The therapist cannot effectively work with the addict or couple without first establishing a good rapport with both partners. The co-addict may be eager to bond with the therapist because of his or her long unfulfilled desire to get help. On the other hand, the addict will be hesitant or resistant to connecting with the therapist. The addict often fears that the therapist may judge him or her, uncover his or her secrets, or push the partner to leave him or her. The therapist should consider using the term, "self-medicater" instead of "addict" to avoid the stigma of the term "addict." The language change also focuses on the functional process of substance abuse and behavioral obsessions. "Self-medication" as a concept is often 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 takes whatever one or both partners identify as a problem: communication, less intimacy, discomfort, or anger for example, and probe for how it affects how one feels. Whether the partners acknowledge or the therapist states or suggests that one or both has anxiety or depression- or stress, therapy can look at how the partners handle the discomfort. The negative feelings become a problem to work on. The therapist can ask, "What do you do when you feel upset?" "What happens when it bothers you?" "How do you deal with those feelings?" "What works for you?" "How do you keep from losing it?" This discussion can lead to how alcohol, drugs, or certain behaviors may have become a way to deal the feelings.
The therapist can be direct in asking whether and how alcohol, drugs, or compulsive behaviors are used. Both partners should be asked how well they work, and what are the consequences of the use or behaviors. Alcohol or drug use or compulsive behaviors can be identified adding to stress because of harm to health, emotions/psychology, academics/vocation, and of course, the relationship. Now the choice or the effects of alcohol or drug use or compulsive behaviors becomes another problem to work on. The addict may assert the substance use or compulsive behavior are not problems, but agree that problems with the partner or at home or work arise from the use or the behavior. Or, that the partner having a problem with his or her use or behavior creates a problem. The addict may argue that the partner also indulges- drinks as well for example, so does not see what is the problem. Tamlyn or Phillip criticize the other partner's drinking or point out their mutual history early in their relationship. Daryl tries to deflect criticisms of his drinking and affairs by accusing Marilyn of overdoing with prescription medication. Shuman counters complaints about his twelve-step activities with accusations that Myanna overeats and overspends. The partner will argue that the use or behavior is not the same. His or her use does not cause problems… not really. Differential use may be indicative of one partner's use crossing over into abuse with associated problems including relationship issues.
"In terms of the impact of different patterns of substance use on marital functioning, we have found cross-sectional evidence that discrepancies in husbands' and wives' heavy drinking are related to lower levels of marital satisfaction. In an extension of this work, we examined if differences between wives' and husbands' heavy drinking (i.e. discrepancies) over the first 3 years of marriage were predictive longitudinally of decreased marital satisfaction. Significant evidence supported the finding that discrepancies in heavy drinking were related to decreased marital satisfaction. Importantly, we found that regardless of whom the heavier drinker was, the association persisted" (Homish et al., 2009, page 1202). Clearly, the therapist would suspect that the discrepancy in use might be between one partner's social use or to relax occasionally, while the other partner's use may be abusive or addictive with significant negative consequences. The therapist should be alert to the suspected addict complaining that the other partner "used to be more fun" or "was just as bad as I am before." Carl said that Bethany used to enjoy drinking with him, before she decided that being "married to a warehouse supervisor wasn't good enough for her." Mitchell claimed that Kat used to be just as bad as him when he was still flush financially and with access to alcohol and drugs associated with the highlife as a professional athlete. In addition, there is nothing- that is-that is no one more aggressive about sobriety as the recently reformed drunk. "…if one partner of a concordant heavy drinking couple enters treatment for his/her alcohol use, positive changes resulting from treatment (i.e. reduction/cessation in heavy drinking) could have unexpected consequences for the relationship. Thus, the break-up of the 'drinking partnership' could have unintended negative outcomes for the couple" (page 1207).
