or Drugs: Epidemiological Evidence
Alcoholism and drug addiction are among the most harmful social, legal, and economic problems for individuals and families in the United States and across the globe. The World Health Organization (2010) estimated that 76.3 million individuals worldwide have an alcohol-use disorder, and 5.3 million individuals have drug-use disorders. Approximately 25 percent of youths under the age of 18 experience alcohol abuse or dependence in the family (Grant et al., 2006). Combined data from the 2002–2007 National Household Survey on Drug Use and Health (NHSDUH) estimated that 8.3 million children (11.9%) under the age of 18 lived with at least one parent who was dependent on or abused alcohol or an illicit drug in the past year. More specifically, approximately 7.3 million (10.3%) children lived with a parent who was dependent on or abused alcohol, and about 2.1 million (3.0%) lived with a parent who was dependent on or abused illicit drugs. The NHSDUH estimates that 5.4 million children under 18 years of age lived with a father who met the criteria for past-year substance dependence or abuse, whereas 3.4 million lived with a mother who met the criteria (Substance Abuse and Mental Health Services Administration [SAMHSA], 2009a).
(p. 470) Effects of Parental Substance Abuse on Children in their Homes
Although children of substance abusers (COSAs) have considerable resiliency and often become successful adults, as a group, youths who live with a substance-abusing parent are at-risk for higher levels of depression and anxiety (Billick et al., 1999; Kelley et al., 2010; Klostermann et al., 2011a; Stanger et al., 1999), poor self-concept (Rangarajan, 2008), externalizing symptoms (Catalano et al., 2002; Wilson et al., 2004), academic problems (Blanchard et al., 2005), and negative health outcomes (Christoffersen & Soothill, 2003; Osborne & Berger, 2009). In a sample of cocaine- and opiate-addicted mothers, Luthar et al. (1998) found that nearly 66% had at least one major psychiatric diagnosis by the time they were 12 years old. Similarly, Wilens et al. (2002) showed that 59% of children of opioid-dependent parents had at least one psychopathological condition as compared to to 41% of children of alcohol-abusing parents and 28% of controls.
Parental substance use is also a major risk factor for offspring alcohol and drug use and abuse (Braitman et al., 2009; Chassin et al., 2002; Coffelt et al., 2006; Hicks et al., 2010; King et al., 2003). For instance, Biederman and colleagues (2000) found that 53% of children who were exposed to parental substance use disorders during adolescence had substance use disorders themselves, compared with 15% of those who were not exposed during adolescence.
Treatment Options for Substance-Abusing Parents and their Children
In response to this clear and growing awareness of the needs of these youth, Tommy Thompson, who at the time was the U.S. Secretary of Health and Human Services, undertook a comprehensive initiative to create programs within substance abuse treatment agencies throughout the country to help children cope with the effects of their parents’ addiction. This effort included very strong encouragement of substance abuse treatment agencies in the United States to implement a program developed by SAMSHA and the National Association of Children of Alcoholics, described in the Children’s Program Kit (CPK; SAMHSA, 2003), which was sent to all the American agencies.
In addition to the CPK, there has been a proliferation of interventions that target a combination of parent and child outcomes. Although intergenerational risk for substance use disorder can, in part, be attributed to genetic factors (e.g., see Dick & Agrawal, 2008; Glantz & Chambers, 2006; Hasin et al., 2006; Merikangas, 2002; Prescott et al., 2005), it is now acknowledged that concomitant sequelae associated with substance use by parents (e.g., poor parenting, high inter-parental conflict and violence, neighborhood violence, poverty) are often the primary contributory factors in the emotional and behavioral problems observed in COSAs (see Glantz & Chambers, 2006; Jacob et al., 2003; Slutske et al., 2008). Moreover, the cumulative effects from multiple risk factors increase the possibility that child development will be compromised (e.g., Sameroff et al., 1987).
(p. 471) From this vantage point, much of the existing research operates from the belief that child outcomes will improve by providing effective services to parents. Therefore, interventions for these parents often include working with parents and children to improve children’s outcomes (Greenberg et al., 2008). Toward this end, a number of programs that address both parent and child needs have been developed (e.g., Catalano et al., 1999; Dawe & Harnett, 2007; Luthar & Suchman, 2000; Schuler et al., 2002); however, these programs are typically designed to treat methadone-maintained mothers of infants or young children.
