15. Self-Soothing/Self-Care-Self-Med - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Mine, Yours, and Ours, Addiction and Compulsivity in Couples and Couple Therapy
Chapter 15: SELF-SOOTHING AND SELF-CARE INSTEAD OF SELF-MEDICATION


"In the early stages of recovery and following relapse, hope often wanes.  The recovering partner may feel flawed and inept, and the non-addicted partner may be battling debilitating doubts, fearing that any evidence of progress is only an illusion.  Whereas guilt is a negative behavioral evaluation focused on corrective action and has been associated with positive interpersonal outcomes, shame is a negative, global judgment about the core self that often enables addiction by impairing interpersonal efficacy; promoting defensiveness, secrecy, and hiding; and crippling growth-promoting guilt (Butler & Seedall, 2006; Covert, Tangney, Maddux, & Heleno, 2003).  The focus of this intervention is monitoring the affective and self-concept consequences of addiction, with the intention of achieving 'just-sufficient' behavioral guilt that promotes and sustains ego strength essential for change.  Couple interaction within enactments represents a significant value added to the goal of mitigating toxic shame and/or shaming while fostering appropriate behavior-focused guilt.  It is essential to recovery for both partners to learn ways to routinely assess for extreme guiltlessness on one hand and toxic shame on the other" (Seedall and Butler, 2008, page 86).

The therapist prompts the partners to reveal their personal feelings and experiences dealing with addiction and its consequences while offering important and alternative points of view.  Shame is a critical destructive feeling in the partners and must be processed for growth.  The partners are encouraged to express their hopes for positive outcomes and relationships to provide counter-balance to their distress and despair from shame.  Hope for change and growth need to be expressed and validated by each partner.  Therapy prompts the partners to accept and have empathy for each other's emotional experiences.  Partners work through previous experiences and dynamics, which may be duplicated in session interactions.  The partners are challenged to check if previous choices and behaviors are congruent with their emotions.  They are further challenged to continue to grow and achieve greater consistency between emotions and behaviors.  "For example, an individual's shame-related behaviors (e.g., defensiveness, isolation, pushing loved ones away) are often incongruent with the internal struggle regarding feelings of inadequacy, worthlessness, remorse, and longings for comfort and reassurance.  Thus, monitoring guilt and shame within enactments can help partners become increasingly self-reliant in maintaining a broader recovery perspective and sustaining a positive self-concept and ego-strength" (page 86).  Therapy guides the partners to deal with shame and guilt with positive affirmative choices for oneself and for the relationship.  Rather than striking out at the partner, shutting down, or acting out with addictive use or behavior, partners must learn to own shame and self-soothe with positive choices, rather than self-medicate.  When the therapist experiences a partner feeling shame or guilt, he or she can challenge the partner to identify the instinctive and dysfunctional reaction.  Then he or she is prompted to choose and attempt an alternative action or communication.  The therapist also guides the other partner to validate the distress, express empathy, and offer healthy soothing responses.  

ACKNOWLEDGING AND USING STRENGTHS
An important counterbalance to shame and guilt is acknowledging positive aspects or strengths in the addict and co-addict.  The individual and the couple do not ordinarily arrive in therapy because of their strengths.  Their focus in life and in therapy often is about weakness and failure.  Discussion about addictive and other dysfunctional choices and problems in the relationship emphasizes deficits in logic and in managing emotional processes.  Addiction is implicitly if not overtly blamed on weak will power.  This implies that a morally stronger individual would have resisted cravings and the resultant toxic choices.  The addict and the partner can easily feel beaten down with the litany of failures, flaws, weakness, mistakes, and poor choices.  Ordinarily, each partner has some important redeeming strengths or virtues that not only need to be acknowledged, but can be activated for recovery.  This approach "strengthens resiliency and desire for change by facilitating a shift in the recovering partner from a deficit-based perspective- all of the errors and mistakes from the past- to a strengths-based perspective- what positive qualities and traits s/he possesses.  This process can be especially valuable any time discouragement or despair is present, such as after a relapse, when cravings persist, or when individuals only see themselves in a negative light.  At these critical times in recovery, explicit identification of redeeming virtues helps to facilitate a more balanced perspective of self and encourage continued work toward recovery.  Thus, acknowledging redeeming virtues removes the tunnel vision focus on addiction as the defining feature of a person's existence and thereby inspires recovery efforts" (Seedall and Butler, 2008, page 86-87).