Another example of behavior that has subjective boundaries between use and abuse is Internet use. Internet use is very much a part of modern life. Everyone in the household can use the Internet, but some clearly more than others. How much and to what consequence may cross a line between use and abuse and further, into addiction is an important discussion. "Aoujaoude et al. reported that 69% of the respondents were regular Internet users and, of this number, 5.9% felt their relationships suffered as a result of excessive Internet use, 8.7% attempted to conceal non-essential Internet use, 3.7% felt preoccupied by the Internet when offline, 13.7% found it hard to stay away from the Internet for several days at a time, 8.2% utilized the Internet as a way to escape problems or relieve negative mood, 12.3% had tried to cut back on Internet use (of whom 93.8% were successful) and 12.4% stayed online longer than intended either very often or often" (Shaw and Black, 2008, page 353-54). Behavior otherwise considered productive or indicative of a good work ethic may get out of hand and considered an addiction as discussed earlier regarding workaholism. " A group of 400 physicians were polled regarding their observations of workaholics as marital spouses (Pietropinto, 1986). Results indicated that workaholics devote an inordinate amount of time to work as opposed to marriage and they have higher than normal expectations for marital satisfaction. They are more demanding of achievement in their children than nonworkaholics and their typical approach to leisure time is to fill it with work activities. The workaholic's usual style in marital disagreements is to avoid confrontation or use passive-aggressive maneuvers such as silence and sulking. Physicians as a group generally agreed that these combined factors wreak havoc on the family unit. Moreover, an inverse relationship between marital satisfaction and career focus has been documented" (Robinson et al., 2001, page 399). Is the workaholism- the addiction itself the problem? Is it a problem because of poor balancing of time and priorities? Is the problem about being so demanding of self and others? An inability to relax? Financial or work pressure? Is it avoidance behavior or deficits in communication skills? Either or both partners may battle the therapist over the answers to these questions. It is not necessary to identify one or another as the key problem. Moreover, therapy can proceed without labeling the individual an addict… or a workaholic for example. Therapy does not need to initially work on the problem of "addiction." Therapy can offer to work on problems such as these: balancing life, communication, financial choices, and so on… for now.
Once the addict or co-addict acknowledge there is distress or pain associated with problems, then getting them to consider offered alternatives for solving some problem other than self-medication follows more readily. Instead of asking (experienced as being accused to being forced to accept the derogatory label) if one is an "alcoholic" or "addict," the individual is asked to accept an offer to help deal with problems of life. While still requiring clinical skills, it is nevertheless much easier for the therapist to get someone to acknowledge that he or she uses substances or behavior to avoid distress or pain. It is easier to admit that use or behavior causes some problems, than it is to get him or her to call oneself an addict. The therapist should be careful not to rush these steps, but instead build the progression judiciously giving the clients the time necessary to absorb the growing implications. Working on any problem can lead eventually to working on addiction and/or the relationship. The therapist needs to be aware that not getting to "the" problem quickly or immediately is not a problem. It is a normal part of therapy when addiction or compulsive behavior is involved. Patience, clinical judgment, and skills are needed to navigate the therapeutic waters.
It can also be a normal part of the therapy that one partner- the co-addict may start with the accusation that the other partner is an addict. The other partner denies it and a fruitless argument ensues. If the therapist joins in with the co-addict pushing the label, he or she runs headlong into against fortified battlements already constructed against the co-addict. In twelve-step self-help programs such as Alcoholics Anonymous, taking on the label is a fundamental step to addressing the problem/disease. However, therapy- individual or couple therapy is not a twelve-step program. Moreover, the addict self-refers to a twelve-step program when he or she has hit bottom. His or her life has become uncontrollable and denial is usually no longer an option. Therapy or couple therapy cannot and should not attempt to duplicate the process of twelve-step programs. The addict often has yet to hit bottom when entering couple therapy. Twelve-step programs are certainly usually considered among the most or the most effective treatment for addiction. However, while requiring self-acceptance of the addiction label as may be critical in Alcoholics Anonymous and other twelve-step programs, in therapy it often immediately waylays the therapeutic process. Forgoing labeling for the time being is a strategic move for the therapist to build rapport and credibility with both partners. It leads into and is a part of the therapeutic process. The therapist will eventually return the individual and the couple back to taking ownership of addiction as a key issue at an opportune later time. This strategy does not mean the therapist should or will avoid the issue of substances or compulsive behavior affecting the individual or the couple. Clinical judgment and skills assessing the condition and progress of the partners, addiction, and the therapeutic progress determines how to deal with taking ownership of the label of addiction. The following, based on the mnemonic "A MESS" is an ostensively psycho-educational approach to include and keep the substance use or compulsive behavior in the domain of therapy by side-stepping (temporarily) the addict labeling issue. Since this approach is psycho-educational and expresses nevertheless the experience of the addict and co-addict without using labels, the approach also builds credibility and therefore, builds rapport.
