2. Behavior Change Plus - 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 2: BEHAVIOR CHANGE PLUS


The therapist must insist on behavior change in the active user.  As it applies to individuals such as Carl (alcohol), Myanna (eating, spending), Tamlyn (bulimia, alcohol), Daryl (alcohol, affairs), Mitchell (pain medication, alcohol, drugs, online gaming), and Samantha (cutting), it also applies to their partners who manifest behavioral or relationship addictions or compulsivity.  Change may be abstinence in the case of affairs that fundamentally corrupt the relationship or abusive use or behavior that threaten relationship stability and viability, or significant reduction to controlled use or behavior if possible.  If Carl could reduce his evening drinking such that he could be emotionally and socially present to interact with Bethany, or for several of the partners codependent behavior be adjusted to being sensitive supportive behavior while balancing personal needs, that may be sufficient for more productive dynamics.  While the therapist may choose to engage in psychotherapy, he or she may opt instead to work from a more behavioral orientation.  Or incorporate behavioral principles in the therapy.  Therapy can focus on stopping, curtailing, harm reduction, trigger avoidance, and other interventions that target behavior change without necessarily delving into emotional, psychological, psychodynamic, or family-of-origin issues.  In that case, the plans or parts of the plan would have alternate behaviors, including twelve-step program behaviors of calling a sponsor, going to a meeting, reading the Big Book, and similar non-drinking, using, or acting out behaviors.  The self-sabotage parts would focus on dealing with craving, associating with users, eating healthy, rest, and other behaviors that twelve-step programs identify as leading to relapse.
  
While behavior change is essential, underlying emotional, psychological, and spiritual often also require attention.  In particular, that may be case with Shuman, the adamant twelve-stepper who remains compulsive and disconnected emotionally from his wife Myanna.  Myanna's over-eating behaviors and spending compulsions indicate matching underlying issues for her.  The distress to despair of the addict may be revealed or intensified with attempting otherwise positive behavior change.  When Mitchell attempted to cut back on his use of pain medication so he could spread his prescription over the whole month, he became irritable.  When he failed to make the prescription last any longer than the previous month, he despaired of ever getting away from the drugs.  His shame further ignited issues from his childhood when his father was highly critical.  Mitchell could never do the right thing or be good enough for his father, especially in comparison to Mitchell's brother- the golden boy.  This would cause the addict to revert to self-destructive use and behavior as it did with Mitchell resorting to compulsive alcohol and drug use in the later parts of the month.  These outcomes required the focus of therapy to go beyond behavior change to include looking at addiction as self-medication for distress and despair.  It can be especially important with personality disorders, or possibly if there is a bi-polar individual in couples, to assess for self-medication with substances and/or behaviors to deal with associated emotional pain: depression and anxiety.  This was relevant for Samantha who had aspects of borderline personality disorder, as demonstrated in her frequent lashing out at Dyson for minor transgressions.  Borderline personality disorder is not uncommon among cutters and individuals who were traumatized- that is, molested in childhood.  Therapy despite her initial insistence on keeping the critical focus on Dyson's infidelity during college, eventually led to Samantha disclosing how between eight to eleven years old, she had been molested by her father's cousin several times.  The astute clinically sound therapist should be aware of various potential conceptual linkages such as from relationship problems from borderline personality disorder and self-soothing behaviors (alcohol, bulimia, cutting, etc.), that are precipitated from developmental family-of-origin experiences such as from trauma (molestation, poor parental attachment).  Other personality disorders for example may be relevant or considered for dependent Marilyn submitting to Daryl's narcissism, Bethany paranoid or narcissistic criticism that passive-aggressive Carl seems to endure, histrionic Tamlyn  glorifying in the accomplishments of her children, or dependent Cybil always catering to or compensating for Gwyn.

Research has found that individuals with addiction issues have a higher percentage of personality disorders than non-addicts (Nadeau et al., 199, page 592).  Or, from the other direction, individuals with personality disorders are more likely to have substance abuse or addiction issues.  Someone who has a personality disorder or bipolar disorder shares extraordinary stress with other individuals susceptible to addiction.  When an individual uses a self-medicating process to deal with stress, anxiety, or depression- which can be extraordinary with personality disorders, therapy can be highly complicated.  In the case of a bipolar, the individual can simulate an addiction effect by purposely not taking medication so he or she can have a planned manic phase.  The mania provides the "high" through the individual's brain chemistry, rather than brain chemistry altered by some outside drug.  With personality disorders and bipolar disorder, the therapist may be challenged to artfully maintain or return to an addiction or self-medication focus if a client is resistant to addressing it.  And secondarily, the therapist must also facilitate change in the enabling behavior of the partner.  The therapist must be forthcoming with this assessment.  Pretending that couples growth is possible with an active self-medicater is an illusion… a dangerous illusion for both the partners and the therapist.  It also serves the denial process of the self-medicater, falsely putting the focus of therapy on communications or some other relational process.

