For the bipolar or other organically affected individual, the therapist must assess for stability. Medication assessment for behavioral and relationship effectiveness and compliance may be important components of therapy. This includes investigating and periodically assessing for stability and maintenance with an otherwise medically stabilized bipolar individual. The therapist should check for history of prior vacations from lithium or other stabilizing medication. Whereas, the substance-using addict will use and experience his/her highs, the bipolar individual may purposely go off medication in order to experience mania… the high. Included in the ongoing assessment is anticipation and planning for purposeful or "accidental" medication vacations. The partner of a bipolar is often perplexed by this behavior. Focused on the negative consequences of the mania, it just doesn't make sense to the partner for the bipolar want to go into manic stages. Bipolar individuals often really enjoy the feelings of mania. It's the subsequent crash to depression-the rebound lows that are so horrible. They will experience cravings for their mania similar to the addict's desire for their drug or behavior. They will do "continued use (experience of mania) despite adverse consequences," crave, have "repeated attempts to quit (maintain chemical balance)," and so forth. The therapist may find the other partner more forthcoming with information about medication holidays than the bipolar individual.
In addition, the therapist should consider if the client from a cultural background where the manic behavior is considered desirable or a socially acceptable expression of creativity. Even when the behavior is relatively sanctioned in a community, extreme behavior may remain functionally problematic in a particular context. Marriage, an intimate partnership, a job, and other different contexts may not tolerate culturally based behavior tolerated in another circumstance. The focus should shift to the problematic nature of the behavior versus its cultural acceptability. If Cole asserts his distancing behavior is what he learned from his father and how "a man is supposed to do," the therapist can refrain from arguing with his deterministic cultural gender stance. Instead, the therapist can question its functionality, "How has that worked for you… with Molly?" The therapist should be aware of any implicit cultural standards. Is the partner (more typically, the woman) supposed to tolerate an occasional "wild" period of behavior or retreat to the "man cave" as a condition of the marriage? Is the man allowed to be emotional? If there is a preponderance of unidentified and unaddressed culturally based dysfunctional expectations, treatment becomes more complex.
With the presentation of high emotional reactivity in couples, the therapist should assess for self-medication with substances and/or behaviors to deal with pain and anxiety. When there is a self-medicating process by one or both partners, therapy becomes further complicated. Another cultural aspect to treatment could be assessment of the cultural propensity to self-medicate. The therapist should for example examine for Cole or Molly engaging in self-medicating behaviors. There may be behaviors that are culturally common (stereotypical) that should be explored first for certain communities or profiles: alcohol, prescription drug abuse, gambling, workaholism, emergence in child care, volunteerism, and so forth. The therapist however should also be alert to atypical behaviors as well. People from societies where there are often lifelong and enduring overwhelming stresses that cannot be addressed through the individual action may turn to various forms of self-medication to handle depression and anxiety. The self-medication process may be a normal and acceptable aspect of coping in a family, community, or culture. The therapist must work on behavior (abstinence or significant reduction to controlled use… if possible) change in the user. This may shift the focus of therapy to working on self-medication issues. Therapy is simplified if an individual is able to accept or own his or her substance or behavioral abuse or dependence. However, the therapist may be challenged to artfully maintain or return to this focus if a client is resistant to addressing self-medication. Secondarily, the therapist must also facilitate change in the enabling behavior of the partner. The therapist must be forthcoming with this assessment. The therapist should present psychoeducation about self-medication as a common response to emotional distress. For a more extensive discussion of this see "Mine, Yours, and Ours, Addiction and Compulsivity in Couples and Couples Therapy" (Mah, 2013)- available at https://www.smashwords.com/books/view/350764 and on this website.
Pretending that couples growth is possible with an active self-medicater is an illusion… a dangerous illusion for both partners and the therapist. It colludes with the denial process of the self-medicater, diverting the focus of therapy to communications or some other relational process. Unfortunately, heavily active self-medicaters (including behavioral self-medication such as video porn addiction, gambling, spending, etc.) will often sabotage therapy because they cannot or will not deal with their problems in couple therapy or anywhere else. In the frustrated therapeutic process, the other partner might realize that the self-medicater's prioritizing of continued use over improved relationships precludes real work. "Drinking IS more important to my partner." Using the term, "self-medicaters" instead of "addict" avoids the stigma of the label "addict," and focuses on the functional process of substance abuse and behavioral obsessions. The functional definition of "self-medicater" is more effective in working with individuals from varied cultural backgrounds who do not identify addiction as relevant, or avoid it as too stigmatizing. The therapist often finds it much easier to get individuals to acknowledge that they use substances or behavior to avoid distress or pain, than it is to get them to call themselves addicts. Once they acknowledge there is distress or pain, then getting them to consider alternatives to self-medication follows more readily. The therapist can reframe the compulsive behaviors of substance abuse or engaging in addictive behaviors as a choice to avoid being overwhelmed by anxiety, depression, pain, or loss. The choice can be validated as a decision to survive, which allows for the therapist to offer alternative more functional options for survival. When individuals or couples who present for help with substance abuse or dependence or other behavioral or addictive processes, the therapist should also explore for issues or disorders for which self-medication is a primary survival strategy. Dual diagnosis clients may be considered to be doubly emotionally reactive. They can be extremely difficult to work with. It would not be surprising for several diagnoses to be appropriate: reactive attachment disorder, molestation, bulimia, borderline personality, substance abuse, lions, and tigers, and bears… oh my! However, such clients would be even more difficult to work with when the therapist fails to recognize the dual diagnosis or multiple diagnoses.