20. Middle-Later Stages of Therapy - 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 20: MIDDLE TO LATER STAGES OF THERAPY


Addiction causes very compelling disruptions in the couple.  There are not only individual issues, but also couples problems involving betrayal, trust, and a need for forgiveness or acceptance.  Inherently, addiction involves problems with boundaries for the individual: use versus abuse, desires versus compulsion, and benign versus harmful consequences.  This automatically creates boundary problems with the partner as the addiction is hidden from him or her over a variety of ways: financially, time and energy, priorities, and so forth.  Conflict arises and deepens as intimacy is harmed.  The addict is more intimately involved with his or her addiction than with his or her partner.  Addiction and relationship problems become intricately interwoven.  "Despite the salience of these issues and the need to address them in couple therapy in order to achieve comprehensive personal and relationship healing, many therapists focus primarily on individual healing in recovery from addiction until late in the treatment process due to the high risk of interactional volatility when both partners are present (Bird, 2006)" (Seedall and Butler, 2008, page 77).  The implicit threat of high reactivity in the session and at home may cause the therapist to minimize or ignore important relational issues. Yet, the intimate partner relationship is often the most compelling and powerful force potentially accessible to the couple to promote abstinence, build recovery, and avoid relapse.   The intensity of the emotions can be as formative as they can be reactive and disruptive in addressing addiction.  The "pairbond attachment relationship is a powerful resource for recovery, but is also the relationship most likely to be compromised by addiction" (Seedall and Butler, 2008, page 78).  Couple therapy, which emphasizes systemic issues often uses the attachment relationship to promote change.  Therapy activates the couple's mechanisms to self-monitor and self-regulate their choices and behaviors to deal with all challenges, including addiction.  The soothing or nurturing capacities of the couple's attachment systems can be activated to work against the self-medicating functions of the addictive behaviors.

Once potential different choices or plans are established, therapy may uncover deeper issues that make it difficult or easier to make different and potentially better choices.  The emotional, psychological, psychodynamic, or cultural reasons that make choices complex may direct therapy to traditional psychotherapy processes at this point.  Therapy may have multiple foci: reducing shame, challenging problematic cognitive frameworks, developing ability to process emotions to reduce avoiding them through addictive use or behaviors, reconceptualizing the behavior, changing the couple or family system, and healing attachment insecurity among other possibilities.  The therapist may prompt Cybil to talk about how the only models of dealing with conflict from the family-of-origin were loud and aggressive.  And, how their conflict transports Gwyn back into the vulnerability and fears experienced in childhood.  Childhood trauma may need to be addressed.  Therapy may uncover that one partner may have borderline tendencies to lash out as seen in Samantha's treatment of Dyson despite his quitting drinking and sincere attempts to be responsive and supportive.  Another may have patriarchal dominance patterns that create narcissistic vulnerability and narcissistic rage from being challenged as occurs with Daryl both in reaction to Marilyn and the therapist over minimal affronts or important explorations such as his emotional process of infidelity.  Daryl's narcissistic reactions were arguably effective in his corporate work-war world.  He could intimidate threats to his omnipotence to avoid accountability.  Cybil's mother may have modeled enabling deferential behavior that Cybil both emulates and  cannot stand.  Cybil may rebel against that forcefully by projecting rage at Gwyn.  Gwyn may have watched her dad self-medicate against depression with alcohol and workaholism.  There may be replication of Gwyn's alcoholic family system in Gwyn and Cybil's new family together.  Examining underlying reasons for attitudes, values, beliefs, and behaviors may become essential parts of their change plan.  Reminding oneself that Gwyn is not the abusive father from childhood, or Cybil recognizing mom's passive behavior does not have to be replicated can become part of therapeutic goals.  The outcome of this process may be to incorporate specific behaviors or communications into the refined plan.  "I'm not your father,"  "Whoever, I'm reminding you of, that's not me,"  "Wait as second, did I just sound like my dad?" are verbalizations of the part of a plan to check for projection or mimicking influential childhood figures.

