Behavioural couples’ therapy is one of two interventions (along with contingency management) highlighted as having ‘particularly strong evidence’ for effectiveness among people being treated for substance use problems. And yet, along with contingency management, it has not become a mainstay of treatment services. The SSA’s Rob Calder talked to Dr Grace Heaphy about what it is, how it works and how it’s been delivered during lock-down.

How to find an expert

Behavioural couple’s therapy is (unsurprisingly) for couples, although it sits within a wider group of couple and family therapies. These therapies are based on the principle that your family, friends and partners affect what you do. And that your behaviour, in turn, influences them. The therapy helps people to change patterns of behaviour in order to help address substance use.

It’s a complicated process and I was looking for someone to help me understand it when I was locked out of my office (okay I forgot my work pass). This was the exact same moment that Grace Heaphy was also ‘locked out’. We met at work as we were both approaching the front desk with the same apologetic smile.

We’re not just interested in what’s happening with the person that’s referred. We’re interested in the patterns of behaviour and thinking of the people around that person

Family therapy

Dr Grace Heaphy is a family therapist and is the course director for family therapy training at the Institute for Psychology, Psychiatry and Neuroscience at King’s College London. For the past 15 years Grace has supervised trainee therapists at the family and couple’s clinic at the Southwark Integrated Psychological Therapies Service, South London & Maudsley NHS Foundation Trust mostly working with mood disorders such as depression and bipolar disorder.

Grace started off as social worker and was struck by seeing lots of problems within families but without feeling like she had the skills to intervene. This prompted her to start her training as a family therapist in Dublin about 30 years ago. She still finds family therapy interesting, partly because families are so complex and different. “You just don’t know who you’re going to meet, and that’s the excitement of it.”

One principle of Behavioural Couples’ Therapy is that a couple’s interactions can inadvertently maintain problems that they are trying to avoid. A therapist will focus on behavioural cycles and help couples to change them to be more positive.

“The idea is that, although some problems may be displayed by one individual in the family, there is absolutely the belief that it not just influences other people in the family but is also influenced by other family members”. Sometimes families’ ways of helping may unwittingly help to maintain the problem they are trying to resolve.

“If someone has a difficulty and is coming to a family therapist, we’re not just interested in what’s happening with the person that’s referred. We’re interested in the patterns of behaviour and thinking of the people around that person.” This includes wider contexts like work or school.

You get years of these kind of destructive patterns, but you often don’t know what’s behind them. So, part of behavioural couple’s therapy is in developing empathy to understand where the other person is coming from

What to expect from behavioural couples’ therapy

What is covered in a first session will, of course, depend on the presenting issues. That said, Grace outlined that the first few sessions of behavioural couples’ therapy “might focus on behaviours that are destructive and corrosive. A therapist will try to slow down patterns and block those kinds of behaviours. Those patterns are often enacted in the very first session.”

“The therapist might observe this and feedback some observations. But most importantly they will help the couple to do something different in relation to those behaviours.”

Behavioural couples’ therapists can be quite active in helping people behave differently and will often use coaching to achieve this. That level of input also extends to examining the thoughts behind behaviours.

“What are the behaviours? The observable and tangible behaviours? Then you start thinking about what’s behind that behaviour in the cycle of an argument. We’ll slow down the process, think a little bit about what what’s driving that behaviour”.

“You get years of these kind of destructive patterns, but you often don’t know what’s behind them. So, part of behavioural couple’s therapy is in developing empathy to understand where the other person is coming from.”

“Someone can be responding not just to their partner, but to experiences from their childhood, but the partner doesn’t know that. Once the partner understands that, there’s a bit more empathy for it. So, developing that tolerance and empathy for one another is a really important part of changing behaviour and caring for one another more.”

Has family therapy changed during COVID-19?

During lock-down, all teaching and therapy moved online, and did so in a rush. Grace and the team are now reviewing what’s worked well and what hasn’t. It still seems unlikely that they will go back to in-person therapy sessions this year.

A surprising upside is that, since offering therapy online, they have had much higher levels of attendance. For example, people who work can attend for an hour during their lunchbreak. And it’s made the difference for young people too.

“Sometimes we get young people and adolescents who don’t want to come, but who might dial in from their bedroom on their own device.”

The benefits for people being able to dial in from somewhere that they consider to be safe has been a real eye-opener.

The downside of online sessions is that therapists often feel like they have far less control. “You also see a lot less of other people’s body language, and you are able to use less of it yourself to calm situations or to show people that you’re listening. It removes a substantial part of the therapist’s toolkit – it’s like working with your hands tied behind your back.”

Does behavioural couple’s therapy work?

Both the Orange Clinical Guidelines and NICE guidelines outline the strong evidence of efficacy for use in drug and alcohol use. Grace points me towards a very accessible book combining systemic and behavioural approaches in work with couples that gives good examples of how the therapy works. It’s useful for those who might be considering therapy for themselves and for practitioners. *

Training in Family Therapy / behavioural couples’ therapy

To become trained in family therapy (which includes working with couples) in the UK you have to complete a 4-year part-time, or 2-year full-time, course. To enrol, you need a professional qualification in psychology, social work, psychiatry or similar. Getting on the courses can be competitive, however, last year, Health Education England supported 57 trainees across the country to complete the MSc in family therapy, so there is broader recognition of the importance of this kind of treatment.

The Association for Family Therapy (AFT) accredits courses in systemic therapies and the AFT website lists the courses all over the country. There are also courses to enhance your skills in working with families where you don’t become a qualified family therapist.

There are a range of approaches to working with couples – psychodynamic or CBT for example – and couples therapists who are trained in different approaches can do additional training in BCT to add to their skills and practice.


Behavioural couple’s therapy may be available on the NHS depending on the services in your NHS Trust. Some Relate services may also offer BCT and again this may be dependent on the area you live in.  It might also be funded as part of a social work care package. The first step, as with many therapies, is to find out what is available, and what can be funded.

* Reibstein, J. and Singh, R (2021) The intercultural Exeter couples model. Wiley

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