There are many issues confronting a couple when one or both partners are in recovery. In this article we will focus on the role of couple’s therapy, methods that are proving to be effective in preventing relapse, the major issues many couples must confront in order for the relationship to be healed, and the role the therapist can play in helping couples address these issues.

Many studies emphasize the importance of supporting the partner in recovery. Encouragement given by the partner plays a key role in the withdrawal process. For example, research shows that treatment has a greater chance of success in women if there is support from their spouse. However, in almost half the cases, alcoholic women have a partner who also has an alcohol-related problem, ensuring a close correlation between the behavior of both (Brown et al., 1995).

According to an article entitled, “Bridg-ing the Gap Between Alcoholism Treat-ment Research and Practice: Identifying What Works and Why,” in Professional Psychology: Research and Practice, the most successful treatment approaches address the role others play in helping a person recover from alcohol or drug use. Community reinforcement and behavioral marital and family therapy mobilize clients’ networks of family and friends to encourage change (Read et al., 2001).

One empirically tested treatment is community reinforcement, or CRA, wherein family members are taught coping skills and strategies to help influence their loved one’s drinking and motivation to change. The approach contrasts with 12-step approaches such as Al-Anon that encourage family members to detach from the person’s behavior (O’Connor, 2001).

In addition to helping alcoholic and drug-addicted partners to remain abstinent, involving
partners in the recovery process also helps them to cope. Loved ones of substance abusers tend to suffer from depression, anxiety, poor health, and diminished self-esteem, along with a myriad of other problems as a result of a substance abuser’s erratic and destructive behavior. Mindful of this, psychologists built treatment modalities upon the principle that recovery is rarely sought or carried out alone. Among the approaches that have emerged is Behavioral Couples Therapy (BCT) — a team effort based upon cohesive, communicative relationships. BCT aims to rebuild and strengthen relationships on the premise that positive feelings, shared activities, and constructive communication are conducive to sobriety. Timothy O’Farrell, PhD, of Harvard Medical School has tested this theory for more than 20 years with substance abusers at the Harvard Families and Addiction Program.

According to Dr. O’Farrell, a behavioral approach assumes that family members can reward abstinence and that substance abusers in happier, more cohesive relationships with better communication have a lower risk of relapse. “Relative to individual-based treatments, you get better substance abuse outcomes, better relationships, and better long-term abstinence rates — statistics that include lower divorce and separation rates in the two years after treatment,” he explains (O’Connor, 2001).

Each session is relatively structured, with the therapist setting the agenda at the outset of each session. A typical session begins with an inquiry about any drinking or drug use or urges that have occurred since the last session. The therapist will also ask about compliance with the daily sobriety contract and the spouse expresses support for the patient’s efforts to stay abstinent. Couples then review any events from the week and report on homework assignments, which are designed to create a home atmosphere of mutual support and caring. The therapist then identifies a specific concern from the past week.

The first few sessions are most important because, according to Dr. O’Farrell, they focus on decreasing negative feelings and interactions related to past or possible future substance abuse and on increasing positive exchanges. This decreases tension about substance use and builds good will — necessary ingredients for dealing with marital and family problems and desired relationship changes in later sessions.

The typical BCT model entails about 20 sessions over five to six months, often followed by periodic maintenance sessions called Couple Relapse Prevention. Briefer treatments would be more economical, but while most patients show a similar pattern of positive outcomes after a shorter amount of time, more severe patients end up with relapses, and this is a false economy.

BCT benefits not only the substance abuser but also sober family members. It has been shown to reduce domestic violence and family breakups more than other treatment models. “In a study of BCT and domestic violence,” Dr. O’Farrell explains, “I found a great reduction in male to female partner violence.” Before engaging in BCT, 65 percent of the alcoholics in Dr. O’Farrell’s study exhibited violence. After treatment, he says, “for patients who stop drinking, the rate goes down to the national norm of 1 in 6 or lower” (O’Connor, 2001).

One of the most significant factors when only one person is in recovery is whether the behavior of the non-recovering partner supports or detracts from recovery.

