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It appears that in the general population, slapping and pushing usually does not engender fear. Iffear is not a large issue in the general population, why is the context of the aggressionimportant.?Approximately 12% of men and women in the general population engage in physical aggressionagainst their partners over a year period, but it seems to some that not all physical aggression isphysical abuse. Why is that the case?Cyberstalking seems to occur in approximately 50 to 60% of women who have been in sheltersto find safe haven from their abuser. What effects does cyberstalking have on these women?Based on what you have learned from lectures and readings about the reciprocity of partneraggression occurring in about 50 of the general population 80% in young married samples, whatis the likelihood that the aggression of J  FOCUS ON
Alcohol Res. 2020;40(2):08 • https://doi.org/10.35946/arcr.v40.2.08
Published: 30 July 2020
TREATMENT INTERVENTIONS
FOR WOMEN WITH ALCOHOL
USE DISORDER
Barbara S. McCrady,1 Elizabeth E. Epstein,2 and Kathryn F. Fokas3
Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico, Albuquerque,
New Mexico
2
Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts
3
Department of Psychology, University of New Mexico, Albuquerque, New Mexico
1
Women with alcohol use disorder (AUD) experience more barriers to AUD treatment and
are less likely to access treatment than men with AUD. A literature review identified several
barriers to women seeking help: low perception of a need for treatment; guilt and shame;
co-occurring disorders; employment, economic, and health insurance disparities; childcare
responsibilities; and fear of child protective services. Women entering treatment present
with more severe AUD and more complex psychological, social, and service needs than
men. Treatment program elements that may reduce barriers to AUD treatment include
provision of childcare, prenatal care, treatment for co-occurring psychological problems,
and supplemental social services. Research has suggested that outcomes for women are
best when treatment is provided in women-only programs that include female-specific
content. To date, research on treatments tailored to the individual needs of women is
limited, but research on mechanisms of change has suggested the importance of targeting
anxiety and depression, affiliative statements in treatment, abstinence self-efficacy, coping
skills, autonomy, and social support for abstinence. Future research should focus on early
interventions, linkages between primary care or mental health clinics and AUD treatment
settings, and integrated treatments for co-occurring AUD and other disorders. Further
research should also explore novel treatment delivery approaches such as digital platforms
and peer support groups.
KEY WORDS: alcohol use disorder; barriers; mechanisms of change; outcomes;
treatment; women
Alcohol Research: Current Reviews
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INTRODUCTION
psychological profiles. They experience some
unique barriers to accessing treatment and present
to treatment with some needs that differ from men
in AUD treatment.
Historically, women with alcohol use disorder
(AUD) have been an underserved population. In the
United States, more than 5 million adult women, or
4.2% of the adult female population, meet criteria
for current AUD.1 Although this percentage is
half that of adult men (8.4%), among adolescents,
more females than males meet criteria for current
AUD (2.7% vs. 2.3%),1 and recent research has
suggested that the gender gap in alcohol use and
alcohol-related harm is narrowing.2 Heterogeneity
in rates of AUD is found among different racial/
ethnic groups, with higher rates among Black and
Hispanic women than among White women,3 and
rates of AUD among gender minority women also
are higher than among heterosexual women.4
A smaller proportion of women than men
received AUD treatment both in the past year1
(7.9% of adult women vs. 9.2% of adult men; 4.6%
of adolescent females vs. 7.4% of adolescent males)
and in their lifetime5 (15.0% of women and 22.0%
of men with AUD who are younger than age 45).
Utilization rates for treatment services by women
and men do not differ across different racial/ethnic
groups.5 Given the increasing rates of AUD among
women and the lower rates of treatment utilization
among women, a rethinking of AUD treatment for
women is in order. The purpose of this article is to
describe the barriers to treatment entry experienced
by women with AUD, the unique characteristics
and presenting concerns of women with AUD who
do seek treatment, and the current knowledge about
effective treatments. Sources of information for this
review included a comprehensive review published
in 2013,6 articles identified in a search in PsycINFO®
using the search terms “women,” “alcohol,” and
“treatment,” and articles identified through selective
reviews to identify key publications on traumainformed treatment and substance use disorder
(SUD) in female veterans.
Characteristics of Women With AUD at
Treatment Entry
Women seeking AUD treatment vary along a
number of dimensions that may impact their
access to treatment, treatment needs, and
treatment response.
Sociodemographic characteristics and
substance use
Women who present to AUD treatment often
have markedly different characteristics and
backgrounds than men in these treatment
settings. Such distinctions among women include
younger age, more severe alcohol and drug use
histories, less education, lower income, higher
unemployment, more housing needs, more
children living at home, and higher parental
stress.6 In terms of substance misuse, rates differ
among subgroups. For example, non-Hispanic
White and American Indian/Alaska Native women
are more likely than women of other racial/
ethnic groups to identify alcohol as their primary
substance of use when entering treatment for
SUD.7 Among pregnant women entering treatment
for SUD, approximately 18% identified alcohol
as their primary substance of use.7 In a study of
women veterans with SUD, researchers found
that entry into and engagement with treatment
were associated with having a co-occurring
psychological disorder and receiving services at
facilities offering women’s treatment.8
Psychological co-occurrences
Compared to men, women who enter AUD/
SUD treatment generally report higher levels of
physical and mental health concerns. Rates of
co-occurring disorders vary with the treatment
setting and population. Epidemiologic data suggest
that compared with men with AUD, women with
AUD have a higher prevalence of co-occurring
DSM-IV Axis I disorders (84.2% vs. 75.5%),
WOMEN SEEKING
AUD TREATMENT
Women seeking AUD treatment differ from men
in their sociodemographic characteristics and
Alcohol Research: Current Reviews
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disclose having an alcohol problem.7 Relatedly,
women are more likely than men to experience
feelings of embarrassment, to experience fear, to
have the belief that no one can help, and to have
the belief that their problem is not serious enough
to require AUD treatment.15 In addition to these
intrapersonal barriers, women may experience less
social support to enter AUD treatment than men
do. Women with AUD are more likely than men
to be in an intimate relationship with a partner
who also has AUD,16 and women tend to have less
spousal and family support for recovery.17 Further,
women generally report more logistical barriers to
treatment utilization, including greater difficulties
with transportation, lack of available childcare,
and inadequate insurance coverage.17
Compared to men, women are more likely to
seek AUD treatment through a general versus
substance use-specific health care sector18 or
in the context of treatment at a general mental
health clinical setting,19,20 and less likely to be
court mandated to treatment.21 Women with
AUD also generally report stressful life events
and nonsubstance-related mental health concerns
as their primary reasons for seeking treatment.22
Welfare, child welfare, and legal systems provide
additional portals through which some women
enter AUD treatment.21 Primary care physicians,
gynecologists, and psychiatrists may benefit from
focused training in identification and referral of
women with AUD to offset the gender discrepancy
observed in women’s entry into AUD treatment.
Relatedly, women have shown a preference for AUD
treatment settings that offer childcare.23 Thus, more
easily accessible, children-friendly treatment centers
with wide availability are also likely to improve
treatment utilization among women with AUD.
a similar prevalence of other drug dependence
(15.2% vs. 14.3%), a higher prevalence of mood
and anxiety disorders (53.1% vs. 29.1% and
44.3% vs. 26.2%, respectively), and a similar
prevalence of personality disorders (36.5% vs.
