Early stages of therapy involving addiction include psychoeducation, creating support systems, dealing with craving, and developing ways to stabilize the couple's reactivity. As the partners experiment with strategies, communication, and behaviors to deal with craving, prevention, and relapse, they move forward to incorporating the most effective and efficient techniques into an individual and joint "lifestyle" or a culture of recovery or abstinence. Sustaining the positive behaviors and choices may be as or more challenging as finding them. As the couple becomes more consistent and their interactions become more predictable, the partners deepen their work on underlying issues of and the damages from addiction. Therapy and their process focus on "repair, healing, and restoration in the attachment relationship. Representative enactment-based interventions that typically occur during the middle stages of therapy and attain added value through an enactment overlay are mapping recovery protective factors, monitoring guilt and shame, and highlighting redeeming virtues. During these interventions, the trend continues towards greater self-reliance in recovery accompanied by pair-bond repair and strengthening through interactional moments known as 'softenings'" (Johnson & Greenberg, 1988; Schachner, Shaver, & Mikulincer, 2003)" (Seedall and Butler, 2008, page 85). Softening becomes possible and allows for increased trust and vulnerability. When the addictive process is out of control and cravings, use, acting out, and relapse intrudes consistently or erratically into the relationship. Having trust and risking vulnerability has become illogical and counter-indicated to psychic survival. The therapist should not assume the partners' ability to risk trust and being vulnerable early in therapy. Facilitating positive formative experiences to once again risk trust and being vulnerable against cautious instinct to hold back is a key therapeutic task. It requires significant skill on the part of the therapist. Overtly presenting this dilemma: the need to risk trust and vulnerability despite experience to do the opposite, and developing trust and vulnerability nevertheless, takes the couple to the middle stages of therapy. At this point, the rudimentary foundations of hope, investment, and confirming consequences can be built upon. Because the injuries of addiction and of early life experiences cannot be ignored, it is only at this later developmental stage of therapy may it be tolerable or safe enough for deeper and more intense work on underlying issues.
"Mapping recovery protective factors is a proactive process through which individuals actively identify how they will replace addictive process with a recovery-sustaining lifestyle. This includes identifying positive spiritual, familial, work-related, social, recreational, physical, and emotional factors that (1) exist in the partners' lives but are underutilized, (2) were effective for them in the past but not perpetuated, or (3) may be potentially constructive and productive but have not yet been attempted. This is an empowering, strengths-focused process, as many report trying very hard in the past not to relapse but not focusing on tapping into existing resources and developing new strengths that allow them to proactively pursue a lifestyle which both sponsors and sustains recovery" (Seedall and Butler, 2008, page 85). For a couple such as Gwyn and Cybil a non-addictive lifestyle incorporating sobriety and healthy choices can involve a number of aspects. Gwyn and Cybil had participated in community work that had been meaningful to both of them. It involved other positive people who shared a mission to support disadvantaged youth gain greater educational opportunities. They had been very involved earlier in their relationship. It was where they met. But they had gotten away from participating other than financially donating once a year. It had been fulfilling volunteer work that gave them something to share outside of the home. They had gotten away from their date nights and vacations alone without kids, other family, or others. Cybil was more of the organizer while Gwyn was more likely to try new things. Drawing on these strengths or styles, Gwyn chose interesting places to explore or visit and Cybil managed the logistics. Gwyn and Cybil had been very selfish about having together for themselves early in their relationship, but had been drawn away to other life demands. Their weekly dinner out gave them two hours of time sharing and talking just to each other without household demands or digital distractions. Gwyn had been very opportunistic about noticing concerts or shows they had shared affection for, and now took the initiative to get tickets and arrange other logistics. Cybil had been the fitness cop and now resumed the role to get them to the gym or a weekend walk.
