Be aware of relationship dynamics in women`s treatment

Across all major addiction treatment modalities—detoxification centers, residential treatment programs, and outpatient treatment with and without medication-assisted therapy—we see evidence that social support outside of treatment constitutes a key component for successful outcomes. For women in particular, being married or having a significant intimate partner relationship is generally associated with increased retention in treatment, particularly at the residential level.1 Given this evidence, it would seem that moving beyond the “identified patient” in the residential treatment context to account for intimate partner dynamics could be essential to a woman's successful recovery. How can clinicians encourage those relationship dynamics that support a woman's recovery, and mitigate those that might impede recovery?

Bevan Gottlieb, program director of Pia's Place in Prescott, Arizona, suggests that when a client first enters residential treatment, initial contact between client and intimate partner be somewhat limited. “A client is likely to get distracted when talking to family following a treatment session,” Gottlieb observes. Getting a “barrage of updates…takes the client out of treatment.” Although the client might have a natural inclination to share with family, particularly with the intimate partner, Gottlieb encourages the client to take these issues into therapy instead.

However, as treatment progresses, bringing the partner into treatment can allow for a new perspective. Gottlieb suggests that in a confidential discussion between the therapist and the client's significant other, the therapist ask about issues that have brought a client to treatment. “In this way,” she says, “we get a different take on the relationship. We have two different historians to report on dynamics.” Gottlieb stresses that clients are “reporting on their experience of the relationship while actively using.… Their reality of the relationship may be very distorted.”

Another benefit of involving the intimate partner in treatment is that the therapist and partner can maintain a united front in countering client resistance. “If a relationship is set up with a spouse or family member, that person can be a huge catalyst to say, ‘It is not OK for you to come home,’” Gottlieb says.

Education around communication

Psychoeducation is a critical component for changing partner dynamics during treatment. Camille Heatherly, director of BrookHaven Retreat in Seymour, Tennessee, says a common misperception among intimate partners is that partners will change if “they understand how ‘bad’ they've been.” In reality, Heatherly says, “Shame causes sobriety to be more difficult rather than easier.”

Sharon Chambers, executive director of the Residence XII program in Kirkland, Washington, agrees. “Some of the spouses we work with in treatment are very angry with their partners, and often with very good reason,” she observes. “They don't understand the disease and their life has been on a roller coaster that has been created by their partner's drug or alcohol use. Not resolving that anger and pulling out this long list of how awful and terrible they've been for years is really going to batter the ego of a newly recovering person.”

For women who have been in treatment multiple times, issues around trust also emerge. Heatherly says that for clients with multiple relapses, “The women want to make it different, but family members are asking how it will be different.” For these women, rebuilding trust with their families and intimate partners is critical.

Heatherly suggests the use of active listening in order to build trust and combat unresolved anger. She says clinicians can model active listening by having the partner speak, and then asking the client what she heard the partner say. She also suggests that clinicians point out sentences that have judgment in them and explain why this is the case.

Chambers agrees that talking constructively about unresolved anger can be a useful clinical tool. “It has to be shared in a way that somebody can hear it without being devastated,” she says. “So it's not screaming and yelling at them.” She adds that having the partner complete a written assignment and then work with the therapist to determine how much of the writing to share with the client can also be a useful clinical practice.

Education around the disease concept for addiction is also essential. “It feels very personal when your partner lets you down,” Chambers says. “And if you learn about the disease of addiction, they're playing out the disease—it's not that they don't love their partner. And so sometimes that's the ‘ah ha!’ that happens.”

According to Annabel Agee, primary therapist for BrookHaven Retreat, “One of the most problematic pieces of an outside relationship for a therapist is when the partner is actively using, and the woman does not want to cut the relationship off.” Research has demonstrated that non-substance abusing partners may begin to emulate their partner's use, and that this pattern is particularly prevalent for women.2 Therefore, after a woman has achieved sobriety, partner use in the home makes it an unsafe place in recovery. Substance-abusing partners may feel that their own substance use is not an issue, because they are not the identified “addict” or “alcoholic.”

