A Qualitative Investigation of Barriers to Entry into Couples Treatment for Alcohol Problems

Abstract

This study used qualitative methodology to evaluate barriers to entry into couples treatment for alcohol problems. Data were collected using semi-structured interviews. Patients were recruited from (1) treatment for primary substance use disorders, (2) treatment for psychiatric disorders (other than substance use disorders), and (3) court-mandated outpatient domestic violence programs. Mental health experts were recruited based on expertise in (1) couples treatment, (2) alcohol treatment, and (3) couples treatment for alcohol problems. Patients (N=57) met criteria for hazardous drinking, and were in committed romantic relationships. Partners (N=19) and mental health experts (N=12) also completed interviews. Interviews were analyzed using accepted qualitative strategies. Barriers to treatment entry were identified at the patient, partner, and couple level. Barriers identified included psychological barriers, alcohol illness factors, treatment preferences and beliefs, and interpersonal factors. Although many barriers are similar to those previously identified in individual alcohol treatment, barriers unique to couples treatment provide guidance for next directions for dissemination.

Despite the existence of well-established and efficacious treatments for alcohol problems, linking patients with such treatments presents a significant challenge. To address this challenge, leaders in the field, have encouraged increased efforts in disseminating and implementing existing treatments into routine practice. In order to effectively disseminate efficacious treatments, it is essential to gather information directly from treatment consumers (i.e., patient populations) to identify salient barriers to treatment entry.

As treatment entry is a complex process with multiple decision points and associated behaviors, information-gathering procedures require strategies that can capture complex phenomena. Qualitative methodologies permit researchers to gather data about complex behaviors through use of interviews that elicit participants' perspectives in participants' own words. Such approaches to data collection and analysis represent a powerful strategy to gather information about barriers to treatment entry.

Almost one third of married individuals meet criteria for an AUD during their lifetime (Hasin, Stinson Ogburn, & Grant, 2007), and a substantial body of research indicates that alcohol use problems lead to relationship problems, including poor relationship functioning, partner violence, and relationship dissolution (e.g., Relationship problems, such as relationship dissolution, in turn, have been linked to worsening alcohol problems (e.g., suggesting an important preventive role for couples treatment for alcohol problems. Taken together, married individuals are well-represented among those with an alcohol use disorders and are likely encounter substantial relationship difficulty as a result of alcohol problems, underscoring the need to extend the reach of treatments tailored to the needs of partnered alcoholics.

Several decades of research evaluating behavioral couples therapy (BCT; have demonstrated impressive outcomes for alcohol and relationship functioning. Despite its status as a well-established treatment, behaviorally oriented couples counseling has been implemented on an extremely limited basis. Although some work has been done to evaluate barriers to providing this treatment, very little information is available regarding barriers to treatment entry on the patient and partner level. While it is essential to continue gathering information about barriers to providing such services (i.e., barriers at the organizational and policy level), it is similarly important to evaluate what barriers exist for patients and their partners to enter into such treatments when they are available. That is, both a top-down and a bottom-up approach to understanding barriers to dissemination are essential to effectively disseminate this efficacious treatment.

Currently, evaluations of barriers to entry into couples treatment from the consumer (i.e., patient and partner) perspective are particularly lacking, limiting our understanding of how to best disseminate efficacious couples treatments in a manner that will maximize accessibility. Indeed, although research evaluating patient barriers to alcohol treatment entry is plentiful, few studies evaluate barriers to involving partners in individual treatment, and only one study has evaluated barriers to entry into couples alcohol treatment. Despite preliminary identification of barriers to treatment entry (including the patient's belief that alcoholism was an individual rather than couple's problem, and concerns about the partner and therapist “ganging up” on the patient), the limited number of studies available and concerns about study methodology suggest the need for further inquiry regarding barriers to treatment entry.

The current study, relying on individual semi-structured interviews, provides such an inquiry through use of an in-depth analysis of patient, partner, and mental health expert perspectives regarding barriers to entry into couples treatment for alcohol problems. Such data will inform future efforts to incorporate this well-established treatment into routine practice, and will provide valuable information about barriers to engaging couples in treatment.

