Introduction - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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**Author's Note: Other than public figures or people identified in the media, all other persons in this book are either composites of individuals the author has worked with and/or have been given different names and had their personal identifying information altered to protect and respect their confidentiality.

CLEAR
Tamlyn and Phillip came for couple therapy because she felt that she was drinking too much.  She had gone to an alcohol and drug treatment program, but they had referred her to therapy instead.  She did not meet their criteria for substance abuse.  She was a sipper.  She had a tall glass of peppermint vodka that she sipped all day long while managing the household and the demands of several children.  Rarely did she have more than that.  At the treatment center intake, they also found that she was not all that happy about her relationship with her husband of twenty-five years.  They suggested that couple therapy might be useful.  In the first session, she revealed that she also was bulimic.  She threw up just about every day- sometimes, a couple of times a day.  Phillip said he came to therapy support her in her recovery.

Mitchell and Kat came for couple therapy because they had been having a lot of conflict over Mitchell's use of pain medication.  Mitchell had been an outstanding athlete through high school and college, playing two or three sports.  He had gotten an invitation to a professional football team training camp.  He had been doing pretty well through the preseason games and stood a chance to make the team as a reserve on the "suicide squad" as the kick coverage and return teams were called.  Then in the last preseason game, he threw himself at the blockers and by the worse of luck cracked vertebrae in his lower back.  That was the end of professional sports.  It was a tough recovery and he was not the best patient- having little or no patience.  He pushed himself too hard too soon and suffered further injuries rather than healing.  His post-athletic career vocation in construction made ongoing demands on his physicality.  Now at thirty-years-old, he had the gait and motion of an eighty-year arthritic old man.  He was in chronic pain and was using up his monthly ration of pain-killers in less than two weeks every month.  He turned to alcohol, marijuana, and other street drugs (methamphetamine, in particular) for the remainder of each month until he could get a new prescription.  Kat was skeptical that Mitchell was in that much pain, but was really a drug addict who used the physical issues as an excuse.  She was on his case all the time to cut back on all the medication whether prescribed or self-prescribed- legal or illegal.  She also complained that instead of being involved with her and the kids, he would lose himself surfing the Internet for hours and playing massively multiplayer online games (also called MMO and MMOG) which are multiplayer video games often involving thousands of participants, and available and active around the clock.

These two couples: Tamlyn and Phillip and Mitchell and Kat came for couple therapy that involved issues of addiction and compulsivity in their relationships.  The therapist concurred with the substance abuse and dependency treatment program that Tamlyn was not a "hard case."  However, while alcohol arguably may not been her core issue, it along with her bulimia were almost certainly responses to deeper issues.  Nevertheless, alcohol and bulimia contributed stress to her life and relationship with Phillip.  A more complete exploration of their relationship found that it was not just Tamlyn with addiction issues.  Alcohol and drugs were always a key component between them from since they first started dating almost thirty years ago.  They and Tamlyn, in particular adjusted their use when they had children.  When the children were younger and more demanding, Tamlyn was the dedicated proud mommy.  She was at every PTA meeting, baked the cookies, and drove the fieldtrips.  And, graciously accepting the accolades for her children's performances and awards.  Phillip had continued to be a daily drinker who overindulged occasionally.  At this point, Phillip also had a significant Internet pornography habit that effectively eliminated their sex life together, as well as exhausting him as he stayed up late nightly perusing one titillating site after another.  It was likely that addictive or compulsive behaviors were important emotional and psychological self-soothing mechanisms for both of them.  Beyond each with addiction issues, they shared addiction issues as a couple.  Conversely, Mitchell claimed he used his prescribed medication, his alcohol, and his street drugs strictly for his physical pain.  Whether or not he used or abused them as an addict, Kat thought he did.  She knew of his demanding and critical father and how damaging it had been for Mitchell.  Mitchell had not done well in school and been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and been prescribed Ritalin.  His father accused him of not trying hard enough and being lazy.  Kat knew about these blows to his self-worth and his injuries, but she still felt he indulged himself with self-pity rather than choosing the correct path for himself, her, their marriage, and their children.  Her suspicion and anger about his use- his weakness to use whether justified or unjustified contaminated their relationship.  They had a cycle of use, abuse, frustration, anger, criticism, resentment, shame and depression, and further use in their addictive process.  Addiction and compulsivity clearly were clearly important if not fundamental issues for couple therapy for these two couples.