The co-addict may be more aware of some of the addict's redeeming virtues than the therapist who meets and experiences the addict in the context of problems demanding couple therapy.  The partner may well be the one who points out positive qualities when either the therapist or the addict is criticizing the addict.  On other occasions when the partner is discouraged or enraged, the therapist may need to prompt or remind the couple of the addict's positive qualities.  Qualities acknowledged may include dedication, care, willingness to keep trying and suffer through the difficulties to change, and so forth.  Positive qualities may be evident in the enactments within therapy or identified as part of the dynamics at home.  Shifting focus from inadequacies and deficits to characteristics of strength serves to activate healthy behavior-based guilt that motivates change.  Otherwise shame-based guilt that infers intrinsic intractable moral deficiency is triggered.  Shameful guilt tends to block change and increase problematic use and behaviors.  "The non-addicted partner is also able to shift focus to partner strengths and competencies rather than deficits and weaknesses, which are magnified if the addiction becomes the central organizing experience of the relationship.  Overall, as factors that represent the very best of both partners and their relationship are highlighted and magnified, the relationship becomes better organized to sponsor recovery efforts" (Seedall and Butler, 2008, page 87).

Therapy involves helping them deal with hope and disappointment, resentments and old wounds, and upset and rage.  There will be insightful connections made, feelings uncovered, and uncomfortable to desperately painful interactions to process in therapy.  Therapy is neither a simple process nor an easy process.  It fundamentally challenges the dysfunctional status quo.  Although, the intention is for positive change, the process itself may be extremely stressful.  For a significant time, it may be more difficult and painful for both partners and the couple than the dysfunctional baseline in the couple or family.  The dysfunctional baseline may be fragile, uncomfortable, and tense with significant devastating eruptions.  Confronting the partner collusion may trigger more anguish than baseline stress and be comparable to the eruptions before there is growth and change.  Any and all of these therapeutic challenges along with life events can exacerbate the addict and co-addict's stress, thus increasing the likelihood of eruptions.  In couples with addiction, this means more substance abuse or compulsive acting out.

The addict and the co-addict often have fundamental deficits in their ability to self-soothe intense painful emotions.  The substance use or acting out behavior may have become abusive use or compulsive behavior when it soothed otherwise uncomfortable to intolerable feelings or thoughts.  The therapist will often need to simultaneously work on issues that bring up difficult feeling and thoughts and on how to self-soothe when anxious, depressed, or in pain.  Personality disorders often involve embedded characterological traits associated with intense negative feelings.  The despair associated with borderline personality disorder over attachment and intimacy losses may be critical to address in couple therapy for both its influence on relationship problems and addiction.  "...women with SUD (substance use disorder), borderline PD (BPD) is among the most frequent co-occurring Axis II conditions, with prevalence ranging from 10% to 65% (median ¼ 36.4%).  Conversely, SUD is highly prevalent in women with BPD.  In the largest and methodologically most stringent study on the co-morbidity of BPD in psychiatric patients, 59% of women with BPD had at least one lifetime SUD, such as alcohol abuse or dependence, and 41% had at least one lifetime diagnosis of drug abuse or dependence.  Overall, BPD and SUD frequently co-occur in psychiatric patients, especially women.  In addition, the co-occurrence of BPD and SUD is associated with heightened risk for a variety of severe adverse outcomes, including participation in the sex trade; a large number of sexual partners; more frequent and serious drug overdoses; needle sharing; an increased risk for suicide attempts; poorer response to treatment; and more severe psychiatric, family, and legal problems.2,4,9–18  Thus, BPD in conjunction with SUD is potentially life-threatening" (Feske, et.al., 2006, page 131).

