Jamie Loveland dissertation

Institute for Clinical Social Work

Therapy with Couples with Addiction: A Psychoanalytic Perspective

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment For the Degree of Doctor of Philosophy

By

Jamie L. Loveland

Chicago, Illinois March 2016

Abstract

This study explored therapists’ experiences in treating couples with substance addiction (SA) to understand and identify psychoanalytic therapeutic factors.

The study was qualitative, using Interpretive Phenomenological Analysis. Four licensed psychoanalytic couple therapists were interviewed in depth about their experiences when working with SA couples. The eight major findings were: 1. The categorical reminder of the role of countertransference.

2. The complexity of SA symptoms and defenses, and underlying causes.

3.

Psychodynamic couple therapy with SA couples is dynamic.

4.

Generally, research participant couple therapists do not distinguish the manner in which they conceptualize couples with SA, and couples without SA.

5.

The psychoanalytic, behavioral, and disease model of treatment are all interrelated when treating SA couples.

6. Psychodynamically, research participant understanding of SA couple therapeutic factors are not distinguishable from those deemed therapeutic when working with non-SA couples.

7.

Psychodynamically, research participant understanding of the markers of change in SA couples is not distinguishable from those of non-SA couples.

8.

Conceptualizing and treating SA through a narrow lens is restrictive.

Conclusions and recommendations based on the findings were offered. ii

To my fellow colleagues who work with couples with substance addiction

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Acknowledgements

It is with great appreciation that I acknowledge my dissertation committee: Karen Bloomberg, for slaying dragons, an unending enthusiasm for couple therapy, and organizational skills beyond belief. Connie Goldberg, for thoughtful responses and an eye for detail and content. John Ridings, for method, design and formatting. Carol Ganzer, for candid discussions, unwavering support, and being able to see it like it is.

And George Youngblood, for expertise on the subject of substance addiction, and for sharing passion and commitment in providing the highest level of care to those who suffer.

A special appreciation to Paula Ammerman for her direction, warmth, support and friendship.

To my family, especially Anne, David, Summer, Truly, and Papa Gene for their patience, love and generosity.

And finally, to my husband Mark, who inspires me to be the best person I can be each and every day. You are my hero.

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Table of Contents

Page Abstract……………………………………………………………………………..……ii Acknowledgements…………………………………………………....………………...iv List of Tables…………………………………………………………………………….ix Chapter I. Introduction ……………………………………………………………….......1 General Statement of Purpose Significance for Clinical Social Work Problem Formulation and Specific Objectives of the Study Epistemological Foundations II. Literature Review……………………………………………………………16 The Biopsychosocial Model Therapeutic Factors/Action Substance Addiction Research Individual Substance Addiction Treatment Couple Substance Addiction Treatment

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Table of Contents-Continued

Page Chapter III. Methodology……………………………………………………………...…82 Rationale for Qualitative Design Rationale for IPA Data Collection Methods Data Analysis Ethical Considerations Issues of Trustworthiness IV. Findings……………………………………………………………………104 Introduction to Participants Presentation of Findings Summary V. Discussion……………………………………………………………...……185 Personal and Professional Journey Conceptualization of SA Therapeutic Action Markers of Change Trial and Error Revisiting Assumptions from Chapter I Summary of Interpretation of Findings

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Table of Contents-Continued

Chapter

Page

VI. Conclusions and Recommendations…………………………………...…250 Therapist Personal and Professional Experiences in Working with SA Couples Therapist Conceptualization of SA Therapist Experiences of the Therapeutic Actions when Working with SA Couples Therapist Experiences of the Markers of Change when Working with SA Couples Therapist Experiences of Factors that Impede the Process of Working with SA Couples Recommendations for Psychodynamic Couples Therapists Recommendations for Schools of Clinical Social Work Recommendations for Consumers Recommendations for Further Research Study Limitations Personal Reflections Conclusion

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Table of Contents-Continued

Appendices

Page

A. Email Script……………………………………………………….…….…263 B. Participant Informed Consent…………………………….….……….….266 C. Study Questionnaire…………………..………………….………….……271 D. Interview Schedule………………………………….…...…………….…..275 References………………………………………………………….............…..279

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List of Tables

Page Table 4.1. Sample Characteristics…………………………………………….………105 4.2. Summary of Findings……………………………………..……………….111 5.1. Therapeutic Action…………………………………………..…………….225

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Chapter I

Introduction

General Statement of Purpose The purpose of this phenomenological study was to explore couple therapists’ experience in treating couples with substance addiction (SA) to understand and identify psychoanalytic psychotherapeutic factors. Utilizing a phenomenological design to better understand and describe the therapeutic elements, study participants were licensed therapists with a minimum ten years’ psychodynamic experience treating couples, a minimum five years’ experience in treating SA couples, and a minimum three months active engagement in working with at least one SA couple over the past year. For the purpose of this study, substance addiction is defined as a “physiological and psychological dependence on a substance” (Barker, 2003, p. 7). In keeping with World Health Organization (WHO) recommendations in terminology, the term substance addiction will be interchanged throughout this study with the expressions substance dependence, alcohol dependence, substance use disorder(s)(SUD’s), alcohol use disorder(s)(AUD’s), and alcohol and/or chemical dependency (Kalant, 2009).

Significance of the Study for Clinical Social Work The core values of the profession of social work according the National Association of Social Workers (NASW) include service, social justice, and dignity and worth of the person (NASW, 1999). Clinical social workers are expected to help those in society who are challenged by cultural, social, political, and financial difficulties and to shed light on populations and problems that might otherwise remain hidden or ignored.

Social workers challenge inequality and prejudice; bringing social justice to those who have lost their voice. They bring dignity, respect, autonomy, and self-sufficiency to those struck down by illness, dysfunction, war, discrimination, poverty, and unemployment.

Individuals who become addicted to substances jeopardize their dignity and self-respect, friends and family, and the means to support themselves financially. They risk losing everything. Their loss is compounded by the damage done to those around them, especially their partners and their children. Such individuals should have choices with regards to treatment that go beyond the medical model of addiction and include their significant other. If social workers’ “primary goal is to help people in need and to address social problems” (NASW, p. 5), there are few greater needs than the preservation of dignity and self-worth, and few social problems more critical at present than addiction.

As Barbara Feldman, chair of the Addictions Committee for NASW New York City states, “addiction permeates all areas of practice, so whether we are specialist or generalist practitioners, clinicians, activists or researchers, knowledge of addiction related issues is essential for all social workers to effectively work with our clients” (NASW, NYC, 2014). A primary mission of the NASW New York City Addictions Committee is the professional development of social workers on all issues pertaining to addiction

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through many means, including education (NASW, NYC). Research is at the very heart of education. The purpose of this study was to inform practice interventions for SA couples, explain the variations and conflict in current couple addiction treatment, and better understand what works. In understanding the psychoanalytic psychotherapeutic factors in SA couples therapy, social workers will be better equipped to identify, respond and treat couples who regularly present in their practice settings.

Problem Formulation and Specific Objectives of the Study Annually in the United States the National Institute on Drug Abuse (NIDA) estimates the economic cost to society of substance use disorders (SUD’s) and addiction to be over $428 billion, with the annual societal cost of alcohol abuse alone at $235 billion (NIDA, 2013). The misuse of substances can lead to homelessness, increases in crime and violence, increases in diseases such as AIDS, cancer, and mental illness, and create a significant burden to health care and overall productivity (NIDA). And although the global burden of disease, injury and economic cost attributed to alcohol use and alcohol-use disorders is significant across all socioeconomic levels, low-income populations and poor people are particularly vulnerable (Rehm et al., 2009).

While substance dependence contributes to health issues in the individual addict, family members also experience higher health care costs as they are more likely to be diagnosed with medical difficulties than family members of similar individuals without the diagnosis (Weisner, Ray & Mertens, 2007). Just as families experiencing unemployment, deployment, and mental illness face insecurity, isolation and a disruption of familiar roles, families struggling with excessive drinking are similarly affected 3

(Orford, 1985). Children of substance abusing parents are more likely to experience physical abuse and neglect (Reid, Machetto & Foster, 1999; Freisthler & Gruenewald, 2013), higher rates of psychopathology including oppositional and conduct disorders (Earles, Shayka, Frankel & Reich, 1993), and are exponentially more at-risk for future addiction due to both biological and environmental factors (Spataro, 2011).

Many clinical social workers are involved in the treatment of SUD’s as they relate to individuals, couples and families. Social workers are an essential part of the U.S. health care system and work across a broad range of settings, providing care to patients from an all-encompassing biopsychosocial spiritual perspective. As of 2013, the United States had almost two million social workers, with thirteen percent working in the specialized fields of mental health, substance abuse, and families (U.S. Bureau of Labor Statistics, 2013). With a predicted nineteen percent overall growth rate in the field of social work between 2012 and 2022, and a 23 percent predicted growth rate in the specialized fields of mental health and substance abuse during the same timeframe (U.S. Bureau of Labor Statistics, 2014), a clearer understanding of the therapeutic factors in treating substance dependence is needed.

Given the societal cost of addiction, both monetary and communal, along with its impact on individuals, children, and families at large, it is essential that we explore every available treatment modality. Addiction in America is not dissipating. In a recent report on nationwide trends on substance misuse, NIDA (2014b) found that illicit drug use in America is increasing, with drug utilization highest among people in their late teens and twenties, and rising among people in their fifties. While historically severe mental health disorders have been treated primarily from an individual context (Wanlass, 2014), studies 4

supporting the importance of family involvement over the years have been abundant, particularly with schizophrenia (Buksti, Munkner, Gade, Roved, Tvarno et al., 2006), posttraumatic stress disorder (Dixon et al., 2001; Rabin & Nardi, 1992; Stanton & Figley, 1978), and drug and alcohol addiction (Klostermann & O’Farrell, 2013; O’Farrell & Clements, 2012).

Research examining the therapeutic outcome of couples therapy over the past two decades has also made progress in addressing ‘individual’ problems including trauma (Monson, Schnurr, Stevens & Guthrie, 2004), childhood sexual abuse (Johnson & Williams-Keeler, 1998), anxiety and depression disorders, agoraphobia, and eating disorders (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998). In some treatment cases such as individual partner depression, spousal involvement may be more preferable than individual treatment (Baucom et al.).

Research on the treatment of addiction in one or both partners has also grown, but the focus has been almost entirely from a behavioral standpoint. In the case of couples coping with substance dependence, the standard treatment approach appears to be couples behavioral therapy (Lefio et al., 2013; O’Farrell & Fals-Stewart, 2000; Read, Kahler & Stevenson, 2001; SAMHSA, 2006), which utilizes behavioral techniques such as shaping, rehearsal, and acceptance, as well as cognitive skills that are thought to increase partner communication through the improvement of coping techniques, problem solving, and relapse prevention (Ladd, 2013). However, when one searches through the literature for treatment guidance in the form of a psychodynamic approach, practitioners are left wanting (Wanlass, 2014).

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The fact that the most popular forms of couple treatment for SUD’s are researchbased behavioral methodologies should not come as a surprise to any mental health professional given the current devotion to the medical disease model (Berger, 1991). But a risk encountered when one model prevails in any form of treatment is in losing sight of the uniqueness of the individual, or couple, in question. As Gabbard (2002) states, “no one argues the importance of examining biological factors at work in the etiology and pathology of addiction, but there is more to a person than a neurobiologically based craving” (p. 582).

If the focus remains on behavioral models in treating couple addiction issues, couple therapists run the risk of neglecting unconscious couple dynamics which are seldom explored when using a behavioral design. While in this case the symptom can be deadly, therapists must be willing to look within and outside the symptom to better grasp underlying factors within the couple dynamic (Wanlass, 2014). For example, a husband’s withdrawal in the relationship might be completely attributed to his alcohol dependence allowing core factors such as his wife’s avoidant attachment style to remain unexplored.

A goal of psychodynamic psychotherapy in addiction is to reveal these underlying dynamics, including emotional factors and defense mechanisms that can lead to substance dependence. Whether looking at addiction from a classical Freudian perspective, a selfpsychology lens, or through the nuances of object relations, all conceptualize addiction as a defensive operation that needs to be appreciated dynamically for treatment to be successful (Guidotti, 1991). The defense can materialize because of an inability to tolerate emotion, an unconscious need to ward off anger and depression due to early 6

object loss, or even a desire to avoid intimacy as a result of a selfobject failure (Guidotti; Leeds, 1993).

While psychoanalytic generalizations in the etiology of substance addiction must be carefully articulated, Leeds (1993) argues that four contemporary authors who write specifically about the treatment of substance abuse disorders from differing theoretical frames have a number of common elements. He writes that Krystal (1982, 1995, 2005), Wurmser (1974, 1995), and Khantzian (1995, 2003b, 2005) , view substance dependence as a substitute for absent intrapsychic functions and agree that such individuals struggle with affect tolerance and regulation, the maintenance of narcissistic stability, and experience extreme difficulty in managing their interpersonal relationships (Leeds).