Method

Participants

The sampling strategy involved both a criterion and a maximum variation approach (Kuzel, 1999), which seeks to include a wide range of perspectives. Therefore, three unique populations of patients in current romantic relationships and their respective partners were recruited from treatment sites in which alcohol problems and relationship problems are common. Treatment sites therefore included treatment of substance problems, (including alcohol problems), treatment of other psychiatric problems, and domestic violence programs. We also sought the perspectives from individuals who were voluntarily in treatment versus those who were mandated for treatment (i.e., domestic violence programs) to better obtain a broader perspective on barriers to alcohol treatment entry. Eligible patients were in relationships of one year or longer, and were currently cohabiting with their partner. Eligible patients also met criteria for hazardous alcohol use (see below). Although the focus of interviews was on alcohol problems, we did not exclude participants with co-occurring drug problems.

Patients and their partners were recruited from three treatment sites: (a) individual partial hospital treatment of substance problems (N = 18), (b) individual partial hospital treatment of psychiatric disorders other than alcohol (N = 19), and (c) court mandated outpatient interventions for domestic violence (N = 20). All patient participants were in commited relationships of one year or longer, were currently cohabiting with their paritner, and met criteria for hazardous drinking, defined by a score of 8 or greater on the Alcohol Use Disorders Identification Test (AUDIT;.

Patient charts in the two partial hospital units were screened for presence of alcohol problems and presence of a current relationship (160 charts screened in the substance treatment unit; 697 charts screened in the psychiatric disorder treatment unit). A total of 59 charts in the substance treatment unit, and a total of 48 charts in the psychiatric treatment unit screened positively for presence of alcohol problems and current romantic relationship. Of these, 33 and 25 patients, respectively, completed the screening survey. A total of 19 and 18 patients, respectively, met eligibility requirements and completed remaining study procedures. Access to chart screening methods was not available in the domestic violence programs. Study staff therefore invited individuals in relationships who were completing, or who had completed, a court mandated domestic violence program, to complete screening procedures. Of the 41 individuals who consented to complete screening measures, 20 were eligible and completed remaining study procedures.

We also requested patients' consent to invite partners to participate in the study. After completing informed consent procedures, 6 partners from the primary alcohol treatment site, 7 from the primary other psychiatric disorder treatment site, and 6 from the domestic violence treatment sites completed qualitative interviews (see Table 2 for further information about the study sample). Finally, 12 mental health experts completed interviews. A convenience sample of mental health experts was selected based on area of expertise, which included treatment of alcohol problems (N = 5), couples treatment (N = 5), and BCT (N = 2). Mental health experts included front-line clinicians in community treatment centers (50%) and prominent researchers in their respective areas of expertise (50%).

Table 2.

Sample characteristics

	Patients (N=57)		Partners (N=19)
	Mean or %	SD	Mean or %	SD
Sex
Male	42.1%		52.6%
Female	57.9%		47.4%
Age	41.70	10.59	43.68	9.70
Years of Education	13.29	2.37	14.39	3.03
Race/Ethnicity
White	86.0%		68.4%
Hispanic	10.5%		21.1%
Length of Current Relationship (Years)	13.74	8.86	12.40	9.18
Number of children	2.36	1.66	2.53	1.50
Quality of Marriage Inventory Score	28.42	10.61	31.68	11.53
AUDIT Score	22.82	8.68	3.89	4.61

The first author conducted all interviews, which were audio-recorded and transcribed, on an individual basis. Interviews ranged in length from 10 to 52 minutes. Open coding strategies, which involve identification, naming, and categorizing phenomena identified in the interview text, were initiated with the mental health expert transcripts to generate a preliminary codebook. Subsequently, the codebook was refined as coding of patient transcripts was completed, and data saturation was achieved (i.e., no new codes emerging as additional transcripts were identified). This codebook was used to code the 19 partner transcripts with similar procedures (i.e., with additional codes added until data saturation was achieved). Finally, we reviewed mental health expert transcripts using the final codebook to verify reliability of coding and data saturation.