Directly involving children of COSAs in treatment may be optimal, but it is important to recognize that many substance-abusing parents may be reluctant to allow their children to receive direct services or may not be aware that their children have mental health needs. Although drug-using mothers often report concern about how their drug use will affect their children (e.g., McMahon et al., 2002; Woodhouse, 1992), their fear of involvement with the child welfare system may prevent substance-abusing parents from seeking treatment (Kearney et al., 1994; Wilson et al., 2007). Specifically, some parents may not want their school-aged children involved in the treatment process, because they are concerned that this will raise concerns about their suitability as parents. Also, youths in these homes may be aware of the stigma associated with substance abuse and may not want to be identified as the child of a substance-abusing parent. For example, 15- to 19-year-olds viewed children of alcoholics as more deviant than typical teenagers and similar to “mentally ill” teenagers (Burk & Sher, 1990).
It is also important to recognize the diversity in parents who experience substance abuse. Although the vast majority of research and programs for substance-abusing parents focus on substance-abusing mothers and the needs of their families (e.g., Colby & Murrell, 1998; Glantz & Chambers, 2006; Redelinghuys & Dar, 2008), men are more likely to abuse or be dependent on alcohol or drugs than women. For instance, in 2008, 12 percent of men age 18 or older indicated substance abuse or dependence in the previous year, and 6.3 percent of women met criteria for abuse or drug dependence (SAMSHA, 2009b). Thus, residing with a substance-abusing father may be a more likely scenario for youth to experience parental substance abuse, and along these same lines, fathers may be less likely to seek treatment for family problems (including parenting). Parenting programs are often focused on the role of mothers, and men are much more difficult to engage and retain in “parenting” programs (Fabiano, 2007); thus, programs that address substance abuse by parents and support family and child functioning, but do not necessarily target parenting, may be key for some families.
Behavioral Couples Therapy for Substance-Abusing Parents
Considering that it may be difficult to treat some COSAs directly, a promising approach is Behavioral Couples Therapy [BCT] for alcoholism and drug abuse. BCT is a comprehensive psychosocial intervention for substance abuse that focuses on reducing addiction severity, improving dyadic adjustment, reducing interparental conflict and violence, and improving the family environment and (p. 472) parent adjustment. As we explain below, BCT may have benefits for the psychological adjustment of youth in these homes.
Origins of Behavioral Couples Therapy
Behavioral Couples Therapy (BCT) was originally developed for martially distressed couples (see Byrne et al., 2004; Jacobson, 1979). In response to the desire to meet the diverse needs of clients and their partners, the standard BCT model has evolved into several offshoot approaches in the general psychotherapy treatment arena, including Enhanced Cognitive Behavioral Therapy (ECBT), Self Regulatory Couples Therapy (SRCT), and Integrative-Behavioral Couples Therapy (IBCT; Kelly & Iwamasa, 2005).
Behavioral Couples Therapy for Alcohol and Drug Abuse
In recent years, BCT has been revised for use as a conjoint treatment for substance use. BCT for alcohol and drug abuse is a theoretically based, manualized, comprehensive psychosocial intervention that focuses on reducing addiction severity, improving dyadic adjustment, reducing interparental conflict and intimate partner violence, and improving the family environment and parent adjustment (Klostermann et al., 2011b; McCrady et al., 2009; O’Farrell & Fals-Stewart, 2006).
BCT operates on the fundamental premise that alcoholism and drug abuse by one partner often contributes to relationship problems between substance abusers and their partners (e.g., relationship dissatisfaction, instability, dyadic conflict, psychological distress, violence). In fact, relationship conflict often accompanies alcohol (e.g., McKinney et al., 2010) and drug use (O’Leary & Schumacher, 2003). In a meta-analytic study of the relationship between alcohol use/abuse and violence, Foran and O’Leary (2008) found a small-to-moderate effect size for the association between alcohol use and male-to-female partner violence; the effect size for female-to-male partner violence was small. However, there was a larger association of alcohol and violence when comparing clinical versus non-clinical samples and when measures assessed more severe alcohol problems.
Similarly, both laboratory and survey studies have shown that cocaine use is associated with aggression. Because cocaine is a powerful central nervous system (CNS) stimulant that causes hyperarousal symptoms (e.g., a tendency to become irritable or angry, exaggerated startle responses, sleep disturbance), cocaine use may have a pharmacological effect or aggression-promoting effect that increases violence (Parrott et al., 2003). It is also possible that illegal drug use may reduce behavioral disinhibition so that physical aggression is more likely to occur (Fillmore, 2012). or that greater impulsivity, which may be higher among cocaine-dependent individuals as opposed to alcohol abusers, may in turn relate to higher levels of partner physical and emotional abuse (Parrott et al., 2003).
