One challenge to integrate into substance abuse treatment programs is couples and family support. You may even hear a lot of substance abuse counselors say that you can't do couples therapy because you’re recovering or in your early stages and it’s just not a good time to do that.
Yet research tells us that after eight years of recovery, the best predictor of a person’s recovery is the quality of their family relationships. If we don’t provide support to the couple and if we don’t provide support to the family when the person is entering recovery, we run the risk of putting that person’s recovery in a vulnerable place.
Gottman’s model conceptualizes therapy as: the person with the addiction and their recovery, the partner and their recovery, and then the couple’s recovery. All three of those spheres are important to strengthen that bond, as well as ensure that they overlap.
Addiction recovery is one of the most challenging situations for a couple to go through. None of us grew up saying I’m going to get into a relationship with a person who has addiction issues or I’m going to be the person who has addiction issues trying to be in a relationship.
That’s where a trained couples therapist can provide support and guidance for couples that are ready to strengthen their relationship as it goes through the changes required in recovery.
When is couples counseling the wrong approach?
Substance use or addiction is a spectrum of severity and dysfunction, ranging from mild to severe. Not everybody who is struggling with a substance will be in the same place on that spectrum. There are, of course, folks who don’t use at all and have absolutely zero behaviors around substances and addictions. On the other end of the spectrum, there are people who have a physiological and psychological dependence on substances including alcohol and may also have received a formal diagnosis for this issue.
Of course, we also have everybody who is in between. A couples therapist has to thoroughly assess where the person sitting with them is on that spectrum of use, misuse, or abuse. Depending upon where a person is on that spectrum will influence whether or not couples therapy is a helpful option at the time of the assessment.
Therapists may differ in their recommendations when substance use issues are present and whether or not couples therapy is appropriate at a given time. In my practice, if I assess that couples therapy would be helpful but there is misuse and I’m concerned about it, I will include the recommendation for couples therapy with the additional support of individual therapy. I recommend the individual therapist have a speciality in addictions work, and ideally with couples/family therapy training in at least one research-based model. We want to make sure that the therapy is helpful and that issues of safety have been addressed. With substance abuse, safety issues that need to be carefully managed include, but are not limited to: physical escalation of fights, withdrawal symptoms, overdose risk, etc.
Every case will be different. The focus is on if couples therapy has a change of being effective at that time. It may be bad timing for couples therapy with some couples because in therapy, we ask the person struggling to show up sober, use new skills for their relationship that are usually hard for folks, and try to manage with either decreased use of a preferred substance or to stop it all together. For some, couples therapy will likely hit a wall, seem circular, or feel like it’s not working. In that case, individual therapy or treatment is a far better investment. We may need to see if a different level of care is needed, e.g., detox, inpatient, an intensive outpatient, etc. A recommendation for individual therapy or support for the non-using partner is also usually provided. In these cases, couples therapy may be more effective later down the road.
What is therapy like? Why is it problematic for couples experiencing addiction?
Is substance use showing up as a third party in the relationship?
Just as in affairs, if the person is not ready to give it up, it is going to be really hard, even impossible, to do couples therapy.
Like with an affair partner, substance abuse and process addictions will show up similarly. A person is celebrating with their substance. A person is grieving and mourning with their substance. A person is spending a lot of time and money with their substance. A person may be hearing from others “hey, maybe you shouldn’t be spending so much time with that substance.” A person may be hiding their substance use from their partner. These are all behaviors that happen when someone is having a third party relationship with a person.
From a Gottman perspective—that person is turning toward the substance or the process addiction instead of turning toward their partner. “I’ve had a rough day at work and alcohol is the only thing that makes me feel like I can relax and just sort of let my guard down.”
Wouldn’t it be wonderful if you could feel that way in your marriage instead?
This is the relationship triangle that people find themselves in when it comes to substance addiction and process addiction. In the case of process addiction, instead of talking to my partner after a rough day, I’m either doing something that shifts me out of depression. Maybe I will get on Amazon and I will make sure that five boxes show up tomorrow by 12:00 p.m. I get a little hit of dopamine in my brain and feel a bit better.
I’m excited to see what shows up tomorrow! But then that shame and the guilt afterward and the dysfunction that it creates. The credit card bills, the hiding the boxes, the arguments if my partner sees my account. These things show up as triangles that start excluding one partner while the other partner is engaged in a close or intimate process with that substance.