Agee observes that this is a sign that a partner is not recognizing the disease's impact on the family system. She considers treating the family system as a whole a critical component for long-term change. In fact, a 1997 meta-analysis of treatment outcomes for individuals engaged in illicit drug use offered evidence that family-couples therapy that focuses on relationship dynamics may be more effective than traditional individual counseling, peer-group therapy, or family psychoeducation.3

Partner participation in aftercare

Even post-discharge, the intimate partner's role in a client's treatment should continue because partner dynamics can shift dramatically following residential treatment. Residence XII's Chambers points to emerging parenting issues. “Often with an alcoholic parent, the kids have been parenting themselves or the other spouse has taken on everything. Then you have a newly sober person coming in and trying to re-establish her parenting role,” she says.

Chambers also points to problems around unrealistic expectations surrounding the woman when she returns home, or the “super mom, super woman syndrome.” She adds that it is “difficult for someone to feel successful with those kinds of expectations.” Also, following treatment, a client still could be unavailable because she is going to many meetings or otherwise receiving outpatient treatment, Chambers observes.

To combat these issues, Chambers advocates that intimate partners work their own recovery program, including attendance in Al-Anon, and that they continue using the communication skills learned in therapy. Chambers also suggests behaviorally focused assignments for couples post-discharge.

“Sometimes it's having a date night once a week where you reconnect,” she says. “What are the things that you and your partner enjoy that you've given up as a result of your addiction? Whatever brought the couple together, that is their commonality. It's important to build on it, and to continue really to emphasize ongoing communication about how the change is working.”

Addressing intimate partner abuse

Any discussion of partner dynamics in addiction treatment must address the issue of intimate partner abuse. Research has demonstrated that as many as 58% of married/cohabitating women seeking substance abuse treatment services may have experienced relationship violence in the past year.4 Still, adequate evaluations of intimate partner violence are sometimes missing from substance abuse treatment programs, meaning that women experiencing violence may not be identified.5 Researchers have suggested that the Conflict Tactics Scale-Revised6 is a relatively brief assessment that can be used to assess for intimate partner violence more effectively.5

Mary Locke, a primary therapist at Pia's Place, observes that a symptom of intimate partner violence may be difficulty in cutting off or reducing contact with the intimate partner upon admission. “If a client is in an abusive cycle, she may feel that contact gives her some sort of control, so she focuses on that instead of on treatment,” Locke says. A benefit of this, Locke believes, is that because the behavior is happening “in the moment, you can help in the moment.”

In cases of intimate partner abuse, partner participation in the client's treatment program might not be appropriate. Safety should be expected, and safety planning is imperative. If a client plans to return to the abusive home, a therapist should work with her to come up with a plan of escape, should the situation escalate into violence.

Conclusion

The research evidence is clear that comprehensive services, particularly those that include partner-involved interventions, are critical to a woman's recovery.5 Although these types of relationship-based treatments are now more widely offered,5 asking partners to work on their own recovery plan (e.g., Al-Anon, active participation in couples counseling) still might be a new idea to some partners and some clinicians.

Chambers states that “getting the word out that it's not ‘his or her problem,’ that ‘it's our problem as a couple,’ and that ‘the treatment will impact all of us in the system’ is a great message.” She adds, “We certainly have family members who are shocked when we say, ‘You're going to work on your own recovery.’”

References

1. Knight DK, Logan SM, Simpson DD. Predictors of program completion for women in residential substance abuse treatment. Am J Drug Alcohol Abuse 2001; 27:1–18.
2. Leonard KE, Das Eiden R. Husband's and wife's drinking: unilateral or bilateral influences among newlyweds in a general population sample. J Stud Alcohol Suppl 1999 March; 13:130–8.
3. Stanton MD, Shadish WR. Outcome, attrition, and family-couples treatment for drug abuse: a meta-analysis and review of the controlled, comparative studies. Psychol Bulletin 1997; 122:170–91.
4. Fals- Stewart W, Golden J, Schumacher J. Intimate partner violence and substance use: a longitudinal day-to-day examination. Addictive Behaviors 2003; 28:1555–74.
5. Fals- Stewart W, Kennedy C. Addressing intimate partner violence in substance abuse treatment. J Subst Abuse Treatment 2005; 29:5–17.
6. Straus MA, Hamby SL, Boney-McCoy S, et al. The revised Conflict Tactics Scales (CTS-2): development and preliminary psychometric data. J Fam Issues 1996; 17:283–316.