In addition, both partners took responsibility to look for and seek new activities that could be beneficial to them as a couple. They agreed to try a dance class, to make a habit of finding some magazine or online article to share with each other each week, and to try socializing with other positive couples in non-drinking or non-addiction conducive events. Gwyn and Cybil learned that recovery is more than not drinking, using, or misbehaving. Recovery involves changing the relationship as well. Working together in any context or for any purpose is supportive of recovery. As Gwyn and Cybil collaborated "to identify ways for building, strengthening, and defending recovery together, they begin the important process of revising personal and relational meaning. Whereas the recovering partner may have previously felt weak and out of control, identifying protective factors allows him/her to realize areas of control and develop an action plan against relapse. In addition, as the non-addicted partner observes his/her partner actively and sincerely engaged in recovery work, hope and change expectancy are generated and enhanced. Mapping protective factors in the context of enactments also provides a context for evaluating the current marital relationship, including highlighting strengths and also identifying and enhancing areas of the relationship that are potential protective factors" Seedall and Butler, 2008, page 85).
As the couple becomes more stable and skilled in their interactions and sobriety or abstinence is less tenuous and volatile, the focus turns to maintaining recovery, relationship improvements, continuing and further augmenting support systems, and sustaining vigilance against problematic thinking and behaviors. Between the partners, the damages to the relationship need ongoing attention. They need to deal with trust issues, repentance, and forgiveness or acceptance. Therapy reviews their processes for growth around these issues and provides a place to practice communication and skills for home and life behaviors. There are various avenues characteristic to relapse for each addict. These entries or nascent steps towards relapse despite significant periods of abstinence can usually be identified and trigger alarm and early intervention. There needs to be a careful assessment of both the condition and status of the relationship and of recovery. The therapist, but more so the partners need to learn how to recognize small early signs of changes in thinking, actions, or patterns that may be indicative of regression. "Thus, gateway monitoring facilitates the identification of potential threats to recovery and relationship goals and encourages necessary attitudinal and behavioral change" (Seedall and Butler, 2008, page 90). The therapist asks the addict to empower the non-addicted partner to offer continual feedback. The partner's observation is defined as supportive rather than being the addiction cop. Warning or pointing out potential slips or early indications of relapse is welcomed rather than seen as hectoring negativity. Since the addict has solicited and accepted the monitoring role for the partner, he or she is less likely to become defensive and become shameful. Or, be better able to modulate defensiveness or shame when reminded of the well-intended motivation for the feedback. Observation and feedback from the partner seeks to be more discriminating, accurate, and effective than the addict's cautions and self-recriminations that depend on his or her own vigilance. Feedback may be about moods, attitudes, or thinking that is potentially harmful to recovery, rather than only about behaviors.
"Another valuable intervention benefiting both relationship and recovery is that of repentance-forgiveness. Repentance-forgiveness work involves expressions of (1) recognition and remorse for past wrongs; (2) desire, commitment to, and evidence of change and restitution; (3) heartfelt acknowledgement and appreciation of change efforts; and (4) establishing a forward-focused, hopeful perspective by letting go of past offenses (see Bird, Butler, & Fife, 2007, for a couple-focused model of forgiveness intervention). Although some form of implicit repentance-forgiveness couple work may have occurred at other stages, this intervention seeks to facilitate and highlight overt expressions of repentance or forgiveness. Thus, this intervention serves as a marker for the process of ongoing repentance-forgiveness, which has been found to yield significant effect outcomes (Baskin & Enright, 2004)" (Seedall and Butler, 2008, page 91). This type of work or interactions is more productive when it occurs between the couple, as opposed to with the therapist. It is more genuine and heart-felt. It is experienced as indicative of commitment to restore and heal the injuries caused by the addiction and the addict. Remorse must be genuine for commitment to change and growth to be trusted. Forgiveness or acceptance is the outcome that fundamentally shifts the relationship. Both partners show and express appreciation for the caring, hard work, and other positive attributes of the other in working on recovery.