It is also important that couples recognize the wounds that came up around active addiction or substance misuse. There can be some scary moments or raw spots that are hard for couples to heal. Some of us don’t show up so well when we see somebody in an active addiction process and those reactions can hurt the other person, as well.
Couples counseling and addiction...the trauma work
Couples need work to help heal from those past traumas and those past hurts and betrayals. If they are going to move forward together, those triggers will continue activating their fight or flight mode. With proper healing you have the skills to talk about them when they come up for each of them.
What are the fundamental differences between individual and couples therapy?
In individual therapy, the individual is considered the client. In couples therapy, the relationship is the client, which is why we focus on the relationship.
For someone with an addiction that is seeing me in individual therapy, that person is my client and a most likely goal is to sort out what’s happening around the addiction process.
How is it creating dysfunction for you? What are some things you want to shift around and what can I do to support you in that?
As a Marriage and Family Therapist, I will always hold the family and the partner in mind while I’m doing that work but it’s a little bit more focused on that individual meeting their individual goals.
During couples therapy we do not want to get into individual therapy with two people in the room.
My role as the couple’s therapist, if past substance abuse is present, is not to identify the person who’s being challenged with the substance abuse. We do not want to go that route. What I want to do is highlight the couple’s dynamics around what is happening. If we highlight one person’s process too much and forget that the other person is in the room, then I can’t empower both individuals to share and shift their own respective steps in the dance.
Get support for the addiction...
It is often going to be necessary for the partner that struggles with addiction to find individual support (and their partner may wish for individual support as well). You will want to make sure there’s a good line of communication between the individual therapist and the couples therapist.
One of the challenges may be when an individual therapist may not be quite as marriage friendly as a couples therapist. Ask a potential therapist if they’re marriage friendly, divorce friendly, or neutral as a therapist.
...and then work on the relationship
If you think that you are ready to work on your relationship it is important to find the right person and the right approach. As you interview potential therapists, be honest about your background with substances so that they can make the most fitting recommendations.
Of course, make sure that your couples therapist is trained as a couples therapist and that they have some really solid training in addiction. There should be certifications or credentials that indicate this person has done at least the minimum education and hours that were supervised by another addiction professional.
There are twelve areas of substance abuse requiring particular training and skills to pass the exam and become certified or licensed, depending upon the state where they practice.
Intensive couples therapy is one of the most effective methods of couples therapy. The weekend intensive format serves couples therapy and couples who have been affected by addiction well.
The weekend starts with an assessment initially on Friday evening and the first half of Saturday morning. The assessment will start to build an understanding about what has been the impact of the substance use and recovery, especially during those individual interviews.
After the assessment we will spend Saturday afternoon and Sunday on therapy. We may need to discuss what the boundaries are in your relationship going forward. This is where couples need interventions like the Gottman Rapoport and the Dreams within Conflict and the Art of the Compromise to say
How do I imagine the boundaries around this?
What would that be like for our relationship and what would that be like for our family?
You will come up with these boundaries together and how you’re going to verify them.
We may also spend time to process the past; using Gottman’s Betrayal Model, a partner may need to atone for some past hurts.
There are two important goals for an intensive.
That you walk away being clear about what is expected of each partner and having boundaries in place for that.
Starting the process of healing the past hurts that the active addiction process may have influenced your relationship.
Couples counseling and addiction...after an intensive
Couples counseling and addiction is a long process. Typically, individuals don’t “dabble” for a year and now have problems. These are usually concrete behavioral, cognitive, emotional relational issues that are complicated and deeply entwined.
In substance abuse treatment, there’s about 10 different areas that need work when it comes to helping a person with the addiction process. Are they engaging in safe sexual practices? Have they gone to a medical provider in the last year or 10? How’s their nutrition? Because sometimes when someone is in an active addiction process, they are also not taking care of other physical needs.
Sobriety just means “I stopped using.” It does not necessarily mean personality and lifestyle changes have been made. It does not mean cognitive distortions have been addressed and the person has changed how they think and feel. It only means that they are not using a particular substance.
It’s a long, slow process and I would not recommend that a couple stop their relationship work after an intensive. Monthly check-ins are highly recommended because working through addiction can be challenging for a couple, follow-up care is critical.