33.3%).9 A recent nationwide study of veterans
with AUD found that women veterans had more
psychological and substance use comorbidities
than men.10 In addition, women in SUD treatment
have a much higher prevalence (up to 80.0%) of
lifetime physical, sexual, and/or emotional abuse
and trauma, and concerns about current domestic
violence are common.11 Rates of current posttraumatic stress disorder (PTSD) among women in
SUD treatment range from 25.0% to 55.0%.12
Barriers to Treatment
Women who do not receive AUD treatment have
some sociodemographic difference from women
in AUD treatment. For example, a sample of
women with AUD who were not in treatment but
perceived a need for treatment were less educated,
had a family income less than $75,000, and were
more likely to use psychotropic medications
compared to those who did not perceive a need for
treatment.13 Women experience both internal and
external barriers to AUD treatment. These barriers
may partially explain the gender discrepancy
in treatment initiation rates and include low
perception of need for treatment; guilt and
shame stemming from the discrepancy between
traditional gender expectations and societal
views of women with AUD; depression and other
co-occurring disorders; greater employment,
economic, and health insurance disparities relative
to men; childcare responsibilities; and fear of child
protective services.6
Recent research has suggested that traditional
gender expectations and lay beliefs about AUD
may contribute to lower AUD treatment utilization
among women. Lale and colleagues found that
compared to men, women were more likely to
attribute AUD to “bad character” and less likely
to attribute AUD to genetics.14 Women also worry
that they will be perceived as “bad mothers” and
potentially lose custody of their children if they
Alcohol Research: Current Reviews
AUD TREATMENT SERVICES
FOR WOMEN
Treatment Retention
In general, the literature is mixed regarding
AUD treatment attrition and gender differences.6
Previous studies have found that women tend to
have longer inpatient stays and that longer inpatient
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stays are associated with an increase in sustained
abstinence for women but not for men.22,24 Bravo
and colleagues reported that women engaged in
outpatient AUD treatment longer and discontinued
treatment at a lower rate than men.25 In a
comprehensive review, Greenfield and colleagues
concluded that although there are no gender
differences in attrition, predictors and mediators of
treatment retention differ by gender.23 Predictors
of better treatment retention among women
include demographic variables, such as lower
psychiatric impairment, higher socioeconomic
status, and greater social support and stability,23
and program variables, such as female-specific
treatment and facilities that allow children to stay
with their mothers.6 A recent investigation of 1.8
million individuals who received SUD treatment
at federally funded facilities found that, across
treatment settings, women and men did not differ in
rates of early discharge.26 However, when treatment
settings were stratified by type (detoxification,
residential, and ambulatory), women were more
likely than men to leave detoxification treatment
prematurely. The authors suggested that lower
rates of female-specific services and higher rates
of psychiatric co-occurring disorders within
detoxification settings might have accounted for
this gender difference.
posttreatment, despite women presenting with
more symptoms of dependence at baseline.25
Results have been more mixed regarding
women’s long-term outcomes compared to men.6
In the same study from Spain described above,
women had superior drinking outcomes compared
to men at 5, 10, and 20 years posttreatment.25
Conversely, Litt and colleagues found that women
had worse drinking outcomes than men in the 2
years following outpatient AUD treatment.28 These
poorer outcomes may have been due to the nature
of the active treatment, which focused on altering
the participant’s social network to gain more
support for abstinence; women in the study had
less abstinence-supportive social networks and
more difficulty altering these networks.
Historically, gender has typically not been
taken into consideration in psychopharmacologic
treatment for AUD, and women have been
underrepresented in AUD medication trials.29
However, research has begun to improve in this
area. A review by Agabio and colleagues found
that too few studies of disulfiram had included
women to test potential gender differences in
response to this medication.30 There were a
sufficient number of studies on acamprosate and
naltrexone, which showed that both medications
were generally efficacious for women; however,
results of gender comparisons were too variable to
draw firm conclusions. Canidate and colleagues
conducted a systematic review of seven studies
on naltrexone for the treatment of AUD among
women.31 Among this limited number of studies,
naltrexone was found to have a modest effect on
drinking quantity and time of relapse but not on
the overall frequency of drinking among women.
The authors concluded that the effect of naltrexone
on women is currently understudied. This Canidate
article highlights the need to continue to use
rigorous research designs to study differences in
the efficacy of naltrexone on women versus men.
Treatment Outcome
In general, studies of mixed-gender treatment
programs have found few gender differences in
short-term outcomes for AUD across a range of
interventions, samples, and sites, despite women
at baseline generally presenting with more severe
clinical issues.6 For example, in their analysis of
five randomized clinical trials (RCTs) of intensive
outpatient contingency management for AUD
and SUD, Rash and Petry found no differences
between men and women’s abstinence rates during
the 3-month treatment period, although women
initially presented with more financial, family/
social, and psychiatric problems.27 Likewise,
a study of a large outpatient AUD treatment
cohort in Spain found no differences between
men and women in alcohol consumption 1 year
Alcohol Research: Current Reviews
Reducing Barriers to Treatment
for Women
A comprehensive review identified six major
elements of SUD treatment programs for women
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that reduce barriers to treatment and/or address
women’s unique needs.32 These include the
provision of childcare, prenatal care, women-only
treatment, treatment for co-occurring mental
health problems, a comprehensive approach to
treatment, and supplemental services that address
women-focused topics. Each of these elements
was linked to favorable treatment outcomes. In
a qualitative meta-synthesis of programs that
included women and their children, several
treatment processes were identified by different
stakeholders (clients, clinicians, and program
administrators) as instrumental to positive
outcomes: developing a sense of agency, giving and
receiving social support, engaging with program
staff, fostering self-disclosure, recognizing selfdestructive patterns of behavior, setting goals, and
feeling motivated by the presence of children.33
Although some of these processes are common to
any AUD treatment, it is necessary to recognize
the unique blend of common and specific treatment
processes that are effective for women in treatment
with their children. Although studies have
repeatedly identified the importance of including
children-supportive services in women’s SUD
treatment programs, a 2018 Substance Abuse
and Mental Health Services Administration
(SAMHSA) survey found that only 5.8% of SUD
treatment facilities provided childcare and only
2.6% of residential programs provided beds for
clients’ children.34
throughout the course of their lives.” Relatedly,
the guidelines address stigma by noting the
importance of “recognizing that ascribed roles and
gender expectations across cultures affect societal
attitudes toward women who abuse substances.”
Other recommendations state that SUD treatments
for women adopt a trauma-informed approach,
which often emphasizes women’s strengths,
and address “women’s unique health concerns”
through “an integrated and multidisciplinary
approach.” The SAMHSA guidelines conclude
that clinical treatment services (e.g., screening,
mental health services), clinical support services
(e.g., parenting education, job training), and
community support services (e.g., childcare,
transportation) would work collaboratively to
facilitate comprehensive AUD treatment for
women of diverse backgrounds.7
Advances and Gaps in Treatment
Development for Women
With increasing recognition of the unique clinical
profiles of women with AUD has come increasing
attention to whether AUD treatment programs are
serving the needs of women. The 2018 SAMHSA
annual survey of substance use treatment programs
found that 49% of programs surveyed provided
special programs or groups for women and 23%
provided services for pregnant or postpartum
women.34 In contrast, data from the Veterans
Health Administration (VHA) revealed that most
VHA facilities offered SUD services to women but
that most of these services were generic rather than
female-specific (85% vs. 30%).35
The need for specialized services for women
has both an empirical and a clinical rationale.
As reviewed earlier in this article, compared
to men, women are less likely to seek AUD
treatment, have different social contexts, present
with different profiles of co-occurring disorders,
and have a unique and complex set of service
needs that may not be addressed in a standard,
mixed-gender AUD treatment program.9,36 Thus,
treatment programs and researchers have been
seeking to create and evaluate services intended
to attract women to AUD treatment and improve
Guiding Principles for Women’s
AUD Treatment
Recognizing the unique treatment needs of
women with AUD and SUD, SAMHSA published
a set of evidence-based principles to guide
gender-responsive treatment for women.7 These
guidelines include several recommendations. For
example, they recommend developing cultural
competence to frame women’s AUD symptoms
and treatment in their socioeconomics contexts
(e.g., employment, income, housing). They
suggest that providers acknowledge the unique
significance of women’s relationships and attend
to the “caregiver roles that women often assume
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outcomes. AUD services for women vary along
two dimensions—whether they are provided
in a mixed-gender or women-only treatment
setting and whether the content of the treatment
is generic or tailored specifically to women’s
clinical and other service needs.37 Thus, delivery
of AUD treatment to women may occur in (a)
mixed-gender programs with no female-specific
programming, (b) mixed-gender programs with
female-specific programming, (c) single-gender
(women-only) programs with no female-specific
programming, or (d) single-gender (women-only)
programs with female-specific programming.
in the same program that had become a womenonly program with no female-specific content.40
Outcomes were similar between the two samples.