VAGUE BUT PROBABLE
In contrast, there was no mention of alcohol or addiction initially when Dyson and Samantha came for couple therapy.  They had been dating since college and now were in their mid to late twenties.  They felt it was time to start thinking about getting married.  But Samantha was not sure if she or they were ready for such a big step.  Dyson was ready and committed, but knew that Samantha needed to get there too.  Samantha brought up various reasons that she felt Dyson was not ready, or how she needed reassurances.  The goals and direction of couple therapy seemed clear to the therapist based on this presentation.  Then in the third session, Samantha brought up that Dyson had a couple of one-night stands with other women early in their relationship when they were in college seven years ago.  Dyson was deeply remorseful about his infidelity.  In both situations, he had been drinking and gotten inebriated.  He knew what he was doing but the dis-inhibitory effects of the alcohol influenced the mistakes.  He was clear they were mistakes.  It was alcohol, lust, and opportunity.  Without the alcohol, Dyson was confident that he would have never lapsed.  He had initiated and gone to therapy for himself.  His relationship with Samantha was too important for him to screw up, so he decided that drinking was too much of a risk... just not worth it.  Dyson stopped drinking alcohol altogether.  It had been seven years since the sexual lapses and over six and a half years since his last alcohol.  He was frustrated that his commitment and his behavior was not enough for Samantha to trust that he would not stray again.  He had accepted that Samantha was not perfect either and had some issues, but he was willing to work through them.  He wondered why couldn't she do the same for him.  There continued a cycle of accusations, resentments, and acting out on Samantha's part that Dyson did not appear to contribute to in their current relationship.  He seemed to have managed any compulsive issues of his own, but remained a reluctant participant in Samantha's addictive or compulsive cycling.

Alcohol was an issue for Cybil and Gwyn, but not because of abusive or dependent use.  They came to couple therapy to help stabilize Gwyn's abstinence from alcoholism.  Drinking was not a current problem they needed to work on.  Gwyn had stopped drinking for close to three years, but she admitted that she was abstinent but not really sober.  She had not worked since several years ago when she was a manager at a big department store chain.  Gwyn had been on permanent disability for a while now.  Her disability occurred in a work accident as a forklift dropped some boxes of heavy appliances that hit her, leading to a chronic back injury.  In the workplace investigation, it was suspected that she had contributed to the accident by not following safety procedures.  She had walked right into the path of the forklift despite all the safety precautions.  The company lawyers could not prove anything, and they settled to avoid further expensive litigation.  Although, the company never found out, Gwyn and Cybil knew that the accident had been due partly to her being impaired.  Whether or not she had been technically under the influence at the time, her drinking and/or hangover had left her disoriented and distracted when she should have been following safety protocols.  Other medical issues now made it dangerous for her to drink alcohol.  Her pancreas and liver had been damaged by years of drinking and resumption of drinking could literally be fatal.  Cybil had a lot of resentment for Gwyn's substance abuse and how it had jeopardized the family stability.  They had two girls- 10 and 16 years old that had very good academic prospects for going to college- not that Cybil knew how to pay for college as things were financially.  Cybil felt the pressure of making the only income in the family as a supervisor at a large mail and package delivery company.  She had been able to work long evening shifts three-four days a week so she could be more available for the girls.  Cybil had done this when Gwyn was working- never quite sure if she would get fired, "take a break," or quit a job.  Now that she was on disability, Cybil remained anxious that Gwyn might lapse and throw their tenuous family and financial stability into arrears.  