Both CRA and BCT address and eliminate three of the major obstacles in the way of continued abstinence and in couples being able to possess the ability to heal their relationship, namely:
1. When a partner is what has been referred to as an “inducer” partner (one who in various ways and for various reasons encourages the alcoholism or addiction of the other). An inducer partner may act in such a way that the drinker is practically prevented from seeing the problems resulting from his or her alcohol consumption. For example, when a partner screens the alcoholic by making false excuses to employers for absenteeism, by paying off debts, or by being more attentive when the spouse is drunk than when he or she is sober (Brown et al., 1995).

2. When a partner behaves in ways as to encourage continuation of the partner’s alcohol abuse. When the partner gives constant reproaches, excessive surveillance, restrictions, threats (Brown et al., 1995).

3. When a partner expresses a high degree of expressed emotions. Harvard psychologist Jill Hooley, DPhil, has pinpointed families’ “expressed emotions” as a predictive variable to relapse. Expressed emotion does not connote histrionic emotional outbursts. Coined by English researchers 40 years ago, the term refers to the extent to which a family reacts with hostility, criticism and/or marked emotional involvement when discussing the patient.

In families with high expressed emotions, patients turned out to be more prone to relapse — a correlation that held true for an array of disorders — even for patients with addiction disorders. The evidence from intensive family therapy is that families spark the relapse, and not vice versa. Where clinicians have effectively lowered the expressed emotion of the family, patients have been less likely to relapse (Hooley, 1996).

Many couples hope that as soon as one or both of them have committed themselves to recovery from substance abuse, their relationship will magically change. Some even experience a brief “honeymoon” period, but sooner or later the initial feelings of relief, joy, and boundless hope give way to a rush of emotions such as sadness, anger, and resentments that have not been admitted before. Oftentimes, their optimism is dashed as they are confronted with both new and old problems.

Saving or healing a relationship when one or both partners are in recovery can be a difficult task. In addition to the difficult work of personal recovery, the relationship itself must be re-evaluated and repaired. Depending upon the level of dysfunction in the relationship and the severity of the addiction, healing the relationship may also include the following:

• Rebuilding trust.
• Having each partner take responsibility for his or her own problems.
• Repairing the harm caused by emotional abuse and physical violence.
• Healing the sexual aspect of the relationship.
• Repairing the harm caused by sexual coercion and marital rape.

The optimum role of the therapist will be to assume that any and all of these issues may exist in the relationship and to bring them up for discussion at the appropriate time, as opposed to waiting for clients to present them. This is particularly true concerning the issues of domestic violence and sexual problems.

Rebuilding trust
Most addiction specialists know that helping the couple to rebuild trust is an important aspect of healing the relationship. Special attention should be paid to helping clients make the connection between trust and boundaries. Instead of either partner deciding whether or not he or she can trust his or her partner, the focus should be on: Can I trust myself to take care of myself? This is particularly important concerning the issues of emotional, physical, and sexual abuse.

Taking responsibility for problems
Both partners need to take responsibility for healing the relationship. The “identified patient,” that is, the substance abuser, cannot be blamed for all the problems in the relationship. Codependency needs to be addressed, as does substance abuse or other addictions of the so-called non-addicted partner. For example, in a recent study, it was discovered that women married to alcoholics were three times more likely to be abusing alcohol than the women in the study who were not married to alcoholics. Dr. Marc Schuckit, director of the Alcohol Research Center in the Veterans Affairs San Diego Healthcare System, has been conducting a long-term genetic study on 453 sons of alcoholics. Since 1978, when the men were first contacted while in college, most married and had families. Ninety-two have become alcoholics. As part of the study of their children, Schuckit also decided to study their mothers. His current findings are based on interviews with 327 women who were the first wives of men whose fathers were alcoholics (Schuckit, 2002).