In a laboratory study, individuals who ingested a low dose of cocaine displayed higher levels of physical aggression than participants in a placebo condition (Licata et al., 1993). Using data from the National Family Violence Survey and the National Survey of Families and Households, O’Leary and Schumacher (2003) (p. 473) found the odds of severe male-to-female physical aggression were higher on days of cocaine use.
Other reasons to address relationship issues in substance abuse treatment are that dyadic factors play a critical role in the maintenance and exacerbation of drinking and drug problems, as well as relapses after treatment for both men (e.g., Emmelkamp & Vedel, 2006; Maisto et al., 1988) and women (e.g., Connors et al., 1998; Epstein & McCrady, 1998; Grella et al., 2003; Sun, 2007). Thus, substance use and relationship problems appear to reinforce each other, thereby creating a “vicious cycle” for many couples.
Based on the awareness of the interrelationship between substance abuse and family interactions, BCT attempts to actively involve a spouse or partner in treatment so that the partner can be involved as a coach in the process of behavior change, disorder-specific relationship issues can be addressed, and general relationship functioning can be addressed (Kelley et al., 2009; Powers et al., 2008). Thus, the goal of BCT is to create a harmonious cycle between substance use recovery and relationship functioning by using interventions designed to address both sets of issues concurrently and reinforce positive behaviors.
Primary BCT Treatment Elements
In the early sessions of treatment, therapists delivering BCT concentrate on shifting the focus from negative feelings and interactions about past and possible future alcohol or drug use to positive behavioral exchanges between partners. In later sessions, emphasis is placed on communication skills training, problem-solving strategies, negotiating behavior change agreements, and continuing recovery strategies.
BCT Methods used to Address Substance use
As the name implies, the therapist treats the substance-abusing patient with his or her intimate partner and works to build support for abstinence from within the dyadic system. The therapist, with extensive input from the partners, develops and has the partners enter into a “recovery contract” (also called a “sobriety contract”). As part of the contract, partners agree to engage in a brief, daily “sobriety trust discussion,” in which the substance-abusing partner states his or her intention not to drink or use drugs that day. In turn, the patient’s partner verbally expresses positive support for the patient’s efforts to remain sober. Couples record their sobriety trust discussion on a daily calendar (used as a visual and temporal record of problems) provided by the therapist. As a condition of the recovery contract, both partners agree not to discuss past drinking or drug use or fears of future substance use between scheduled couple therapy sessions. Rather, disagreements regarding past substance use and fears of future use are reserved for the couple therapy sessions. Many contracts also include specific conditions for partners’ regular attendance at self-help meetings (e.g., Alcoholics Anonymous, Narcotics Anonymous).
(p. 474) BCT Methods used to Enhance Relationship Functioning
BCT also seeks to increase positive feelings, shared activities, and constructive communication through the use of standard couples-based behavioral assignments that are conducive to sobriety. Catch Your Partner Doing Something Nice (Turner, 1972) has each partner notice and acknowledge one pleasing behavior performed by the other each day. In the Caring Day assignment (e.g., Liberman et al., 1980), each partner is asked to surprise their significant other with a day of special things that show that they care for their partner. Because years of alcohol and drug abuse often result in a decrease in shared enjoyable activities, the focus of Shared Rewarding Activities (O’Farrell & Cutter, 1984) is to help the couple plan and engage in a mutually agreed-upon activity. Each activity must involve both partners, either as a dyad or with their children or other adults, and can be performed either at or away from home. Teaching Communication Skills (e.g., Gottman et al., 1976) such as paraphrasing, empathizing, and validating can help the substance-abusing patient and his or her partner better address stressors in their relationship and in their lives as they arise, which also decreases the risk of relapse.
Couples-Based Relapse Prevention and Planning
Relapse prevention occurs during the later stages of BCT. In this phase, the partners develop a written plan (i.e., Continuing Recovery Plan) designed to support abstinence (e.g., continuation of a daily Sobriety Trust Discussion, attending self-help support meetings) and list contingency plans should a relapse occur post-treatment (e.g., re-contacting the therapist, re-engaging in self-help support meetings, contacting a sponsor). A key element in creating the Continuing Recovery Plan is the negotiation of the post-treatment BCT activities. For example, the substance-abusing partner typically does not want a life that involves the structured exercises and homework that are part of BCT, whereas the non-substance-abusing partner is often suspicious of progress made in treatment (i.e., relationship improvement, abstinence) and advocates for continued participation in some activities (e.g., self-help meeting attendance, Sobriety Trust Discussions). In the Continuing Recovery Plan, partners develop a mutually agreed-to, long-term gradual decrease in the frequency of the various BCT activities until they are terminated. In the case of problems with any of the planned transitions, partners are encouraged to contact their BCT counselor.