There was no active drinking or substance use either when Shuman and Myanna came for couple therapy, referred by a therapist who had been working with their elementary age son.  The therapist had felt that there were significant family issues that were affecting the son's emotional stability and had done a few family sessions.  In the family sessions, the therapist saw that there were major communication issues between the parents as they were out of sync in many ways.  They came to couple therapy to get more in tune with each other and be consistent in dealing with their son's needs.  As the couple therapist conducted the initial intake, each partner was asked about any current or past history with alcohol or drug use.  Shuman revealed that he had an alcohol problem for almost twenty years, but now had been clean and sober for twelve years.  He said he worked really hard at his sobriety regularly working his twelve-step program.  Myanna acknowledged that he was much worse when they were younger and in the early years of their marriage.  He had alcohol and drug problems and they had separated a couple of times.  But they got back together as he could get sober and because of their son.  Myanna complained that Shuman did not spend enough time with her and their son.  She felt that if he spent as much time with them as he spent "working the program," attending meetings, and sponsoring drunks that they would do a lot better as a couple and as parents.  In addition, she said he was so negative towards her and their son.  Myanna admitted that she had an issue with credit cards.  They had more than twenty thousand dollars in credit card debt, which made their hopes of ever getting their own house difficult.  Myanna said he was so nasty about it and never gave her any credit for the money she saved within the household budget.  What was worse for her was how Shuman made critical comments about their son's weight.  Myanna said he called her fat too, but calling their son fat… making snide remarks at meals really hurt.  It made Myanna want to protect their son, which led to arguments at the kitchen table regularly.

None of these three couples: Dyson and Samantha, Cybil and Gwyn, and Shuman and Myanna presented current alcohol, drugs, addiction, or compulsivity problems in their relationship.  While there had been problematic use if not abuse or addiction to alcohol or drugs, getting clean was not an issue.  The chaos of ongoing abusive or dependent use on the relationship, finances, children and family, and work was not the problems that they had sought the assistance of couple therapy.  However, the shadow of addiction and compulsivity sat heavily upon each of their relationships.  There were vague indications or probable concerns involving addiction and compulsivity that the therapist sensed.  Dyson had betrayed Samantha sexually when drunk.  Samantha was not sure if his sexual infidelity was another compulsivity beyond alcohol.  Samantha was relentless harassing him about his one-night stands from seven years ago, despite admitting that there had not been any lapses or indications of Dyson being tempted by other women.  Her adamant demands on Dyson eventually triggered him to bring up her "issues" a couple months into couple therapy.  Further exploration found that Samantha frequently cut herself when stressed.  The therapist realized that while Dyson may not have an addiction issue, Samantha had some compulsive behaviors that came from deeper issues as yet unarticulated in their relationship.  Fortunately for the couple, therapy shifted to explore these issues, which included significant trauma from Samantha's childhood.  The trauma triggered her suspicions of Dyson beyond what he had deserved.  As yet, Samantha did not own or admit compulsive behavior was important.

Gwyn in contrast was an admitted alcoholic and substance abuser.  She was committed to staying clean.  However, there were decades of unresolved issues, resentments, and emotional betrayal between Gwyn and Cybil over her addiction that they needed to deal with now that she was finally if unstably abstinent.  Cybil had tolerated her addiction and accommodated for her in the family and house with righteous self-pity for a long time.  Cybil could be identified as a co-addict, enabler, or co-dependent.  Cybil was thus, an addict in her own way.  Without Cybil's indulgence, participation, and support, Gwyn would not have been able to "keep it together" for all these years.  Cybil had helped her be an addict.  Beyond that, although she was proficient at being the spouse of an active addict, Cybil did not know how to be the spouse of a sober person- especially, one who was learning how to be healthy and sober.  Shuman thought he had learned how to be healthy- that is, clean and sober.  He was proud of his ten years of abstinence and deeply committed to his twelve-step programs.  He went to meeting regularly and sponsored and had sponsored several alcoholics and addicts currently and over the years.  Myanna however thought he was addicted to his twelve-step program.   What was more, she suspected him of being involved with other women.  He had been with other women on their "breaks" before, but it seemed to Myanna that some of these women were around before they had separated those times.  Spending money for the children and the household was a reasonable explanation for their credit card balance, but did not justify some compulsive purchases that drove up the debt.  Myanna's eating and spending was out of control as much as Shuman's twelve-step involvement and family balance was out of whack.  Despite addiction and compulsivity not initially identified as a goal of couple therapy for these three couples, the therapist's sense of submerged issues required restructuring of the work.  Effective treatment demanded shifting them from peripheral concerns they had named as key dynamics, to addressing, if not attacking submerged addiction and compulsivity issues as foundational to relationship problems.