Later in therapy, the therapist continued to coach Gwyn and Cybil as needed in their self-monitoring and self-regulation of their recovery and relationship. They did not need to be introduced to more global interventions any more but were supported in making relatively more minor adjustments to sustain their continued growth. Occasionally, they were directed to exam behaviors or attitudes that returned to negative rituals, regression, and harmful relationship patterns. They were vulnerable to slip whenever either partner experienced any stress in other parts of their lives. They tended to become more emotionally reactive and explosive. Instead of reaching out to each other, Gwyn shut down verbally, while Cybil tended to find ways to keep over-occupied. Therapy was useful to enact or work through their stresses and behaviors. They looked at how their stability in recovery and in the relationship was disrupted by stress and their reactions. The process helped them go over and go back to the individual choices and interactional activities that had reduced negative choices, including addictive behaviors. Prompted by the therapeutic discussion, they tried to draw upon the same positive choices that had led to their improved relationship. The therapist often had Gwyn and Cybil work through their conflicts in session, emphasizing cooperative behavior that fostered greater openness and vulnerability. The couple spoke openly-sometimes prompted by the therapist's direct questions regarding their hope for a better life without addiction and a healthier more fulfilling relationship. They discussed their trust and confidence, which despite ups and downs had an overall upward trajectory.
Therapy for addiction often fails to duplicate the complete and fulfilling (and unrealistic) change portrayed in the movies or possibly promotional messaging by treatment centers. The preferred result of therapy would be the addict completely quitting his or her addiction. The addict, now a non- or former addict is securely abstinent with sound psychological, emotional, mental, and relationship health. Intimacy including sexual closeness is fulfilling to both partners. Profusely appreciative and thankful for the partner hanging in and supporting him or her through the process, love is confirmed and strengthened. All is accepted, forgiven, and there are no residual grievances or resentments. Tidily settled in slightly less than two hours in the average movie, the couple expect comparable results almost immediately to live happily ever after starting therapy. Whether the partners express this wishful thinking or hold it secretly, the therapist should direct them to a more realistic, uneven, and difficult process. "A more realistic goal is to make significant individual and couple changes so that the marriage is no longer controlled by compulsive behavior" (McCarthy, 2002, page 280). With sexual addictions, couple sexuality needs to become a positive, rather than draining aspect of the marital bond. With other addictions, their mutual dynamics become a positive rather than corrosive influence on the relationship and recovery. The addict is helped to confront his or her compulsive use or behavior and significantly reduce how it controls and affects him or her. However, slips returning to use of substances or compulsive behavior are often more the norm than the exception. Admitting problems with use or behavior may be difficult. Although, the addict may acknowledge within him or herself that eliminating addictive use or behavior makes his or her life better, the addict also craves the exhilaration of the forbidden rush. Normal interactions and normal feelings and sensory stimulation may be healthier, but pale in comparison to the energy of compulsive highs. AA and other twelve-step self-help programs remind the addict and co-addict that one does not recover from addiction but must be in an active process of recovery. The terminology of being "In recovery" versus being "recovered" acknowledges the power of the craving and addiction.
The partner or co-addict wants and enjoys positive changes in the addict, with intimacy, and in the relationship but often finds the process of change uncomfortable, exhausting, and challenging. The difficulty to prompt, create, and sustain change goes against common romantic notions of the relationship. True love is supposed to create automatic sensitivity and instantaneous appropriate response to the partner's desires and needs. The individual is supposed to know immediately that minor actions, much less major addictive transgressions bother the partner. And, the individual therefore should change behavior or speak words to assuage any discomfort or uncertainty in the partner. This highly romantic but unrealistic relationship "rule" can be particularly distressing to the partner when the addiction is sexually based or has impact on couple's sexual desire or activity. "…she is disappointed that the man's sexuality is such a struggle. It is a challenge to build a sexual relationship that requires that she assume an active, initiating role to reinforce the value of marital sexuality. Knowing that he has a sexual 'demon' which needs to be monitored is unsettling even after a number of years. More difficult to accept is that the 'demon' is more erotically charged than even their best marital sex" (McCarthy, 2002, page 281). Alternating with punitive threats, the partner makes a variety of offers to charm, entice, seduce, or threaten the addict from his or her demon. Each use or return to compulsive behavior (not necessarily only sexual compulsion) becomes tantamount to a romantic rejection. The therapist has to confront this toxic interpretation so that sensitive wounds do not get continually re-traumatized during the virtually inevitable lapses and relapses.