Interpersonal relationship problems with people who turn towards substances instead of their partners is a given. When people consistently turn away from their relationships in favor of alcohol or drugs their partners feel ignored, lonely, angry, resentful, fearful, sorrowful, helpless, and hopeless. They can respond cruelly and unempathically to a diagnosis of ‘addiction’ if they perceive a lack of personal responsibility on behalf of the addict. If interpersonal relationships are indeed a supportive factor in the treatment of severe mental illness (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998), why has it taken the psychoanalytic community so long to engage couples struggling with addiction in treatment? While there is a significant amount of psychoanalytic literature detailing the etiology of SA and its treatment in individuals, there is a noteworthy void of literature and research centered on the treatment of the SA couple dyad.

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There are several valid explanations for the lack of available literature. First, couple therapy has consistently taken a backseat to individual and family therapy over the years (Gurman & Fraenkel, 2002). From a psychoanalytic perspective, beginning interest in couple therapy in the early 1930’s stemmed from curiosity about how individuals selected their spouses, as well as interest in how a spouse was affected when a partner was going through analysis (Meissner, 1978). While over the year’s analytic couple therapy gradually grew in stature, a lack of effective interventions combined with the explosion of the family therapy movement in the 1960’s marginalized its contributions.

In the mid-1980’s refinements in theory and technique and the growth of integrative models examining both intrapersonal and interpersonal factors began to emerge (Gurman & Fraenkel). Yet even with the richness and depth that several well-known clinical theorists have provided the field (i.e., Scharff & Scharff; Solomon; Siegel; Bader & Pearson), the examination of psychodynamic couple therapy as an effective treatment paradigm for severe mental illness is still in its beginning stages (Gurman & Fraenkel).

To some degree the analytic community has avoided SA. The community at large has taken a passive stance in treating individuals with SA by emphasizing observation until sobriety is met (Johnson, 1999). While there are many dilemmas to this approach, a major quandary is that passivity and lack of action are the very characteristics that substance abusers defend against when they partake in their substance of choice (Director, 2002). “The substance user tends to be do-er and act-er, and, on technical grounds alone, needs an active approach to feel meaningfully engaged, even adequately “gripped” by the therapeutic process” (Director, p. 554). Instead of sitting back and passively waiting for the substance abuser to stop abusing, clinicians should interpret the 8

abuse as a way in which addicted individuals “communicate unsymbolized experience”, and consider the behavior to be the birth of treatment (Director, p. 554).

Several factors have led to an aversion on behalf of the psychoanalytic community to treat individuals struggling with addiction. Historically, Dodes (2002) shows that for the first half of the 19th century addictions were seen as “a direct expression of drive derivatives” (p. 124) and, as such, patients were deemed poor candidates for analysis, particularly if the individual in question was still using. Addicted individuals were seen as impulsive, irresponsible and morally deficient. Dodes argues that undue emphasis has been placed on the biological and genetic components of addiction, resulting in all forms of psychotherapy becoming secondary to non-analytical approaches to treatment. Stating that behavioral methodologies are overrated in their assumed helpfulness, Dodes argues that if addiction was viewed as a subset of compulsion we would understand that the presence of the actual addiction has little to do with whether or not an individual is analyzable. Instead, citing early analytic work on addiction to support his argument, Dodes insists that treatment outcome is less about drive offshoots, biology, or sobriety and more about the addicted individual’s psychological health, which varies from person to person.

If the psychoanalytic community continues to insist on abstinence prior to treatment and demonstrate passivity in working with SA, a significant disservice will be done to those who suffer with this illness. While considering whether or not to engage addicted persons in treatment, many clinicians encourage their patients to attend Alcoholics Anonymous (AA), and other self-help groups, pointing to their 12-step protocols and addiction communities as sources of healing. While AA is a life-line for 9

many, it does not work for all. For some individuals in ongoing recovery, attending typical AA meetings can be worse than alternative treatments or no treatment at all (Kownacki, & Shadish, 1999). Fifty percent of those who do attend 12-step gatherings do not remain for the introductory interval of 90 days (McIntire, 2000). Dodes (2010) statistics are even more dire, stating that only about 10 percent of people who attend AA become sober.

From personal experience in working with couples with addiction, 12-step groups can be extremely helpful in the maintenance of sobriety and the development of an accepting and supportive peer community. However, it is my experience that addiction groups can perpetuate a ‘turning away’ between partners that replicates the addiction and can damage the couple dyad. Instead of turning towards their partners to heal wounds and garner support, addicted individuals can turn towards peers who ‘better understand’ their pain. They are ‘fed’ by group members and sponsors and can view their partners as being unable to understand, or grasp, the extent of their hurting. By the time these couples make it into therapy, their relationship is being held together by a thread that is, at best, tenuous.

It was the purpose of this phenomenological study to better understand the psychoanalytic factors that work together in healing couples with substance addiction.

The problem, as stated above, is significant. While there is psychodynamic understanding of SA from various theoretical camps, and some history of treatment with addicted individuals, SA manifestation and treatment is still uncharted territory from a couple perspective.

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Research Questions The questions this research sought to answer and describe were: 1. How do couple therapists experience working with couples with substance addiction?

2. What do couple therapists who work with substance dependent couples experience as being therapeutic?

3. What is the understanding of couple therapists as to what works when working with couples with substance addiction?

4. What about the process feels helpful to couple therapists who work with substance dependent couples?

5. What do couple therapists who work with substance dependent couples experience as consistent markers of change?

6. What understanding do couple therapists who work with substance dependent couples perceive might harm or impede the process?

Theoretical and Operational Definitions Psychodynamic or psychoanalytic psychotherapy: As per Blagys & Hilsenroth, (2000), treatment which reflects psychoanalytic ideas and techniques as distinguished by: 1. A focus on affect and expression of emotion; 2. An exploration of attempts to avoid upsetting thoughts and feelings; 3. Identification of repetitive emotional, cognitive, behavioral and relational themes and patterns;

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4. Consideration of past experiences; 5. A focus on interpersonal understandings; 6. Attention to the therapy relationship; and 7. An exploration of dreams, wishes and fantasies.

Psychodynamic psychotherapy is insight-oriented and utilizes psychoanalytic theory. It is considered to be a modified form of psychoanalytic treatment where sessions occur once or twice a week, the patient and therapist face each other in sessions, and the therapist and patient actively engage and interact (Lightdale, Mack & Frances, 2011).

Throughout this paper psychodynamic psychotherapy and psychoanalytic psychotherapy are interchangeable.

Therapeutic factors: The means by which psychoanalytic treatment affects therapeutic gain (Auchincloss & Samberg, 2012).

Couple: Two people engaged in a committed, intimate partnership who are married, unmarried heterosexual, or unmarried homosexual (Zeitner, 2012).

Substance Addiction: Dependence on a substance that is both physiological and psychological (Barker, 2003). Throughout this study the term addiction will be interchanged with the phrases substance dependence, alcohol dependence, substance use disorders (SUD’s), alcohol use disorders (AUD’s), and alcohol and/or chemical dependency.

Statement of Assumptions This study was informed by researcher assumptions that: 12

1. Mutual dependency in intimate couple relationships is healthy and natural.

2. Many individual psychological problems can be best treated with couple therapy.

3. Couples have the capacity to heal each other’s deep childhood wounds.

4. We establish implicit unconscious defensive patterns of relating to shield ourselves from experiencing pain.

5. Empathy, compassion and validation are key factors in the healing of distressed couple relationships.

6. Addiction is a physiological and psychological illness with social constructs and manifestations.

7. Behavioral methodologies, while important, neglect unconscious couple dynamics that are key to sustained healing.

8. Twelve-step groups can cause couples to turn away, rather than towards, each other.

Epistemological Foundations Epistemology is the study of philosophy that questions what knowledge is, and how it is acquired and validated (Greco, 1999). While there are a multitude of ways in which researchers examine and explain their queries, their approach is shaped and influenced by a philosophical worldview which affects the research design and the methodology that transpires (Cresswell, 2014). Given the absence of research on the psychoanalytic therapeutic factors in treating SA couples, this study begged a

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phenomenological approach that would deepen understanding of the ‘lived experiences’ of couple therapists who work with SA couples.

With the assistance of a biopsychosocial lens, focus was on clinician perceptions, understandings, and observations in working with this challenging population. First introduced by George Engel in the 1970’s as a way of looking at the mind and body of a patient as two important systems that are interlinked, the biopsychosocial model treats individual biological, psychological, and social structures as united systems of the body (Dowling, 2005). It is the antithesis of the reductive biomedical model of medicine which disregards psychological and social elements, and is instead “based on general systems theory which assumes a complex, reciprocal relationship between the mind and body whereby health problems are at once a biological, psychological and social experience” (Evans et al., 2012, pp. 320).

Understanding that there are biological, psychological, and social components to SUD’s, this study sought to better understand the therapeutic factors when working with SA couples from a psychological perspective.

From a qualitative reliability standpoint, it is not uncommon to combine a phenomenological approach with a biopsychosocial lens. This is seen in studies of the impact of end-stage renal disease (White & Grenyer, 2001), studies examining experiences of posttraumatic stress disorder (Buechler, 2007), the treatment of chronic illness (Sperry, 2006), the development and maintenance of self-mutilation behaviors (Wanaguru, 2010), attempts to control obesity (Ellis, 2013), and patients infected with HIV (Lawrence, 2011).

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Dissertation Outline This phenomenological study takes the form of a first chapter introducing overall concepts, followed by chapters covering a review of the literature, methodology, findings, discussion, and a final chapter offering conclusions and recommendations. The Appendix consists of the participant email script (A), research participant consent form (B), study questionnaire (C), and interview schedule (D). It also includes the list of tables utilized throughout.

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Chapter II

Review of the Literature

The purpose of this phenomenological study was to explore couple therapists’ experiences in treating couples with addiction to better discern and distinguish psychotherapeutic factors. Specifically, this study sought to understand how couple therapists treating SA couples identify and understand the various psychodynamic elements that influence healing. To carry out this study a critical review of the literature was required. This review was purposeful in design, meaning that themes specifically related to the purpose statement were examined. In order to ground readers in the theoretical underpinnings of the study, as well as its primary focus, an examination of the terms ‘biopsychosocial’ and ‘therapeutic action/factors’ were conducted.

Additional areas of emphasis include a review of the substance use disorder (SUD) research, as well as individual treatment protocols that include the neurobiological, behavioral, 12-step, and psychodynamic viewpoints. While it was not possible in the scope of this paper to cover every behavioral or analytic concept on SA treatment, I attempted to cover those concepts and theoretical constructs most prevalent in the literature. Finally, this review examined SA treatment as it relates specifically to couple therapy from both behavioral and psychodynamic perspectives.

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Key words used to search data bases included ‘substance dependence treatment, ‘SUD treatment’, ‘couple treatment with addiction’, ‘marital treatment for SUD’s, ‘couple and/or marital analytic treatment for SUD’s, ‘couple and/or marital addiction treatment’, ‘couple and/or marital psychodynamic treatment for addiction’, and ‘couple and/or marital psychotherapeutic treatment for substance dependence.’

To conduct this selected literature review, multiple resources were utilized including books, dissertations, peer reviewed professional journals, internet sources, and periodicals. These were accessed through PEP, EBSCO, NCBI, PsychInfo, and PsychArticles throughout the spring and summer of 2015 with no date limitations. Each section of the review details anomalies, conflicts, gaps, and omissions and includes summaries synthesizing key points and relevance to the topic at hand (Bloomberg & Volpe, 2012). Each foci includes an introduction, discussion, and conclusions/implications/summary (Bloomberg & Volpe), that relate to the psychodynamic psychotherapeutic treatment of SA couples, and their therapeutic factors.

The Biopsychosocial Model Clinical social workers are trained to incorporate a biopsychosocial perspective to treatment approach. The biopsychosocial model was first introduced by psychiatrist George Engel in the 1970’s as a way of looking at the mind and body of a patient as two important systems that are interlinked (Dowling, 2005). The model treats the biological, psychological, and social structures as united systems of the body in contrast to the traditional biomedical model of medicine which disregards psychological and environmental elements (Dowling). The approach attests that “every level of organization 17

– molecular, cellular, organic, personal, experiential, interpersonal, familial, societal, and biospheric – affects every other level” (Williams, Frankel, Campbell & Deci, 2003, p.

110).

Theoretical underpinnings and research.