A MESS is a mnemonic for etiology theories of substance use or self-destructive behavior. It is intended to help the therapist, teacher, other professional, and parent not make A MESS of substance or behavioral abuse or addiction intervention. The conversation or approach, intended hopefully to facilitate change and good choices may be with a child, teen, or an adult.
A: The first letter "A" stands for "addiction." Substance use or self-destructive behavior is seen as being caused by addiction. A genetic vulnerability to addiction may be implied. Many people take this to mean that there is a physical, emotional, or cognitive weakness that leads individuals to use substances or engage in self-destructive behavior. It can be a highly stigmatizing label in our society. Requiring the individual to take on this label can be highly problematic, in as far as the implied negativity of being an addict is so powerful. Individuals will resist this label and thus, effectively preclude any problem-solving or other change/growth process. In addition, while valuable conceptually, the boundaries between experimental use, social use, problematic use, abuse, and dependence are not absolute or concrete. And certainly, the precise labels are not worth the therapist and therapy losing focus to fight over. The therapist can examine the individual's experimental or early use and social use without any overt or implied judgment. The initial key is whether the individual's use or behavior has crossed to problematic use. Problematic use or behavior is subjectively and individually determined. It is not about the number of drinks, the legality or illicit nature of the substance or behavior per se, or whether it is done alone or with a peer group. By definition use becomes abuse when there are problems associated with the use. Problems in physical or medical health, psychology or emotional well-being, relationships, and academic or vocational functioning are the key areas where use or actions can become abuse of substances or continued behaviors.
There are further distinctions between problematic use or abuse and dependence or addiction. The therapist does not necessarily need to get the individual to admit dependence or addiction once the individual has acknowledged that there are problems that result from use or behaviors. The individual may be addicted or dependent on some substance or behavior, which the therapist will inevitably need to address. At the beginning or early stages of therapy, however the therapist must get the individual to accept that there is some issue to address and agree to a therapeutic contract. Agreement to work on reducing or eliminating problematic substance use or behaviors is sufficient… for the time being. In addition, the individual may have significant problems with his or her substance use or behaviors without being dependent or addicted. The therapist who tries to force the addict label on such an individual who uses or behaves problematically without dependence immediately loses credibility. The "A" to work on is not getting the individual to admit to being an "addict," but to get him or her to "agree" or "accept" that his or her substance use or behaviors has caused problems in life… and in the couple.
M: The second letter, "M" stands for "moral." Substance use or self-destructive behavior is often seen in society as being caused by a significant lack of moral fiber. This implies a moral vulnerability to addiction- a weakness and lack of proper values in the individual. Although the therapist or the individual or partner may not say this out loud, but the implicit condemnation is evident. Self-destructive substance abuse or behavioral addiction is often considered to be a lack of will power and/or a deficit in character. Implying or labeling the individual as morally deficient because of the substance use or behavior is an automatic insult. The individual, despite abusive or addictive use or behavior usually will resist this moral deficit label. Such resistance effectively precludes any problem-solving or other change/growth process. Starting a therapeutic relationship or maintaining a relationship by starting with the premise and assertion that the other person is "bad" automatically damages progress. In fact, whether or not the person resists or owns it, the immoral label harms the probability of rapport and growth. The therapist will have significant difficulty empowering change in the individual who morally condemns him or herself as deficient because of his or her inability to resist continued problematic use and self-destructive behavior. The self-loathing individual usually does not see him or herself becoming a "good" person- that is, as someone good enough or worthy enough to become a non-addict or former addict. Or, sees him or herself as worthy enough to have a healthy relationship. The individual needs to identify his or her own story or meaning of his or her substance or behavior problems separate from a moral deficiency model.
