BACKGROUND/RATIONALE:
Involvement of veteran spouses and cohabitants is a national mental health priority. Behavioral Couples Therapy (BCT) treats the alcoholic or drug-abusing patient with their partner to build support for abstinence and improve relationship functioning. Compared to patients receiving traditional individual-based treatment, patients who received BCT report significantly (a) fewer days of substance use, (b) longer periods of abstinence, (c) fewer arrests, (d) fewer alcohol-or drug-related hospitalizations, and (e) better relationship functioning (e.g., improved dyadic adjustment, reduced partner violence, and lower risk for separation and divorce).

OBJECTIVE(S):
Primary objective:
(1)To identify clinician, program, and facility-level supports and barriers for BCT implementation within SUD specialty care outpatient programs
Secondary objectives were to identify:
(1) How BCT is being used and to what degree
(2) How family members are involved in SUD treatment
(3) Identify practitioner training needs

METHODS:
This was a mixed-methods developmental evaluation guided by the Promoting Action on Research in Health Services (PARiHS) framework that included a screening phase followed by indepth investigation (interviews and surveys) of selected programs.

Setting
All interviews were conducted over the phone and online surveys used Qualtrics except one that was conducted in writing.

Participants
Drug and Alcohol Program Survey (DAPS) points of contact (POCs) were contacted for each of the 26 SUD outpatient programs that reported implementing BCT (n=5), Family Therapy (FT; n=3), or both (n=16) on the FY08 DAPS (n=24), or identified by the treatment developer (n= 2), for a total of 26 programs. POCs were invited to participate along with other staff in their program knowledgeable about couples/family services in SUD treatment.

Screening Interview
Screening questions addressed use of BCT and other kinds of family services including training, supervision, and referrals to treatment. Phone screening was completed over 4 months (n = 56).

In-Depth Interview
The intensive interviews elicited descriptive information about facilitators and barriers of BCT utilization, including the characteristics of curricula, clients, therapists, and the context/environment (N = 20). We also asked for suggestions and preferences for future training. A codebook was created by the PI and members of the research team using 10% of the transcripts to derive initial concepts and themes characterizing subject responses. A 2nd sample of transcripts were coded by Drs. Lewis and Oser and the codes revised and compiled into final codebook of 53 codes. The reconciled codes were entered into Atlas TI. There was a total of 1294 coded pieces of text. We then looked for themes within each code, as well as response frequencies and variability.

Survey
The online survey addressed demographics, services available in their program, and barriers and facilitators to BCT utilization. The survey also contained the Organizational Readiness to Change Assessment (ORCA) evidence and context subscales, which have been used in a variety of QUERI projects to assess EBP implementation. A total of 19 providers participated in the survey.

FINDINGS/RESULTS:
From the screening interviews (n=56), we found that in spite of previous self report, only 6 of the 26 programs were providing BCT. Twenty-two sites offered family involvement, which we defined as education, group education or phone consultations. Twenty-five of the sites offered family therapy, which we classified as BCT, structured therapy (evidence-based), unstructured (non-evidence based) therapy or group treatment.

The ORCA indicates an overall positive view of BCT, with a scale mean of 4.05 (Std Dev=.49), on the 1-5 Likert scale. The evidence scale includes research (mean=4), clinical experience (mean=3.9), and patient preferences (mean=4.3), which were all rated positively. Providers also view BCT as fitting well with the current orientation of their program, e.g., incorporating medication and behavioral intervention. Most are willing to use BCT as an addiction treatment and believe that their program would be willing to use BCT.

Describing the client characteristics, providers mentioned the changes and increases in complexity of their patients' problems and needs. Providers report often seeing SUD/PTSD dual-diagnosis patients and also treating a large number of homeless veterans. Also, a large increase in veterans from OEF/OIF, which tend to be younger, have children, and need evening or weekend treatment hours.
Providers indicated that more training for providers on engaging family members is important. Successful providers use motivational interviewing or focus on the potential benefits to the Veteran motivate them to include CSOs. Providers also directly engage the CSOs using phone calls or conversations while they are there for other appointments.

Providers viewed the context as somewhat less positive and more varied ( =3.32, =.84). The context scale assesses the culture of senior leadership ( =3.5) and staff ( =4), measurement ( =3.2), leadership ( =3.1), readiness to change ( =3.8), and resources ( =2.3). The resource scale (addressing facilities, staffing and financial resources) was the only scale with a negative score. In interviews providers reported under-staffed programs and being unable to fill frozen positions.

Providers would like more than one person trained per site and a thoughtful selection process of choosing providers for trainings. They highlighted the importance of role-playing during training, and clear and ready to use materials. After the in person training, providers want follow up including supervision, conference calls and online forums.

IMPACT:
This project identified the importance of training in family engagement and evidence based treatment among SUD specialty care providers, including facilitators and barriers to involving families in care, and has been provided to OMHS to inform upcoming BCT national trainings.

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External Links for this Project

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PUBLICATIONS:

None at this time.

DRA: Substance Use Disorders
DRE: Treatment - Efficacy/Effectiveness Clinical Trial, Treatment - Observational
Keywords: Addiction, Mental health care delivery
MeSH Terms: none