More extensive research has compared mixedgender to single-gender programs that incorporate
female-specific themes, services, or content. For
example, interviewed providers of services for
female veterans with SUD identified five femalespecific themes and services that they viewed as
key to treatment: a focus on safety; scheduling
that accommodates women’s work and family
responsibilities; flexibility in the resources
provided; staff trained in serving women’s
clinical needs; provision of on-site childcare;
and a positive, supportive, nonconfrontational
treatment environment.41 Although some of these
treatment elements may be relevant to treatment
for any patient with SUD, the combination of
these elements was seen as key to successful
treatment for the female veteran population. In
addition to treatment elements, female-specific
content has focused on clinical issues of particular
significance to women, such as trauma, physical
abuse, relationships, parenting, assertiveness, and
treatment of co-occurring disorders.
One of the earliest studies of women-only
treatment with female-specific content was the
Early Treatment of Women with Alcohol Addiction
(EWA) study.42 A 2-year follow-up of women
found better clinical outcomes in the EWA than
mixed-gender treatment, and a long-term study
of mortality revealed lower mortality rates for
younger women who participated in the EWA
program than the mixed-gender treatment.43
A later study of a large sample of women in
women-only versus mixed-gender residential
SUD treatment found that women were twice
as likely to complete the women-only treatment
and that higher retention was associated with
higher rates of abstinence posttreatment.44,45
More recent studies have found that (a) treatment
retention and entry to aftercare were enhanced by
gender-specific services in an intensive treatment
program that also provided transitional housing,
particularly for women who completed residential
treatment;46 (b) women-only treatment predicted
Mixed-gender versus single-gender treatment
Single-gender treatment services seem appealing
because they have the potential to provide an
environment in which women may feel more
comfortable sharing emotional and personal
information. For instance, it is possible that among
women who have a history of trauma or abuse from
men, single-gender treatment might be preferable
because of the possibility that participation in
a mixed-gender program could trigger traumarelated symptoms. In addition, given the broader
literature on the relative interactional dominance
of men in mixed-gender groups, women may have
more opportunities to participate when in womenonly groups.38 However, research on women’s
treatment preferences yields a more nuanced
picture. Although some research suggests that
women prefer women-only groups,23 a narrative
analysis of interviews with women with a range of
SUD treatment experiences found that the women
reported concerns and anxiety about being in
women-only treatment because of their own history
of dysfunctional relationships with women and
their greater comfort in being with men.39 However,
women in the study reported positive experiences
once they entered women-only services.
Few studies have compared women’s outcomes
from mixed-gender versus women-only programs
that were not adapted with female-specific content.
In one early study, Bride compared the outcomes
for women who were in a mixed-gender program
to the outcomes for women who later participated
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better legal and drug outcomes but no differences
in alcohol use outcomes;47 and (c) women in the
single-gender treatment had significantly less
substance use (participants were primary stimulant
users) and less criminal activity than those in the
mixed-gender treatment.48 In contrast, Kaskutas
and colleagues found that a mixed-gender,
comprehensive, hospital-based treatment resulted
in better alcohol abstinence outcomes than womenonly treatment and was superior to generic,
community-based, mixed-gender treatment.49
of a primary care provider, care management,
education about alcohol, and referral to addiction
services. Compared to women who received
treatment as usual in a health care clinic for
homeless women, women who participated in the
chronic care program engaged with more SUD
treatment services in the 3 months after starting
the program.54
Single-gender treatment with femalespecific programming
There has been substantial research on womenonly treatment with female-specific content.
For example, Polcin and colleagues compared
intensive, nine-session motivational interviewing
(MI) for women with standard one-session MI.55
For the intensive treatment, therapists were trained
to use MI to focus on alcohol use as well as femalespecific themes—such as personal relationships,
issues related to parenting, abuse, and barriers
to treatment—and other psychological concerns,
such as low self-esteem or co-occurring disorders.
Compliance with the treatment was high (80% of
heavy drinkers completed at least seven sessions),
and women receiving intensive MI reduced their
drinking more than women receiving standard
MI. Connors and Walitzer developed and tested an
intervention to help heavy-drinking, nonalcoholdependent women reduce their drinking.56,57 The
intervention focused on skills to reduce drinking
and other life skills believed to be relevant to
women, such as problem-solving, communication
and assertiveness, and strategies to enhance their
social support system. Compared to treatment
focused only on drinking, women who also
received the life skills interventions and booster
sessions had outcomes that were more positive.
Another single-gender treatment with womenspecific programming was developed by Epstein
and colleagues. The outpatient, female-specific
cognitive behavioral treatment (FS-CBT) was
an adaptation of a the gender-neutral cognitive
behavior therapy manual-guided treatment for
AUD.58 The FS-CBT manual (a) highlighted
two clinical themes meaningful to women, selfcare and autonomy; (b) included female-specific
Single-gender treatment with no femalespecific programming
Some empirically supported treatments have been
tested in female samples with any adaptation of the
treatment to women’s treatment needs. Two studies
compared behavioral couple therapy to individual
treatment for women with AUD and their male
partners.50,51 O’Farrell and colleagues compared
behavioral couple therapy to individual treatment
for women with SUD and their male partners.52
All three studies found that the behavioral couple
therapy led to positive changes in alcohol or drug
use, with better alcohol or drug use outcomes
for the women receiving couple therapy. In their
study, McCrady and colleagues found that women
presenting with higher levels of relationship
distress and women with co-occurring Axis I or II
disorders had greater improvements in drinking.50
Note, however, that couple therapy is a modality
available to only a small proportion of the
population of women with AUD. Notably, when
given the choice, even women with male partners
indicated a preference for individual rather than
couple therapy, stating that they wanted to work on
their own problems, did not see their partners as
supportive, or thought the logistics of scheduling
couple sessions was too difficult.53
Chronic care models for persons with serious
mental illness and SUD are another empirically
supported approach that has been tested in female
samples without female-specific programming.
These models have been developed and tested
with homeless women who have AUD. The
chronic care model emphasizes availability
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In a subsequent, larger RCT,65 with a similar
design except that the WRG groups offered rolling
admission, outcomes of 52 women in WRG
were compared with those of 48 women in GDC
(with 58 men in GDC). All participants had SUD
or AUD. Women in both treatments reduced
drinking, and there were no treatment condition
differences in within- or posttreatment drinking
outcomes. Because WRG had both a women-only
group composition and female-specific content
compared to GDC, which had both a mixedgender format and no female-specific content, it is
unclear whether study results were linked to group
composition, female-specific content, or both, but
both the pilot and the larger RCT demonstrated that
WRG is at least comparable to a typical “treatmentas-usual” such as a mixed-gender GDC in
community settings. The authors also noted that the
WRG in the larger trial was delivered on a rolling
admissions basis and suggested that the revised
format may have diluted the impact of the WRG.
In a series of three studies on putative
mechanisms of change in WRG, secondary
analyses of the pilot and/or larger RCT data from
studies just described here above, showed that
more affiliative statements were made in WRG
than GDC66,67 and that more affiliative statements
were associated positively with women’s drinking
outcomes during and 6 months after treatment,
particularly in the WRG condition.68 Sugarman
and colleagues created and piloted (for feasibility,
acceptability, and satisfaction) a web-based,
gender-specific individual psychoeducation
intervention based on WRG content.69 The genderspecific modules might ultimately comprise a
female-specific component of care to be delivered
in a mixed-gender setting.