E: The "E" stands for "education," which provides an alternative to moral failing as an explanation for use or behavior. However, an educational approach to substance use or self-destructive behavior can backfire and further the individual's negativity and resistance to therapy. Problematic use and behavior can be presented as being caused by a lack of knowledge or education about the effects and consequences of the use or behavior. This implies that if the individual is informed about the effects and consequences, he or she will logically refrain from use or behavior. He or she will be appropriated scared or intimidated. The education approach unfortunately has been distorted to include scare tactics based on dubious "facts" or outright lies. The "Reefer Madness" (Gasnier, 1936) movies would an example of such deception, or parental horror stories about someone they "heard about." Such scare tactics have often backfire when individuals discover that use does not automatically result in addiction, moral degradation, madness, and/or death. In fact, having a few beers, getting buzzed on pot, another piece chocolate, or buying a gorgeous new toy can be quite fun! While education about substances and their effects and the dynamics of abuse and addiction is important, knowledge does not in of itself, motivate many individuals to stop or curtain use or behavior. In fact, many substance abusers or addicts are more knowledgeable about their drug of choice or intricacies of behavior than the therapist. The therapist is unlikely for example to be that versed in many aspects of drugs and their use. He or she may not even recognize what the user is talking about given the various names for a drug. Marijuana, for example has many names with new ones being coined all the time: "Weed, Pot, Reefer, Grass, Dope, Ganja, Mary Jane, Hash, Herb, Aunt Mary, Skunk, Boom, Chronic, Cheeba, Blunt, Ashes, Atshitshi, Baby Bhang, Bammy, Blanket, Bo-Bo, Bobo Bush, Bomber, Boom, Broccoli, Cripple, Dagga, Dinkie Dow, Ding, Dona Juana or Juanita, Flower, Flower Tops, Ganja, Gasper, Giggle Smoke, Good Giggles, Good Butt, Hot Stick, Jay, Jolly Green, Joy Smoke, Joy Stick, Roach" (www.casapalmera.com, 2012).
In addition, the therapist will not probably be up to date on cost, safe dosages versus overdose, various incarnations of drugs, duration and intensity of intoxication, extending and losing the high, where to score, triggers, and more. The therapist may be similarly uninformed about behavioral addictions, or unclear about an individual's idiosyncratic compulsive manifestations. For example, not all therapists are knowledgeable about how and why an individual such as Samantha cut themselves, the demographics of self-mutilators, distinct from piercings and tattoos, and the hormonal responses of the brain and body. Or, may be aware of etiological considerations for Tamlyn's bulimia. Samantha or Tamlyn may be more expert about cutting or self-mutilation and eating disorders than many therapists. However, many abusers or addicts use or persist despite more than adequate education and knowledge about the harm and dangers. And, when the individual does not stop or curtail use despite being properly educated, then the implicit or sometimes overt conclusion or accusation is that the individual is simply stupid, stupid, stupid! Yet, most abusers or addicts are of normal intelligence and sometimes, quite brilliant. These misguided principles are equally applicable to behavioral abuse and addictions. The bulimic knows… the cutter knows… the gambler… and so other behavioral abusers or addicts can know almost everything about their dysfunctional self-destructive behaviors. In almost all cases, they also know more than the therapist. They know and they know better than to continue use or behavior, but continue nevertheless. Asserting someone who uses or behaves self-destructively is intellectually deficient is not an effective way to start therapy. It is either another insult that creates resistance or confirms deep shame that complicates empowering change.