Questions were asked to elicit perspectives in patients', partners', and mental health experts' own words about barriers to generic alcohol treatment entry, and specifically into couples treatment for alcohol problems. A brief description of couples treatment was provided to participants unfamiliar with this approach. The primary question “What might make it difficult to seek this treatment?” was asked, and follow-ups (e.g., “Tell me more”) were used to obtain further clarification and information. Table 1 provides outlines of interview questions. Order of questions varied depending on patient's identified problem, or based on mental health expert's area of expertise.

Table 1.

Sample Interview Guide(s).

Patient/Partner	Mental Health Expert
1. Describe purpose of study: “This is a study examining what makes it hard to get into treatment (alcohol treatment/couples treatment/couples treatment for alcohol).
2. Establish rapport: Since you were asked to participate in this project because you/your partner was in treatment, I'd like to start by hearing a little bit (more) about your experience with treatment. In particular, I am interested in your experience with treatment for alcohol use. Have you ever been in treatment before? Have you ever been in couples' treatment?
3. Initiate discussion on treatment: “What do you think makes it hard to get into treatment (for alcohol problems)?”	2. Initiate discussion on barriers: “What do you think are some of the central barriers to entry into couples' treatment/treatment of alcohol problems?”
3/4. Transition to discussion of couples treatment for alcohol: “Given research supporting outcomes for couples' treatment for alcohol problems, I am also very interested in barriers to getting into couples' treatment for alcohol problems.”
5. Barriers to entry into couples treatment for alcohol: What might make it difficult to seek this treatment? Have you ever considered entering couples' therapy for treatment of alcohol problems? If couples' therapy for alcohol problems was offered to you, what are reasons that you might not accept it? Are there other issues regarding barriers to entry into couples' treatment of alcohol problems you would like to raise?	4. Barriers to entry into couples treatment for alcohol: What might make it difficult to seek this treatment? Are there other issues regarding barriers to entry into couples' treatment of alcohol problems you would like to raise?
Probes: And what other barriers might there be? What might encourage you/your partner/patients to seek treatment?

The first author and two research assistants analyzed and coded each transcribed interview. Each coder independently reviewed, selected, and coded qualitative responses. Quotations that most accurately reflected an emerging concept (e.g., affordability) were chosen from among text that had been marked. During weekly meetings, transcripts were discussed line by line, and coding among the three coders was reconciled to represent team consensus about the meaning of utterances. Coding was initially conducted on the specific concept level (e.g., lack of transportation); identification of higher-order themes (e.g., logistical barriers) emerged from a review of like content, which was grouped together during consensus meetings among coders.

Results

The goal of data analysis was to identify themes representing barriers to entry into couples treatment of alcohol problems. All participants endorsed the perspective that entry into couples treatment for alcohol problems would pose difficulties, and emerging themes underscored the importance of specific barriers. Notably, many participants described a belief that couples treatment for alcohol problems would be “beneficial”. A thematic analysis of the transcripts identified 3 higher-order level themes: patient-specific (Table 3), partner-specific, (Table 4) and interpersonal/couple level barriers (Table 5).

Table 3.

Key Themes Regarding Patient Level Barriers to Entry into Couples Treatment of Alcohol Problems

Theme 1: Psychological Factors Experiencing emotions of guilt, shame, or anger Having another psychiatric problem that might interfere with treatment, and which may be primary to the alcohol problem Perceived inability to quit, even with professional help

Theme 2: Alcohol Related Illness Factors An avoidant coping style contributing to an unwillingness to enter into treatment Beliefs that one does not have a problem, or that the problem is not severe enough to warrant treatment Lack of motivation to change drinking behavior

Theme 3: Treatment preferences and treatment fears Preference for independent change and wanting to focus on oneself in treatment Fear that seeking treatment will necessitate hospitalization or medication Feeling to overwhelmed, or too burned out from current treatment, to want to partake in further treatment

Table 4.