The biopsychosocial model interweaves several theoretical perspectives including self-determination theory, social constructionism, and family systems theory (Williams et al., 2003). Studies centered on self-determination theory examine patient behaviors in many settings, including substance abuse treatment centers from an autonomous, as opposed to controlled, standpoint. Here it is the autonomous relationship between patient and physician which becomes a primary focal point in treatment as compared to biomedical model research which is considered physician-centered (Williams et al.). In one such study (Ryan, Plant & O’Malley, 1995), which examined internal and external motivation for seeking outpatient treatment for alcohol misuse, researchers found that individuals whose motivation was more autonomous showed the highest attendance and best treatment retention compared to those whose motivation was more controlled (i.e., external). Similar outcomes have been reported in research examining patient motivation and autonomy in long-term medication regimens, weight loss programs, management of diabetes, and smoking cessation (for a review of all studies refer to Williams et al.). Selfdetermination theory is a cornerstone to the biopsychosocial model of treatment; emphasizing relationship-centered care.

Social constructionism, which attests that an “individual’s reality is socially constructed” has also been used to examine properties of the biopsychosocial approach 18

(Williams et al., 2003, p. 114). This research has studied power differentials in treatment relationships, as well as analysis on the meaning, behavior, experience, and interpretation within the physician-patient dyad, and patient perceptions of physician availability and willingness to listen to their concerns (Williams et al.). In one such study (Beckman & Frankel, 1984), researchers examined first time office visits between 74 patients and internists. It was found that 57 of the patients (77 %) were unable to voice their main reason for coming before being interrupted by the doctor, and in 51 (69%) of the visits, after the interruption, the doctor then proceeded to direct questions toward a specific concern which they were hearing.

Social constructionist studies such as this indicate that treatment approaches which control interactions through close ended questions and frequent interruptions in the initial encounter, and which fail to provide adequate time to listen to patient concerns (i.e., physician-centered), contribute to the possible loss of relative treatment information and patient overall dissatisfaction (Beckman & Frankel, 1984). If medical professionals do not allow patients to explain reasons for seeking treatment there is little chance for such treatment to be a success (for a review of all studies refer to Williams et al., 2003).

A third theoretical underpinning in the biopsychosocial model is family systems theory which highlights “reciprocal relationships and mutual influences between the individual components and the whole and vice versa” (Barker, 2003, p. 157). The construct is similar to the ‘cyclical approach’ based on the concept of the hermeneutic circle, whereby one looks simultaneously to the whole to understand each moving part and to the parts in order to understand the whole (Smith, Flowers & Larkin, 2009).

Family systems theory emphasizes interdependence within a system (i.e., familial, 19

patient-physician dyad, etc.) and its multi-directional flow (Williams et al., 2003). From a substance misuse perspective family systems theory sees the addicted individual as a symptom of dysfunctional family relationships and the role which the addicted individual plays, as an attempt to maintain homeostasis within the system. Such a model suggests that family interactions significantly impact health-care outcomes, which has indeed found substantial support in the research (Campbell, 1986; Franks, Campbell, & Shields, 1992; McDaniel, Campbell, Hepworth, & Lorenz, 2005).

In one particular study (Franks, Campbell, & Shields, 1992), which examined the roles of family functioning and social support on cardiovascular health, researchers found family criticism and emotional involvement to be directly associated with both depressive symptoms and health-related behaviors (i.e., eating healthy, exercising, etc.), suggesting a strong link between familial relationships, mental health, and health behaviors. In another study, a meta-analysis which reviewed family impact on health as it relates to alcoholism and drug use, Campbell (1986) found that alcoholic family interactions exhibited different patterns than nonalcoholic families and contributed significantly to the addicted individual’s continuation of drinking. Campbell also found that families of drug dependent individuals see themselves differently than other families, whereby mothers are more dominant, fathers are passive and withdrawn, and addicted individuals have low self-esteem and exhibit dependence.

Family systems research supports the premise that families have a significant impact on the mental and physical health of its members, and also explains how familial roles are sometimes interpreted in families dealing with alcohol and drug misuse.

Together, with research from both self-determination theory and the discipline of social 20

constructionism, family systems theory provides an ample framework by which to understand and utilize the biopsychosocial model of assessment and treatment. In summary, not only does this framework suggest that providers using a relationshipcentered approach with both patients and families may be much more successful in providing effective health care and better outcomes, the research also tell us that such patients tend to be more internally motivated, better satisfied with their overall treatment, and have higher rates of attendance and treatment retention (Williams et al., 2003).

The biomedical model.

Despite these findings, the biomedical model of care continues to be the dominant model in medicine, characterizing Western science (Engel, 2003). It is a disease model of care whereby treatment is viewed “as a successful response to a pathophysiological event” (Engel, p. 23). The model focuses on the biological processes that impact health (i.e., physiology, biochemistry) and seeks to resolve pathology by getting at the underlying biological components which are seen as operating objectively. The model attests that health is an absence of disease, and that disease itself stems from purely biological sources whereby the “patient is a victim of circumstance with little or no responsibility for the presence or cause of the illness, and [therefore] is a passive recipient of treatment” (Wade & Halligan, 2004, p. 1398).

Proponents of the biomedical model of treatment present its many successes including vast improvements in medical science and technology, and increase in cures and treatments which have inarguably improved quality of life for many with debilitating illnesses and extended life expectancy overall (Konoroth, 2013). With its focus on 21

diagnosis and intervention, the model has contributed to the advancement of many diagnostic tests including x-rays, scans, mammograms and MRI’s, as well as the advancement of prescription medicine, surgery and hospitalization (Konoroth). But it is specifically these advances that Jewson (2009) argues created hospital medicine and a new definition of treatment: Interest in the whole person evaporated to be replaced by studies of specific organic lesions and malfunctions. Diseases became a precise and objectively identifiable event occurring within the tissues, of which the patient might be unaware. The fundamental realities of pathological analysis shifted from the total body system to the specialized anatomical structures. The patient’s interest in prognosis and therapy was eclipsed by the clinician’s concern with diagnosis and pathology. In short, the sick-man was no longer regarded as a singular synthesis of meaningful sensations. Instead, the sick in general were perceived as a unitary medium within which diseases were manifested (p. 628).

As a result it has been reasoned health care became a form of reductionism and a mind/body dualism whereby individuals can be regarded “as quasi-machine[s] that [are] the passive target of therapeutic interventions, without the need for much attention to social or psychological factors” (Checkland et al., 2008, p. 789). Indeed, in the July, 2014, online booklet released by NIDA titled Drugs, Brains, and Behavior: The Science of Addiction, recommended treatment for SUD’s combines medication and behavioral therapy as “the best way to ensure success for most patients” (p. 26). Such a perspective negates much that the biopsychosocial model of treatment embraces, reducing patient autonomy as well as possible environmental, psychological, and social circumstances; 22

literally throwing out the principles of social constructionism and exchanging it for deterministic doctrine.

Summary.

The neurobiology of addiction is invaluable in the successful overall treatment of SUD’s, and a review of this literature will be included in this chapter under the subject of substance use treatment. That said, researchers do argue that the biological aspects of addiction cannot be allowed to operate as the primary source of assessment and treatment when dealing with this disorder. To do so would dictate a biomedical lens towards treatment that depends only on “science” and categorizes diagnostic findings into discrete disease entities disregarding the patient’s experience altogether (Epstein et al., 2003). In the biomedical approach “the ideal is to find as quickly as possible the simplest explanation, preferably the diagnosis of a single disease, and to regard all else as complication, “overlay,” or just plain irrelevant to the doctor’s task” (Engel, 2003, p. 8).

By incorporating a biopsychosocial focus clinicians have an opportunity to entertain an all-inclusive view of assessment and treatment; valuing each component equally and understanding that “all human life is shaped by the interplay of forces that arise from within and without” (Berzoff, Melano, Flanagan & Hertz, 1996, p. 1). This focus allows for a fuller understanding of how SUD’s shape both the inner world and interpersonal relationships of couples, and furthers clinical capabilities by responding to the complexity of circumstances to which these couples find themselves.

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Therapeutic Factors/Action In the simplest of terms, therapeutic action has been described as “the means by which psychoanalytic treatment affects therapeutic gain” (Auchincloss & Samberg, 2012, p. 260). But exactly what comprises therapeutic action in psychodynamic psychotherapy usually depends on the theoretical perspective by which one abides and its ensuing principles of “what works”; and here is where simplicity draws its last breath. Each psychoanalytic model has its own theory of mind and pathogenesis of which its therapeutic action is implicitly coupled (Auchincloss & Samberg). While it can be argued that there is little empirical research substantiating psychoanalytic action with specific outcomes, making therapeutic factors exploratory at best, it can also be argued that there are multiple sources of clinical material detailing both the successes and failures of analytic endeavors which powerfully support the therapeutic action of numerous approaches (Auchincloss & Samberg).

Models: Classical vs. contemporary.

Stark (2000), suggests that there are two models of therapeutic action which stem from age old theoretical constructs of either insight through interpretation, or corrective provision through the analytic dyad. The first mode is based on the drive-conflict model wherein change occurs through an interpretive process which increases patient knowledge and understanding, and ultimately strengthens ego functioning, disciplines the id, and moderates the super ego (Stark). Here the therapist drives the therapeutic action deciding when an interpretation is best made and “emphasis is on the therapist’s ability to

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offer the patient the truth” (Stark, p. 12). The ultimate goal in this mode of treatment is to resolve the patient’s structural (i.e., id, ego, superego) conflicts (Stark).

The second model is based on the deficiency-compensation model of therapeutic action posited by self psychology as well as object relations theorists who believe that structural disruptions are caused by deficits (Stark, 2000). In this representation therapeutic action occurs when the therapist is able to operate as either an empathic selfobject which provides functions the patient is unable to perform, or as a good object which serves to heal early relational deficits, including negative interactive dynamics, that have been internalized (Stark). Unlike the drive-conflict model which emphasizes the therapists’ truth, the deficit-corrective model focuses on the patient’s experience of the truth (Stark). The ultimate goal in this mode of therapeutic action is to complete the patient’s structural deficits (i.e., fill in) and consolidate the patient’s self (Stark).

While Stark (2000) states that both models are highly valued and necessary to the therapeutic action, she argues for a third model which must also be integrated, more contemporary in design, which attributes therapeutic action to the formation of an authentic interactive relationship between patient and therapist. It is the relationship itself that heals: A relationship that involves not subject and drive object, not subject and selfobject, not subject and good object, not subject and good mother, but, rather, subject and subject, both of whom bring their authentic selves to the therapeutic interaction – both of whom influence and are influenced by the other. (p. 20).

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Interaction focuses on the here and now as compared to early childhood experiences, with the short-term goal to help the patient understand relational patterns playing out between themselves and the therapist, and the long-term goal to improve the patient’s ability for relatedness (Stark).

For Stark (2000), all three modes of therapeutic action are interdependent. In Model 1, interpretations are effective only when they come from a profoundly personal therapeutic alliance (Stark). In Model 2, the use of empathy in offering patients a new, deeply subjective, affective experience must also occur in the context of the therapeutic relationship (Stark). And in Model 3, some form of empathic connection is necessary for relational clinicians to join intimately with their patients; without this ability there is no relationship (Stark). In addition, in order to utilize therapist use of self (i.e., countertransference and transference) to engage the patient, interpretation may be employed; it is not solely a Model 1 technique (Stark). While empathy, countertransference, and transference all play out in slightly different manners in each of the models mentioned, Stark (2000) attests that all three modes of therapeutic action – interpretation, provision, and interaction – allow the therapist to conceptualize her options and: Move back and forth, between being with the patient where she is and directing the patient’s attention elsewhere, back and forth, between engaging the patient’s experiencing ego and engaging the patient’s observing ego, back and forth, between offering the patient an opportunity to feel understood and offering the patient an opportunity to understand. (p. 45).

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Pluralism: Therapeutic actions.

Stark’s (2000) mode of therapeutic action is pluralistic in nature and follows a contemporary trend amongst theorists who are open to the question of “what works” and who no longer cling to any singular theoretical exclusivity (Aron, 2000; Frank & Bernstein, 2012; Gabbard & Westen, 2003; Shapiro, 2012; Wachtel, 2012). No longer an “either-or” paradigm, models of therapeutic gain include: (1) both intrapsychic and intersubjective dimensions (Aron, 2000); (2) “therapeutic actions, rather than action” (Gabbard & Westen, p. 823); (3) collaborative approaches that involve analytic, behavioral (i.e., exposure to experiences) and neuroscientific, dimensions (Shapiro; Wachtel); and (4) therapy that “is not a fixed set of processes, applicable across the board, but is contextual, dynamic, and repeatedly co-created by each unique analytic pair during the course of treatment” (Frank & Bernstein, p. 3). In fact, Aron (in Safran, 2009), argues that pluralism is a sign of health in psychoanalysis and contributes to the disciplines power and identity. He also reasons that we make mistakes when we privilege one school of psychoanalysis over another and that the success of the field is in its ability to engage in ongoing discussions between different schools of thought, including research based modalities such as cognitive therapy and neuropsychoanalysis (Aron, in Safran).