Repairing the harm
Substance abusers are often prone to engaging in conflict and being emotionally abusive. When one or both partners have been addicted to alcohol or drugs it is also likely that incidents of domestic violence have occurred in the relationship. Research strongly supports the link between substance use and violence. While substance abuse is not a risk factor, it can strengthen probability of occurrence by causing loss of control, decreased inhibitions, and impaired judgment. Half of domestic violence incidents involve alcohol use by both partners. Women using illicit drugs or alcohol are more likely to be physically and verbally abused compared to non-users of drugs or alcohol. Similarly, women who are alcoholics report significantly more abuses than their nonalcoholic counterparts (Fernaughty et al., 2001).

According to The New England Journal of Medicine, a primary risk factor for domestic violence against women is men who use drugs or alcohol. The Research Institute of Addictions also found that heavy drinking by husbands is a key contributor to marital violence. In almost one-third of the participating couples, a study reported that husband-to-wife aggression occurred in the first year of marriage. Fifteen percent of couples indicated that marital aggression occurred more than once in this time. Almost 17 percent reported episodes involving severe aggression, either because of the mental and emotional state produced by heavy drinking or because some people perceive intoxication as an excuse for aggression (Brown et al., 1995). If domestic violence has occurred, both the victim and the abuser are likely to be afraid that it will reoccur. This can create tension, fear, and a lack of spontaneity in the relationship. Although the risk certainly remains, it is important for both partners to realize the connection between substance abuse and domestic violence. The therapist’s role will be to help determine whether or not there is underlying hostility even when alcohol or drugs are not present. If it is determined that there is such hostility, anger management will be a necessary and important part of the recovery process. Continuing to facilitate better communication between the couple and the teaching of fair fighting techniques will also be important.

Sexual healing
The illnesses of alcoholism and drug addiction make the loss of sexual intimacy inevitable. As communication in general breaks down, sexual communication and sexual activity suffer as well. As alcoholism or drug addiction progress, loving expressions of warmth and tenderness tend to decrease. At the same time, resentments increase dramatically. For these reasons, alcohol and drug addiction usually result not only in physical, mental, emotional, and spiritual alienation, but in sexual alienation as well. Anything resembling an active, mutually pleasurable sexual relationship disappears ... (Marlin, 1990).

Chronic alcohol abuse produces hormonal, physiological, and psychosexual consequences all of which affect sexuality adversely. Problems such as sexual dysfunction and loss of desire tend to occur. Impotence is frequently a problem for males who are excessive drinkers. Drinking suppresses the physiological responses of sex organs, which means alcoholic women have a more difficult time being responsive to touch, lubricating, and achieving orgasm than non-drinking women. Getting aroused and achieving satisfaction sexually while actively drinking may seem futile, and many women just stop trying.

Recovering and rehabilitated alcoholics deal frequently with problems surrounding sexual adaptation in a sober state. When simply getting and staying sober takes so much effort, few people place sexuality high on their list of priorities. But as recovery from addiction and codependency continues, couples will discover they can no longer deny sexual problems that exist in themselves or in their relationship.

For example, codependent women and men tend to put their partner’s sexual needs ahead of their own — engaging in sex when they aren’t aroused, allowing penetration before they are sufficiently lubricated, having intercourse when they are feeling angry, giving in to their partner’s pattern of having sex even if it doesn’t meet their needs.

Women and men alike may drink or take drugs as a way to decrease their sexual inhibitions. For example, a man may use alcohol to give himself a feeling of confidence he lacks otherwise. After a few drinks he feels in control and is able to make the first move with his wife. In early recovery, without the aid alcohol, he becomes far more reticent to approach her. He feels more vulnerable and more fearful of rejection.

Those who became involved with an alcoholic or drug addicted partner as a way of avoiding sex are often confronted with their sexual avoidance once their partner begins to function normally.
Therapists need to take a thorough sexual history when the couple enters therapy, asking specific questions that address all the above issues. Then, at the appropriate time, further inquiry concerning each of these issues needs to be made and an open discussion needs to ensue. Specific homework assignments such as Masters and Johnson’s sensate focus exercises can also be given.