HIDDEN
In other couple therapy presentations, there may be no overt clues that addiction or compulsivity impact or define the relationship.  Everything may be obscured or hidden.  This may be intentional or as is often the case, the consequence of misunderstanding, ignorance, denial, or secrecy.  Daryl and Marilyn came to couple therapy as a part of their family therapy to help their son who was acting out in high school.  From an almost straight-A student, student body officer, and varsity sports star, he had plummeted academically to Ds and Fs and dropped out of student government and teams.  And he was often out late and coming home high or drunk or both.  "Getting shitfaced" was his new favorite pastime.  In a family session with their son's therapist, their son had confronted them, accusing of being completely fake to everyone.  "Yeah, so you look good and smell good to everyone… big shot corporate vice-president and housewify- president of the PTA, but there's so much shit that you two have going on.  You think I don't know?  You should deal with your own f—kn' crap before you start to get on my ass."  When the therapist asked if there were issues between them, Daryl and Marilyn had stiffly admitted there was some "tension."  Their son rolled his eyes at this "admission."  Their son's therapist sensed that "some tension" was probably quite substantial and decided to stay focused on the son's therapy and refer the parents out to another therapist for couple's therapy.  They came to couple therapy ostensively to work on communication and alleviating relationship stress.

Communication and stress were also concerns for Carl and Bethany.  They came for couple therapy because they felt they had stagnated.  Carl had a supervisor job at a small office supply warehouse.  He had been there fifteen years- in the supervisory job for five years.  He had taken some community college classes but had quit long before he met Bethany.  Bethany said it took years of nagging to get him to go for the supervisor's job.  She said he had no ambition.  They had one child together and a teenager from her prior relationship.  Bethany said she had the only ambition in the family.  She had cut back on her job and been into a marketing program for the last two years that specialized in holistic nutritional supplements and vitamins and other associated health and lifestyle products.  That meant spending less time with Carl and household issues.  He took issue with her absence from the household and the loss of income as she was "doing her thing."  Relationship tension and stagnation sound like grist for the mill in couple therapy.  Clinical sophistication and awareness however eventually directed the therapist to explore for both causes, consequences, and reactions to tension, stagnation, or other relationship issues such as loss of passion, disinterest, disconnection, emotional, verbal, financial, and physical abuse, betrayal, infidelity, trauma, personality disorders, and more.  The problem often comes from another problem or problems, or a succession of problems.

Daryl and Marilyn's son getting "shitfaced" regularly could be a problem from such a series of other issues.  Drinking and carousing may be much more than some social peer pressure or developmental experimentation.  The therapist should be aware of family precedents with alcohol, substance abuse, and other dysfunctionality that predict generational transmission.  Individuals that have problems with addiction and compulsivity often have parental and prior generational history and sometimes, specific models of such dysfunctional behavior.  Both bio-genetic and social modeling theories predict concordance in subsequent and previous generations.  Couple therapy eventually revealed that Daryl binged once or twice a month with alcohol and had affairs throughout their marriage.  Almost none of the affair partners were important to him in any meaningful way.  Illicit opportunistic sex was a compulsion that he could not control… had not controlled.  Marilyn endured his infidelities with the stoicism she had seen and learned from her alcoholic family-of-origin.  That was how her mother dealt with Marilyn's father's alcoholism and frequent affairs as well.  That is, along with medication prescribed for "nerves," which Marilyn has also duplicated.  Based on theories of complementarity and mutual attraction (however dysfunctional), their courtship itself and their relationship despite distress and turmoil was compulsive in the first place.  Couple therapy needed to explore how, why, and what compelled them to be drawn and to stay together despite clear warnings against their partnering.