Najavits and colleagues reported an RCT
comparing the A Woman’s Path to Recovery
(WPR) model to the gender-neutral 12-Step
Facilitation (TSF) model for women veterans with
SUD, the majority of whom (i.e., more than 74%)
had current AUD.70 The WPR model is based on
cognitive behavioral, interpersonal, and emotive
therapy methods, and theory on gender differences
in addiction and recovery. The “exploration”
phase of the treatment highlights five themes:
interventions focused on coping with negative
emotions and developing/enhancing women’s
social network supportive of abstinence; and (c)
provided women-specific examples throughout
to personalize the material to each woman’s
issues, such as dealing with heavy drinkers in the
social network, parenting, life-stage transitions,
trauma, self-esteem, and relationships.59 In an RCT
comparing FS-CBT to an evidence-based, genderneutral CBT for AUD, Epstein and McCrady
found that women in both treatment conditions
were highly engaged, reported a high level of
satisfaction with the treatment, significantly
reduced their drinking, and improved in other
areas of life functioning such as depression,
anxiety, autonomy, and sociotropy.58 There were
no treatment condition effects, and the FS-CBT
treatment was equally effective as the genderneutral one. In a subsequent RCT, Epstein and
colleagues tested the individual modality FS-CBT
treatment versus a new group therapy format of
the same contents in a “pure comparison” design.60
Both FS-CBT treatment modalities (individual
and group therapy) resulted in significant positive
changes in drinking, depression, anxiety, coping
skills, self-confidence, interpersonal functioning,
and self-care even though treatment attendance
and therapeutic alliance were greater in the
individual FS-CBT condition. Cost-effectiveness
analyses favored the group format.61
In a pilot study, Greenfield and colleagues
tested a women-only Women’s Recovery Group
(WRG, n = 16) for SUD against mixed-gender
Group Drug Counseling (GDC, n = 7 women,
10 men).62 WRG included cognitive behavioral
and relapse prevention elements, as well as
“repair work” relevant for women (repairing
SUD-related damage to relationships and self,
and learning to enjoy life without substances).63
GDC was a traditional mixed-gender treatment
program focused on substance-related topics with
no gender-specific content. During treatment,
the groups did not differ in substance62 or
psychiatric improvement;64 however, women in
WRG continued to reduce substance use in the 6
months posttreatment, and also reported higher
satisfaction with the treatment they received.
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“body and sexuality, stress, relationships, trauma
and violence, and thrill-seeking.”70(p211) The
“healing” section covers “recovery methods in
four domains—relationships, beliefs, actions, and
feelings.”70(p211) Both WPR and TSF were singlegender groups, facilitated by women clinicians,
and provided compensation to offset potential
childcare costs or other financial barriers to
participation. The treatments resulted in similar
improvements in alcohol and drug use, coping
skills, and psychiatric functioning. The authors
noted that female-specific treatment content
might be less relevant to veterans than to their
civilian counterparts because male-dominated
military culture may diminish traditional gender
experiences for women.
In summary, several forms of empirically
supported treatments have been tested and found
to be efficacious with women, and several womenonly treatments with female-specific content
have been tested in rigorous RCTs. Overall, most
of these studies have found limited evidence for
superior alcohol use outcomes, but several of
these studies have found greater satisfaction with
the female-specific format and treatment content.
Because these programs are appealing to women,
they may increase women’s utilization of AUD
treatment, and enhance both engagement and
retention in AUD treatment.
even if clients do not meet diagnostic criteria for
PTSD. Trauma-informed AUD treatment does not
need to target trauma explicitly, but rather may
consider trauma in the assessment and planning
phases of treatment. For example, SAMHSA
recommends that AUD treatment providers should
assess women at intake for trauma histories and
PTSD symptomatology and refer clients with
severe symptomatology to providers who have
experience working with traumatized populations
(i.e., if they lack such experience themselves).
Another recommendation is to “avoid triggering
trauma reactions or re-traumatizing women.” For
example, violating a client’s trust or disregarding
a client’s emotions or experiences may trigger
trauma reactions. SAMHSA also recommends
that programs should “adjust staff behavior” and
modify the treatment environment “to support
clients’ coping capacities and safety concerns.”
Specific strategies may include ensuring that
urine specimens are collected in a private setting
and establishing consistency in the treatment
program’s routines and enforcement of rules. In
addition, AUD treatment providers should “allow
survivors to manage their trauma symptoms” in a
manner conducive to AUD treatment engagement
and success. For example, allowing clients to
express strong feelings without facing judgment
and explicitly addressing trauma only when a
client is ready are considered trauma-informed
approaches. Finally, SAMHSA recommends
that trauma-informed AUD treatment for
women should “emphasize skills and strengths,
interactive education, growth, and change beyond
stabilization.” Specific skills to incorporate into
treatment may include assertiveness training and
relaxation techniques.
Covington developed the Helping Women
Recover program for the treatment of SUD.71
Following the principles of trauma-informed care,
this treatment aims to provide a “healing” (i.e.,
safe, empowering, relational) environment that
emphasizes strengths and is sensitive to cultural
and gender issues. Treatment modules include
topics hypothesized to be essential to women’s
recovery: a focus on self and the integration
of roles with feelings, thoughts, and attitudes;
Treatment for Co-occurring Disorders
Treatment for co-occurring disorders may be
indicated for the many women with AUD who
present with additional mental health concerns.
Interventions that address the co-occurrence of
AUD with trauma and PTSD, mood disorders, and
borderline personality disorder may be especially
relevant for women.
Trauma
Given the highly elevated rates of trauma among
women with AUD/SUD, SAMHSA has suggested
that treatment for this population may benefit
from adopting principles of trauma-informed
care.7 A trauma-informed approach recognizes
the prevalence and impact of trauma in women
with AUD and adjusts treatment accordingly,
Alcohol Research: Current Reviews
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emphasizes themes of establishing safety, taking
back power, being honest, setting boundaries,
practicing compassion, healing from anger,
grounding, creating meaning, and increasing selfcare. Hien and colleagues tested the efficacy of
SS and another active treatment condition Relapse
Prevention against a treatment-as-usual control
condition.78 Women in SS and relapse prevention
had comparable posttreatment reductions in both
PTSD and SUD symptoms, and both treatments
were superior to the control condition. Likewise,
a study conducted through the National Institute
on Drug Abuse Clinical Trials Network found no
differences in PTSD or SUD outcomes between an
abbreviated version of SS and a health education
control condition, both delivered as adjuncts to
standard SUD treatment.79
Morrissey and colleagues studied another
integrated treatment approach for women with
SUD.80 The researchers used a quasi-experimental
design to examine a large cohort treated across
nine sites. Participants were mostly of low
socioeconomic status and had serious mental
and/or physical health problems as well as an
interpersonal trauma history. The integrated
treatment was associated with lower substance
use and improved general mental health but
not with reduced PTSD symptoms. Overall, it
remains unclear whether integrated treatments
for PTSD and AUD/SUD in women are superior
to stand-alone SUD treatments. Widespread
methodological limitations in the current literature
warrant continued investigation of integrated
treatments, including outcomes that may be
specific to women with AUD.75,76
healthy interpersonal relationships; sexuality; and
spirituality. Covington also developed the Beyond
Trauma: A Healing Journey for Women treatment
program, which teaches women how to identify
trauma and other forms of abuse, helps them
understand typical reactions to trauma and abuse,
and fosters the development of coping skills.72
In an RCT with incarcerated women, 77% of
whom were primary stimulant users, Messina and
colleagues integrated the Helping Women Recover
and Beyond Trauma protocols into a genderresponsive treatment (GRT) program.73 GRT was
compared to a standard prison-based therapeutic
community (TC), which, like GRT, was singlegender and targeted SUD, but unlike GRT did not
focus on gender-specific issues or trauma histories.
Both conditions improved women’s psychological
well-being and alcohol use outcomes, but women
in GRT also had more favorable outcomes for drug
use, length of aftercare treatment engagement, and
rate of reincarceration in the year following release
from parole. A subsequent analysis showed that
women with physical/sexual abuse histories had
significantly better posttreatment depression and
substance use outcomes following GRT than TC.74
An extension of trauma-informed care is
treatment for co-occurring SUD and PTSD.
In general, this co-occurrence is complex and
difficult to treat because SUD and PTSD are
reciprocally functional and often exacerbate each
other.75,76 Drinking or drug use often functions
to self-medicate PTSD symptoms and enable
avoidance of remembering traumatic events.