Open to the suggestion that successful treatment involves a multifaceted and flexible approach that must be tailored to each therapeutic dyad, Gabbard & Weston (2003) argue that any therapeutic endeavor must still be able to “describe both what changes (the aims of treatment), and what strategies are likely to be useful in facilitating those changes (techniques)” (p. 826). According to the authors, the central goal in psychoanalytic treatment is to rework unconscious networks that activate and underlie 27

dysfunctional and problematic emotional, defensive, and interpersonal reactions (Gabbard & Weston). A secondary goal consists of changing conscious patterns of “thought, feeling, motivation and affect regulation” (p. 827). The authors (Gabbard & Weston), posit that the three classes of technique which are used to create change are those which focus on insight (i.e., free association and interpretation), those which stem from the therapeutic relationship (i.e., transference, countertransference, strategies for self-reflection, and internalization of function and affective attitudes), and secondary approaches which include confrontation, self-disclosure, collaborative problem solving and exposure (p. 831).

Similar to Starks’ (2000) multimodal approach, here the clinician moves back and forth in the therapy between unconscious and conscious material, the past and the present, and an understanding of both therapist and patient experiences. In their conclusions, Gabbard & Weston (2003) remind readers that every therapeutic dyad is unique in its presentation and unfolding, whereby change occurs through a multitude of means, and where no single formula will be useful for all patients. As a final caveat, clinicians are advised not to question if a technique is analytic in nature, but instead to ask if it works (Gabbard & Weston).

One researcher who did exactly this is Shelder (2010), in his landmark paper examining the efficacy of psychodynamic psychotherapy. Within its pages, Shedler reviews more than three decades of general outcome studies supporting the efficacy of various forms of psychotherapy, including short- and long-term psychodynamic treatment. While Shedler (2010) avoids using the term therapeutic action, he meticulously reports the techniques of successful psychodynamic psychotherapy that 28

make it distinctive from other forms of treatment, as per Blagys & Hilsenroth (2000).

These practices include: 1. A focus on emotional expression; 2. An exploration of unconscious defense mechanisms; 3. Identification of problematic and recurrent thoughts, feelings, self-concepts, relationships and life experiences; 4. A focus on developmental experiences; 5. A focus on interpersonal relations; 6. An exploration of patient fantasy life; and 7. An ongoing focus on the therapeutic dyad.

While Shedler (2010) acknowledges that other forms of treatment, including cognitive behavioral therapies, have shown efficacy in outcome studies, he insists that this is because their “active ingredients” include techniques which specifically define psychodynamic treatment (p. 107).

Researchers Joseph, Hilsenroth & Diener (2014), support the use of several of these techniques in a study investigating the relationship amongst patient participation, practices, and the working alliance during early sessions of psychodynamic psychotherapy. With the help of 88 outpatient participants the researchers found that the exploration of uncomfortable feelings, attention to repetitive relationship patterns, and a focus on the overall working alliance were all significantly related to increases in patient participation (Joseph et al.). While the study did not equate the use of technique with successful outcome, it stands to reason that individuals must participate in order to reap

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therapeutic benefit, and all that can be done to ensure their early commitment can only serve to improve their treatment experiences. But not everyone agrees that technique is at the center of successful therapeutic outcome.

Therapeutic factors: Is technique inconsequential?

In summarizing the research thus far, therapeutic factors involve both classical and contemporary theoretical underpinnings that support the use of a variety of techniques for the sake of therapeutic gain. Some of these factors are related to the analyst (i.e., interpretation, analysis of transference and countertransference, etc.) and some are stimulated as the work unfolds (i.e., insight, therapeutic relationship, etc.). But what of those researchers who believe that specific therapy techniques may not matter very much, and in fact contribute very little, to therapeutic success?

James Drisko, researcher and associate professor of social work at Smith College, was interviewed by NASW News in March, 2002 on this specific subject (O’Neill, 2002).

Drisko cites the work of Michael Lambert, a psychologist and professor at Brigham Young University, who attributes four factors as to how and why therapy works. Of those cited, techniques unique to specific treatment protocols accounted for only 15 percent of outcome (O’Neill). In the interview, Drisko states: The catch is, it may be that my belief in a model and my ability to convey that persuasively to the client, and their belief in my faith, in turn, is what makes it work. The specific technique is less important than my allegiance to it and the comfort it gives me that this can make a change (p. 2).

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Drisko argues that theory is important to help clinicians appreciate and organize thinking, and that technique matters, but less so than client factors (i.e., support, severity of problems, ability to engage, accessible services) and the therapeutic alliance. Together, these two dynamics make up as much as 70 percent of outcome (O’Neill, 2002).

Lambert’s fourth factor attributing to the final 15 percent of outcome is referred to as the “placebo effect” whereby patients feel hopeful and expectant given that they are working within an accepted approach to successful change (O’Neill, p. 2). Arguing against additional research on the efficacy of specific types of therapy, Drisko believes that focus instead should be on the overall efficacy of psychotherapy and include research which examines problem severity, client motivation, and relational factors like empathy and warmth (O’Neill).

Supportive of Drisko and Lambert’s perspectives, researchers Duncan, Miller & Sparks (2007) agree that factors common to all treatment approaches are the backbone of successful therapeutic outcomes. These researchers argue that it is the “client’s active engagement in the process, [and] the quality of their participation, [that] is the single best indication of the likelihood of success” (p. 39) and that “change principally results from factors common to all approaches and from the client’s preexisting abilities and participation” (p. 35). The authors (Duncan et al.) also argue against the use of the medical model in diagnosing and treating issues of mental health, stating that a model which emphasizes diagnostic classification and evidence based practice is ill suited for therapy: Fifty years of outcome research shows that change doesn’t result from focusing on disorders, diseases, or dysfunctions…Change is spurred by what’s 31

right…resources, creativity, and relational support networks – not the labels they carry or even the techniques employed by professional helpers. (p. 34).

Concluding thoughts.

It is evident that the literature on therapeutic action, and factors, is complex, varied, and far from simple. But one thing is clear. Any theory of therapeutic action has to value the patient’s role as an actively engaged and motivated participant (Auchincloss & Samberg, 2012). While the classical techniques of interpretation and free association are highly valued, along with therapist use of self, current developments in thinking about what works in psychoanalysis are leaning towards a focus on the here and now, the importance of the analyst’s countertransference, and the significance of the analytic relationship (Auchincloss & Samberg). The method is collaborative in nature, and, at times, pools various treatment approaches for the purpose of therapeutic gain.

One side note.

While a theoretically combined treatment approach to therapeutic action may seem rather generous to many, Orange (2012), warns clinicians that the very expression “therapeutic action” can be problematic. Orange argues that equating the term with mechanistic approaches and an Aristotelian causality that expects change, cure, or healing to be the direct result of a singular “mechanism”, neglects human complexity.

She claims that while natural science has its place in many forms of research, “our causal discourse, indispensable to the world of natural science, places us at a great emotional distance from our patients’ suffering and from our own situated experience with them”

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(Orange, p. 71). Instead, Orange implores clinicians to consider the value of differing perspectives as described in phenomenological and hermeneutic terms, where they may find themselves naked, vulnerable, and unknowing at times but fighting to avoid a reductionist approach which can strip patients of dignity and suggest that theorizing is more than just supposition.

Substance Addiction Research According to the definition of addiction within this framework, which is interchanged with the terms substance use disorders (SUD’s), alcohol use disorders (AUD’s), substance dependence, and chemical dependency, addiction is defined as “dependence on a substance that is both physiological and psychological” (Barker, 2003, p. 7). A broader classification of addiction could include the additional features of impaired control, compulsion, irritability, persistence, relapse, and craving (Maté, 2008).

The definition, for those operating from a neuroscientific model of addiction would also include the term ‘chronic, relapsing disorder’ (Koob, 2010). And for those working from the biopsychosocial model, the description might also involve emotional, developmental, social, political, economic, familial, cultural, and spiritual underpinnings (Engel, 2003).

This section of the literature review will examine research which reasons addiction to be substance dependent in nature (i.e., disease model), as well as that which considers addiction to be, in part, experience dependent (i.e., biopsychosocial). It will include arguments associated with both models, treatment protocols consistent with each perspective, and conclude with implications to this research. While this study is interested specifically in the psychoanalytic factors contributing to the therapeutic action of 33

working with couples with substance addiction, and does not seek to predict relativity in any form, the following portion of the literature review simply reflects that research which it succeeds.

The disease (biomedical) model of addiction.

Nora Volkow, MD, and Director of NIDA, once stated: Recent brain imaging studies have revealed an underlying disruption to brain regions that are important for the normal processes of motivation, reward, and inhibitory control in addicted individuals. This provides the basis for a different view: that drug addiction is a disease of the brain, and the associated abnormal behavior is the result of dysfunction of brain tissue, just as cardiac insufficiency is a disease of the heart (Maté, 2008, p. 133).

Alan Leshner (2014), MD, and former director of NIDA, reports that the concept of addiction being a brain disease has developed over the past decade and stems from three significant findings from neuroscience: 1. The identification of some of the brain mechanisms through which substances modify perception, mood, memory, and affect states.

2. The identification of some of the brain structures and functions which are altered through repeated substance use in central and everlasting ways that continue after the use has stopped.

3. The identification of possible neuro-adaptive changes in the brain, including the development and strengthening of new memory connections, which implies how addiction transpires.

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As such, addiction is seen as “a condition caused by persistent changes in brain structure and function” and characterized by “uncontrollable, compulsive drug craving, seeking, and use, even in the face of negative health and social consequences” (Leshner, p. 2).

While science does not know all the relevant mechanisms involved in the neurological changes, nor does it have a clear understanding of the “biological or behavioral marker of [the] transition from voluntary drug use to addiction” (Leshner, 2014, p. 3), science is clearly in sync in its understanding of addiction as a “different state of the brain” (O’Brien, 2003, p. 540). The dispute, according to Maté (2008), is about how, specifically, this abnormal state occurs. Are the brain changes the result of chronic use or is there something within these chronic users’ brains that was already present prior to their use to make them susceptible to addiction?

Addiction effects decision making, impulse control, overall health, and can rob those affected with the ability to live a fully conscious, connected, effective life. While it is critical for clinicians to “avoid the trap of believing that addiction can be reduced to the actions of brain chemicals or nerve circuits or any other kind of neurobiological, psychological, or sociological data” (Maté, 2008, p. 137), it is crucial to understand each facet of the disorder, including those deemed biological. While many researchers assert that psychosocial factors function as the bedrock of addiction, and elicit its evolution, there is accuracy in the belief that for a small number of people, who are susceptible and exposed to certain substances, addiction will be triggered (Maté).

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The biology of addiction.

Contemporary studies on the neurobiology of addiction have focused on the role of genetics, the significance of dopamine and the reward system, and the relevance of neurotransmitter connections, intracellular signaling, and plasticity (Bennett & Petrash, 2014; Kalant, 2009).

Genetics.

To date, more than 50 family studies have shown that alcoholism runs in families, but the question has always been whether this similarity has been because of shared genes or shared environment (Prescott, 2003). From a genetic standpoint, it has long been argued that addiction is an inheritable disease with twin, family and adoption studies estimating that 40% to 60% of individual susceptibility towards addiction stem from genetic factors (NIDA, 2014).

Such studies are titled genetic epidemiology studies and have been assigned the task of determining just how much genes influence the risk of developing a disorder; in this case alcoholism. Adoption and twin studies with men have shown that participants with a family history of alcoholism had a 1.6 to 3.6 times greater risk for developing alcoholism than those without, and a heritability estimate of approximately 50 to 60 percent of the variation in risk for alcoholism, respectively (Prescott, 2003). However, adoption studies with women have been less conclusive because of the small numbers of female alcoholics studied, and twin studies with women, based on samples identified through treatment settings, indicate that shared environment rather than (or in addition to) genetic factors add more weight to the development of the disorder (Prescott).

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The most prominent family study to date that has had success in identifying certain gene regions contributing to the risk for alcoholism was originally designed by H. Begleiter and continues to be administered by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). This study falls under the category of molecular genetic research, which works to identify specific genes involved in the development of various disorders, and is called the Collaborative Study on the Genetics of Alcoholism (COGA).

Scientists here have been collecting data since 1989 on more than 300 extended families affected by alcoholism, identifying several chromosomal regions which appear to contain genes affecting the phenotypes of these families (Edenberg & Foroud, 2006). Scientists associated with the study have found strong suggestions of linkage for alcohol dependence on the regions of several chromosomes, including chromosome 8 (Reich, 1996), chromosomes 1 and 7 (Reich at al., 1998), chromosome 3 (Foroud et al, 2000), and chromosome 2 (Wang et al., 2004). In addition, data collected suggests that several GABA receptors genes also have a function in alcoholism susceptibility (Edenberg & Foroud), as do individual GABRA2 and ADH4 genes identified through singlenucleotide polymorphism (SNP) genotyping whereby multiple SNPs were analyzed for each regional candidate gene (Edenberg et al., 2005).

