The therapist might assume that therapy is sufficient in of itself to deal with most issues that clients present. However, effective treatment strategy should consider whether alternative or additional services or resources would be needed. The therapist should always check for possible medical issues that contribute to problematic behavior. Relevant for all addictions, this is particularly important for substance use, abuse, and addiction since they can have medical, brain functioning, and physical effects. Substance abuse or addiction can be considered from the perspective of a thought disorder, a medical disorder, an emotional or psychological disorder, a moral disorder, or a spiritual disorder among other viewpoints. Or, some combination of the perspectives may be appropriate for one addict with another combination relevant for another individual. The therapist may be negligent to assume that psychotherapy is sufficient to treat all aspects of the individual and couple's problem. The therapist should help create one or more support systems based on these and any other relevant considerations. These may include twelve-step programs, individual, couples, family, or group therapy, medical consultation, spiritual/religious, and educational resources. Since substance abuse and behavioral addictions can cause academic, vocational, financial, and social problems as well, other targeted referrals to community or professional resources may be useful. Carl for example despite being appreciated at the warehouse had limited opportunities for advancement without a college degree. Tamlyn felt stuck in her marriage to Phillip in part because she had not gotten education or training to do anything other than be the mother to their children. She was at the point in early twenties where she might have begun exploring vocational options, but Phillip being about ten years older was ready to have children. So, her "career" choice was to be a mother, which she had dedicated herself to while self-medicating her emptiness. With the last children reaching adolescence, they needed her less and less. Without the diversion of parenting and reduced self-medication, what was she to do? Gwyn was hard pressed to find a job after losing her previous position, especially with her physical issues that put her on disability. Mitchell's ADHD issues which probably were strengths as a professional athlete, negatively affected his work and relationships, and most of all his self-esteem. Such issues are common co-existing challenges for the addict. Moreover, the addict tends to isolate him or herself from help. Activities with family, friends, and in the community can provide important support.
Craving the substance of choice or the strong desire to act out compulsively remains a powerful force for the addict and couple. The addict has shown his or her fundamental inability to resist his or her craving. Will power has proven to be insufficient. Trying harder has not worked. Trying harder has consisted basically of doing more intensely what has been proven over and over not to work. Knowing and experiencing toxic personal and relationship consequences has not been sufficient to motivate change either. Being shamed and feeling guilty has not worked except to make the addict feel worse. Feeling worse often increases the addict's temptation to self-soothe or self-medicate feelings with use or behavior, and subsequently increases the craving. Since craving is often experienced as confirmation of moral failing and deepens shame, the addict hides it from his or her partner. The addict and the couple need to have a plan to somehow manage the previously unmanageable cravings- or at least, manage them better if not perfectly. The plan needs to extend beyond the individual and the couple. Twelve-step programs and the tradition of Alcoholics Anonymous utilize regular if not ritualized social support. Sponsors take on and are given a key role to support the addict. "The utilization of sponsors is in part anchored in the experience that fighting cravings entirely on your own- 'inside your own head'- can be an intrapsychic torment, while moving and managing cues and cravings in an interpersonal context readily attenuates their intrapsychic force and persistence" (Seedall and Butler, 2008, page 83). The partner and the therapist are other individuals to share ones feelings and experiences. However, the addict can find others who more fully share addictive feelings and experiences in self-help groups: other alcoholics in AA, other drug addicts in NA (Narcotics Anonymous), other sex and relationship addicts in SLA (Sex and Love Anonymous), other co-dependents in Co-Dependents Anonymous (CoDA), and so forth. The sponsor and the community of addictive peers can empathize at a depth and with a nuance of "having been there."
Other people not only provide models of non-abusive or non-addictive use or behavior, but also may be more direct in influencing the addict to change problematic behaviors. For example, alcohol can be offered more or less aggressively or discouraged directly or subtly. The couple can comprise a support system of partner-to-partner, as opposed to co-addict-to-addict. Female partners or spouses tend to have greater influence on male partners or spouses' alcohol use. Kat fits this stereotype in her consistent hectoring of Mitchell to curtail his alcohol and prescription and illicit drug use. However, she was arguably ineffective in actually influencing him. "Social control may also partly explain the gender differences that we identified. In the current report, we found more consistent evidence to suggest that wives were influencing their husbands' alcohol use and alcohol use–related problems. Holmila (1988) has argued that wives' roles after marriage involve more 'caring behaviors,' and attempts to control alcohol use may be seen from this perspective. Similar patterns of gender influence have been observed with respect to other behaviors related to health. For example, Umberson (1992) found that married men more often report that they experience others' attempts to control their health compared to unmarried men. Among women, there was no relation between marital status and exposure to social control of their health. The majority of the men (n = 590, 80%) reported that the person who attempted to control their health behaviors was their spouse. Women were significantly less likely to report that their husbands attempted to control their health behaviors. Westmaas, Wild, and Ferrence (2002) examined the role of gender in social control of smoking cessation. After controlling for age, income, and level of dependence, men who reported more partner influence experienced greater reductions in their daily level of smoking. This relation was not found among women" (Homish and Leonard, 2007, page 1437). Since men tend to be less involved in influencing a female partner, the therapist may need to overtly activate male partners to influence their addicted female partners. Cybil had been alternately passive and aggressive pushing Gwyn to stop drinking over the years of their relationship and through her work injuries and disability issues. The therapist should consider that in the case of a female addict, the male co-addict might have made strong but ineffective attempts to influence or control her use or choices. There may be a possibility that the male partner might not be particularly well-versed exerting influence on the female partner. Dyson was relatively clueless how to address Samantha's cutting. He knew it was not healthy but could not identify with what could be her motivation. In this situation, the therapist should educate and guide the male co-addict how to try to influence, rather than control the addict.
In other social relationships or groups, there is no therapist to give direct guidance to them. However, being with other people whether professionals assisting treatment, peer addicts, friends, or family, will nevertheless challenge the individual's instincts to avoid interaction. The greater the social interactions, the greater potential there is that his or her problematic use or behaviors will be confronted and exposed. The co-addict who may be otherwise very social also attempts to isolate awareness of the partner's addiction from family and friends. This may be relatively simple for someone such as Marilyn with Daryl the workaholic and corporate superstar absent much of the time. Unless she told her family and friends, they would never know about his affairs. It was significantly harder for Cybil to hide Gwyn's dysfunctionality since cultural expectations for her act like a mother required a greater presence and visibility socially. There was also social pressure as an out lesbian couple to look good to the community as two moms. At the school function, it was more palatable for Marilyn to declare that "Daryl is on a business trip," than for Cybil to claim "Gwyn is a bit under the weather… again." Father absence is socially much more acceptable than mother absence. Substance abuse and behavioral excesses as well as co-dependent enabling behavior are often purposely conducted in isolation because of the stigma involved. Shame is always difficult, so therefore is least intolerable alone. Hiding use and avoiding letting others know reinforces and intensifies the shame. Further isolation follows. While the addict and co-addict look to the therapist for leadership, they also "isolate" from the therapist. They may compartmentalize the therapist's recommendations that they are not uncomfortable with from the ones that are easier- that is less disconcerting. The addict will tend to resist recommendations to avoid isolation, which involves socialization. Resistance to these and other recommendations make continued substance abuse or compulsive behavior or relapse more likely.