Reducing substance use may initially intensify
PTSD symptoms and thus predispose the client
to relapse. An increasing focus has emerged on
targeting PTSD and SUD concurrently.75,76 This
integrated focus is particularly relevant to women
who present to SUD treatment and often have
elevated rates of trauma history and PTSD.12
Recently, integrated models of treatment
for PTSD and SUD have been developed and
tested with mixed results. For instance, Najavits
developed Seeking Safety (SS), a CBT-based
treatment model that aims to reduce co-occurring
PTSD and SUD by enhancing coping skills.77 SS
Alcohol Research: Current Reviews
Mood disorders
Another promising area of treatment development
for women is integrated behavioral therapy for
SUD and depression. Treating depression and
AUD concurrently may be important because
negative affect is a particularly salient trigger
for drinking among women. In turn, regular
heavy drinking may inhibit recovery from mood
disorders. Further, more women than men with
AUD have a co-occurring mood disorder, and
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AUD.84 Dialectical behavior therapy (DBT) is an
empirically supported treatment for BPD that has
been successfully adapted for co-occurring SUD.85
A systematic review found that DBT has shown
positive potential for the treatment of women
with co-occurring SUD and BPD,86 leading
to reductions in substance use, suicidal/selfinjurious behaviors, treatment attrition, and social
functioning problems. No studies that tested DBT
specifically with women who have co-occurring
AUD and BPD have been found.
there is an elevated suicide risk among women
with AUD.6 However, research on integrated
AUD and mood disorder treatments for women is
limited. For example, in a pilot study, researchers
tested 8 sessions of interpersonal psychotherapy
as an adjunct to outpatient AUD treatment for
14 women with co-occurring AUD and major
depression.81 The study found that women were
highly engaged and satisfied with the adjunct
treatment and reported follow-up reductions in
drinking, depressive symptoms, and interpersonal
problems. A study of men and women with
depressive symptoms and hazardous drinking
compared the effects of integrated alcoholdepression treatment, alcohol-only treatment,
and depression-only treatment.82 The integrated
treatment generally produced the best alcohol and
depression outcomes for both women and men. In
the nonintegrated treatments, women’s drinking
and depressive symptoms improved more in the
depression-only treatment, whereas men improved
more in the alcohol-only treatment. These findings
highlight the unique benefit of treating depression
among women with co-occurring AUD and
suggest the need for more RCTs targeting this cooccurrence in women.
Given that drinking and antidepressant use are
generally contraindicated adds to the significance
of concurrent treatment of AUD and depression
to maximize the effectiveness of psychotropic
medications.6 One RCT tested the effect of
citalopram plus naltrexone and clinical case
management for men and women with AUD and
depression.83 Compared to placebo, citalopram did
not produce greater improvements in drinking or
mood with one exception: women (but not men)
on citalopram had a higher percentage of abstinent
days. These findings point to the potential for
tailoring antidepressant treatment to maximize
treatment benefits for women with co-occurring
AUD and depression.
Mechanisms of Change: How
Change Occurs
The goal of understanding moderators and
mechanisms of change in treatment is to
identify how patient characteristics interact with
treatments, identify variables key to successful
change, and then develop or modify treatments to
target those variables more efficiently in treatment.
Currently, there are relatively limited data on
moderators and mechanisms of change in alcohol
use during and after AUD treatment for women.
Moderators are defined as “specification variables”
that impact the association between two other
variables,87 for instance, the effect of baseline
major depressive disorder on treatment outcome
of female-specific versus gender-neutral treatment
for AUD. A mediator is an “intervening variable”
that “transmits the effect of the independent
variable on the dependent variable”;87 for instance,
cognitive behavioral treatment of AUD has its
effect on drinking outcome in part by increased
use of effective coping skills among clients.
Research on moderators of outcome has
elucidated the need for heterogeneity in samples
and helped to refine female-specific treatments.87
For example, findings that anxiety pretreatment
and depression pre- and posttreatment predicted
poorer drinking outcomes for women88 suggest
the value of including interventions to alleviate
depression and anxiety in female-specific AUD
treatment. Recent and more sophisticated research
has studied the interaction of moderators and
mediators of treatment response. For instance,
Holzhauer and colleagues combined a moderator
Borderline personality disorder
Research has demonstrated elevated rates (i.e.,
of approximately 18%) of borderline personality
disorder (BPD) in women seeking treatment for
Alcohol Research: Current Reviews
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analysis with testing the intensity and timing of
reductions in drinking after specific outpatient
treatment sessions that targeted depression and
anxiety in female-specific AUD treatment.89 Three
moderators assessed at baseline—depression,
anxiety, and self-efficacy to remain abstinent in
negative affect situations—predicted sudden gains
(i.e., a steep decrease in drinking) after Session
5 or 6, which included interventions to attenuate
negative affect. The results suggest that women
who enter treatment struggling with negative
affect may respond well to very specific, targeted
interventions for those problems.
Hallgren and colleagues examined three
hypothesized mechanisms of change—abstinence
self-efficacy, coping skills, and therapeutic
alliance—in outpatient AUD treatment for
women.90 These authors used daily data from the
individual versus group female-specific parent
study60 and sophisticated longitudinal statistical
modeling to quantify rates of change around
initiation of abstinence for each participant in
outpatient FS-CBT. They also tested time-linked
change in mediators before each of the 12 therapy
sessions. Data on daily drinking and craving
were available for the baseline, in-treatment, and
12-month follow-up periods. Results focused
on two subgroups of women: those who had
initiated abstinence before treatment and those
who initiated abstinence during treatment. Those
who initiated abstinence during treatment showed
marked improvements in two key hypothesized
mechanisms of change (abstinence self-efficacy
and coping skills) during the week that they
initiated abstinence. Women who were abstinent at
the start of treatment maintained higher abstinence
self-efficacy and coping skills throughout
treatment. Previously, Hallgren and colleagues had
found that daily-rated alcohol craving (a different
mediator) decreased in relation to initiation of
abstinence in men and women in outpatient CBT
for AUD.91
Using Network Analysis, a novel statistical
approach that uses multilevel vector autoregression
estimation for multiple time series data to
simultaneously examine change among several
Alcohol Research: Current Reviews
hypothesized mechanisms of change, Holzhauer
and colleagues compared pathways to drinking
reduction among women in gender-neutral versus
FS-CBT.59,92 Across treatments, women changed
their drinking via increased coping skills,
abstinence self-efficacy, and increased autonomy.
For women in FS-CBT, change in drinking
also occurred through decreases in sociotropy
and increases in social support for abstinence.
Surprisingly, change in depression was linked to
better drinking outcomes for women in genderneutral CBT.
Going forward, continuing moderated
mediation studies that examine the response
of gender-specific moderators of response to
medications or behavioral interventions for AUD,
and the mechanisms by which these treatments
operate for specific subpopulations, will help guide
the development of personalized medicine for
addiction.30 A moderated mediation approach can
facilitate examination of individual differences and
sample heterogeneity that are linked to drinking
outcomes and help to identify gender differences
in pathways to successful treatment outcomes.
CONCLUSIONS AND
RECOMMENDATIONS
Since the National Institutes of Health mandate
in 1994 that biomedical research include female
participants in clinical research,93 a substantive
body of literature emerged describing the unique
aspects of AUD among women, which led to an
accelerated development of treatments targeting
women’s unique clinical presentation. In 2006,
the National Institute on Alcohol Abuse and
Alcoholism (NIAAA) identified women as an
understudied population in treatment research
and prioritized research to better understand the
mechanisms by which treatments for AUD effect
change in drinking.94,95 Findings that drinking
outcomes of female-specific and gender-neutral
treatments may be similar does not mean that
the development of female-specific treatments
should not be pursued. First, there is evidence that
mechanisms of women’s response to treatment
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Vol 40 No 2 | 2020
(i.e., pathways to change) may differ from that of
men, and identification of these gender-specific
pathways can guide the development of efficient,
gender-differentiated active ingredients in
treatment. Second, there may be greater benefits of
women-specific (vs. gender-neutral) treatment for
secondary outcomes, such as psychosocial wellbeing, psychiatric health, pregnancy outcomes, and
HIV risk reduction. Third, further study is needed
on whether the availability of women-specific and
women-only treatments enhances treatment access
and engagement for women with AUD.
