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You're Not the Person I Married
I. Introduction
First, I should note that the title, "You're Not the Person I Married" does not apply only to
legally married couples. Rather, it applies to all couples seen as "committed" by the
couple itself.
That being said, relationships and substance abuse can mix in one of three basic ways:
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1) Both people use casually, and one develops an abusive pattern over time while
the other "hovers" just below the "abuse line"; the net effect is they become
more alike over time. They both spin out of control over time with periodic
crises, only one members seems to spin "faster" and has the more problematic
history.
2) Both people are heavy users when they meet, and over time both become
abusive and balance each other out to form some stability; the net effect is they
become highly similar over time. Some family research supports that this kind of
alcoholic family can remain stable for years because they alternate who is the
"functional" one and who is the "drunken" one and are able to take care of things.
3) One uses and the other doesn't, but over time the user develops abusive
patterns; the net effect is they become more and more dissimilar over time. The
user becomes more impaired due to increased use, and the codependency of the
non-user becomes more pronounced and developed as well, sometimes leading to
apparent "super-functioning" next to apparent inability to function. |
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These relationships can come to you in one of two "places" in their lives:
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before they recognize that there is a substance abuse problem
or
after they recognize the problem and have entered or completed treatment |
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How Non-Abusive Couples Present Before Treatment
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1) One person has "had it" with the other, or has great fears of losing the other;
sometimes affairs are part of this. This person is usually the one to contact me.
2) The couple comes in, is able to reveal a key problem they can start with, but a
review shows other problems. We begin work where they are comfortable and
slowly go on to the other problems.
3) Sometimes a deeper issue is revealed that must be addressed. Part of my job
is to offer some explanation and then either realistic hope if it appears to be a
surmountable problem, or some realism if it seems insurmountable.
4) There's some big argument or fight, and the couple reveals some of how they
handle distance and closeness. We discuss how to fight better.
5) We spend time in sessions talking about "loaded issues" in an effort to defuse
some of their toxicity, improve communication when there is conflict, and rebuild
empathy between the couple.
6) We build in a sixth session review to re-assess where we are going and if
therapy is helpful. We adjust our path or direction as needed after this.
7) The couple shows fewer arguments, periods of anger, and crises, and can grow
closer to each other. |
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How Substance Abusing Couples Present Before Treatment
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1) One person has had it with the other, or sees the relationship as basically
being interrupted by an "affair" with the drugs. Generally it is the co-dependent
one who initiates therapy.
2) The couple comes in, reveals a key problem to start with, but gives glimpses
of other problems. We begin work where they are comfortable and try to go on
to the other problems. This is essentially the same as 2 above.
3) The deeper issue of substance abuse comes out soon in treatment, but the
couple may dismiss it as "no big deal"; one or both may use, and they may use
separately or together, and the same substance or different ones. It's very hard
to go into and make progress in other areas identified as hidden problems.
4) Some crises comes up, such as a big argument, a DUI, a positive drug
screening at work..., and the role that substances plays in allowing closeness and
distance becomes more clear; the heavy codependency is also clearer at this
time.
5) We spend time in sessions talking about "loaded issues," but it never seems to
defuse any tension or provide any assurances. We make little progress improving
communication, or communication actually becomes more conflicted because
deeper issues they used to never discuss now come up and lead to more blow ups
and crises. We make little progress building healthy empathy between the
couple.
6) We try a review of our work, but some crises often prevents us from doing
this, as if they use the crises as a way to avoid facing where they are at and what
they are doing, and the lack of progress they have made in trying to repair the
relationship without addressing substance abuse.
7) The couple shows more arguments as therapy progresses; they either break
up after some painful fight, or they enter a period of intense denial and go back
to "happy as before." |
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Thus, the relationship may start in one of the three key positions noted above, but
substance abuse changes the dynamics between them and the abusing partner no longer is
"the person I married."