Key Themes Regarding Partner Level Barriers to Entry into Couples Treatment of Alcohol Problems

Theme 1: Partner Psychological Factors Feelings of being burned out or resentful towards the patient due to longstanding alcohol problems, and resulting unwillingness to help the patient in their treatment

Theme 2: Partner's perspectives and approaches to dealing with own or patient's alcohol related illness factors Partner's difficulty with identifying the patient's alcohol problem Partner feeling that the problem should be handled independently by the patient Partner's own lack of readiness to change their drinking or relationship behavior

Theme 3: Partner treatment preferences, treatment fears, and information about treatment Partner beliefs and fears about therapy Partner's beliefs that the patient should be able to stop drinking without professional help and/or beliefs that therapy is not helpful Partner concerns about privacy from the therapist

Table 5.

Interpersonal/Couple Level Barriers to Entry into Couples Treatment of Alcohol Problems

Theme 1: Both partners being willing to engage in treatment together

Theme 2: Logistical Barriers, including scheduling, financial considerations, transportation, childcare, and availability of treatment

Theme 3: Fears and beliefs about partner involvement Assuming one's partner is not interested or would not be helpful in treatment Beliefs that if the partner were to participate, that they would not be helpful Patient and partner fears about being blamed or held responsible for alcohol and/or relationship problems Patient fears about disappointing or causing excessive burden to the partner

Theme 4: Perceived Lack of Support From Others Family, partner, or friends not encouraging treatment seeking because they are not aware that the patient has a drinking problem Family, partner, or friends discouraging treatment because of secondary gains resulting from the patient continuing to drink

Theme 5: Treatment preferences, treatment fears, and information about treatment Lack of information that couples treatment is an option Beliefs that therapy or a therapist is would not be helpful Concerns about disclosure of private information to individuals outside of the relationship, to the therapist, and even to one's partner Coming from a culture or community in which substance and/or couples treatment is heavily stigmatized

Table 4. Interpersonal/Couple Level Barriers to Entry into Couples Treatment of Alcohol Problems

Theme 6: Relationship Factors Relationship functioning, including level of commitment, concerns about relationship worsening or dissolving, and fears of confrontation or increasing risk of relationship violence

Patient-Specific Barriers

Theme 1: Psychological Factors

Feelings (e.g., shame, anger, guilt) about alcohol use were described to contribute to difficulty with treatment entry. One patient noted “I would say the barrier would be definitely embarrassment and failure.” In addition to shame and guilt, participants also endorsed anger as a psychological factor that influenced one's ability to gain entry into treatment. As one participant described, “You just resent people telling you how to run your own life.”

The presence of co-morbid mental health conditions was also portrayed as a factor impeding entry into couples treatment for alcohol problems. One participant described, “I have, like, a social phobia. I don't like going into large crowds, or different people and stuff, so coming into like, [this hospital], or anywhere else where strangers are here, even to talk aloud, that's a barrier for me.” Depression was also described to contribute to difficulty in seeking treatment. One depressed patient noted “There was no commitment for myself, for the future.”

Perceived inability to quit drinking also emerged as an important contributor to difficulty seeking treatment. One patient described that he “…knew, from my past experience, that I could not stop.” This perspective contributed to the belief that treatment entry would ultimately be ineffective, and therefore not worth the effort to attain sobriety in the present.

Theme 2: Alcohol Related Illness Factors

Participants also described an avoidant style of coping that contributed to difficulty in treatment entry. One patient noted, “I'm sitting there, in my head, like, if I do this then, that means that I'm not going to be able to drink again…. And I'm like, no, can't happen.” Patients also described denial of alcohol problems as an important impediment to entry into couples treatment: “I… thought [treatment] was great for the people that needed it, but that wasn't me.” A general lack of motivation to work towards drinking behavior change also emerged as an important obstacle to seeking couples treatment, stating “I guess you've got to really want help for it. I don't really want help right now.” One mental health expert described how this factor might be particularly problematic in the context of couples therapy: “the concern is that there, there's an implied… higher level of commitment to change when you're… engaging in change behavior in front of another person.”

Theme 3: Treatment preferences and fears

Treatment preferences emerged as an important patient-level barrier to entry into couples treatment. First, many patients described wanting to change autonomously. “I feel it's the person that really has to do that for themselves.” Mental health experts reflected on this barrier: “… people might not identify it as a couples' issue. And so they might be more inclined to seek individual treatment as opposed to couples treatment.”