Gaps in knowledge remain; however,
increasingly sophisticated research approaches are
available to continue to tackle the questions of how
and which treatments work best for whom. The
contemporary focus on personalized medicine96,97
extends to women with AUD; the end goal is not
only to provide an array of specialized treatment
options specifically tailored to enhance women’s
treatment access and engagement but also to
provide science-based treatment elements and
options uniquely matched to various common
clinical presentations among women with AUD.
A critical problem to resolve is treatment access
and utilization. Only 15% of women with lifetime
AUD ever seek treatment for it, and women
experience multiple individual-based barriers
to accessing treatment. In addition, systemic
barriers to AUD treatment for women need
attention, as a minority of substance use treatment
services in the United States offer gendersegregated or female-specific programming.
Extant literature suggests that women may prefer
gender-segregated treatment for AUD but also
suggests this treatment offers no added benefit
in the absence of female-specific programming
content. Thus, widespread availability of femaleonly treatment settings that include evidencebased female-specific interventions and content
is likely to increase treatment utilization and
enhance outcomes for women with AUD. In
order to populate female-only treatment settings
with female-specific programming, we need to
develop an array of evidence-based options. A
number of RCTs have yielded newly available,
Alcohol Research: Current Reviews
evidence-based female-specific treatment
protocols for AUD and SUD treatment that are at
least equivalent in positive outcomes to evidencebased control treatments.59,60,62,70,74,79 Outcomes for
secondary (non-AUD) patient problems, such as
depression and anxiety,59,60 trauma symptoms,69
cardiovascular function,98 health behaviors, drug
use, and quality of life99,100 from these femalespecific treatments also have been positive.
NIAAA’s focus on implementation studies
in conjunction with the study of mechanisms
of change101 should accelerate testing the
incorporation of female-specific interventions
into community settings—not just addiction
specialty clinics but also primary care and general
mental health settings. These interventions
should ultimately lead to algorithms for optimal
personalization of treatment components to
individuals’ clinical presentation. In the meantime,
since most women currently receive treatment
in gender-neutral settings, it is important to
address women’s specific needs even in the
context of mixed-gender, gender-neutral102 clinical
programming. Research to address unresolved
gaps in the knowledge base is needed. For
example, does the availability of female-specific
programming, whether in female-segregated or
mixed-gender settings, increase AUD treatment
utilization by women? In addition, there is a dearth
of rigorous RCTs comparing female-only versus
mixed-gender treatment formats that contain
female-specific programming to test differential
treatment engagement and positive outcomes.
Notable areas of additional needed research on
women and AUD treatment follow.
Prevention
Women who enter treatment for AUD present with
greater addiction and more severe psychosocial
issues than men. Secondary prevention research
has focused on engaging women in treatment as
well as on providing alcohol psychoeducation
earlier in women’s problem drinking careers,
which may help arrest the telescoped trajectory
to AUD and SUD and the corresponding
psychosocial decline.
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Setting
positive development of a recovery coach industry
may help with in vivo social support especially for
women, but research is necessary to establish an
evidence base.
Women are more likely to self-identify as having
an alcohol problem and enter AUD treatment
through a medical or mental health portal than
a substance use specialty clinic. For instance,
women may obtain AUD treatment in the course
of seeking treatment for a co-occurring psychiatric
disorder, such as PTSD or depression, in a general
mental health setting.19,20 Also, brief interventions
in primary care settings have been found to
be promising in reducing drinking among less
complex cases of women with low co-occurrence,103
but no studies have examined the co-location of
more intensive outpatient female-specific AUD
treatments in primary care or women’s medical
clinic settings.
Medications
Research on medications for women with AUD
as one treatment element should continue. A
precision medicine approach testing gender,
genetic profiles, and specific medications is an
important avenue to pursue.
Mechanisms of Change Research
Research on mechanisms of change is crucial
to untangle whether similar drinking outcomes
of women and men with AUD are achieved via
gender-specific pathways to change and to identify
active ingredients and mediators of treatment
change best suited for women with only AUD and
for women with specific types of co-occurring
disorders. New methodologies in statistics,
neuroscience, and research design are helping
to clarify these questions; however, additional
research is needed to streamline and personalize
optimally efficient treatment components for every
woman seeking care for AUD.
Treatment Silos
Increasing rates of drug use among women point
to a need for integrated AUD and SUD femalespecific treatments. Although some evidencebased treatments are available,103 the net can
be cast even wider to include a range of health
behaviors such as nutrition, sleep, exercise,
smoking cessation, and use of benzodiazepines.
Framing AUD treatment for women in the context
of a general health and wellness approach that
addresses other health behaviors may increase
appeal, reduce stigma, and enhance utilization.
Acknowledgments
This article was supported in part by NIAAA grant T32 AA018180.
Financial Disclosure
Digital Delivery Platforms
The authors declare that they have no competing financial interests.
Testing telehealth platforms for individual and
group AUD treatments may help reduce barriers
to use among women. Likewise, testing ancillary
smartphone applications that link women to in vivo
coping skills training and social network support
could enhance outcomes of existing in-person
programs or serve as stand-alone aids for women
who face insurmountable treatment entry barriers.
Publisher’s note
Opinions expressed in contributed articles do not necessarily reflect
the views of the National Institute on Alcohol Abuse and Alcoholism
(NIAAA), National Institutes of Health. The U.S. government does
not endorse or favor any specific commercial product or commodity.
Any trade or proprietary names appearing in Alcohol Research:
Current Reviews are used only because they are considered essential
in the context of the studies reported herein.
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JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / MARCH 2020
Group Versus Standard Behavioral Couples’ Therapy for
Alcohol Use Disorder Patients: Cost-Effectiveness
LAURA J. DUNLAP, ph.d.,a,* TIMOTHY J. O’FARRELL, ph.d., abpp,b,c JEREMIAH A. SCHUMM, ph.d.,d
STEPHEN S. ORME, m.a.,e MARIE MURPHY, ph.d.,b,c & PATRICE M. MURCHOWSKI, sc.d.f
aRTI International, Research Triangle Park, North Carolina
bVeterans Affairs Boston Healthcare System, Brockton, Massachusetts
cHarvard Medical School Department of Psychiatry, Boston, Massachusetts
dSchool of Professional Psychology, Wright State University, Ellis Human Development Institute, Dayton, Ohio
eRTI International, Washington, DC
fAdCare Hospital of Worcester, Worcester, Massachusetts
ABSTRACT. Objective: The purpose of this study was to evaluate
the costs and cost-effectiveness of two treatments for 101 alcohol use
disorder patients and their intimate partners—group behavioral couples’
therapy plus individual-based treatment (G-BCT), or standard behavioral
couples’ therapy plus individual-based treatment (S-BCT). Method: We
estimated the per-patient cost of each intervention using a microcosting
approach that allowed us to estimate costs of specific components in
each intervention as well as the overall total costs. Using simple means
analysis and multiple regression models, we estimated the incremental
effectiveness of G-BCT relative to S-BCT. Immediately after treatment
and 12 months after treatment, we computed incremental cost-effectiveness ratios (ICER) and cost-effectiveness acceptability curves for
percentage days abstinent, adverse consequences of alcohol and drugs,
and overall relationship functioning. Results: The average per-patient
cost of delivering G-BCT was $674, significantly less than the cost of
S-BCT ($831). However, 12 months after treatment, S-BCT participants
performed better on all outcomes compared with those in G-BCT, and
the calculated ICER moving from G-BCT to S-BCT ranged from $10 to
$12 across these outcomes. The current findings indicated that, except
at very low willingness-to-pay values, S-BCT is a cost-effective option
relative to G-BCT when considering 12-month posttreatment outcomes.
Conclusions: As expected, G-BCT was delivered at a lower cost per
patient than S-BCT; however, S-BCT performed better over time on the
clinical outcomes studied. These economic findings indicate that alcohol
use disorder treatment providers should seriously consider S-BCT over
G-BCT when deciding what format to use in behavioral couples’ therapy.
(J. Stud. Alcohol Drugs, 81, 152–163, 2020)
A
LCOHOL MISUSE, including abuse and dependence,
is associated with serious health and social consequences (e.g., losses in work productivity, criminal justice
involvement, and motor vehicle accidents). The social costs
associated with excessive alcohol use have been estimated
to exceed $249 billion yearly in the United States (Sacks et
al., 2015). These substantial costs have prompted considerable interest in implementing treatments that are effective at
lessening the negative consequences of problematic drinking.
