"Erikson and others suggested that intimate relationships are a key influence on our development. Therefore, it should not surprise us to discover relationships influence 'substance abuse.' Understanding the meaningful relationships of clients is an important issue because it may have a significant impact on treatment success" (Cavacuiti, 2004, page 653). Assessment for addiction and compulsivity is critical in working with couples. Specific addictions or compulsive behaviors often require directed treatment approaches that fit their particular nuances and demand. In depth examination of particular addictions or compulsive behaviors are beyond the scope of this book. The therapist should examine the expansive research when aware of a specific issue for a client or a couple. However, there exist principles regarding addiction and compulsivity that aid and guide the therapist when addiction or compulsivity becomes a part of therapy. When there is powerful addictive or compulsive element in a couple, much of the "logical" work of therapy (insight work, communications training, etc.) can be sabotaged. Following principles from the philosophy or theory of addiction treatment, the addiction must be treated (perhaps, "first") for other processes to move forward. The therapist often has clinical instincts that relationship problems and substance abuse, behavioral compulsion, or addiction are intricately intertwined. Or, the therapist finds that ambiguous or confusing individual or relationship behaviors become conceptually clear when addiction is uncovered.
Marriage or the intimate committed partnership changes both one's perspective of self and how society and others view the individual and the couple. The individual is less self-centered and becomes more interdependent with values befitting a partner or spouse. Creating a relationship that serves the needs of both partners rather only serving the self coincides with developing additional important relationships with the partner's friends and family. The partners have to get goals, values, and expectations in sync. "To a large degree, these shifts and accommodations may be integral to the emerging adult period and may be necessary for the emerging adult to seriously consider marriage. However, it is also clear that the accomplishment of these transitional tasks continues into the early years of marriage. Throughout the period of emerging adulthood, substance use appears to first increase and subsequently, to decrease. Alcohol use tends to peak during the early 20s among men and women and then, for most, it gradually declines (Muthen & Muthen, 2000)...Although the prevalence of marijuana use peaked... (around age 19), a similar decline in use was found when the participants entered their mid 20s. These trends were similar in both men and women. Some have suggested that this decline in substance use represents a maturation process (e.g., Labouvie, 1996). Through this process, individuals may gradually come to feel more responsible for their own behaviors, find that substance use interferes with the pursuit of their goals (Labouvie, 1996), or find that it prevents them from moving into adult roles (Brook, Richter, Whiteman, & Cohen, 1999)" (Leonard and Homish, 2005, page 409-10).
Substance use appears to increase with greater independence in adolescence and young adulthood and decreases with taking on new responsibility such as marriage, children, and the family. The assumption is that frivolity including alcohol and drug use would lessen or stop with new adult roles. This is not always the case. Among users, marriage appears to increase the rate of using marijuana in both men and women. For women, marriage decreases the likelihood of restarting or starting marijuana use. There are similar influences on other substance use and alcohol consumption (page 411). The influence may be particularly important early in the committed relationship. "…most of those who become drug- or alcohol dependent in their life-times do so by age 30. Patterns of substance use, particularly peaks and declines in use, may help to explain the fragility of young adult marriages" (Collins et al, 2006, page 786). Substance use is often named as contributing to the break up of marriage. In one American study, 11% of partners said it influenced their having divorced. Only infidelity and incompatibility were identified as more influential. Other studies found high divorce rates among alcoholics, as well as high rates of alcoholism among partners in couple therapy. Substance use and addiction have been consistently found to be greater for divorced versus married individuals in the general American population (page 787).
Paolini et al (1978, page 130) discussed Burton and Kaplan's research. "Forty-seven alcoholic marriage couples were in weekly couples group therapy for an average of 30 sessions over a one year period. Extensive pretreatment and follow-up data were obtained, and the amount of drinking and family pathology was evaluated. At follow-up, 75 per cent of the couples indicated fewer marital problems and 56 per cent of the alcoholics either significantly decreased drinking or achieved abstinence." Was fewer marital problems reported by 75% of the couples a consequence of the significantly decreased drinking or abstinence by 56% of the alcoholics? Or, was the significantly decreased drinking or abstinence by 56% of the alcoholics a consequence of fewer marital problems reported by 75% of the couples? Or, was it some other factor or influence that helped both the alcoholics and the couples improve? The chicken or the egg dichotomy is less relevant than the therapist needing to assess for addiction and compulsivity in individuals and the couple. Furthermore, for dealing with substance abuse, "Evidence suggests that couples treatment may be an important and effective treatment modality. A meta-analysis of drug user treatment outcomes demonstrated that not only is family-couple therapy more effective than no therapy, it also documented that family-couple therapy is more successful than (1) individual counseling (2) peer group therapy, and (3) family psychoeducation (Stanton and Shadish, 1997). Moreover, the meta-analysis also concluded that couple therapy appears to be equally effective in adolescents and adults" (Cavacioto. 2004, page 651). Couple therapy can be used to conceptualize and structure the relationship to promote sobriety or recover from addiction. Simultaneously, couple therapy promotes emotional and psychological healing from the damages of relationship dysfunction, including from addiction, and can address relevant underlying issues.
Substance abuse, problematic behavioral compulsions, alcohol or drug dependence or addiction, and behavioral and relationship addictions have some important distinctions as well as existing on subjective continuums of behavior. In this discussion unless otherwise stated, the terms "addict" and "addiction" will be used to include the areas of the continuum beyond use to problematic use, abuse, and dependency and addiction. Addict and addiction will, unless otherwise differentiated refer to both substance addiction including alcohol and drugs and behavior addictions such as sexual addictions, Internet addiction, eating disorders, gambling addictions, and so forth. In addition, the partner to the identified addict or individual with identified problematic use or behavior will be referenced at times, as the non-addict or non-addicted partner or co-alcoholic. This does not preclude the possibility that this partner may not also have addiction issues and addictive or compulsive use or behaviors. Such addiction or addictive or compulsive use or behaviors, especially co-dependence or enabling may become the object of therapeutic attention despite not being initially presented as issues in couple therapy.
The therapist will find that applying diagnostic criteria for substance dependency to behavioral addictions to be just as important, and may be extremely informative to clients. Compulsive excessive behavior rather than a chemical substance that is self-destructive can be the person's addiction. Other behavioral addictions include hoarding addiction, spending addiction, pornography addiction, workaholism, and so forth. Controlled social drinking or use of drugs to relax or for recreation that does not cause problems should not be labeled problematic, abusive, dependent, or addictive. Cultural, moral, or religious prohibitions do not per se cause such use or behavior to be functionally problematic. By the same token, an occasional visit to the casino, working overtime to complete some tasks, overeating once in a while, and other behaviors are not de facto indicative of addiction. In addition, being a caring and giving person who prioritizes another's well-being is not ordinarily problematic. However, a person can have an interpersonal addiction as well (co-dependent, enabler, co-alcoholic, co-addict) where diagnostic criteria of compulsion and harm become relevant. As a result, treatment planning for the person addicted to a partner may have the same goals and strategies as that of a person addicted to a substance or other behavior.