Treatment perceptions were described as being influential. For example, many patients reported beliefs that couples treatment would result in their being medicated or hospitalized. Patients also described that entry into an additional form of treatment for their alcohol problem felt too burdensome. One patient noted, “at this point, I'm kind of therapied out, you know?”

Partner-Specific Barriers

Theme 1: Partner Psychological Factors

Participants noted that by the time treatment had become an option, many partners were already exhausted and resentful. One partner described, “I just get to a point where you're like, `I don't want to do it, I don't want to do this anymore. You know, I want to move on.'” Patients were able to recognize the toll of their disorder, and the result it might have on partners' willingness to engage in treatment with them. One patient described, “they feel resentful because, `You've put me through all this, now you want me to do more for you?'”

Theme 2: Partner's Perspectives and Approaches to Dealing with Own or Patient's Alcohol Related Illness Factors

Patients, partners, and mental health experts all described partner perspectives on alcohol problems that represented barriers to treatment entry. First, patients and partners described the difficulty some partners had in identifying the presence of the patient's alcohol problem. Second, many participants described a belief that when the partner was able to identify the problem, it was not viewed as a shared problem: “Why should I have to deal with her problems?”

Because couples therapy frequently requires changes by both members of the couple, lack of partner readiness to make alcohol use or relationship behavior changes was described as an important obstacle to treatment. One patient noted: “If… you want to go to counseling but your partner still wants to drink, and get high all day…, then how are you gonna go to couples?” Similarly, relationship behaviors that may have previously enabled the patient to continue drinking could be identified as targets of change in treatment, and partners described that they may not feel prepared to make such changes.

Theme 3: Partner treatment preferences, treatment fears, and information about treatment

Partners' beliefs and fears about treatment influenced their willingness to consider couples treatment for alcohol problems. One partner noted that they would participate in treatment “… if I thought that the treatment would help… but if I thought it was just a quick fix, probably not.” Another partner explained his belief that individual treatment should take precedence over couples treatment: “You could have a huge setback with that, just throwing them into couples counseling.” Others expressed concern about what they might discover through treatment with the patient: “Maybe that I didn't know [what] he was feeling. Or… maybe the reason he goes out on Friday night and has 12 beers is because he's feeling badly about something I did.” Many partners expressed the belief that one should be able to handle alcohol problems without professional help. One partner described telling his wife: “We don't need to go [to treatment].”

Partner concerns about privacy emerged as an important barrier to treatment entry. One such concern was that the therapist might discover the partner's drinking: “[The therapist] might ask him questions about his alcohol use… and that that might be scary for him.”

Interpersonal/Couple Level Barriers

Theme 1: Both partners being willing

Patients, partners, and mental health experts all described lack of agreement between partners on attending treatment as an important barrier. As described by one patient, “I think it's hard to get both partners to actually agree on going to counseling.”

Theme 2: Logistical Barriers

Patients, partners, and mental health experts all described logistical barriers to entry into couples treatment. For example, scheduling difficulties, childcare issues, and financial limitations were noted to be more salient barriers to treatment entry for couples than individual treatment. As one partner described, “I mean it might sound mundane, but… trying to coordinate one more thing is hard.” One mental health expert provided the following example: “If there are children in the family if someone is going in for individual therapy, the other partner could watch the kids. Whereas if both members of the couples are going in for couples therapy, then who is going to be watching the kids?”

Theme 3: Fears and Beliefs about Partner Involvement

Patient assumptions about partners' willingness to engage in treatment were described as treatment barriers. One patient described that if invited, her partner “… just wouldn't want to participate.” One mental health expert elaborated that “A lot of patients don't want to even bring up the subject with their partner because they're quite sure their partner will say no.” Furthermore, a number of patients described the belief that if their partner were to participate, it would not be helpful.

An additional concern about partner involvement was fear that entry into treatment with their partner would result in the patient being blamed for all of the problems in the relationship. One mental health expert described that patients believe“…it's going to be two people, the treater and the wife, sitting there telling them what a terrible person they are.” Conversely, some partners endorsed fears that participating in treatment with the patient would place them in the position of being blamed for the problems. Another mental health expert noted “…people assume that if they are going to be involved in the treatment, they're going to be held responsible for the problem.”