Behavioral couples’ therapy (BCT) for adults with alcohol
use disorder and their intimate partners is one approach that
has been developed over the past few decades (Epstein &
McCrady, 1998). BCT recognizes that the behaviors of the
drinker’s partner and the interactions between the drinker and
his or her partner can trigger problematic drinking. BCT also
recognizes that promoting a positive relationship between the
patient and partner and fostering the support of the partner
in the patient’s recovery may help achieve desired changes
in drinking behavior (O’Farrell & Fals-Stewart, 2006). Research has shown that BCT produces greater abstinence,
fewer substance-related problems, and better relationship
functioning than standard individual-based therapy, and it
reduces domestic violence and emotional problems of the
couples’ children (e.g., Meis et al., 2013; O’Farrell & Clements, 2012; Powers et al., 2008).
Previous studies have examined the cost-effectiveness
or cost-benefit for group-based therapies in substance use
treatment (e.g., French et al., 2008; Goorden et al., 2016),
with some findings suggesting that group-based therapies
may be cost-effective. However, few studies have examined
the cost-effectiveness or cost-benefit of BCT for substanceusing adults relative to individual treatment. Fals-Stewart
and colleagues (2005) examined the cost-effectiveness of
brief BCT, and they found that brief BCT was significantly
more cost-effective in reducing heavy drinking than standard
BCT or individual treatment. In two cost-benefit studies of
BCT for men with alcohol use disorders and their partners,
O’Farrell et al. (1996a, 1996b) estimated the cost savings
attributable to declines in alcohol-related hospital treatment
and jail stays 12 months (O’Farrell et al., 1996a) and 24
months (O’Farrell et al., 1996b) following treatment. They
found statistically significant reductions in social costs with
an average cost savings per patient ranging from U.S. $5,000
Received: August 31, 2018. Revision: November 21, 2019.
This research was supported by National Institute on Alcohol Abuse and
Alcoholism Grant R01AA017865 awarded to the second author and by the
Department of Veterans Affairs. We gratefully acknowledge assistance from
Fay Larkin, Anne Gribauskas, and Leslie Reid.
*Correspondence may be sent to Laura J. Dunlap at RTI International,
3040 East Cornwallis Road, Research Triangle Park, NC 27709, or via email
at: ljd@rti.org.
152
DUNLAP ET AL.
to $6,700. Further, in a cost-benefit study, Fals-Stewart et al.
(1997) found that BCT for male substance users resulted in
statistically significant reductions in social costs that were
associated with an average cost savings of $6,600 per patient in the year following treatment compared with $1,900
per patient for those patients who received individual treatment only. Despite these findings, the adoption of BCT in
substance use treatment programs continues to be slow, and
costs are often cited as a barrier to its implementation (Gifford, 2012; Schonbrun et al., 2012).
In response to perceived cost implementation barriers,
O’Farrell and colleagues (2016) developed a group BCT
(G-BCT). G-BCT incorporates a couples’ group format with
rotating content and rolling admissions in which couples
receive group sessions of BCT. In contrast, standard conjoint
BCT (S-BCT) is delivered to one couple at a time. The expectation was that G-BCT would produce similar outcomes
as S-BCT, but at a lower per-patient cost. In this article, we
present a cost-effectiveness analysis (CEA) for the O’Farrell
et al. (2016) randomized controlled clinical trial that examined G-BCT relative to S-BCT.
Method
Study design
The study design has been described previously by
O’Farrell et al. (2016). In brief, married or cohabiting
male and female patients seeking treatment for an alcohol
use disorder at a large treatment center in the northeastern
United States were randomly assigned to either G-BCT
or S-BCT. All patients were expected to attend 12 weekly
12-step–oriented group individual-based treatment (IBT)
sessions, which were based on the group drug counseling
manual (Daley et al., 2002), slightly modified to focus on
alcohol dependence. Patients and their partners also were
expected to attend the treatment-specific couples’ treatment
(i.e., multi-couple group BCT or single-couple standard
BCT) for 11 consecutive weeks during the 12-week period.
The G-BCT-specific couples’ treatment consisted of two
60-minute conjoint introductory counseling sessions and
nine 90-minute group BCT sessions with three to five couples each. The S-BCT-specific couple treatment consisted of
two 60-minute conjoint introductory counseling sessions and
nine 60-minute conjoint standard BCT sessions. All sessions
were conducted by study-trained therapists who were either
masters-level, licensed addiction counselors or a doctorallevel psychologist. Urine tests were collected weekly during
the treatment period. The larger study from which data used
in the economic evaluation were collected was approved by
institutional review boards at Harvard Medical School and
at the Veterans Affairs Boston (O’Farrell et al., 2016).
Participants were patients (N = 101) with alcohol dependence and their heterosexual relationship partners without
153
substance use disorder, mostly White, in their forties, and
30% of patients were women. Participants underwent assessments before treatment (baseline), after treatment, and
at 3, 6, 9, and 12 months following the scheduled end of
treatment. For more details, see O’Farrell et al. (2016).
Cost analysis
We used a microcosting approach to compute servicelevel costs of G-BCT and S-BCT. Costs were calculated
from the provider perspective as it is the most relevant for
providers looking to implement these types of therapies in
real-world practice. We included the labor time and nonlabor
costs incurred by the treatment site to deliver these services
to the patients and their partners. We did not include the
value of the patient’s or partner’s time or other costs that
they may have incurred to undergo this treatment (e.g.,
travel costs to/from treatment). In addition, because this was
a research study, we wanted to estimate treatment costs that
would be incurred in real-world settings (as opposed to those
required to implement a clinical trial research protocol).
Therefore, we identified the clinical activities and services
that constituted each treatment. Treatment activities included
planned information and counseling sessions, unplanned
crisis sessions (i.e., sessions to offer immediate, short-term
help to patients experiencing distress or problems), and urine
testing. We did not include nontreatment activities related to
implementing the clinical research trial such as randomization and conducting follow-up assessments because these
costs would not be incurred in real-world clinical practice.
All costs were converted to 2017 dollars using the Bureau of
Labor Statistics’ Consumer Price Index (www.bls.gov/cpi).
We used a study-specific treatment attendance form to
track the amount of services received by each patient each
week and the duration of each service. This information was
summed across services to calculate the total direct treatment time each patient received. Study intervention staff
also estimated the average time spent on support activities
(e.g., session preparation, note taking, administrative work)
for each type of direct care service. Support time was calculated for each direct care service based on the quantity
of services received by that patient. By summing across the
direct care services, we calculated the total support time for
each patient. Information on therapists’ wages was collected
from the study’s principal investigator based on the grant’s
financial records. Labor costs were calculated by taking
the average therapist hourly wage (including fringe benefit
rate) and multiplying by the total time reported (time spent
providing direct care plus support time) for each session
attended by the patient. Estimates for the building space
size and associated costs used for the therapy sessions were
provided by the administrative office of the clinic where the
study was implemented. Last, the material cost of urine testing supplies was provided by the study’s principal investiga-
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JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / MARCH 2020
tor and was included in the costs for a urine test along with
the labor time to provide that service.
The total cost of a service was simply the sum of costs
for labor time, building space, and materials. Summing
across all services received by the patient yielded the total
cost of the treatment for that patient, and summing across all
patients yielded the total cost of the treatment (i.e., G-BCT
or S-BCT). To get the cost per patient for group counseling
sessions, we divided the total session costs over the number
of patients in the G-BCT sessions. Finally, we derived the
average costs per patient for each treatment by dividing the
total costs of the treatment by the number of patients assigned to that treatment.
Effectiveness measures
Following the analytic approach of the main findings
article (O’Farrell et al., 2016), the CEA examined four effectiveness measures: (a) percentage days abstinent (PDA)
from the Timeline Followback (TLFB) interview (Sobell &
Sobell, 1996), (b) the Inventory of Drug Use Consequences
(InDUC; Tonigan & Miller, 2002), (c) patient-reported Dyadic Adjustment Scale (DAS; Spanier, 2001) score, and (d)
partner-reported DAS score. We focused on the immediate
posttreatment and 12-month posttreatment assessments,
which allowed us to examine the immediate effect, if any,
of the treatments and whether this effect was sustained 12
months later.