Dealing with sexual coercion and marital rape
Marital rape also tends to occur when one or both partners are addicted to alcohol or drugs. For example, use of illicit drugs and alcohol by either partner in a relationship may contribute to the occurrence of sexual abuse of the female partner. Substance abuse by the male partner has been linked with the likelihood of his becoming violent toward his female partner. Use of alcohol and illicit drugs by the man may increase the likelihood of his sexual aggression. Alcohol and drug use may facilitate miscommunication and resentment and reduce the ability to take into account the consequences of aggressive actions. Furthermore, men are more likely than women to associate alcohol use with a decreased ability to manage anger and increased feelings of superiority over others. Above and beyond any pharmacologic effect of the alcohol, these expectations themselves may have an effect on the man’s likelihood of aggression within the context of an intimate relationship (Fernaughty et al., 2001).

Women who use illicit drugs or alcohol are at particular risk of experiencing sexual abuse for several reasons. An intoxicated woman may be less able to defend herself against an assault and may be more likely to become aggressive herself, leading her partner to respond with physical aggression (Fernaughty et al., 2001).

In addition to feeling betrayed and needing to reestablish trust, many female partners experience sexual problems as a result of being coerced or forced to have sex. Problems such as vaginismus (an involuntary contraction of the vaginal muscles) and painful intercourse can ensue. Homework assignments such as sensate focus exercises have proven successful, as has allowing the female partner to initiate all sexual advances.

Providing hope
Relationships in recovery demand the same commitment and vigilance that personal recovery requires. If only one person is willing to change, it makes little sense to try to work as a team.

On the other hand, if both partners make a commitment to work on recovery, on themselves, and on their relationship, couples therapy can be beneficial. Community Reinforcement (CRA) and Behavioral Couples Therapy (BCT) have proven to be particularly effective in helping couples to avoid relapse, in teaching sober partners coping skills and in facilitating better communication between couples. The therapist’s role is to facilitate constructive communication and assign homework assignments that will require the active participation of both partners.

Healing a relationship when one or both partners are in recovery can be a difficult task. In addition to the hard work of recovery, the relationship itself must be re-evaluated and repaired. Depending on the relationship, the therapist may wish to bring up any or all of the following issues for discussion: rebuilding trust, personal accountability, repairing harm caused by emotional and physical abuse, healing the sexual aspects of the relationship, and repairing the harm caused by sexual coercion or marital rape.

Beverly Engel, MFT, has been a psychotherapist for 25+ years. She is an expert in recovery, abuse, relationships and sexuality and has written 15 self-help books on the subjects. Her latest books include: The Emotionally Abusive Relationship, Loving Him without Losing You and The Power of Apology.

References
Brown, T.G., et al. (1995). “The role of spouses of substance abusers in treatment: gender differences.” Journal of Psychoactive Drugs; 27:223-229.
Fernaughty, A.M., Farris, C., & Bruce S.R. (2001). “Sexual coercion and substance use among drug-using women: an event analysis.” Contemporary Drug Problems, 2001; 28:463.
Hooley, J. (1996). Families’ reaction to sick member may predict relapse. Behavioral Health Treatment; 1:12.
Kyriacou, D.N., Anglin, D: Taliaferro, E., Stone, S., Tubb, T., Linden, J.A., Muelleman, R., Barton, E., Krauss, J.F. (1999). “Risk factors for injury to women from domestic violence.” The New England Journal of Medicine, 1999; 341:1892.
Marlin, E. (1990). Relationships in Recovery: Healing Strategies for Couples and Families. Harper & Row: New York, New York.
O’Connor, E. (2001). “Lean on Me: Behavioral Couples Therapy offers addicts a path to recovery alongside a loved one.” Monitor on Psychology; 32:5.
Read, J.P., Kahler, C.W., and Stevenson, J.F. (2001). “Bridging the gap between alcoholism treatment research and practice: identifying what works and why.” Professional Psychology: Research and Practice; 32:3.
Schuckit, M. (2002). Journal of Alcoholism. September issue.

This article is published in Counselor, The Magazine for Addiction Professionals, June 2003, v.4, n.3, pp. 43-47.

No one has commented on this article.

Please keep your comments brief and on topic, and remember that this is not a discussion thread.
Name :
Comment(s) :

J! Reactions 1.09.00 • Professional Site License
Copyright © 2006 S. A. DeCaro

---