Session Structure and Treatment Duration
BCT is moderately to highly structured. Each BCT session consists of three objectives: 1) review of relationship problems, any substance use, and home practice; 2) introduction of new material; and 3) assignment of home practice. A typical BCT session begins with an update on any alcohol or drug use that has occurred since the last session. Next, compliance with the Recovery Contract is reviewed and any impediments to compliance are addressed. The session then transitions to a review (p. 475) of any home practice from the previous session. This is followed by a discussion of any relationship or other difficulties that may have arisen since the last session, with the goal being problem resolution. Next, new material (e.g., instruction in and rehearsal of skills to be practiced at home during the week) is introduced and modeled in front of the therapist to ensure the activity is conducted correctly. Finally, at the end of each session, partners are given specific home practice assignments involving the material learned in session to complete before the next scheduled session.
Evidence for Couples-Based Treatment for Substance Abusers and their Partners
During the last three decades, couples therapy for substance abuse has received extensive empirical scrutiny, with most research focusing on BCT. In general, these studies have compared BCT to some form of traditional individual-based treatment for substance abuse (e.g., coping skills therapy, 12-Step facilitation).
In a sample of male alcoholics and their female partners, O’Farrell et al. (1985) randomly assigned participants to alcoholism counseling (e.g., 12-Step facilitation, disulfiram encouragement), alcoholism counseling plus interactional couples group therapy, or alcoholism counseling plus BCT. Clients in the BCT condition continued to report relationship benefits during the two-year follow-up; however, men in all conditions improved significantly, as indicated by non-drinking days.
McCrady et al. (1986) examined the impact of spouse involvement in behavioral interventions for alcoholism. This investigation compared minimal spouse involvement (MSI), alcohol-focused spouse intervention (AFSI), or BCT in a sample of 37 alcohol-abusing patients and their partners. Findings revealed that BCT was superior to AFSI and MSI in reducing alcohol use and increasing relationship satisfaction at post-treatment and at the 18-month follow-up phase of the study.
In a sample of problem drinkers, Walitzer and Derman (2004) compared individual, cognitive behavioral treatment (CBT), AFSI, and BCT. Although participants in both the BCT and AFSI interventions outperformed the CBT condition in terms of drinking outcomes at post-treatment and follow-up, BCT did not produce significantly better relationship satisfaction than AFSI.
Vedel, Emmelkamp, and Schippers (2008) enrolled 64 alcohol-disorder patients (male and female) and their partners in BCT or CBT. Drinking outcomes were similar at post-treatment for clients in each condition; however, participants in the BCT condition reported greater relationship satisfaction. Powers et al. (2008) showed that couples who attended BCT for substance abuse were less likely to experience relationship dissolution (e.g., separation, divorce).
A study of veterans who received BCT for substance use disorder found those with and without post-traumatic stress disorder showed improved from pretreatment to post-deployment. Regardless of whether or not the veteran had PTSD, improvements were noted in dyadic satisfaction, and decreases were found in alcohol use, alcohol consequences, male-to-female violence, and psychological distress (p. 476) symptoms (Rotunda, O’Farrell, Murphy, & Babey, 2008). These results suggest that BCT may benefit those with alcohol use disorder and comorbid PTSD.
Importantly, improvements in specific objectives of BCT (i.e., positive communication, shared activities, and negotiation of agreements) have been positively correlated with marital satisfaction in couples taking part in BCT for alcohol abuse. In addition, compared to baseline levels, BCT has been associated with a 60 percent reduction of intimate-partner violence (IPV) prevalence and frequency among alcohol- and drug-abusing men and their non-substance-abusing female partners (O’Farrell et al., 2004) during the year after treatment. Reducing IPV is critical, given that among couples who enter treatment for substance abuse, the vast majority (i.e., more than 95%) report instances of partner violence in the year prior to treatment (Klostermann & Fals-Stewart, 2006).
Collectively, research has shown that BCT results in equal or greater likelihood of client abstinence. Moreover, with few exceptions (see Walitzer & Derman, 2004), BCT has been shown to result in superior outcomes in terms of relationship functioning.