The Established Couple During the Abusive Period
The organization of the family around substance abuse is strong and not easy to break
into. Both the abuser and the co-dependent partner learns to do a number of things:
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 deal with chronic crises and accept them as "normal" parts of life.
avoid real relationship issues and deny their loneliness, isolation, and pain,
including possible substance abuse problems in the "sober" partner, the chronic
and serious health problems a partner faces, and the impact of substance use on
their relationships with others.
collude not to see, not to name, not to challenge, and not to acknowledge the
power of the drugs and alcohol. This entails "little white lies" they tell themselves
and others.
maintain "split" realities, or a body of knowledge dealing with the "real world,"
and a body of knowledge dealing with the "world of denial." the "little white lies"
become "real" and the couple starts to believe them, and ignore anything that
would contradict them.
play roles with each other (e.g. the responsible one, the adjuster, the placater
from Claudia Black, or if you prefer, the hero, mascot, lost child, and scapegoat
from Wegsheider, or if you prefer, the rescuer, the victim, and the persecutor)
and triangulate others into their problems. Therapy without focusing on the
substance abuse may fall into this category and be used only as a "bandaid" for
their problems.
use twisted and distorted communication patterns (e.g. distorting, use of
euphemisms, scapegoating to allay blame, omission of some problems
altogether) that may be new or may be an extension of what they learned in their
family of origin. |
As I noted, my experience is that these couples don't do well in traditional therapy that
focuses on communication, skills-building, and generational processes, etc.... Growth is
painful and hard, and they may run from intimacy or back to previous patterns. It's hard
to make any inroads to improving any specific areas when the substance abuse continues
to disrupt the couples' life.
Therapy can, however, begin to highlight the role of the substance abuse in destabilizing
their relationship, and the ways that substances both solve some problems in
their eyes but create new ones. The one who denies having a problem can sometimes be
enticed to drastically cut back on use for a short time, but can't hold to this. Sometimes
the couple can then see that the problem is really bigger than they thought. This could
trigger an even bigger relapse, however.
II. Does Couples therapy Belong in Substance Abuse Treatment?
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Some professionals, companies, and agencies may focus exclusively on the addict
and forget the partner. The partner may be happy with this, thinking they aren't
the one with the problem; rather, the abuser is the one with the problem, and if
they simply stop using, all will be well.
The problem is that the partner may be depressed, may have a less obvious
substance abuse problem of their own, or may have learned to somaticize
distress and have apparent health problems. They may well be real health
problems; I don't mean to imply they are "all in their head." However, their
health problems may be aggravated by the stress caused by dealing with the
substance abuse. These problems may spell relapse for the abuser, meaning the
treatment team should know about them, or may simply be treated more
effectively in the partner by knowing the context of their development, meaning
the partner's therapist or doctor should know about this.
Even when this is so, the partner of an abuser may have difficulty accepting the
help of the treatment staff. Whitney offers three big fears the partner may face.
First, since such partners tend to blame themselves for the abuse in many
relationships, they fear professionals will do the same. Second, they fear the
focus of treatment may be to end their relationships. Third, especially if they
abuse too, they may fear confrontation.
Further, when the abuser begins recovery, the partner may not know how to
react without these familiar and comforting roles. They may themselves come
from an alcoholic family, and carry "baggage" as a result: |
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the alcoholism could have left them emotionally "dead" inside, and they
need the emotional chaos the abuse causes to feel "alive" and connected
to the partner. It seems normal to them too, so it is hard to consider that
things could be different
the abuse in their family may have left them with a high need to control
and "heal" a partner as they tried with their parent. They may need to
take responsibility and control for everything, simply as a way to feel that
everything isn't slipping away. They may have a hard time accepting the
user's helplessness, since they have such a hard time expressing their own
helplessness
they may distrust and fear abandonment and hurt as a general rule.
Removing the alcoholic partner may remove the only way they have
known to deal with the user and the only way they know how to be close
and safe at the same time |
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Whitney argues that partners of alcoholic gay men tend to be "Type A
personalities who have few sources of support and lead highly compartmentalized
lives." they may have given up outside friends due to the problems and
embarrassment their partner has caused them. He argues they have learned to
accommodate the user so well, that they don't know how to be themselves with
the user or communicate clearly anymore, and may have lost the social skills
needed to make friendships outside the relationship.
When the abuser enters treatment, the idea of "if she stopped drinking, all our
problems would stop" doesn't pan out. Things don't get better, they don't feel
happier, and the feelings of loneliness and misery continue. The partner may
have worked hard to compensate for the user in the past, and "be helpful," but
now are told, "You can't do this" and "You're part of the problem." This rejection,
coupled with the user's new focus on himself, may leave his partner feeling lonely
and cut off. If the partner wasn't depressed before, she is now.