PDA was calculated by dividing the number of days
during which the patient was not in a hospital or jail for
alcohol-related reasons and they remained abstinent from
alcohol and other drugs by the total days during a given assessment period. To reduce possible underreporting of the
patients’ substance use, the lowest reported PDA was used
when both partners’ data were available. The InDUC measured the adverse consequences of the patient’s alcohol and
drug use, with higher scores indicating more adverse consequences. To reduce possible underreporting of the patients’
substance-related problems, the higher report (i.e., worse
outcome) was used when both partners provided responses
to an InDUC item. Both patient and partner completed the
TLFB and InDUC assessments with reference to the patient’s
behavior. The DAS measured overall relationship adjustment
as reported by the patient and by the partner, with higher
scores indicating a better functioning relationship.
Using the methodology employed in the main clinical
findings article (O’Farrell et al. 2016), we calculated predicted values for each of the outcomes with generalized estimating equations (GEE; Hall et al, 2001) analyses that included
a time effect1, the baseline outcome of interest, baseline days
of nonstudy treatment, assigned study treatment, and a time
1All
GEE regression models included a linear time effect. In
addition, as described in O’Farrell et al. (2016), we also included a
quadratic effect of time in the partner-DAS outcome model.
by treatment interaction. Although we had a low degree of
missing data, using GEE modeling for outcomes has the
advantage of allowing the inclusion of covariate-dependent
missing data.
Cost-effectiveness analysis
The CEA compared G-BCT to S-BCT by calculating
an incremental cost-effectiveness ratio (ICER) for each of
the outcomes. The first step in the CEA was to rank the
treatments in increasing order of average per-patient cost.
The ICER for each outcome was then computed, defined as
the difference in average cost divided by the difference in
average effectiveness. If one treatment is both less expensive and more effective, it strictly dominates the alternative
intervention. When neither therapy is strictly dominated, the
cost-effectiveness ratio is calculated regardless of statistical
significance.
Choosing the optimal treatment after strictly dominated
options are removed depends on a decision maker’s willingness to pay (WTP). WTP refers to the value that a person
is willing to pay to achieve a given outcome. We calculated
a cost-effectiveness acceptability curve (CEAC) to show
the probability that a treatment is the cost-effective option
as a function of the decision maker’s WTP for each of the
outcomes. The use of CEACs as well as sensitivity analysis,
described below, is important in reporting CEAs, especially
given the combination of smaller sample sizes, skewed costs,
and outcomes present in this study, which can introduce variability in the average estimates. The CEAC incorporates the
inherent variability of the cost and effectiveness estimates
and allows us to better capture the variability in our CEA in
lieu of confidence intervals for the ICERs (Fenwick et al.,
2001, 2006). We used a nonparametric bootstrap method to
calculate the CEAC that compared the G-BCT and S-BCT
across the four outcomes.
In addition to the use of CEACs, we performed sensitivity
analyses examining the impact of changes in unit costs. We
examined the effect of both increasing and decreasing the
hourly wage (i.e., unit cost of labor) and nonlabor costs. The
sensitivity analyses revealed that our point-estimate ICERs
increased as labor costs increased because S-BCT used proportionally greater staff time relative to G-BCT. Conversely,
the ICERs decreased as nonlabor costs increased because
G-BCT had proportionally greater nonlabor costs. The interpretation of the cost-effectiveness results was not greatly
affected by these analyses, although the overall costs of
G-BCT and S-BCT changed. S-BCT was still economically
dominated by G-BCT for the PDA and InDUC outcomes
after treatment. S-BCT remained the more likely optimal
choice when the WTP exceeded the estimated ICER, which
still supported the overall findings of this study (see the Appendix). (The supplemental appendix appears as an onlineonly addendum to the article on the journal’s website.)
DUNLAP ET AL.
Table 1.
155
Mean characteristics of service utilization
Average per session
Treatment
G-BCT arm
IBT activities
Information session
Introductory counseling sessions
Counseling sessions
Crisis sessions
G-BCT activities
Introductory counseling sessions
Counseling sessions
Crisis sessions
Total G-BCT arm
(IBT plus G-BCT activities)
S-BCT arm
IBT activities
Information session
Introductory counseling sessions
Counseling sessions
Crisis sessions
S-BCT activities
Introductory counseling sessions
Counseling sessions
Crisis sessions
Total S-BCT arm
(IBT plus S-BCT activities)
Average per patient
Average no.
of patientsa
(SD)
Direct
treatment time
(face-to face)
(hours)b
(SD)
Support
activities
time
(hours)b
(SD)
Total time
(direct +
support)
(hours)b
(SD)
Average
no. of
sessions
(SD)
Average
total time
(hours)
(SD)
1.000
(0.000)
1.000
(0.000)
7.547
(1.743)
1.000
(0.000)
0.897
(0.174)
0.658
(0.174)
1.490
(0.070)
0.683
(0.137
0.480
(0.000)
0.480
(0.000)
0.889
(0.109)
0.230
(0.000)
1.377
(0.174)
1.137
(0.174)
2.379
(0.132)
0.913
(0.137)
1.000
(0.000)
0.980
(0.140)
8.333
(3.615)
0.157
(0.543)
1.377
(0.174)
1.115
(0.234)
19.692
(8.390)
1.534
(1.048)
1.000
(0.000)
3.446
(0.772)
1.000
(0.000)
0.927
(0.126)
1.467
(0.091)
0.782
(0.375)
0.480
(0.000)
0.632
(0.048)
0.230
(0.000)
1.406
(0.126)
2.099
(0.113)
1.011
(0.375)
1.941
(0.580)
6.922
(3.463)
0.255
(0.523)
19.588
(7.261)
2.840
(0.673)
16.063
(5.736)
1.258
(0.798)
39.821*
(15.790)
1.000
(0.000)
1.000
(0.000)
7.525
(1.786)
1.000
(0.000)
0.877
(0.167)
0.653
(0.174)
1.500
(0.000)
0.708
(0.358)
0.480
(0.000)
0.480
(0.000)
0.887
(0.112)
0.230
(0.000)
1.357
(0.167)
1.132
(0.200)
2.387
(0.112)
0.938
(0.358)
1.000
(0.000)
0.980
(0.140)
8.549
(3.466)
0.157
(0.543)
1.357
(0.167)
1.132
(0.200)
20.765
(7.838)
1.367
(0.769)
1.000
(0.000)
1.000
(0.000)
1.000
(0.000)
1.033
(0.096)
0.982
(0.106)
0.996
(0.259)
0.480
(0.000)
0.480
(0.000)
0.230
(0.000)
1.512
(0.096)
1.462
(0.106)
1.226
(0.259)
4.027
(0.666)
7.098
(3.590)
0.333
(0.766)
19.549
(7.018)
4.907
(0.710)
11.457
(4.073)
1.893
(1.118)
35.823*
(13.270)
Notes: G-BCT = group behavioral couples’ therapy plus individual-based treatment; IBT = individual-based treatment; S-BCT = standard behavioral
couples’ therapy plus individual-based treatment; no. = number. aAverage no. of patients per session is a conditional mean calculated only for those
patients receiving the service indicated; breported average times per session (i.e., direct, support, and total) are conditional means calculated only for
those patients receiving the service indicated.
*Significantly different at p < .05 (two-sample Wilcoxon rank-sum [Mann–Whitney] test). Results Table 1 shows the average time per session for each of the treatment activities and the average number of sessions received per patient. On average, G-BCT patients received more time per patient across all treatment activities (approximately 40 hours) compared with S-BCT patients (36 hours). The variance in average total time between the two treatments was primarily due to the treatment-specific couples’ counseling sessions. G-BCT counseling sessions averaged 1.47 hours per session and the S-BCT counseling sessions averaged 0.982 direct hours per session. This difference was part of the study design with the group format of the GBCT counseling specifying 90-minute sessions, whe...

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