Patient fears about disappointing one's partner also emerged as a treatment barrier: “They might think they failed their partner by admitting [to their partner] that they have a problem.” Patients and partners also endorsed the concern that having the partner participate in treatment for the patient's alcohol problem would be an excessive burden to place on the partner. One partner empathized with the patient, stating “She would say `I'm imposing on you. I'm being a burden to him.”

Theme 4: Perceived Lack of Support From Others

Perceived lack of support from others for entering treatment was also described as barrier: “You're not going to seek treatment. It's simple. Because your family is going to back you up on that you don't have a problem.” Patients frequently attributed a lack of support for treatment seeking to relationship factors. For example, one patient noted: “[My wife] says, “When he's doing drugs and drinking, I like him better.” Several patients also noted that their partners did not want them to stop drinking because drinking was a shared activity.

Theme 5: Treatment information, preferences, and fears

Perspectives on treatment were described to influence likelihood of entry into treatment. Across all treatment sites, the majority of patients and partners were not aware of couples treatment for alcohol problems as an effective treatment option, and very few had been offered this treatment. As one patient noted, “this is the first time I've ever heard that there's couples counseling for alcohol.”

Some patients described beliefs that treatment would not be helpful. One patient described how the portrayal of couples treatments in pop culture contributed to a negative view of couples therapy: “Just seeing how they portray couples counseling on TV and stuff, it makes it seem like it is far-fetched.” Additionally, concerns that “… the counselor is finding more stuff that's wrong than what is already wrong” was also cited as a barrier.

Disclosure to people outside of the couple (e.g., family members, community members, employers) was reported as a significant concern influencing entry into couples treatment. As one partner noted, “They're probably thinking that somebody is gonna find out.” Several participants specifically noted that finding someone to watch their children might necessitate disclosure: “And then, what do you tell the people that you have watching your children while you're both going off?” Some patients also reported concerns that their partner would disclose something to the therapist that might portray them as the bad partner. Other patients and partners reported concern that disclosure of feelings, past events, or hopes for the future were also an unpleasant aspect of engaging in couples treatment. As one patient noted, “I know that if we were in counseling…, that would be the place to tell him the truth. And I'd kind of feel obligated to tell him the truth at that point and I don't know if I want to do that.” Another perspective was that having one's partner sitting beside them in treatment would make it more difficult to be honest: “I don't know if I'd be as frank if he was sitting next to me.”

Stigma about treatment was also described as a barrier to treatment entry. Some patients described the stigma related to their gender: “Well, the hard part would be, I'm a man and my arm would be falling off before I went to see a doctor.” Certain cultures were described as possessing high levels of stigma for alcohol treatment. As one Japanese patient described, “… going to seek mental help in Japan is very stigmatized.” Not only was the stigma of alcohol treatment cited as an important barrier to seeking treatment, but involving one's partner in a couples treatment was noted to carry particular stigma: “Like people wondering, “Why? What do you need couples therapy for? Is there a problem in your marriage?”

Theme 6: Relationship Factors

Participants reported a variety of relationship factors obstructing entry into treatment. One patient described how a fight just prior to a scheduled couples session caused them to cancel the appointment. Other relationship factors, including level of commitment to the relationship, emerged as important themes influencing treatment entry. As one partner described “If I wasn't willing to commit… I'd probably be less willing to commit to spending time to devote to improving the other partner.” Others noted that by the time alcohol treatment would be sought, the alcohol problems would already have taken too great a toll on the marriage: “… By the time people discover they have an alcohol problem their marriage is already destroyed.” The opposite was also true, as some participants reported the belief that a lack of relationship problems is indicative of there being no need couples treatment for alcohol problems: “…if our relationship doesn't have any problems, then we don't need couples therapy.”