"Therapist-facilitated couple interaction has been used in the context of numerous theoretical models for a variety of reasons, including empowering couples in addressing a wide range of essential recovery and relationship issues.  In this manner, enactments can be adapted to provide a context in which change can be fostered across theoretical models and presenting problems" (Seedall and Butler, 2008, page 78).  Called enactments, the therapist facilitates the partners' interactions in therapy to access the pair bond attachment relationship.  Enactments using attachment is efficient to foster productive relationship attitudes and actions.  Therapy prompts each partner to feel and hold responsibility for the relationship.  Eventually, the partners become less dependent on the therapist's guidance and are more self-reliant in their communication and exchange.  The therapist can manage and adjust as needed to regulate degrees of relationship distress and reactivity.  The partners learn to heal attachment wounds for their recovery and to soften negative attitudes between them.  The therapist guides them in learning healing communication.  The partners learn how to comfort and support each other.  They become able to risk reaching out to each other with empathy while seeking positive resolution.

Whatever is uncovered in therapy or in their relationship drama is integrated into an increasingly nuanced and purposeful plan- both the sequence of behaviors and the anti-sabotage behaviors.  Plan III, which is a repetition and deepening of Plan I and II is also the process of ongoing couple's therapy that increases insight and can lead to reducing, minimizing, and breaking the negative patterns in the couple's relationship.  Plan III may be months or years of therapy if the sabotaging behaviors are deeply embedded compulsive issues.  Substance abuse and behavioral addictions may take a long time to address, and the outcome is unpredictable.  "Couples and families can be seen to go through a developmental progression from active 'substance abuse,' into transition, early recovery, and finally a stable ongoing recovery, just like the individual (Brown, 1985).  Many of these relationships may not survive this process.  There is a high incidence of divorce within the first 3 to 5 years of recovery (Brown and Lewis, 1998).  At times, it may simply be that the couple has outgrown each other.  Sometimes, the damage associated with 'substance abuse' cannot be repaired or integrated.  Often, one partner moves into strong recovery and the other cannot (or will not) come along.  In cases where couples have built their relationship around their mutual substance use, a painful vacuum may exist without it.  In these cases, partners may be forced to choose between their relationship and their recovery.  Some couples will quite understandably find this too high a price to pay for recovery" (Cavcuiti, 2004, page 652).  From the start of therapy, the therapist should let the partners know that a "successful" outcome for one or both partners becoming abstinent or going into recovery does not ensure the couple will come out intact.

The much more substantial discussion of the initial and early stages of therapy is not matched by comparable discussion of middle and late stages.  If and when the couple including the addict gets to the middle and late stages, the most important and critical progress of therapy or change have already occurred.  Middle and late stage therapy or treatment can be considered the problem-solving and fine tuning of the client's process.  It is arguable that prior failed attempts to stop addictive behavior or resolve the harm of addiction or compulsivities to the couple failed because they attempted problem-solving or fine tuning without having completed fundamental steps.  The addict and the couple need to identify and accept the dysfunctionality of addiction and the addicted affected couple, work through the desire for any illusionary magical solutions, let go of cognitive distortions, and manage and resolve any neurotic, cultural, traumatic, and other developmental resistance to an honest change and growth process.  These and other foundational aspects are by far the most difficult to be dealt with.  And must be dealt with first to ever hope to get to problem-solving or fine tuning stages.

If problem solving had been effective in the first place, a case can be made that the issue was not of addiction but of a bad habit.  A bad habit like addiction is also a pattern of choices or behaviors.  However, a bad habit is a pattern primarily because of being a pattern.  There is little or minor compulsion to repeat the pattern other than rote repetition of something familiar.  An addictive choice or behavior is a harmful pattern whose compulsion is deeply embedded.  Bad habits are easier to extinguish using various techniques including behavior modification with positive or negative reinforcement (punishment, for example) or simple will power.  The inherent negative reinforcement and punishment from addictive behaviors which should tend to extinguish the behavior are overwhelmed by compelling forces that must be addressed in the initial and early stages of therapy.  As they are addressed and resolved, then behavior modification is simpler in the middle and late stages. Successful therapy depends on sequence and progression.  "Fixing" the addict or the relationship can only occur if what to "fix" has clearly been identified and the distractions, rationalizations, denials, and other sabotaging mechanisms inherent to addiction and compulsivity also identified.  Since self-medicating processes and sabotaging mechanisms inevitably have deeply rooted causes, fixing anything is often highly complex.  The intense, convoluted, and resistant requirements to get to the middle and late stages of therapy, treatment, or recovery make subsequent work comparably simple.

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