Borderline personality disorder was found to be a significant predictor of different types of substance abuse: alcohol, heroin, cocaine, or poly drug use.  Borderline personality disorder shares core traits, for example affective lability and impulsivity that make one vulnerable to substance use.  The family experiences of individuals with borderline personality disorder and substance use are often shared: child abuse or neglect, and family history of borderline personality disorder and antisocial personality disorder.  Among the partners discussed, Samantha has borderline personality disorder or at least, borderline tendencies, while others may be suspected of it.  "BPD appears to have a localizable neurobiological diathesis, most saliently evidenced as prefrontal cortex dysfunction, which is also implicated in the etiology of SUD (Feske, et.al., 2006, page 135).   Among personality disorders, borderline personality disorder is often distinguished by very high subject distress, including "depression, hopelessness, anxiety, boredom, emptiness, and aversive physical states that can serve as triggers for substance use in vulnerable individuals."  There are models based on personality and motivational traits to explain substance use disorders and forms of disinhibitory psychopathology such as antisocial personality disorder in addition to borderline personality disorder.  These may share traits such as impulsivity.  The behaviors can be considered as coming from impulse control disorders comparable to obsessive compulsive disorder, kleptomania, pyromania" (Shaw and Black, 2008).  

Research by Taylor et al., (2006) confirm that low restraint, high impulsivity, strong behavioral activation system, and weak behavioral inhibition system are characteristics of men and women with both substance use disorder and disinhibitory psychology.  While it is not clear whether what causes the disorder or if both are consequential to some third factor, the therapist should explore for the association and work on all relevant issues.  Other personality disorders can also be present in one or the other partner- the addict or the non-addict.  Narcissistic personality disorder for example may be an issue for Daryl.  Successful men and narcissism are not uncommon pairings.  Narcissism and alcoholism or narcissism and sexual affairs are also not uncommon pairings.  The deep and hidden psychic pain of the narcissist does not allow for vulnerability to be seen by others.  Relationship destructive narcissistic defense mechanisms often intensify old narcissistic wounds, which can lead to desperate self-medicating behaviors.  Other personality disorders- passive-aggressive personality disorder for example may be an issue for Carl and possibly dependent personality disorder for Marilyn or Myanna by definition constitute poor intimacy and relational dynamics.  As such, the personality disorders are often critical influences on both the relationship and the addiction.

The couple will ask the therapist how to avoid and prevent such feelings and thoughts from intruding upon them.  The addict and co-addict ask for a miracle- therapeutic magic to extinguish desires immediately what has been resistant to change often for years despite tremendous effort.  The therapist needs to make clear that eliminating difficult feelings and thoughts is not possible.  Therapy may be able to help the partners and the couple gradually reduce the frequency, intensity, duration, damage, and resonance of difficult feelings and thoughts so they can become manageable.  The addict and the partner needs to learn how to experience, handle, and survive distressing feelings so they do not morph into debilitating despair.  Therapy also should guide the addict and the couple how to care for themselves individually and collectively.  A positive mood, overall satisfaction, and a sense of mastery enable the partners and the couple to deal with stresses that can ignite anxiety, depression, distress, and despair.  Basic self-care habits: eating regularly to maintain adequate blood sugar and energy, healthy food, rest and sleep, recreation and diversions, exercise, spiritual balance, and intellectual and creative stimulation for example, give the individual greater stability and psychic resources to deal with emotional assaults.  Effective consistent self-care supports necessary self-soothing abilities to prevent potential triggers from activating substance abuse and compulsive acting out.  The addict and the couple have a mix of habitual behaviors.  Some behaviors intensify rather than reduce stress for both partners and the couple.  Other behaviors are areas of strength or potential strength that the therapist should encourage.  The therapist has to help them parse out substance abuse and compulsive acting out, plus enabling behaviors that are usually intricately woven into their dynamics for self-care.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
(510) 614-5641 or (510) 582-5788
fax: (510) 889-6553
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