Some participants described beliefs that couples treatment would worsen relationship functioning. One patient described that “… a lot of things would probably come up in couples counseling that would be bad on the relationship in general.” Some participants described that discussing the relationship and alcohol use might negatively influence relationship outcomes. One patient described fears that his partner might discover “that she's fed up with me.” Participants also described fears of being confronted by their partner: “I guess I'd be afraid that maybe he'd feel freer saying things that he doesn't want to say to me in front of someone else.” Finally, some patients described fears that engaging in couples treatment would increase the risk for domestic violence: “Maybe their partner with a drug or alcohol problem is abusive.”

Discussion

This analysis represents one of few efforts to utilize qualitative methods to identify obstacles to seeking couples treatment for alcohol problems. Although interviews focused on barriers to treatment entry, consistent with literature demonstrating the efficacy of couples' treatment, many participants also noted that this treatment would be “beneficial if obstacles to entry could be overcome.” Indeed, many participants endorsed willingness to do this treatment, and some spontaneously suggested strategies to overcome barriers, such as “if they had a little playground where the kids could go in and there was like a teenager watching them or something for the hour, that would be perfect.”

Many barriers to entry into couples treatment for alcohol problems confirm findings from previous studies evaluating barriers to entry into individual alcohol treatment. Namely, psychological barriers, logistical barriers, and concerns about privacy have all been identified in previous work on generic barriers to entry into alcohol treatment. The current study augments these previous findings by demonstrating that these barriers also pertain to couples treatment. Indeed, many participants noted that some barriers relevant to individual treatment, such as scheduling, were far more salient in the context of couples treatment. Therefore, while addressing common barriers to treatment entry is important for enhancing alcohol treatment entry of all kinds, it is particularly important to address these barriers in trying to increase access to couples treatment. Suggestions made by participants included offering more flexible hours (evenings and weekends) for sessions and providing on-site childcare.

This study also identified additional barriers to treatment entry that were specific to couples treatment. For example, partner views of the patient's alcohol problem, and partner beliefs about their own participation in treatment emerged as important factors influencing entry into this treatment. Additional barriers on the couple level included difficulty getting both partners on board for treatment, preferences for individual treatment, negative beliefs about couples treatment, and current relationship status and relationship functioning. Clearly, gaining entry into couples treatment requires that both the partner and the patient are able and willing to overcome barriers to treatment. This is a difficult task for many couples, particularly those who have experienced the chronic toll alcohol problems.

Although addressing barriers to entry into couples treatment may seem a daunting task, it is notable that many identified barriers are addressable through actions taken by policy makers, researchers, and clinicians. Indeed, as one of the first studies to evaluate barriers to engaging couples in treatment, this study paves the way to taking concrete steps to address identified barriers to treatment entry. For example, implementation of public health campaigns to increase awareness of the efficacy of couples treatment for alcohol problems for both treatment providers and treatment consumers would be an important first step in increasing dissemination of this treatment.

On the patient/partner levels, strategies to diminish patient and partner burden for participating in treatment, and making this treatment increasingly available may facilitate treatment entry. Other strategies based on these results might include involving the partner earlier in treatment (e.g., during assessment sessions) to directly address patient and partner concerns about engaging in treatment together and to provide experiential and didactic information to the patient and the partner about treatment. Therefore, an approach that incorporates both top down (provider level) strategies, as well as bottom up (patient/partner level) strategies, will be likely to enhance the dissemination of this treatment. In addition, this study demonstrates the importance of addressing barriers to treatment entry for both the patient and the partner. Effectiveness studies evaluating some of these strategies to disseminate and modify the BCT treatment protocol remain a task for future investigations.

Despite the contributions of the current study, several limitations should be noted. First, despite the inclusion of patients and partners from various treatment sites and mental health experts from varied backgrounds, this study relies on a non-representative convenience sample of patients, partners, and mental health experts. Therefore, conclusions should be made with caution until they can be replicated in a more generalizable sample. Second, participants were asked to speculate on treatment barriers, and were not followed over time to determine if these barriers prevented entry into couples treatment. Future work would benefit from longitudinal study designs that evaluate the association between identified barriers and treatment entry.

These limitations notwithstanding, the current study provides a useful evaluation of barriers to entry into couples treatment for alcohol problems. Such information provides a valuable guide in improving dissemination and implementation of couples treatment for alcohol problems.