Or, the user may be depressed now that they have started to discuss some of
their past and started feeling what they used to repress. The depression
that comes may make the "competent" and sober partner feel confused and
helpless. Accepting powerlessness comes in again.
Some programs may supply some educational counseling as part of family
therapy and work, while others may not. Even when "family therapy" is offered,
the couple may be dealing with a "family of choice" as opposed to only a
biological family.
The National Institute on Drug Abuse offers several therapy Manuals for Drug
Addiction including ideas on "couples therapy," but it is really only a short-term
treatment that "buys time" to keep the relationships together through the
recovery process. The partner is told in the first session they are responsible for
what they do that makes abstinence harder, and that the addict's recovery is the
prime goal of therapy. Urine screenings and any medications that need
monitoring are the first topic of every session. Sessions two through eight focus
on relationships attitudes, setting simple goals to improve the relationship, and
communication around those goals.
While this can be helpful in "holding it together" for the short-run, this won't address any deeper couples' issues. This may simply "keep the peace" between them. As in other areas of work these kinds of couples, you at times can only delay facing a problem. On the one hand, This gives them time to gain strength to face it, focus on taking responsibility for problems in general before confronting a particular one, and can be helpful. On the other hand, putting off issues doesn't make them less painful or toxic.
There is some research to support the efficacy of a couples intervention for
sobriety (i.e., Behavioral couples therapy
for alcoholism and drug abuse, Maintaining change after
conjoint behavioral alcohol treatment for men: outcomes at 6 months, and
Twelve-month abstinence
from alcohol and long-term drinking and marital outcomes in men with severe
alcohol problems), as well as to address domestic violence in the couple (i.e.,
Domestic violence before
and after alcoholism treatment: a two-year longitudinal study). |
III. So What Do You Do In Your Work With Substance Abusing Couples?
You should always keep three issues in mind:
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First, there's "normal dysfunction" the couple must deal with, such as career
stress, financial hassles of life, and family difficulties and developmental changes
(i.e., children grow up, mid-life crises hits, parents become older and perhaps
more dependent on their adult children)
Second, there's the substance abuse, and all the affairs, lying, recklessness,
irresponsible spending... that go with it that causes more problems
Third, there's issues of being gay or lesbian, such as internalized homophobia,
being an "invisible couple," fears of being outed... that go with this |
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Where do you start?
One way to start is to help the couple admit to their need to remain together. Why else
would people go through all this pain and dysfunction? Why would they stay in obviously
dysfunctional relationships? the needs to be attached, safely and securely, are powerful.
they may be a mess, but the evil you know is better than the evil you don't know.
However, there is more involved that may be revealed when the couples enters treatment:
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Bowen argues that multigenerational processes come into play. Modeling for
how to be close and to handle loss and conflict, for how men and women behave,
and for what caring and love entail all come into this. Gender roles may switch
between generations, with gay men becoming like their mother or lesbians like
their fathers. Holiday and family rituals may reinforce drinking. "Open family
systems" may become too disorganized and chaotic to intervene, while "closed
family systems" may be able to contain signs of abuse until it reaches a crises.
Helping them see the multigenerational patterns in their use, abuse, dependency,
etc... can set the stage for many changes and growth-prompting realizations.
Violence can also come into play during times of use, both from weakened
defenses, as well as surfacing of buried and now more intense emotions, such as
resentment, loneliness, and hurt. Denial of the problems the substance abuse
causes becomes common, as well as periods of greater closeness associated with
the cycle of violence. A pattern of violence may have been associated with the
substance abuse, and while they might anticipate the violence ending (with
greater control over the user's behavior), they might also fear interacting around
many issues for fear that the "soothing" effects of the alcohol or drugs will not be
there. Small fights will automatically go to big fights. Teaching simple
communication skills, rules for arguing, permission not to discuss some issues,
and instructions not to discuss others without the therapist may help. If violence
does erupt, the couple may not be appropriate for couples therapy and may need
to go back to individual work with referrals for shelters and domestic violence
programs.