Unfortunately, addict who is heavily in use (including behaviorally such as video porn addiction, gambling, etc.) will often sabotage therapy because the addict cannot or will not deal with his or her obsessive use or behavior in couple therapy… or anywhere else.  In such cases, the partner or co-addict can get clarity that the addict's prioritizing of continued use over improved relationships precludes real work.  The partner or co-addict realizes or fears, "Drinking IS more important than I am… or the kids are to my partner."  Kat accused Mitchell of this- drinking specifically, as well as the high from the pain killers.  Bethany also accused Carl of making drinking more important that spending time with her in the evenings, and she was not totally inaccurate.  Drinking helped him tolerate her or block her out.  Marilyn feared that gratuitous sex with strangers was more important to Daryl than her feelings, their marriage, and their family.  Myanna tried to convince herself differently but kept coming back to Shuman's twelve-step programs and sponsorees being more important to him than time with her or their son.  Getting buzzed nightly and watching porn sure seemed more important to Phillip than spending time with or having real sex with Tamlyn.  This contributed to her sense of isolation and depression which triggered her bulimia.  Ironically, Dyson swearing off and staying abstinent from alcohol also was expressly and precisely the opposite assertion.  Dyson had declared Samantha was more important than drinking.  He had made the behavior change willingly and had maintained it stably over many years.  Yet, something else... something compulsively else was more important to Samantha to hold than to accept his fidelity.

While behavior change is essential, the therapist has to make clinical judgments how to facilitate change for the partners.  To create change, the therapist may take many different paths.  Within the varied paths, common themes will be necessary for behavior change.  The following major themes and subthemes (Zitzman and Butler 2005) linked to couples' experience of conjoint marital therapy for recovery from sexual addiction are applicable to recovery from other addictions as well.

(1) restoration of trust (consisting of honest and open communication, a second witness, overt signs of effort and progress, wives' supportive responses, an invitation to participate, and letting go of control—no more policing);

(2) softening (consisting of education and understanding, wives' separation of self from the problem—externalizing, enacting significant couple communication, and an end in sight);

(3) shifts in recovery approaches and attitudes (consisting of mutual support, shifting from 'I'll do it myself' thinking, watchtower work, disclosing the secret, recovery in growth perspective, refocusing on lifespan goals/vision, and specific interventions); and

(4) secondary marital gains/enhancement (consisting of honest communication and effective problem-solving, and increased unity) (page 320).

For some non-addicted partners, individual treatment or therapy for the addict makes them feel disempowered, helpless, invalidated, and unimportant.  This can lead to additional distress, irritation, and anger.  When the partner is included in couple therapy, the addict may feel supported and less intimidated by needing to do it alone.  The partner rather than feeling participation interfered with recovery, can feel he or she is an important participant in the process.  Addiction is not only the addict's story but also of his or her partner.  "Providing space for, honoring, and incorporating the wife's story and experience, issues, and needs is, in our view, an imperative part of the clinical process for individual and relationship recovery and reparation.  Therapists need to not only invite the wife's presence, but also actively incorporate her experience and expertise, involvement and interaction, eliciting the her story and coaching the husband's engagement in it, respect for it, and attention to it—for individual recovery and relationship healing.  Further, the clearly evident and inherent interactional basis of these observed experiences and outcomes indicates that simply providing separate therapies for husbands and wives is structurally and processually inadequate and unlikely to produce these same advantages and outcomes, at least not to the same degree" (Zitzman and Butler, 2005, page 333).  Couple therapy challenges the presumptive directive to the addict to "Go fix yourself!" to include the system and relationship that needs attention as well.  Tamlyn without Phillip, Carl without Bethany or conversely, Gwyn and Cybil together, the mixture of Mitchell and Kat's issues, and so forth ... the descriptions of the seven couples in this book make it clear that everyone and the couple collectively need to fix him or herself and themselves.  Addiction or compulsivity issues were not exclusively "mine" or "yours," but often "ours."

Seedall and Butler (2008) "submit that for the person in recovery, the pair-bond partner is the ideal source from which to gain needed assistance and encouragement, and with proper therapist modeling and coaching, the pair-bond attachment relationship can bring to the recovery endeavor resources not found in other relationships… Research confirms that utilizing 'natural' or pre-existing social systems in support of recovery is more successful than arranging artificial support groups.  'The attempt to manipulate social support is unlikely to result in reduced relapse rates… It is supportiveness of the most significant person in the [addict's] naturally occurring social network that matters' (Barber & Crisp, 1995, pp. 292–293).  Couple relationship enactments organize a supportive, collaborative relationship and interaction process between partners that paves the way for effective social management of inevitable cues and cravings.  In this manner, enactments provide a context for gradually normalizing and socializing open disclosure, facilitating a greater degree of inclusion and constructive participation of the pair-bond partner in this process, and building patterns of availability and responsiveness that are supportive and non-threatening" (Seedall and Butler, 2008, page 83).  See Appendix for a list of enactment interventions and benefits for recovery and the relationship.

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