The therapist should periodically ask the partners to review how they originally had been when they started therapy versus where they are at a current time. This is particularly important because both partners tended to be more sensationalized and scared about any negative experience and downturn in recovery or the relationship than uplifted about any positive change. When reminded about their original toxic dynamics and the strangle hold of addiction, they gain perspective about a recent period of flat or backsliding behaviors. By reviewing the progress they had made, Gwyn became quiet and then expressed remorse for hurting Cybil. Validating that Gwyn was have some strong feelings, the therapist asked Gwyn to look directly at Cybil and express those feelings. Gwyn, looking directly at Cybil and with deep emotion asked for forgiveness. Cybil offered forgiveness. Cybil expressed gratitude to be included in Gwyn's recovery process. Being allowed and welcomed to participate had been a pivotal shift in therapy and for their relationship. Cybil also expressed relief and joy at being able to trust Gwyn again. Trust between them was exciting and fulfilling for Gwyn too. More and more in sessions and at home, Gwyn and Cybil managed their process competently. By the time they terminated therapy, sessions were mostly about their reporting how they had successfully dealt with potential relapse triggers and worked out communication and relationship problems during the week. They had taken ownership of their recovery and health process and could fine-tune and problem-solve it as needed on their own as a partnership.
When "…compared to individual therapy or to therapist-centered couple therapy for recovery, couple-centered, enactment-based therapy and interventions are (1) more emotionally authentic- accessing and directly utilizing real-life attachment relationships in affirming, motivating, softening and strengthening both partners; (2) more emotionally focused- inherently eliciting, heightening, and intensifying emotions facilitative to recovery and relationship repair; (3) more relevant- since attachment partners are more attuned and therefore more able to identify pertinent issues and to adapt and fit process to produce positive outcomes; (4) more effective- involving the individual with the greatest and most enduring opportunity to sponsor recovery, the pair-bond attachment figure; and (5) more influential and comprehensive- because the therapist simultaneously coaches both content (the what of recovery and relationship) and process (the interactional how of recovery and relationship) with interactional self-reliance around relevant recovery and relationship content being the ultimate outcome objective" (Seedall and Butler, 2008, page 93).
In some situations, what appears to be addiction or constitutes functional addiction, is driven by self-medication needs to tolerate stress, anxiety, depression, and loss from the couple's relationship. Activating the couple and the partner to promote recovery from addiction may feel counter-indicated for the addict. The addict may not desire a true partnership or believe that there can be real intimacy between them. Confronting the inherent dysfunctionality and lack of fulfillment or joy in the relationship is unacceptable for some reason: cultural, religion, stigma, financial fears, and so forth. Stopping his or her addictive use or behavior may remove all that keeps the addict from blowing up the relationship and possibly turning everyone's life upside down. Stepping outside the relationship for sex, immersing oneself in work or exercise, creating endorphin rushes with gambling or spending, or chemically inducing emotional filters has become the price to pay in order to stay in the relationship. The addiction or the addictive looking use or behavior hides the unhappy world and relationship that the "addict" feels compelled to maintain. The therapist and the partner may have been given a false agenda- to foster recovery and facilitate a healthy relationship. The "addict's" secret agenda may be to maintain the dysfunctional relationship and to secretly maintain the use or behavior that enables him or her to stay. That may mean to make sufficient changes or adjustments without making fundamental changes in addictive use or behaviors or in the relationship. Couple's therapy may be another cover or ploy to maintain the status quo. In such a case, couple's therapy is doomed as far as healing the relationship or conquering an addiction. However, the failure may be a necessary step in the addict's process of denial, the co-addict's acceptance of the futility of changing the addict, and the couple finally giving up their illusion of functionality. What should would will work, except when there is more to it. Sometimes, there is too much more to it.