Findings from both epidemiologic and molecular research sound rather formidable even if there is a general scientific understanding that environmental factors, including gene and environment interactions, account for the remainder of the risk (NIAAA, 2012). But the problems many researchers have in generalizing genetic findings in addiction are multiple (Dodes, 2002). First, in diseases where there is a predictable genetic inheritability, such as PKU, Down’s syndrome, and Huntington’s 37

disease, a single gene or chromosome has been identified as being defective (Dodes). In addiction this is not the case. To date, scientists have been unable to find a “gene for alcoholism”, a gene that increases the chance of developing alcoholism, nor has science proven that alcoholism can be directly inherited as can the diseases stated above (Dodes, p. 81). Instead, as demonstrated in the ongoing COGA research, there appear to be multiple genes that may indirectly affect individual susceptibility in the development of alcoholism, similar to high blood pressure and peptic ulcer disease (Dodes). In conditions such as these science understands that genes can be an indirect factor for their development in certain individuals, but additional factors must fall into place in order for the condition to take hold (Cozolino, 2010; Dodes).

Kalant (2009) agrees, stating that there are “literally hundreds of genes [which] have been identified that may contribute individually to increased vulnerability to drug use and drug addiction” (p. 785), but there is no one gene for drug or alcohol addiction itself. Kalant also argues that some genes which might indirectly influence individual susceptibility to substance dependence, such as those associated with impulsivity, can be present in other behaviors that “are not related specifically to addiction” (p. 785). He also reminds us that “it must be remembered that a gene does not encode a trait” (p. 785); asserting that genes can be turned on and off under various circumstances and “are not necessarily continuously active” (p. 785).

Dodes (2002) elaborates on this construct, stating “most of DNA is not composed of genes. Instead, the rest of the DNA molecule contains information, “switches”, which control when or if the genes are “turned on” (p. 82). Dodes maintains that these switches are significantly influenced by nongenetic environmental components including emotions 38

or events; giving his readers an example whereby stress is brought on by final exams which activates genes that “switch on” the immune system and potentially lead to the development of a cold. While the identification of genes that are linked to addiction helps researchers to better understand the cellular mechanisms involved in chronic drug use, they “are not likely to explain causation” (Kalant, 2009, p. 786).

Neurochemistry.

This research tell us that genetics cannot be the only biological factor in the development of addiction, so let us now turn our attention to the role of brain chemistry.

There is no doubt that drugs of abuse chronically change one or more neurotransmitter systems in the brain, including dopamine, glutamate, acetylcholine, serotonin, gammaaminobutyric (GABA), and/or opioid peptides (Farmer, 2009). While all of these systems become pathologically altered with ongoing abuse, dopamine appears to be the most significant as it is the primary chemical messenger in the brain’s reward system; hence its reputation as the “pleasure chemical” (Farmer, p. 142). Levels of dopamine are thought to increase rapidly when first stimulated by drugs of abuse, creating initial feelings of euphoria which decrease and become more difficult to achieve with ongoing, recurrent use (Farmer). With repeated use amounts of dopamine in the brain decrease and the number of available receptors diminished, hindering the brain’s reward system in its ability to release normal amounts of the neurotransmitter during typical pleasurable activities such as eating and sex (Farmer; NIDA, 2014). When this occurs, such activities become less satisfying and larger amounts of the drug of choice become necessary for the individual to feel pleasure (Farmer, NIDA).

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In drug abuse, dopamine has also been linked to craving (Farmer, 2009), increased tolerance (NIDA, 2014), relapse (Koob, 2010), and physical dependence (Bennett & Petrash, 2014; Koob). It is present in many areas of the brain, and is believed to play a significant role in learning, movement, emotional response, memory, and, as explained above, the regulation of pleasure and pain (Bennett & Petrash; Farmer; NIDA).

Dopamine signaling plays a critical role in the biomedical model of addiction although opinions differ as to how it operates. While some researchers believe its release serves as a reward mechanism, others argue that dopamine works as a judge per se of what is or is not important for us to focus on (Farmer). Additional perspectives are that it operates as a process that stimulates and alerts the brain to new internal or external or stimuli (Kalant, 2009), or even as a system that differentiates between anticipated versus experienced rewards (Schultz, as per Kalant, 2009). While varying perspectives exist, it is clear that all drugs that are regularly abused including marijuana, heroin, morphine, alcohol, nicotine, caffeine, crystal meth, and cocaine impact the brain’s dopamine functioning, albeit in different ways (Maté, 2008).

Glutamate, acetylcholine, serotonin, gamma-aminobutyric (GABA), and opioid peptides also have important roles in the biology of addiction. Glutamate is thought to influence the reward circuit, memory, relapse, and the ability to learn, and also functions as a general stimulant to nerve cells (Davies, 2003; NIDA, 2014). When glutamate levels are changed through drug use, the brain works to compensate for the change which can create problems in cognitive functioning (NIDA). GABA, on the other hand, is believed to inhibit nerve cells, as in alcohol use, where it plays a central role in mediating its short - and long-term effects in the central nervous system (Davies). Medications that work on 40

GABA receptor antagonists, inverse agonists, and receptor agonists are understood to play a role in decreasing alcohol self-administration and blocking drug seeking behaviors (Koob, 2010).

Research on acetylcholine implies the neurotransmitter to be influential in the experience and progression of cocaine use, including reinforcement, conditioned responses, and drug seeking behaviors through its signaling effects on arousal and attention (Williams & Adinoff, 2008). Serotonin also appears to play a role in drug seeking behaviors, but in a different manner. This neurotransmitter is believed to become elevated when certain drugs are ingested, causing further motivation to use so as to avoid withdrawal symptoms that include depression and anxiety (Bardi, 2003). Finally, research indicates that opioid peptides are also important to the biology of addiction, particularly in the brain’s reward system where opioid receptors and endogenous opioid peptides are largely distributed and serve to modulate dopaminergic activity (Trigo, Martin-Garcia, Berrendero, Robledo, & Maldonada, 2010). Chronic exposure to various drugs has been reported to produce changes within the endogenous opioid system that appear to play a significant role in the development of the addictive process (Trigo et al.).

Kalant (2009) writes that all cells have “an innate ability to adapt to changes produced by influences external to them”, and that they seek to restore equilibrium by adapting “opposite to the changes that initiated them” (p. 781). For example, when an individual uses an opioid, adenylate cyclase and ion channels in the cell membrane which maintain cell excitability are inhibited, activating a variety of different protein kinases that phosphorylate specific proteins which work to counterbalance the opioid’s effects on the cells (Kalant).When the opioid is withdrawn, the adaptive changes which worked to 41

restore equilibrium “become the basis of a withdrawal reaction” and are thought to play a significant role in increasing tolerance and physical dependence (p. 782).

Because similar adaptive responses are found in nerve cells that are exposed to stress, and sensory stimuli that evoke memory and are involved in learning, researchers believe that the signaling pathways are switched on when the cells equilibrium is disturbed by a variety of functional disturbances, not just chronic drug use (Kalant, 2009). But given the massive number of synaptic and cellular changes that occur during acute and chronic drug use, and the fact that nearly every neurotransmitter in the brain is affected, Kalant argues: Many of the changes are probably secondary to the drug actions, or may be part of the adaptive responses underlying tolerance and physical dependence: but unless they are specifically linked to self-administration, they may not tell us much about the generation and expression of addiction (p. 785).

In other words, cell molecules, or cellular structure, do not cause compulsive use of drugs and alcohol; this confuses mechanism with cause (Felitti, 2003). In addition, Kalant states, “knowledge of these mechanisms can tell us how the change is brought about, but not why” (p. 782).

Brain structure and neuroplasticity.

“Plasticity then, in the wide sense of the word, means the possession of a structure weak enough to yield to an influence, but strong enough not to yield all at once.”

-William James 42

When the drug of abuse hijacks the brain’s dopamine system it activates the limbic region which is the seat of the brain’s reward system, and which also controls how individuals perceive both negative and positive emotions; possibly explaining the ability drugs have to alter mood (NIDA, 2014). Other areas of the brain affected include the cerebral cortex which is responsible for processing information from our senses as well as our ability to function “executively”; to plan, think, solve problems and make decisions (Farmer, 2009; NIDA). As well, understandably, the brain stem which controls critical life functions such as breathing, heart rate, and our ability to sleep, is also adversely affected (NIDA). All in all, drugs of abuse affect integral areas of the brain which provide people with the ability to understand and respond to ongoing experiences, and which shape their thoughts, feelings, and actions (NIDA).

Because of technological advances which allow scientists to view and compare the brains of addicted individuals to non-addicted individuals, we know that these areas of the brain are seen as particularly vulnerable to chronic substance use. The drug addicted brain appears very different compared to the non-addicted brain when viewed through the techniques of magnetic resonance imaging (MRI), and positron-emission tomography (PET) scans; it does not look the same, nor does it work in the same manner (Maté, 2008). For example, MRI’s are capable in measuring the brain’s white matter (i.e., connecting fibers that permit communication between neurons), and grey matter (cell bodies of nerve cells where processing occurs), in individuals who abuse substances. In one study examining individuals with chronic cocaine habits, the age-related white matter in the frontal and temporal lobes, which normally increases up to age 47, was completely absent (Bartzokis et al., 2002). Similar deficits in white matter can be found in 43

individuals who chronically abuse heroin, cocaine and cannabis (Li et al., 2013; Schlaepfer et al., 2006), ketamine (Liao et al., 2010), and alcohol (Fortier et al., 2014).

This is problematic given that the seat of all learning and adaptation is in the growth and connectivity of neurons (Cozolino, 2010). If this ability becomes compromised, individuals struggle to make clear choices, absorb new information, and adjust to new situations (Maté).

Similarly, research using MRI’s have indicated that prolonged use of certain drugs, including cocaine, also decreases grey matter in brain regions that include the anterior cingulate, lateral prefrontal and insular cortex (Connolly, Bell, Foxe & Garavan, 2013). Voxel-based morphometry (VBM) research measuring grey matter in opiatedependent individuals also shows a decrease in gray matter density in the prefrontal and temporal cortex (Lyoo et al., 2006). Moreover, the longer the drug use the less grey matter volume exists in brain regions that include the anterior cingulate, inferior frontal gyrus and insular cortex (Connolly et al.). Research on alcoholism suggests that grey matter volumes can increase with abstinence, but the deficits can last for prolonged periods. In one particular study which examined grey matter volume in alcoholics with over 6 months of abstinence, some regrowth could be seen in the ventricular system but none could be found in the prefrontal lobes (Wobrock et al., 2009). And whereas the ventricular system appears to repair at a moderate rate in patients who reduce their alcohol consumption or stay abstinent (Wobrock et al.), complete recovery of brain damage incurred in chronic use of alcohol is questionable (Maté, 2008; Muuronen, Bergman, Hindmarsh & Telakivi, 1989).

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Simply speaking, white matter actively affects how the brain learns and dysfunctions, controls the signals that neurons share, and coordinates how well brain regions collaborate, while gray matter does the brain’s thinking and calculating (Fields, 2008). White and grey matter volume deficits interfere with emotional wellbeing, impulsivity, rational decision making, spatial processing, ability to think and learn, memory (both short and long-term), maintaining control, dual task performances (i.e., talking on the phone while driving), and a myriad of additional consequences too long to enumerate (Connolly et al., 2013; Lyoo et al., 2006; Maté, 2008, & Wobrock et al., 2009).

While it has been shown that the brain works to adapt to various types of functional alterations as in the case of unlearning phantom limb pain (Ramachandran, 2012), or post-stroke recovery of motor functioning (Wittenberg, 2010), the neurobiological changes associated with addiction can be long lasting and, in some cases, possibly permanent (Bailey, Hurley, & Gold, 2010; NIDA, 2012). Indeed, researchers Robinson & Kolb (2004) argue: Some of the most compelling examples of experience-dependent changes in behavior and psychological function, changes that can last a lifetime, are those that accrue with the development of addictions. Exposure to amphetamine, cocaine, nicotine or morphine produces persistent changes in the structure of dendrites and dendritic spines on cells in brain regions involved in incentive motivation and reward, and judgment and the inhibitory control of behavior (p.

33).

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In short, neurons that fire together, wire together. Or, as Hebb originally stated: “an excited neuron tends to decrease its discharge to inactive neurons, and increase this discharge to any active neuron” (2009, p. F7). If a specific pattern has been activated in the past, the possibility of the pattern being reactivated in the future significantly increases, especially if the pattern is fired repetitively (Siegel, 1999). It is understandable that the medical model refers to addiction as a chronic disease given the understanding that the brain determines the way we behave, and addicted individuals behave differently due to biological changes in their brain’s chemical makeup, structure, and physiological operations (Maté, 2008). However, where imaging studies of the brain can show us the areas that are activated with drug use, they cannot tell us why some people, and not others, use them addictively (Dodes, 2002).