Why BCT may have Secondary Benefits for Children in their Homes
Although the relationship between parental substance abuse and children’s risk has been well established (e.g., Stanger et al., 1999), we know less about the mechanisms of action underlying this risk. Although parental modeling of alcohol or drug use presents a certain degree of risk for youth substance use (Abar, Abar & Turrisi, 2009), a growing body of research has demonstrated that interparental conflict, particularly partner violence, has a direct and corrosive impact on children’s emotional and behavioral development (e.g., Grych & Fincham, 1990). As we explain below, partner conflict and violence may be an indicator of an aggressive interpersonal interaction style that a parent is likely to use, not only with his or her partner, but also in parenting children. Thus, it is plausible that substance abuse treatments that attempt to reduce parental substance use and improve dyadic functioning may have dual benefits for children in these homes.
Parental Substance Abuse, Interparental Conflict, and Children’s Emotional Security and Behavior
Exposure to severe interparental conflict has been linked to children’s feelings of terror and helplessness; fears for their own and their parents’ safety (Levendosky & Graham-Berman, 1998); and children’s depression, anxiety, somatic complaints, and sleep disruptions (Kitzmann et al., 2003; Lewis-O’Connor et al., 2006; McFarlane et al., 2003). Davies and Cummings (1994) contend that children evaluate marital conflict in terms of its implications for their emotional security and respond accordingly. IPV may affect children’s emotional security, and, in turn, may increase risk for adjustment problems (Cassidy & Shaver, 1999).
Exposure to IPV, and the victimization that children experience from their exposure to IPV, may also increase children’s proneness to bullying and aggressive, (p. 477) violent, and delinquent behavior (Baldry, 2003; Lemmey et al., 2001; McFarlane et al., 2003; Moretti et al., 2006). Although there is variability in the causes of antisocial behavior, early externalizing problems with a pattern of aggressive behavior by middle childhood are related to a developmental trajectory of highly stable and intensifying aggression during adolescence that may persist into adulthood (Moffitt et al., 2002; Nagin & Tremblay, 1999). For instance, Huesmann et al. (1984) found that eight-year-old boys identified as “aggressive” were more likely to commit serious criminal acts, abuse their spouses, and drive while intoxicated as adults.
Moreover, adolescent boys exposed to IPV are more likely to believe that use of aggression is acceptable in romantic relationships (Kinsfogel & Grych, 2004) and engage in more aggressive behaviors with their romantic partners (Heyman & Slep Smith, 2001; Kinsfogel & Grych, 2004). Violent men are less effective problem-solvers, exhibit more negative communication, and are more hostile during conflict with female partners (e.g., Anglin & Holtzworth-Munroe, 1997). Young men who have witnessed interparental conflict may bring ineffective conflict management skills into adult relationships, and their poor conflict management skills may mediate relationship violence (Skuja & Halford, 2004).
Parental Substance Abuse, Interparental Conflict, and Family Processes
In recent years, there has also been a growing awareness that interparental conflict is intrinsically and empirically linked to family processes and parenting (Bradford & Barber, 2005; Krishnakumar & Buehler, 2000). Although there are different forms of interparental conflict (Krishnakumar & Buehler, 2000), the overtly hostile style (Ahrons, 1981; Camara & Resnick, 1988) that involves frictional conflict in which couples display verbal aggression and physical violence (Buehler et al., 1997) is characteristic of many substance-abusing couples (Klostermann & Fals-Stewart, 2006). In these couples, poor communication is hypothesized as the mode by which partners communicate and work through everyday disagreements that “spill over” into parent–child interactions and parenting behaviors (Erel & Burman, 1995).
More specifically, Krishnakumar and Buehler (2000) have argued that parents in aggressive relationships may try to control their children by exhibiting coerciveness and harsh discipline. Coercive parent–child interactions are characterized by inconsistency, poor monitoring, little warmth, harsh discipline, and frequent negative verbalizations toward children (Reid et al., 2002). Coercive parenting has been related to children’s noncompliance, stealing (Anderson et al., 1996), and aggression (McFadyen-Ketchum et al., 1996).
Children who live with a substance-abusing parent often manifest emotional and behavioral problems (e.g., Luthar et al., 1999) and many risks to healthy development. Given the heterogeneity among substance-abusing families, it is important (p. 478) to recognize that different types of empirically validated treatments are available to support children in these homes. One such treatment that has considerable empirical support is BCT (Powers et al., 2008). In particular, BCT may be appropriate for families in which one parent is substance-abusing and the other is not, for parents who do not want their children to receive direct treatment or for children who do not want to receive direct treatment, and for couples who display chronic interparental conflict in addition to alcohol or drug abuse. It is plausible that the mechanisms presumed to change during BCT treatment (e.g., communication skills, problem solving) may transfer to other family interactions such as parent–child interactions (e.g., reduce parental over-reactivity, improve problem-solving), which, in turn, affect child behavior.