Internalized homophobia comes into play here too. Ideas about really
whether it's OK to be gay, and how all gay people socialize in bars can also be
comforting rationalizations. "It's not the alcohol, it's just that two men can't be
monogamous" to some is less hurtful than facing the substance abuse. When
one's sexuality is seen as "dirty" or something to hide, alcohol and substances
can have a powerful effect on soothing guilt and shame, easing anxiety, and
loosening inhibitions. I'm not saying that gay sex is dirty and should be hidden,
or that coming out entails substance abuse. Rather, dealing with negative social
stereotypes can make drinking and using more powerful. Harry Stack Sullivan
wrote in the 1940's that: |
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With truly distressing frequency, the sundry problems connected
with early adolescence cause the person concerned to turn to
alcohol, one of the great mental hygiene props in the culture... And
the problems that get one all too dependent on alcohol are, I think,
the problems of sexual adjustment, which hit hardest in
adolescence (1953, p.273) |
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Interestingly, I read a dissertation study from the U of I at Champagne that found
gay men and women who drank at the bars and became alcoholic had histories
that indicated alcoholism in the family, and heavy drinking before self-identifying.
Thus, going to the bars more frequently did not cause alcoholism. Rather,
alcoholics tended to result in focusing more of one's life around drinking and bar
interactions.
Many samples tying gay/lesbian identity to substance use have shown gays and
lesbians to have abuse problems at three to even seven times the level of
heterosexuals. These studies are often based on bartender reports, limited self-reports on questionnaires covering other issues, non-representative samples,
etc... and so it is hard to know whether gays and lesbians really have more
substance abuse problems or not, but they may. It is interesting to note that
many "coming out" books now a days have sections on pot, alcohol, crystal, and
X.
McWhirter and Mattison wrote the Male Couple, and even talk about stage
discrepancy, which happens when the two men are at different points in the
coming out process.
HIV comes into play as well. Repressed fear, anxiety, anger, and resentment, as
well as feelings of distrust in one partner can result in deep unspoken and
unresolved emotions effecting all the couple's problems. For the HIV+ partner,
they may be used to substances and sex together, and sexual intimacy without
this "buffer" is scary. Further, facing mortality, losing the partner, and guilt and shame over HIV can all complicate treatment.
Smith (1982) recommends a "bifocal approach" in which being gay or lesbian is
seen as having nothing to do with substance abuse, and alternately as having
everything to do with it. Issues that can be separated but also deeply
connected to sexual orientation include:
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feelings of being "different" from others at the basic core, and being
misunderstood by everyone as a result; this could lead to real isolation
from others and limited social contacts, as well as ready-made
rationalizations interfering with treatment
ideas of lower self-esteem related to rejection and estrangement from
family, sometimes tied to a sense of insecurity related to body shape,
appearance, and "attractiveness." Family issues may come into play when
a client enters treatment and the family now must deal face to face with
their partner. Issues of whether their sexual orientation is "real" or an
aspect of the substance abuse may come up. I recall a friend who finally
left his lover of five years because he wouldn't seek treatment. His family
responded with support, and then suggested that maybe it was time to
"stop seeing men now and get over this completely"
impaired social skills with members of the same sex after years of using
substances, acting out, failing in commitments, and abandoning
relationships with people who expected more; the "real" intimacy that
sober dating requires may be more than they can handle, or so they think,
and they may reject their relationships as being "second rate" at best, and
demean real closeness
compartmentalization and objectification regarding sex beyond that normally seen in
substance abusers. The client could have been raped or
placed in other victimizing sexual relationships in order to obtain
substances or while under the influence of them, and may have repressed
fears and traumas that substances used to help keep buried. Intimacy
without substances may allow these traumas to resurface
fears of sexual compulsion; while obsessive or compulsive behaviors can
be seen in some recovering people as a way to organize and make sense
of their world, sexual activity can be higher frequency without being
compulsive, and all sorts of stigma may come to the surface in gay men
issues around aging, review of one's life, desires for a longterm partner,
etc... |
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Be careful not to push the couple too hard or too fast, as you can strengthen their
defenses, or overload them with issues that are too intense and too early, and prompt
relapse.
After the partner enters treatment, the couples' view of their world is smashed. At that
point, the abusing partner stops being the person you married, and even stops being the
person you learned to live with. They now become someone else altogether. There are
several issues to keep in mind in your individual work, educational meetings, or brief
counseling when you begin to discuss these issues.
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The Partner
Be willing to discuss the person as someone in a relationship, someone who may
fear losing that relationship since they don't know how to be close without alcohol
or drugs. Some panic through the period of "pausing" is normal; this is the time
when recovery begins, when each needs to focus on themselves as separate from
the relationship. Offer some guidance that they must focus on healing
themselves and building new skills before they can begin any real work at healing
their relationship; the skills they learn in recovery (e.g., clear communication,
taking responsibility, and admitting to their problems) will be required for any
real change in the relationship.