Multifarious interactions.

Genetic studies, research on dopamine and its effect on rewards, and studies on cellular signaling have all greatly contributed to an understanding of addiction as a chronic brain condition, but have thus far provided no insight into the reasons why some people become addicted while the majority of users remain unaffected, and why some users develop dependency with rather minor drug exposure. Moreover, given the understanding that gene expression, cellular signaling, and brain structure/chemistry are affected by a variety of environmental and contextual factors, Levy (2013) argues that addiction would be better understood as “a disorder of a person, embedded in a social context, [even] though it certainly involves pathological neuropsychological dysfunction” (p. 4).

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While some researchers argue that addiction treatment should be integrated into mainstream medicine (Dackis & O’Brien, 2005), and refer to addiction as a bio behavioral disorder that requires biomedical treatment (Leshner, 2014), most treatment providers understand addiction to be the result of multifactorial interactions that include psychosocial factors such as co-occurring disorders, stress, trauma, and environmental conditions (Bennett & Poltrash, 2014; Dodes, 2002; Farmer, 2009; Levy, 2013; Maté, 2008). Indeed, Kalant (2009) writes that this disorder is created within “an extremely complex interactive system of drug, individual user, environment and changing circumstances [and] is no longer the terrain of pharmacology or neurobiology or psychology or sociology, but an amalgam of all of them” (p. 786).

The origins of addiction?

The human brain at birth contains almost 100 billion neurons which begin forming at about 42 days after conception (Bruer, 1999). As the neurons begin to form, and continue to multiply at significant rates, they are shaped by their prenatal environment. There is increasing evidence that as babies form they can become susceptible to maternal stress as result of their shared biological world (Cozolino, 2010).

Prenatal stress has been linked to lower birth rates and lower mental and motor developmental scores in infancy, as well as learning disabilities, increased hyperactivity and irritability, externalizing problems, anxiety, and decreased gray matter density in children (Buss, Poggie Davis, Muftuler, Head & Sandman, 2010; Gunnar, 1992; Gunnar, 1998; Huizink, Robles de Medina, Mulder, Visser & Buitelaar, 2003; Van den Bergh & Marcoen, 2004; Zucherman, Bauchner, Parker, & Cabral, 1990). Individuals who have

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experienced stress in utero have a higher likelihood of developing ineffective stresscontrol mechanisms which creates a risk factor for the development of addiction (Maté, 2008), as does the presence of ADHD, anxiety and depression (NIDA, 2014; Silberman et al., 2009). While this research does not discount twin studies which point to genetics as influential in addiction, it does suggest that environmental influences prior to birth may have an important biological influence in whether or not an individual is predisposed (Maté).

Brain development during childhood is equally critical. In the timeframe following birth the brain continues to grow at the same rate as during pregnancy, with three quarters of brain growth occurring outside the womb during the early years (Maté, 2008). Humans do not keep all the neural connections present at birth; indeed, some are used and some are lost to what is referred to as synaptic pruning. Neurons and neural connections are believed to compete in order to survive, and developmental experiences determine those kept and those lost (Maté). Daniel Siegel, child psychiatrist and founding member of the University of California, Los Angeles’s Center for Culture, Brain, and Development, writes in The Developing Mind (1999): For the growing brain of a young child, the social world supplies the most important experiences influencing the expression of genes, which determines how neurons connect to one another in creating the neuronal pathways which give rise to mental activity. The function of these pathways is determined by their structure; thus alterations in genetic expression change brain structure and shape the developing mind. The functioning of the mind – derived from neural activity –

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in turn alters the physiological environment of the brain, and thus itself can produce changes in gene expression (p. 20).

Siegel argues that the most influential environmental factors that shape the development of the brain during its periods of maximal growth are attachment relationships with primary caregivers that the infant and young child uses to organize their own processes.

This hypothesis is supported by significant research that understands early attachment experiences to be critical to emotional and physical health as we age. Louis Cozolino, researcher, practitioner, and author, discusses the neurobiology of attachment in his book The Neuroscience of Psychotherapy (2010), 2nd edition. Here Cozolino presents extensive research findings which clearly state that attachment experiences are key to the development of neurobiological systems that are connected to stress regulation, learning and memory, and attachment behavior. The neural hubs and regulatory systems which he describes, including cortical and subcortical structures and sensory, motor, and affective systems, are believed to be created in an experience-dependent manner whereby “early relationships shape the building of neural circuitry, which guides how we are able to learn, react to stress, and attach to others” (p. 236).

Vincent Felitti (2003), chief investigator in a landmark study which has examined over 17,000 middle-class American adults for Kaiser Permanente and the U.S. Centers for Disease Control and Prevention, agrees. In the 1980’s the Adverse Childhood Experiences (ACE) study invited 26,000 consecutive adults voluntarily seeking comprehensive medical evaluation in the department of preventive medicine to help researchers understand how adverse events in childhood might affect health status in

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adult life. Almost 70 percent of those contacted agreed to be a part of the study (Felitti).

Over the years participants provided detailed information about childhood experiences of abuse, neglect, and family dysfunction. To date more than 50 scientific articles have been published which ascertain that certain events and experiences are major risk factors for poor quality of life as well as the development of mental and physical illness and early death (Felitti). The eight categories of adverse experiences measured (prevalence of each category is in parenthesis) were: 1. Recurrent and severe physical abuse (11%); 2. Recurrent and severe emotional abuse (11%); 3. Contact sexual abuse (22%); 4. Growing up in a household with: an alcoholic or drug user (25%); 5. Growing up in a household with: a member being imprisoned (3%); 6. Growing up in a household with: a mentally ill, chronically depressed, or institutionalized member (19%); 7. The mother being treated violently (12%); and 8. One/or both biological parents not being present (22%) (Felitti).

ACE research specifically related to substance use and addiction have found that adverse childhood experiences are strongly related to ever drinking alcohol and to alcohol initiation in early and middle adolescence, with a “dose response” relationship between the number of adverse experiences and these alcohol use behaviors (Dube et al, 2006). In another study examining ACE scores with personal alcohol abuse as an adult, researchers determined that each of the eight individual ACE’s was associated with a higher risk of alcohol abuse as an adult (Dube, Anda, Felitti, Edwards, & Croft, 2002). Compared to 50

individuals with no ACEs, the risk of self-reported alcoholism, heavy drinking, and marrying an alcoholic were increased twofold to fourfold by the presence of multiple ACEs, regardless of parental alcoholism (Dube et al., 2002).

ACE research on prescription drug use has also determined that compared to persons with an ACE score of 0, persons with a score equal to, or higher, than 5, had increased rates of prescription drug use by 40% (Adna, Brown, Felitti, Dube, & Giles, 2008). These researchers concluded that ACEs significantly increased the number of prescriptions and classes of drugs used for as long as seven or eight decades after their occurrence (Adna et al.). Additional research (Felitti, 2003) has found that chronic use of alcohol, nicotine and injected street drugs increased proportionally in a dose-response manner which parallels the intensity of ACEs during childhood. For example, in the case of injected drug use, a male child with an ACE score of 6, when compared to a male child with an ACE score of 0, has a 46-fold (4,600%) increase in the likelihood of becoming an injection drug user at some point in their lifetime (Felitti).

The ongoing ACE study challenges the medical model of addiction whereby addiction is seen primary as a chronic brain disease which is substance-dependent. The ACE study, in sync with Cozolino and Siegel, strongly suggests addiction to be experience-dependent during childhood and that the condition is “best viewed as an understandable, unconscious, compulsive use of psychoactive materials in response to abnormal prior life experiences, most of which are concealed by shame, secrecy, and social taboo” (Felitti, 2003, p. 9).

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Individual Substance Addiction Treatment Given the convincing argument that addiction is experience-dependent one might think that the principal treatment for this condition would include addressing its underlying causes which would very much espouse a psychodynamic approach. But this is not the case in the age of the biomedical model.

Psychopharmacology.

Considering the numerous neurological pathways that are thought to contribute to SUD’s, several medications have been approved by the Food and Drug Administration (FDA) for treatment that works to suppress withdrawal symptoms, decrease relapse rates, and reduce cravings (NIDA, 2009). Naltrexone is one of the most familiar medications used in the biological management of heroin and alcohol addiction which works by blocking opioid receptors that are key to the drugs rewarding effects (NIDA).

Two additional medicines for treating alcohol dependence are acamprosate and disulfiram. Acamprosate is thought to be particularly effective with in patients with severe dependence and is being used to reduce symptoms of prolonged withdrawal that include anxiety, restlessness, insomnia, and dysphoria (NIDA; O’Brien, 2003).

Disulfiram, commonly known as antabuse, interferes with individual attempts to consume alcohol by causing an unpleasant reaction that includes severe nausea, flushing, and heart palpitations (NIDA).

Methadone and buprenorphine are used to treat opiate addiction. Methadone works as an agonist substitution whereby it is seen as a lesser evil than, for example, heroin. This is similar to the use of nicotine patches, sprays, gum, and lozenges for the 52

treatment of tobacco dependence. Both methadone and buprenorphine are believed to suppress withdrawal symptoms and relieve cravings (NIDA, 2009).

Future research focus in the area of psychopharm is on genetic variation studies that might better determine individual subpopulation clinical benefits, and on the components of disease progression where medications might target stage-specific biochemical mechanisms (Heilig, Goldman, Berrettini, & O’Brien, 2011.; Koob, 2010).

Fellowship programs.

Statistics regarding the effectiveness of structured 12-step programs differ greatly amongst published studies (Dodes, 2002; Moos & Timko, 2008). One of the difficulties in attaining clear data is the simple fact that attendance in these groups is anonymous.

Another challenge is the insular nature of the groups themselves that tend to operate from a one-size-fits-all approach based on concepts first penned in 1939, which state that as long as the individual works the program as prescribed they will find the ‘solution.’

Despite the detractors and conflicting statistics there are many success stories to be found in all four editions of Alcoholics Anonymous (AA), and throughout the published research, that must be considered (Moos & Timko). As well there are varying perspectives as to what makes these programs successful for those who find recovery within their doors.

Gabbard (2005) believes that structured 12-step programs provide mutual support amongst similarly affected caring individuals. He writes that such programs “can be internalized in the same manner that a psychotherapist is internalized, and they can assist the alcoholic individual with affect management, impulse control, and other ego 53

functions, also as a psychotherapist would” (p. 347). Moos & Timko (2008) argue that 12-step programs are successful because members are exposed to coping skills, goal direction, substance-free events and activities, a safe setting where individuals can freely express feelings and experiences, and opportunities to boost self efficacy by helping others overcome substance use problems.

Supporting studies suggest that attendance in self-help groups is associated with a higher likelihood of abstinence (Walitzer, Dermen, & Barrick, 2009), greater reductions in consumption following inpatient treatment (Gossop et al., 2003), better psychiatric and family/social functioning at one-year following residential treatment (Timko & Sempel, 2004), and argue that one-year outcome findings show that 12-step treatment and cognitive-behavioral programs result in similar remission rates (Ritsher, Moos, & Finney, 2002).

Contrasting views suggest that AA is not suitable for all patients with alcoholism, especially those struggling with other psychiatric disorders (Gabbard, 2005). Additional perspectives suggests that 12 step programs are linked too closely to the biomedical model of treatment and more consideration should be given to the psychological elements that comprise addiction (Berger, 1991). Berger argues that little emphasis is placed on a psychotherapeutic approach which would examine factors relating to substance use disorders that are not immediately apparent but are instead unconscious and much more complex in nature.

Dodes (2002) writes that the main problem with 12-step programs is that they are not helpful in increasing understanding around the basis for addictive behaviors and

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suggests that while some individuals may benefit from programs that emphasize humility and admitting defeat, in the sense that they “learn to question themselves in a healthier way” (p. 228), many may find that this approach only confirms a deep seated belief in their brokenness and inability to thrive.

A 1990 (Craigt, 2008) summary of approximately 980,000 AA members from five different membership surveys (from 1977-1989), was composed in order to provide “the need for current and reliable information on A.A. for the public and for the professional community” (p. 1). The summary recognized that in the first three months of attendance there was a 50 percent attrition rate amongst the membership and an 81 percent attrition rate within the first year. In addition, only 5 percent of members surveyed had been attending meetings for more than 12 months.

Whether 12-step attrition is due to aspects of programming, or individual struggles with motivation and readiness to change, it is clear that they are beneficial to some but not the bulk of first year participants. Dodes (2002) and Chanin (2000) suggest that 12 step programs are best for people who connect to the idea of a “higher power”, or “spiritual center” and can be helpful as an adjunct to individual psychotherapy which seeks understanding about the meanings behind the behavior.

