In it together

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Behavioural couples therapy for alcohol dependence can both strengthen relationships and reduce problematic drinking, says Kate Thompson.

two people old time dancingAlthough behavioural couples therapy has been recommended in NICE guidance since 2011 for ‘harmful drinkers and people with mild alcohol dependence who have a regular partner who is willing to participate in treatment’, counselling and therapy that focuses on the couple and parental relationship has never formed any significant part of the alcohol treatment service landscape.

In 2009 Tavistock Relationships was commissioned by the NHS to develop a couple-based treatment for depression – known as couple therapy for depression or behavioural couples therapy – a talking therapy which year-on-year achieves some of the highest rates of recovery from depression and anxiety within IAPT (improving access to psychological therapies) services nationally. So, when the ‘children of alcohol dependent parents’ funding stream was announced by the Department for Health and Social Care in 2018, we were keen to take on the challenge of delivering training to practitioners in behavioural couples therapy for alcohol dependence (BCT-AD) to see whether this treatment could be introduced and embedded into existing treatment services.

Kate Thompson is couple psychotherapist at the Tavistock Centre for Couple Relationships
Kate Thompson is couple psychotherapist at the Tavistock Centre for Couple Relationships

To this end, in 2019, Tavistock Relationships delivered a total of three sets of training – in Leeds, Bristol and London – to 29 practitioners from a range of professional backgrounds including counsellors and drug and alcohol workers. We then supervised these trainees as they set about identifying suitable couples experiencing alcohol dependence who would become their ‘training cases’, over a period of eight to 12 months.

Playing to Strengths

As with couple therapy for depression, a basic premise of BCT-AD is that the strengths of the couple relationship can, wherever possible, be utilised as a resource to enable positive change, leading to either improvement in mental health or reduction in dependence on alcohol. The model also explores with the couple the possible functions of the drinking within their relationship and what it enables and disables between them. By reducing damaging interactions, BCT-AD aims to build emotional openness and closeness between the couple, improve communication and behaviour, and help the couple cope with the ordinary and not-so ordinary stresses that arise without such a high degree of dependence on alcohol.

So, how did our trainees get on? And to what extent can we feel confident that we have made inroads into changing the way that people in alcohol treatment services are treated? All practitioners on the training recognised that this way of working addressed a gap in their expertise, and while changing the focus of their work to think about the couple relationship presented a number of conceptual and practical challenges, the practitioners were all very positive about what was essentially a new way of working to them. So far, so good.

Difficult deliveries

The difficulties that our trainees faced in actually delivering BCT-AD to clients subsequent to the training, however, were many and various. The pandemic didn’t help matters, of course, with some trainees finding couples that they had begun to work with face-to-face not wanting to continue their sessions via Zoom, and some services simply not being able to function during the lockdown periods.

Some practitioners found it was difficult to identify couples who were suitable for this approach – either because the assessment process unearthed issues around domestic violence which would have made delivering this therapy too risky – or, more commonly, because the alcohol treatment service simply wasn’t set up or commissioned to work with couples. As we progressed, service managers began to identify important sources for future referrals, such as social care or probation services, but needed more time to establish these.

Additional challenges included the precarious nature of the services in which the alcohol practitioners were working, with funding being withdrawn from many and several subsequent redundancies or resignations among the cohort of people that we trained, as well as the relative lack of clinical training for practitioners working in this sector. Taking on board and incorporating skills around working with couples presented a significant issue for some trainees – as one of our supervisors observed, many felt that such was the focus on the individual within their services that they had to effectively generate a completely new pathway to make a success of this new way of working.

Emotionally closer

On the positive side, many BCT-AD trainees have found that the couples they worked with benefited from this approach. One couple, for example, said some way into the therapy that their sexual relationship had resumed as a result of the work they were doing together (they had been too ashamed to admit it had been nonexistent before), their depression and anxiety had reduced, and they were finding space and time to do things together as a couple. According to practitioners, other couples became emotionally closer and more open and more empathically attuned to one another, calming the atmosphere at home – which their children had begun to notice.

New challenges

In conclusion, this pilot project was positive, but presented services and practitioners with challenges, and it’s too soon to say how successful the project’s ambition to provide an alternate way of reducing alcohol consumption by improving the couple relationship has been. We are buoyed by the fact that while the alcohol treatment service of one of our trainees was decommissioned during the time period of this project, that person is now working in the NHS as an addictions practitioner helping to design services for people with dual diagnosis and has ambitions to include behavioural couples work in that service’s care pathway. So the legacy continues, albeit in a small way, and we hope that more services will appreciate the value that working with couples can bring to the lives and experiences of people struggling with alcohol dependence.

To find out more about this project and about behavioural couples therapy for alcohol dependence, contact Kate Thompson at kthompson@tavistockrelationships.org