In Carl and Bethany's situation, Carl felt fundamentally and chronically dominated and dismissed by Bethany.  He felt emasculated.  When asked how he dealt with that, he first minimized her effect on him.  He said he just shut her out.  Under the therapist's relentless investigation, Carl finally admitted that he drank every night.  It started with a couple of beers before and during dinner.  After dinner and after putting the kids to bed, he turned to the hard stuff.  Chivas Regal in the purple velvet bag was his standby to get duly buzzed more efficiently.  He said it helped him mute the "noise."  Bethany hated Carl's drinking at night.  She said he was not emotionally or socially available when he drank.  And, he sure "the hell wasn't sexy!"  Bethany nagged him relentlessly about his drinking on top of everything else.  Carl said being nagged about drinking was just one more thing.  He drank because she was on his ass all the time for doing this or not doing that, and then complained about his drinking.  The cycle of dysfunctional behavior and communications between them needed to be interrupted.  And drinking was one important cause, consequence, and reaction within the cycle that couple therapy tried to address.

The therapist may naively choose not to work with addiction and compulsivity in individual therapy, couple therapy, or family therapy.  However, addiction and compulsivity very much like abuse and trauma are often intrinsic to individual and relationship dysfunction.  The couples discussed here are but a few examples of how pervasive addiction and compulsivity can be intertwined within an individual's and a couple's emotional and psychological dynamics.  Theoretical or therapeutic attempts to compartmentalize addiction and compulsivity, and therefore to focus on only on other aspects of relationship dynamics make for clinical convenience rather than clinical integrity.  More importantly, therapeutic effectiveness inevitably must address addiction and compulsivity in individuals and how they manifest in the foundational relationships of the couple and the family.  Just about any stressful situation, stressor, trauma, problematic issue… just about anything can cause or trigger abusive use or behavior, dependency, addiction, or compulsivity.  Couple therapy has to be much more than telling or instructing partners on how to behave and how to speak to each other.  Instructional videos, communication pamphlets, any number of relationship books or articles, the golden rule… or just about any four-year-old can tell one how to behave or speak reasonably and civilly.  "Be nice, take turns, be fair, share, listen…" and so forth suffice for advice.  

None of the partners in the couples just described are stupid, ignorant, or uncaring.  Psychologically or emotionally unsophisticated, but none lacked basic common sense.  Tamlyn and Phillip, Mitchell and Kat, Dyson and Samantha, Gwyn and Cybil, and Shuman and Myanna, Carl and Bethany, and Daryl and Marilyn were all arguably or obviously functional individuals who were educated to highly educated, employable and employed, and financial and vocationally or professional proficient.  They initiated and could afford couple therapy.  Yet, they could not consistently "be nice."  Each person admitted reluctantly or openly that he or she had failed to be honorable individual or good partner he or she had aspired to be.  They betrayed their own standards of behavior.  The therapist must address how addiction and compulsivity cause or trigger violations of such simple rules for conduct and communication.  That is why one has another alcoholic drink, says rude and abusive things, overeats, purges, cuts, over-spends, gambles the household budget, is unfaithful, and other self and other harming behaviors despite admonitions not to and repeatedly suffering severe consequences.  The therapy of individual and couple therapy, rather than the counseling or problem-solving lay in addressing addictive and compulsive behavior that occurs despite being aware of inevitable adverse consequences.  Therapy must address how a bad choice clearly identified and previously experienced has become an addictive behavior and/or a compelled choice… that is, a destructive compulsion.

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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