In determining whether or not a 12 step is suitable, author William Silkworth, MD, writes in the Big Book of AA that there are three types of alcoholics, “the psychopath who [is] emotionally unstable, the manic-depressive type, and [the type that is] entirely normal in every respect except in the effect alcohol has upon them” (p. xxx).

Perhaps treatment of individuals struggling with substance use disorders would be more

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effective if clinicians were to better understand each category of alcoholic? Bill W., the founder of AA, understood the importance of treating the disorder from multiple standpoints. He writes (2001) “the main problem of the alcoholic centers in his mind, rather than his body” (p. 23), and that “of necessity there will have to be discussion of matters medical, psychiatric, social, and religious” (p. 19).

Psychotherapy treatment.

While the scientific community is actively researching numerous pharmacological options for the treatment of SUD’s, current pharmacotherapies have been shown to be moderately successful at best and non-effective for many patients (Heilig, Goldman, Berrettini, & O’Brien, 2011; Koob, 2010). This understanding simply means that while prescriptive methods are very helpful for some, it is not the answer for many, which leaves us continuing to question; what works?

The two forms of psychotherapy for individuals with addiction that have received significant research-based support are Motivational Interviewing (MI) and CognitiveBehavior Therapy (CBT). MI is a directive, client-centered behavioral therapy that is thought to enhance motivation for change in individuals with SUD’s by helping them explore and resolve ambivalence (Miller, Yahne, & Tonigan, 2003). The approach is typically short-term and is collaborative between therapist and client de-emphasizing labels while accentuating personal choice and responsibility (Miller & Rollnick, 1991).

MI has been seen as most effective when used as a prelude to other forms of treatment (Weiss, Mills, Westra & Carter, 2013), in the beginning stages of treatment with co-

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occurring diagnoses (Bennett & Petrash, 2014), or when used in combination with other interventions including CBT (Acosta, Haller & Ingersoll, 2010).

Once the problem has been pinpointed, and acknowledged, CBT is used to help individuals identify and correct behaviors that may contribute to relapse (Bennett & Petrash, 2014; NIDA, 2012). Specific techniques used in the model include the exploration of positive and negative consequences associated with use, help with recognizing cognitive distortions that might be contributing to problematic behaviors, and assistance developing skills that help avoid high risk situations and improve self-control (NIDA). With SUD’s, CBT appears to be most effective for cannabis use and least effective with polysubstance use (Dutra et al., 2008; Magill & Ray, 2009).

As previously discussed under therapeutic factors, it has been argued (Shedler, 2010), that CBT and other psychotherapies have shown efficacy in specific outcome studies because the studies shared features that specifically define psychodynamic treatment. In fact, research suggests that the very factors assumed to operate as the mechanisms of change in cognitive therapy (i.e., the cognitions) have, in fact, very little effect on treatment gains (Kazdin, 2007). The same can be said of behavioral models of addiction, whereby several decades of research still leaves researchers and practitioners with a very limited understanding as to the mechanisms of change (Morgenstern, Naqvi, Debellis, & Breiter, 2013).

One of the many issues psychodynamic psychotherapy treatment providers have with behavioral and cognitive forms of treatment is that they typically conclude when the acute symptom(s), has(have) subsided. This is extremely problematic on several

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accounts. Firstly, cognitive and behavioral therapies are typically short-term models that focus on symptom reduction over a specific period of time. Many are manually based; meaning that there is a specific sequence in which the treatment unfolds and a specific manner in which each symptom is addressed. For example, in CBT cravings might be managed by asking the patient to journal a daily record of cravings that includes the situation, the thoughts or feelings associated with the situation, the degree of craving, and the rational response and/or coping skill to use to keep the craving in check (Beck, Wright, Newman, & Liese, 1993). One of the objectives is that the patient learns to associate certain situations with increased cravings, and begins to identify alternative means in which to manage associated thoughts and feelings that decrease the risk for relapse.

While the identification of events that increase stress is extremely important in the management of addiction, in most cognitive and behavioral models there is little exploration of the interpersonal components, or the unconscious mechanisms (i.e., defense strategies), that may be contributing to the crisis. These interpersonal dynamics and unconscious mechanisms are not easily identified, especially if specific focus is on the cognitive, or behavioral, components of the disorder. In using the same example around cravings for instance, psychodynamic therapists might work to realign the need for the substance back into a need for people, which includes the clinician (Frances, Mack, Borg & Franklin, 2004). This takes some time to develop within the treatment and occurs only after a secure therapeutic alliance has been formed and repetitive enactments have occurred to the extent that both patient and clinician can put words to the often implicit, and unconscious, forces at work. Until this occurs, the symptom (i.e., craving) 58

might be better understood intellectually and behaviorally with cognitive behavioral therapies but the unconscious mechanisms involved in its triggering will still be at large, leaving the addicted individual vulnerable to setback.

In addition, while cognitive behavioral approaches are heralded as cost-effective in the treatment of SUD’s because of their short-term focus, given that treatment can last many years with numerous occurrences of care including hospital inpatient, residential outpatient, day treatment/partial hospitalization, screening and assessment, testing, individual, group, family, and couples counseling, transitional services, pharmacotherapies, and ancillary services that include case management, mentoring/peer support, and employment counseling (SAMHSA, 2011)… how cost effective is it really?

In reality time-limited treatment modalities may not adequately address chronic relapse issues; if indeed this is what addiction entails (Dennis, Scott, Funk & Foss, 2005; McKay & Hiller-Sturmhöfel, 2011).

Psychodynamic treatment.

Psychodynamic treatment of individuals struggling with SUD’s, on the other hand, has a long history of examining the unconscious factors possibly involved in the development, and prolongation, of the disorder.

Self-medication hypothesis.

Several prominent researchers (Dodes, 2002; Khantzian, 2003; Krystal & Raskin,1970; McKenna, 1982; Wurmser, 1974) espouse a self-medication hypothesis of addiction whereby individual struggles with overpowering affects, relationships, and 59

behavioral instabilities contribute to drug use. Khantzian goes one step further suggesting that users choose specific drugs which help them manage their particular emotional problem. He argues, for example, that opiates find favor in individuals who are struggling with aggression and rage and who may have been exposed to violence or deprivation in their family of origin, and that alcohol can be used by individuals who feel alone, isolated, empty and who struggle with symptoms of anxiety.

There are those who question the idea that specific drugs are chosen to manage specific areas of psychological distress. Dodes (2002), who supports the broader perspective of the self-medication hypothesis, argues that many users interchange drugs regularly that create very different mind states, which to Dodes, undermines the premise of a specific drug-to-feeling-state. But the connecting of affective experience and drug of choice has been duplicated in additional studies, including recent research by Suh, Ruffins, Robins, Albanese & Khantzian (2008) who found repression and depression to be linked to alcohol use, cynicism to predict preference to heroin, and psychomotor acceleration a predictor of cocaine use.

Research on dual-diagnosis supports the self-medication hypothesis (Back, Brady, Jaanimagi, & Jackson, 2006; Leeies, Pagura, Sareen, & Bolton, 2010), including longitudinal studies on PTSD (Chilcoat & Breslau, 1998), but there are some researchers who believe that it is the dopamine depletion that occurs as a result of withdrawal from cocaine, morphine, amphetamines, and alcohol that leads to dysphoric states (Dackis & Gold, 1985; Pickens & Calu, 2012), which in turn leads to co-occurring diagnoses of depression and other mood disorders. Research overall supports a high prevalence and

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comorbidity of SUD’s and independent mood and anxiety disorders (Grant et al., 2004; Chen et al., 2011).

Clinicians supporting the self-medication hypothesis utilize treatment modalities that “focus on core areas or sectors of vulnerability to access and modify substance abusers’ problems” (Khantzian, 1995, p. 39). These core areas include exploration into states of helplessness (Dodes, 2002), disturbances in affect forms and function as well as capacity for self-care and alexithymia (Krystal, 1997), the roles of narcissistic rage, regressive gratification, shame, hurt, loneliness, abandonment, and rejection (Wurmser, 1974), and vulnerabilities involving emotions, relationships, and self-esteem (Khantzian).

Treatment requires the clinician “to pay very close attention to [the] addiction while understanding the psychology behind it” (Dodes, p. 230). In other words, do what needs to be done from a practicality standpoint (i.e., hospitalization, detoxification, etc.), but do not lose sight of the disorders’ psychological roots. Khantzian suggests psychodynamic treatment in the form of individual or group psychotherapy so that defensive vulnerabilities are given time to reveal themselves in a safe manner and can be examined and modified in the ensuing relationships which result. He writes that supportive methods (i.e., the ‘primary care’ therapist) “are not inconsistent or incompatible with expressive approaches which allow for analysis of defenses and the vulnerabilities they mask or disguise” (p. 40).

Co-occurring personality disorders and addiction.

Research has also found a strong correlation between personality disorders (PD’s) and substance use dependence (Chaves, 2015; Grant et al., 2004b; Langås, Malt & 61

Opjordsmoen, 2012; Olsson & Fridell, 2015; Treece & Khantzian, 1986). In a national epidemiologic survey on alcohol and related conditions, Grant et al. conducted over 43,000 face-to-face interviews for the DSM-IV in order to present national data on sex differences in the co-occurrence of various PD’s and alcohol and drug use disorders. In general they found alcohol and drug use disorders most strongly correlated to antisocial, histrionic, and dependent PD’s; a higher correlation between obsessive-compulsive, histrionic, schizoid, and antisocial PD’s and specific alcohol and drug use disorders amongst more women than men; and a higher association between dependent PD and drug dependence among more men than women.

In another study examining comorbid PD’s in first-admission patients with SUD’s, Langås et al. (2012), found that 46 percent of the patients had at least one PD (16% antisocial [males only]; 13% borderline; and 8% paranoid, avoidant, and obsessivecompulsive, respectively). The study also found Cluster C disorders as prevalent as those in Cluster B; that PD and substance use disordered patients were younger at the onset of their first SUD and at admission; had greater degrees of anxiety disorders, in particular social phobia; used more illegal drugs; were more distressed; had more severe depressive symptoms; and attended work or school less often.

When working with patients with co-occurring PD’s and SUD’s, Treece & Khantzian (1986), argue that the problem must be seen from the individual drug users self-experience and psychological structure. The researchers state that such individuals typically struggle with emotional dysregulation, narcissism, objects relations, self-care, and judgment; developmental and structurally determined problems that find relief in drug taking. In order to find success the authors argue that the drug user “must be able to 62

relinquish behaviors and drug effects that have come to be experienced as a valued (even if also hated) part of the self-capacity to function, cope, and be comforted in distress” which includes dealing with both the unconscious and conscious components of their dependence (p. 399).

The container and the contained.

Additional psychoanalytic concepts that might fall under the auspices of the selfmedication theory include Bion’s notion of the container and the contained (Williams, 2002). While Bion wrote very little about SUD’s in general, his model offers a conceptual perspective that “explores how people with infantile feelings of emptiness or the distress of separation, often played out in the transference, resort to drugs to contain feelings that are otherwise uncontainable” (Khantzian, 2002, P. xii). Given that persistent mood pathology cannot be contained by the use of drugs and alcohol for an extended period of time without further affecting intrapsychic, interpersonal and external factors, in this model the user is left feeling less and less capable of “holding” their torment, leading to increases in use (Williams). While treatment is complex and draws to some extent from conflict theory (e.g., reintegrating ego functioning; subduing the super ego), one of the most important precepts here is that the therapist has a strong grasp of the patient’s need for containment and has an ability to serve as such (Williams).

This form of treatment might be particularly effective with opiate addicted individuals who have been found to struggle particularly with issues of shame, guilt, selfcriticism, worthlessness, and depression (Blatt, McDonald, Sugarman & Wilber, 1984).

Such individuals are seen as struggling to contain feelings of anxiety, depression, and 63

anger, preferring instead to “withdraw from the pain and stress of interpersonal relationships into self-induced grandiose omnipotent experiences of bliss” brought on by opiates (Blatt et al., p. 159).

Self psychology.

Another analytic theory often used to better understand, and treat, individuals with SUD’s, is self-psychology. While Kohut did not work with individuals struggling with addiction (Weegmann, 2002), he did write about the addictive need for a selfadmiring other (Ulman & Paul, 1989), and introduce into the analytic arena constructs such as narcissistic vulnerability, self-deficits, and selfobject functioning which therapists have used in their approach to treatment SUD’s. Kohut (1971) suggests that addictive personalities suffer from having an ‘empathy-defective’ caregiver who cannot fulfill the growth-related functions needed in the development of self-structure that allow the child to acquire the ability to self sooth and provide self-validation. He concludes: Such individuals remain thus fixated on aspects of archaic objects and they find them, for example, in the form of drugs. The drug, however, serves not as a substitute for loved or loving objects, or for a relationship with them, but as a replacement for a defect in the psychological structure (p. 46).