S: The first "S" of two stands for social. The social approach asserts that substance use or self-destructive behavior is caused by influences from the individual's social peer group. In other words, the individual is too vulnerable or too weak to resist the standards of behavior and morality of his or her social peer group, and consequently assume those behaviors and morality. As a result, this approach asserts that the key to whether or not the individual used substances or engaged in problematic behaviors is whom he or she associates with. Hanging out with "bad" individuals and groups then leads the individual to problematic use or behavior, abuse, and addiction. On the other hand, choosing to socialize only with "good" individuals and groups leads to appropriate use or behavior, or abstinence from negative use or behavior. Georgia, the mother kept insisting that her son- Ned's negative behavior was the result of hanging out with bad influences, particularly one boy Damien who she constantly criticized. The therapist challenged Georgia how did she know that her son was not the bad influence on Damien!? Ned burst out in laughter, asking his mom, "Ha ha ha! Yeah Mom, how do you know I'm not the bad influence!" Bethany accused Carl of staying late after work at the warehouse to indulge with the other deadbeats. Kat accused Mitchell of hanging out with drinkers and druggies from his construction work, who influenced them to abuse alcohol and/or drugs. While peer pressure is a relevant influence on behavior and choices, many individuals neither use nor abuse drugs or alcohol nor engage in negative behaviors despite hanging out with those who do. The social approach tends to ignore other influences on the individual that may be as or more relevant to substance or behavioral abuse and addiction.
This theory incorporates the social influence of the media upon the individual. Television, movies, literature, music, and video games may promote and glorify models of substance use and problematic behaviors that can influence the individual. This theory however also ignores the fact that many individuals are also exposed to and enjoy the same media influences without succumbing to such use and behaviors. The therapist should consider as a theory potentially as relevant, that the individual with the same sensitivities, vulnerabilities, and needs as those presented by such media would gravitate to such media. As opposed to media creates such characteristics in an individual, such an individual with such characteristics will seek various experiences, including not only entertainment but also peers that validate his or her inclinations and actions. This would extend to intimate relationships. "Among newly married couples, significant concordance has been found for alcohol use, cigarette smoking and illicit drug use. Selecting a mate based on the similarity of characteristics, experience and behaviors can also mean that future behaviors are derived from earlier, shared experiences. For example, Rhule-Louie &McMahon suggest that concordance of problem behaviors among couples (e.g. substance abuse) may be a secondary outcome on the basis of couples who share similar, antisocial environments" (Homish, et al., 2009, page 1201). Looking at common habits from a partner or peer influence model, a social contagion model, versus a social convergence model, including assertive mating with similar habits or inclinations changes the therapist's subsequent therapeutic strategies.
The social approach implies another insult to the individual. It proposes that the individual does not have sufficient ego strength to make up and hold his or her own values and beliefs. The individual is considered to be easily malleable to whatever his or her social group believes in. The assumption is that the social chameleon will shift easily to another set of values and behaviors with different and successive groups of peers. Therapy or change therefore would consist of removing the individual from his or her social peer group, changing media habits, and instilling him or her in a new "healthy" community involved in positive new activities. In addition to the implicit insult of the social peer approach, the individual is often resistant to leaving his or her social peer group. The peer group constitutes often more than a set of friends, but the individual's sanctuary. The peer group of like-minded and like-behaving people confirms the individual as a member of a community rather than a social moral misfit. Leaving the social community becomes more than leaving substance or behavioral use, abuse, or addiction. Carl or Mitchell hang out with like-minded and like behaving peers for the comradery and acceptance. They bend less to the group versus find a group they can fit into. Hanging and drinking or toking with the "fellas" were precious breaks from the stress within their intimate partner relationships. The therapist needs to be aware that the social approach, with its implicit recommendation becomes tantamount to tearing the individual out of his or her sanctuary- his or her place of refuge or safety.