It is also important to recognize that BCT appears to be a flexible treatment that can be modified to meet the specific needs of families. Thus, it is possible that additions to the standard BCT approach can be made to address the particular needs of COSAs. In fact, results of a pilot study in which we integrated parent skills training with BCT yielded very promising effect sizes and trends that suggest that the addition of parent skill training to BCT is feasible and may enhance the effects of BCT for internalizing behavior in preadolescent children (Lam et al., 2007). Although modifications to BCT may be necessary, BCT holds promise for benefiting youth behavior despite not being directly administered to children in these homes.
However, in order to provide an empirically supported BCT option for agencies who work with these families, a clear understanding of the treatment’s potential secondary benefits (i.e., “trickle down” effects) across youth behaviors and across children’s developmental stages, as well as the mechanisms through which the program works (i.e., mechanisms of action), is critical. For instance, a focus of BCT is developing clear, non-critical, supportive communication. It is possible that this type of communication may also benefit parent–child interactions. Moreover, couples learn ways to support each other, and engage in fun activities they enjoyed prior to the development of the client’s substance use problem (O’Farrell & Fals-Stewart, 2006). We believe improving communication, learning to support one another, and shifting family energy away from the client’s drug and toward other enjoyable activities may extend to the larger family. In fact, it is important to examine whether BCT has important benefits for children in their homes and parent–child interactions (i.e., more positive family interactions and less negative behavior for children [depression, anxiety, aggressive behavior and so forth] and better relationships between parents and their children).
Also, many couples who enter substance abuse treatment engage in intimate-partner violence (e.g., Klostermann & Fals-Stewart, 2006). Although couples in which one partner is a batterer (e.g., Johnson, 2002) or engages in severe physical violence, or in which one or both partners fear physical reprisal from their partner (e.g., O’Leary, 1993) are not considered appropriate for couples therapy, it is possible that BCT for substance abuse may benefit couples who engage in infrequent partner aggression and lesser forms of partner violence (e.g., pushing or slapping). Although the decision to engage in BCT should be weighed carefully and with many factors considered (e.g., relationship commitment, couple safety, (p. 479) therapist training), it is possible that BCT may work to reduce both parental drug use and interparental aggression. Thus, BCT has the potential to reduce interparental violence. Importantly, both parental drug use (Luthar et al., 1999) and interparental violence (Kitzmann et al., 2003) have been linked to negative child outcomes. Clearly, the question of if the reduction of parental drug use, the reduction of parental violence, or both will benefit youths in these homes is important to address.
We would also appeal to investigators to examine the relative effectiveness of BCT for different family forms. For instance, Osborne and Berger (2009) found that the risk of health and behavior problems in children living with a substance-abusing parent was not moderated by parent gender. However, to date, there have been no studies of the effectiveness of BCT for children of substance-abusing mothers. Globally, there is also a need to see if BCT can be adapted for different family types. For instance, it is possible that BCT can be adapted for single parents and other family members (e.g., grandparents) or close friends. This is especially important as the 2010 American Communities Survey estimated that 5.4 million grandparents were living with grandchildren in their homes (U.S. Census Bureau, 2011).
Although the question of whether BCT has positive influences on children in their homes warrants greater attention, we know that the indirect effects of BCT on children are limited. For instance, the effectiveness of BCT may vary as a function of the severity of parental drug use and as a function of children’s developmental stage and gender. For instance, it is possible that adolescents who reside with a substance-abusing parent have spent more years in homes characterized by low emotional support (Miller et al., 1999). In turn, prolonged exposure to this type of corrosive family environment may result in higher levels of negative affect, more insecurity, higher acceptance of aggression, and a greater likelihood of serious negative behaviors (e.g., aggression, delinquency, violence, and substance abuse). Thus, for some youth, individual treatment may be warranted. At present, however, it is important to examine the secondary effects and potential mechanisms of action associated with BCT. Once these mechanisms are understood, it may be possible to refine or modify the treatment (as needed) to address youth with different family and clinical needs.
This chapter was supported in part by a grant from the National Institute on Drug Abuse (R01 DA024740).
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