Unfortunately and realistically some couples cannot make it work. More than one of the couples discussed in this book were able to resolve the addiction, although almost all stayed together- at least, for the time being. Individually, some addicts are unable to stop their use or behavior, or are not able to stop and maintain the relationship at the same time. Getting to and maintaining recovery may cost the current relationship too much, and a successful relationship may only be possible with the next relationship. There may have been deeply hidden and powerful issues that prevented recovery- some of which had not been uncovered in couple therapy. Daryl and Marilyn were too intricately involved with mutual addictive behaviors and holding too much resentment for Daryl to address his drinking and affairs successfully within the marriage. However, upon separation Daryl continued therapy and was able to stop his illicit sexual affairs and reduce his drinking to manageable levels. After his divorce and the disintegration of his well-constructed facade of propriety, Daryl finally began to explore and express his conflicted sexuality. He had never been able to voice this previously because of his spiritual, emotional, and psychological inhibitions had not developed or progressed sufficiently. Perhaps, he had to play out his masculine role in a heterosexual marriage and hypersexual affairs and fail before he could own his suppressed attraction to men. In individual therapy, Daryl began to explore how repeated sexual conquests of available women "proved" his heterosexuality and discounted his homosexual feelings. Compulsive illicit sexual activity and his other addictions: alcohol and workaholism served to mute his internal psychic turmoil as he tried to deny himself. No one including Marilyn and the couple therapist had asked the key questions about his sexuality and attractions. His suppressed feelings, his narcissistic intimidation that limited inquiry by anyone who questioned him, and/or others' heterosexual assumptions (the therapist may have been unconsciously complicit in not checking this) may have somehow combined to preclude his sexuality from being broached.
Daryl subsequently began to explore his sexuality and attractions to other men as distinct from a sexual addiction and compulsion for illicit sex. Eventually, he began an intimate relationship with another man that became monogamous that has lasted four years to date. Early in this relationship, Daryl still had occasional one-night stands with women he met casually. He also became promiscuous with multiple male partners. It was a negotiation within himself as to what and who he was. As he came to own his sexuality and attraction to men, his compulsion to sexually act out waned. Therapy helped him process these behaviors' relationship not only to his sexuality, but also to attachment issues from childhood. Narcissism continued to an issue that complicated his relationships. This was a major challenge to any intimate mutually fulfilling relationship. That would not be essentially different for a heterosexual or homosexual relationship. After about a year and a few other gratuitous sexual encounters, he was able to stop and become faithful to his partner. Daryl continued to be challenged in the couple's relationship but his addictive and compulsive compensations were less compelling without his hidden sexuality issues. There may be highly unremitting intense emotional and psychological traumas or issues that drive the addictive self-medicating process. It is arguable whether Daryl's sexual acting out was a sexual addiction per se or part of a more pervasive self-medicating addictive repertoire for emotional and psychological distress. In the case of some individuals with sexual addictions, the may be little or no desire for the addict to stay married or stay together with the partner. For one reason or another, the marriage or partnership may be of convenience, for status, for children, or for social camouflage of one sort or another. Being married to Marilyn had been a part of Daryl's camouflage. He had tolerated his personal psychic destruction and denied and minimized its cost to Marilyn, but the consequences to his son were worse than he could handle. For some individuals, however some form of sexual addiction remains compelling. "A common pattern is the man who prefers the predictability of masturbation to partner sex. Without either the stimuli of pornography or the control of self-stimulation, he has little genuine desire for couple sex. Another pattern is that the combination of eroticism and shame concerning the paraphiliac arousal pattern controls sexuality, and he is unwilling to invite her to be an intimate ally" (McCarthy, 2002, page 282).