S: The last "S" stands for self-medication. The principle of self-medication sees substance use or self-destructive behavior as being caused by profound needs in the individual to self-medicate for severe emotional and psychological (and sometimes physical) pain. This is often the most effective approach to working with a "user" of any problematic type. Rather than pathologizing the individual with a severe label, as morally deficient, stupid or ignorant, or psychically weak and easily influenced by others, it focuses on the internal pain of the individual that otherwise may be missed. This reveals and honors internal distresses such as anxiety, depression, and loss, and effectively de-pathologizes him or her. The use or behavior is recognized as attempts by the individual to avoid feelings that would otherwise be overwhelming. The individual may or may not be an addict. The issue becomes not of a label of problematic use of whatever degree: problematic, abusive, or addictive, but of inner psychological turmoil. What drives Gwyn? Where does Daryl's compulsions come from? What trauma did Samantha experience? Or, what compels another individual's self and other destructive behavior?
The morality of the use and behavior shifts from one of character or lack thereof, to a morality of survival in the face of overwhelming feelings. Education from the dangers and risks of use or behavior moves to education about the process of self-medication for emotional pain. The social peer group is exposed as a means to have a community that supports self-medication- a sanctuary from distress. Once the connection to self-medication to avoid suffering is made, then the therapist or other interventionist can help the individual explore feelings, and subsequently explore alternative (more healthy and less destructive) ways to deal with intense feelings. The importance of dealing with the individual's dependence or addiction is not diminished with acknowledging self-medication in use of substances or compulsive behavior. This is a critical therapeutic goal not just for the addict or problematic using or behaving partner, but also for the other partner. This is an understanding or acceptance for the partner of the addict that is critical for the relationship. For this partner, becoming educated or informed about self-medication serves "a process of softening leading to unity and mutual supportiveness in the recovery process. Whether the process occurred previous to or during therapy, all couples reported a need to work through initial feelings of anger, bitterness, resentment, and so forth. Most commonly this strident affect was reported by (non-addicted) wives; some husbands, however, also noted a similar process of softening" (Zitzman and Butler, 2005, page 323). Softening may be described as empathic acceptance or compassionate identification or a metaphoric softening of the stone-hard heart set against caring or trusting the betraying addict again.
Identifying the practice of self-medication is a part of the psychoeducational component of treatment. This would be psychoeducation about addiction, origins and causes of addiction, addicts, being a partner of an addict, emotional, psychological, medical, spiritual, social, financial, and other consequences of addiction rather than about education about a substance or behavior of choice: alcohol or marijuana or gambling per se. Psychoeducation about self-medication and other important issues in addiction are not only for the addict, but may be essential to get the partner invested to participate in couple therapy. Zitzman and Butler described the process for partner of an addict. "Amy reported the following changes that occurred for her: I remember one of the sessions that we had that was educational, just getting really interested… It was really interesting to me how it was really turning a light on for me [about] what's going on, and… starting to see how things are playing out within our marriage, and kind of [thinking], 'I would like to come back to find out more.'… It made me more compassionate, because I understood what he was going through… You don't just stop and just don't do it anymore… It did bring… compassion that, 'Yeah, he does need this fixed time to be supportive'" (2005, page 323-24). Treatment for dependence and addiction involves a litany of approaches and interventions. It constitutes specialized conceptualization, strategies, and interventions either in conjunction to psychotherapy or separate from psychotherapy, including individual, couples, and family therapy. The therapist or addictions treatment professional must make the decision to incorporate psychotherapy or not based on theoretical orientations and individual assessment. Referral to twelve-step programs, in-patient hospitalization, or group treatment may be the best treatment for a given individual. The following discussion assumes that the therapist after careful assessment deemed that therapeutic treatment, including possibly couple therapy is appropriate for the individual.