Get help for the partner, whether this means for depression, anxiety, or
substance abuse, whether it means individual therapy or support group work,
whether it means help renewing lost relationships or book readings. Be willing to
discuss feelings of jealousy toward AA friends and abandonment for the 12 Step
Program, as well as frustration over slow marital change and the disillusionment
that stopping the abuse didn't fix everything. You are working with a person who
has already had their life twisted from abuse, shaken up from the start of
recovery, and now jerked out of place again when you tell them they are part of
the problem and that they must "wait" until the addict is firmly in recovery.
The Couple
"One day at a time" means both "I'm not drinking today" as well as "I'm not
leaving you today" so you have to help both clients see this and accept it. The
couple in essence stops looking to each other for their needs, becomes more
independent, and then learns to start looking to the other one need at a time.
Allow them to take the pressure off of the relationship, and simply live it one day
at a time instead of being faced with five years of abuse and a whole future of
being together or alone.
Some relationships don't make it during recovery as the love may have been
eroded, or the powerful prompt for the dependent partner to face their own abuse
may be too frightening. If they had a life before using, they may be able to
reclaim it, if not they may be especially lost. They need reminding of strengths,
triggers for both of them, as well as weaknesses and mistaken or rationalized
beliefs that are hard to let go of.
More Specifically
Sexual problems may develop as well, and impotence, changes in specific sexual
activities they engage in without substances, having sex at all without
substances, etc... may raise other issues for consideration such as fear, anxiety,
and feelings of inadequacy. Straight-forward Masters and Johnson work on
improving communication around sex, sensate focusing, asking for physical
needs, etc... may be very helpful.
An unbelievable well of buried emotions may come to the surface, bringing with it
everything from past affairs to financial problems. You may not be able to put off
some problems, so be willing to discuss what is really a crises and offer some
sound advice. That may mean telling them that part of abuse is irresponsible
spending and financial management. They should go to a financial or credit
consultant to deal with their financial problems and hear some sound, realistic,
and clear advice, and when they are ready in a few months, they can deal with
some of the issues surrounding their feelings of resentment.
Referral to a lawyer may also be helpful in dealing with legal issues, wills, powers
of attorney, debt consolidation, etc.... Likewise, when HIV issues have come into
play, referral for sound medical care and continued work on what it means to
follow up on that and maintain health will be needed.
Be willing to open communication and some negotiation around behavioral contracts. A partner might be able to accept daily AA/NA meetings more easily if she is able to spend one evening a week with her partner without anyone else being involved. One couples night could be traded for more frequent clear verbal support for AA/NA attendance. Even if the abuser can't do this yet, saying to the partner, "It's not that I don't want to spend an evening with you, it's that I'm scared. Right now, I don't think I can make it through a day without using unless I go to a meeting." This kind of admission can communicate love, as well as the fragility of the recovering addict's defenses. It may be enough for now for the partner to hear this, or may open up other options so both get what they need.
The Abuser
If both are in treatment, a sponsor who's been there with a partner who abused
might help. Otherwise, be willing to discuss how they can support each other
through abstinence, relapse prevention, and recovery work, but realize no
changes can really occur until the addict is on the road to recovery, and that too
much focus on the couple can hinder this. Some couples can work the steps
together, but some can't and trying to do so ends up interfering with each
person's work. Give them the option of one, the other, or a little bit of both. Be
willing to voice fears of, "If she relapses, I won't be able to stop myself" and
discuss this.
Spend some time on time management skills to start meeting responsibilities
before they are crises, on couples improvement skills (e.g., when was the last
time you rented a movie together or brought the other flowers? Said "I love you
because..."? Did something totally as a gift for the other person to make their
day easier? Renegotiated household chores and responsibilities to deal with
changes in schedules and work load?), on sober individual and couple friends to
socialize with, and on repairing frayed family relationships. |
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Even when several years of sobriety have been accomplished and the family returns for
counseling, continued focus on "what is the problem" and "what keeps you sober" have to
go hand-in-hand. The addict never "heals" and is over the addiction; the couple never
"heals" this way either, and it is easy for past hurts, fears, and dysfunctional patterns to
return in times of stress and doubt.
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