The therapist should also be aware that Daryl's conflict and distress over his sexual attractions are by no means the only underlying conflict that can motivate addictive behavior. His pattern of narcissism, alcoholism, and sexual acting out may be identical to another person responding to some other combination of attachment anxiety, trauma, family dysfunction, or cultural models. Marilyn's response or partner pattern is also not the only way- much less the only dysfunctional manner as a co-addict. These qualifications are true for the other couples discussed throughout this book. There can be many and/or different core issues that compel the need to self-medicate or self-soothe with substances or compulsive behavior. The therapist is forewarned not to diagnose from a favorite etiological theory, but to careful assess each individual and couple. The expanse of issues presented in the seven couples profiled in the book are not intended to be comprehensive, but as representative of an even greater potential multiplicity of addiction and compulsivity's origins and their effects on a couple.
Addiction is a compelling and arguably the most compelling destructive force for the individual and in the relationship. Identification of the individual's place on a continuum of experimental use or behavior, social use or behavior to problematic to dependent/addictive use or behavior changes treatment or therapy. Addiction may be the consequence of more fundamental psychic issues. After all, individual issues may drive self-medication resulting in addiction. Or, addiction may make relationship problems tolerable and intolerable. Without addictive use or behaviors the relationship may not survive. Does the addict create the co-addict? Do the addict and co-addict find each other? Are they really just two addicts with different complementary addictions? The therapist that faces a flock-of-chickens or a-dozen-eggs clinical choice may best serve the addict and co-addict by addressing every aspect: individual issues, addiction, and the relationship dynamics. Since individual issues can have layers and convoluted complexities, there are potentially innumerable mutually interactive dynamics for the partners to work through. Addiction varies for each individual and co-addiction matches (mismatches) vary as much. The therapist's challenge barely begins with diagnosis of addiction. Trauma, personality disorders, family-of-origin models, cultural influences, self-esteem, and other psycho-social and emotional-cognitive issues do not necessarily address physiological or biochemical influences. In addition, the therapist may need to look beyond general principles discussed in this book for nuances and specifics relevant to particular addictions or compulsivities whether substances or behaviors. For example, the cognitive-psycho-physical effects of alcohol have important distinctions among other chemical substances of abuse and dependence such as the stimulant drugs, hallucinogens, marijuana, heroin, and so forth. The therapist should be aware of behavioral compulsions that can have various additional effects and consequences socially and physically that are more or less culturally accepted or reviled.
Couple therapy may be of necessity a part of a multi-layered approach to treatment or change. The timing relative to the stage of addiction and recovery of the addict and the couple's entry into therapy may be more important than the process of therapy. The couple therapist may need to keep this in mind or suffer being humbled by having his or her therapeutic arrogance crushed. At the same time, couple therapy may find underlying addiction issues critical to address for successful relationship healing and growth. The therapist will only know how much addiction may be relevant as clinical investigation uncovers the partners' history and as therapeutic interventions are frustrated. The therapist is reminded again that addiction should not be ignored as potentially relevant. "Conservatively, one out of ten people, or one out of five couples in therapy, wrestle with addiction issues" (Taylor, 2012, page 7). The conservative estimate may belie the reality in couple therapy. Along with many other tools, the therapist needs to have addiction treatment theory, strategies, and interventions available in the therapeutic tool chest. The therapist who tries to choose to not work with clients or couples with addiction and compulsivity issues cannot conduct therapy with integrity. As individuals, couples, and family enter therapy, so inevitably does addiction and compulsivity. The therapist is further cautioned that addiction or compulsivity claimed to be "mine" by a partner or declared pointedly to be "yours" as the other partner's, should be considered to the "their" issue. Getting the partners to accept that "The addiction… the compulsivity… the problem is ours" is often the first step to recovery or healing together.