While addiction treatment appears to vary amongst those practicing a self-psychological approach, it seems to focus on the development of self-structure through the therapeutic relationship via transmuting internalizations and the monitoring and development of the mirroring and idealizing selfobject functions. In layman’s terms, treatment seeks to assist

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in self-cohesion whereby individuals learn how to self-soothe and self-care so that external events are less likely to trigger fragmentation.

Attachment theory.

Finally, the role of attachment processes as first introduced by Bowlby has also garnered strength amongst clinicians providing addiction treatment (Bennett & Petrash, 2014) due to the understanding of the important role they play in the early development of affect regulation and interpersonal relationships, and their continued influence throughout the lifespan (Schore & Schore, 2007; Wallin, 2007). The basic premise of attachment theory places onus on attunement and mutual gaze episodes between primary care giver and infant which serve to co-regulate the baby’s autonomic nervous (ANS) and postnatally developing central nervous (CNS) systems (Schore & Schore). When the caregivers ability to attune to the dynamic shifts of the infant’s internal systems are good enough, despite moments of misattunement, a secure attachment is formed which manifests in children who are flexible, emotionally open, confident, empathic, and secure-resourceful in their relationships (Wallin). When this does not occur because of constant misattunement due to intrusiveness, detachment, unpredictability, or trauma, as the child matures he or she finds it difficult to regulate arousal, self-soothe, and contain affective experiences (Wallin). While “nonverbal, affective experience within an attachment context constitutes the original core of the self” (Wallin, p. 113), researchers also understand that psychotherapy and healthy attachment relationships can help restructure problematic attachment by providing new attachment experiences (Crowell, Treboux, & Waters, 2002; Fonagy et al., 1996; Hesse, 1999).

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Neurobiological research has assisted in expanding Bowlby’s original model with significant data suggesting that early attachment interactions influence brain growth and development, particularly the right brain areas associated with stress modulation, selfregulation, and the processing of emotions (Schore, 1994). These same right brain, nonverbal, modulating capacities are key in shaping, developing and sustaining intimate and stable couple relationships (Lapides, 2014). These neurobiological systems are dominant the first 18 months of life prior to language acquisition and involve behavioral, perceptual and emotional learning that is unconscious and implicit (Siegel, 1999). Given that these functions are especially compromised with SUD’s (Khantzian, 1995; Koob, 2010; NIDA, 2012), it should come as no surprise as to the relevance which clinicians are giving to attachment and its biopsychosocial constructs.

While there is a paucity of research detailing the use of attachment theory and SUD’s, there is a large body of work supporting attachment theory as a clinical intervention as seen in Daniel Hughes’ Attachment-Focused Family therapy, Mentalization-Based Therapy, and Emotionally Focused Couples Therapy. Also, studies on addiction and attachment based interventions are slowly beginning to trickle out of the therapeutic community and are clearly indicating a relationship between secure attachment and addiction recovery (DeRick, Vanheule, & Verhaeghe, 2009; Molnar Sadava, DeCourville, & Perrier, 2010), and insecure attachment with inability to maintain intimacy and regulate affect (Thorberg & Lyvers, 2010).

Additional researchers (Fletcher, Nutton, & Broad, 2015; Bennett & Petrash, 2014) working with SUD patients strongly support the use of attachment based interventions, and go as far as to say that addiction is an attachment disorder; period 66

(Flores, 2006). Research has found that a sense of attachment can alter brain responses to threat (Coan, Schaefer, & Davidson, 2006) and cause the release of oxytocin which both calms the autonomic nervous system and increases positive social interactions (Carter, 1998). Research also shows that individuals who are attachment avoidant have a much more difficult time engaging in fellowship based groups such as AA than individuals who are securely attached (Jenkins & Tonigan, 2011), and that insecurity in attachment styles greatly impacts the therapeutic relationship (Wedekind et al., 2013). Attachment based interventions include the use of therapist as a new attachment experience to help foster understanding of the addicted individuals’ ‘emotional self (Flores), and develop a capacity for healthy relationships (Fletcher, Nutton & Broad; Flores).

Integrative approaches.

Many researchers attest to a combined treatment approach of behavioral and neurobiological components (Farmer, 2009; Saitz, 2007; Volkow & Li, 2005). One unique integrative approach is the bio-behavioral model (Matto, 2005). This approach is used to help hard-to-treat populations including chronic substance-dependent individuals, and uses cognitive theory and expressive art therapy to tap into both right and left brain hemispheres (Matto). Integration of these hemispheres during the treatment of addiction is thought to be particularly important given that affect dysregulation and stress are significant risk factors for relapse (Farmer).

Integrative approaches can be particularly important for individuals managing cooccurring disorders (Morgan-Lopez et al., 2014; Wüsthoff, Waal, & Gråwe, 2014), especially considering that 25 percent of all suicides occur in alcoholics, and an 67

alcoholics’ likelihood of suicide is between 60 and 120 times higher than that of an individual without a psychiatric condition (Murphy & Wetzel, 1990). Given the high level of comorbidity between addiction and other psychiatric diagnoses, in some populations between 55 and 93 percent (Khantzian & Treece, 1985; Rounsaville et al., 1991), many experts argue that psychotherapy should be included as part of the treatment paradigm (Woody & Mercer, 2005).

The Stage-wise treatment model supported by SAMHSA (2013) for co-occurring mental and SUD’s has a 4-stage protocol that includes engagement, persuasion, active treatment, and relapse prevention. The integrated treatment approaches within the model include the use of screening, assessment, treatment planning, CBT, MI, and peer support.

The approach stems from the perspective that individuals go through different stages as they move towards recovery and treatment should be tailored to fit this process.

Dodes (2002), states that treatment may involve individual therapy, psychoeducation, 12-step programs, professional group therapy, medication, and/or couples therapy but each individual should be assessed by a professional therapist so that their treatment protocol is individually tailored. He also argues against “the mistaken idea that if you have an addiction, you are incapable of thinking about it or dealing with the emotions that lie behind it” (p. 230), finding this mentality insulting to individuals with addictions and harmful in that it discourages therapists working with this population.

Similarly, Dodes argues against the idea that “even in therapy, therapists should first only talk about narrow practical details of an addiction” (p. 231), believing that this is not at all necessary and, in fact, delays the work of treatment.

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Summary.

As this section suggests, treatment of SUD’s is indeed complex and at times contradictory, with interventions running the gamut from behavioral, psychopharm, psychodynamic, psychoeducational and an integration of all the above. From Birkett’s (2003) perspective, addiction appears to be the result of “damage to the self that begins with environmental deficit, secondarily by the psychic defenses erected to cope with this, and finally by the physical and social destructiveness of drug use” (p. 338). As Birkett (2003) attests, if only the biological and social aspects are treated, as is often the case, underlying problems that may have led to the abuse will remain untouched and relapse becomes an expected part of the treatment process. This may be one of the reasons the behavioral community has turned to concepts derived from the harm reduction model (Marlatt & Tapert, 1993), as opposed to complete abstinence, as a primary goal in treating SUD’s.

Psychodynamic treatment includes addressing the disorders’ underlying processes, with the premise being that some form of psychic distress predates the manifestation of the disorder. Here treatment is not reduced into a manualized practice based on “objective” diagnostic tools (e.g., DSM V), that place little credence on subjective experience or individual differences. In the age of the biomedical model and randomized controlled clinical trials, “[marginalizing] consciousness in relation to how the brain works is likely to lead [modern neuroscientists and biological psychiatrists] badly astray” (Solms, 2012, p. 207). The lifelong effects of addiction permeate every aspect of the patient’s life; they cannot be quarantined to the brain.

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Couple Substance Addiction Treatment Alcoholism is a family disease – all addictions are – and therefore the whole family needs healing. Addiction represents a family condition not just because the behaviors of the addict have an unhealthy impact on those around him, but more profoundly because something in the family dynamic has probably contributed – and continues to contribute – to the addict’s acting out. While his behaviors are fully his responsibility, the more people around him who can shoulder responsibility for their own attitudes and actions without blaming and shaming the addict, the greater is the likelihood that everyone will come to a place of freedom.

-Gabor Maté, MD As discussed throughout this paper severe mental health disorders including addiction, have been historically treated primarily from an individual context (Wanlass, 2014). Nevertheless studies supporting the importance of family involvement over the years have been abundant including those in the area of SUD’s (Klostermann & O’Farrell, 2013; NIDA, 2012; O’Farrell & Clements, 2012; Stanton & Figley, 1978).

Many such studies have examined the effects of SUD on the family which are plentiful and include emotional and economic stressors, relationship dissatisfaction and distress, family instability, and the increased risk on children for abuse, neglect, poor emotional regulation, oppositional disorders, poor academic performance, and the development of depression, anxiety, and substance abuse disorders (Daley, 2013). Many family and couple protocols have been found to be successful in the treatment of adult SUD’s, which is important given that these disorders clearly effect both the couples’ and familys’ ability to function effectively (Daley).

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Couple behavioral treatment for addiction.

Research on couple treatment with addiction in one or both partners has grown exponentially, but couple treatment options are not always apparent and, if they are the focus, have been almost entirely from a behavioral standpoint. For example, when accessing the SAMHSA website and searching for ‘treatments for substance use disorders’ the recommendations are individual and group counseling, inpatient and residential treatment, intensive outpatient treatment, partial hospital programs, case or care management, medication, recovery support services, 12-step fellowship, and peer supports (SAMHSA, 2015). Couple therapy is noticeably absent from SAMHSA recommendations and family therapy is mentioned as a possible component only with adolescent treatment. This is disturbing given that SAMHSA is one of the premier organizations to which treatment professionals defer when seeking the most recent data and statistics as well as deciding possible treatment protocols.

Using a more in-depth search on the SAMHSA website under ‘couples therapy’ the first and most prolific treatment approach recommended in its National Registry of Evidence-based Programs and Practices is Behavioral Couples Therapy (BCT) for Alcoholism and Drug Abuse (SAMHSA, 2006). BCT is based on the assumptions that relationship distress increases the risk for relapse, and intimate partners can reward abstinence (SAMHSA). Program components, when working from a drug and alcohol perspective, include a sobriety/recovery contract; homework designed to increase positive feelings, shared activities, and improved communication; and relapse prevention planning (SAMHSA). The individual partner and/or couple typically meets with their counselor 15-20 times over 5 to 6 months, and sessions are structured to include current substance 71

use, compliance with the contract, a discussion of homework, a discussion of relationship problems that have surfaced, and a new homework assignment (SAMHSA).

After providing a full description of BCT, SAMHSA (2006), then provides readers with links to more than 20 research studies detailing the intervention, and almost 100 articles that include aspects of BCT research as it might apply to family and group treatment protocols. All in all, BCT for couples with SUD is cited to provide greater abstinence, fewer hospitalizations, happier relationships, fewer couple separations, lower risk of divorce, and better relationship functioning than typical individually-based treatment as well as reductions in intimate partner violence, and improved psychosocial functioning for the children of couples being treated (Fals-Stewart, Birchler & O’Farrell, 1996; O’Farrell & Fals-Stewart, 2000; O’Farrell & Fals-Stewart, 2002).

Unfortunately, all of this research has one thing in common. It was conducted by W. Fals-Stewart who was charged with falsifying data in his addictions research in 2007 in order to access federal funding (Handelsman, 2010). When the case was taken to court, Fals-Stewart was found not guilty on the basis of false testimony; he had used paid actors to give evidence at his hearing (Handelsman). Subsequently, Fals-Stewart was charged with several felonies including perjury, identity theft, attempted grand larceny, and falsifying business records (Handelsman). Fals-Stewart died at his home in 2010 a week after the second set of charges was filed and before they could be refuted.

Despite the seriousness of the charges, SAMHSA continues to support the research on BCT, as evidenced by the agency’s provision of BCA research and links available on its site and inclusion in its National Registry (SAMHSA, 2006). NIDA uses

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SAMHSA as a referral source on their website for individuals seeking SUD treatment.

While research studies utilizing BCT for alcoholism and drug abuse appear to have stalled somewhat après 2011, SAMHSA still includes training information on this modality on its website for clinicians, including costs ($7,000 for 2-day training and clinical supervision) (SAMHSA, 2006).

Meta-analysis research summarizing BCT treatments for SUD’s during the time frame in which Fals-Stewart practiced continues to appear in the literature. For example, in a review of the literature over the past 20 years (1992-2012), Fletcher (2013) examined more than 1,500 studies with a focus on couple therapy or couple interventions as they related to SUD’s. Fletcher ended up reviewing less than 20 studies; all of which, with one exception, detailed BCT or a variant thereof. In the analysis descriptive and qualitative studies were excluded, as were studies that did not include a control group, randomization, or included family members who were not intimate partners, or were determined as non-intervention focused (Fletcher). While Fletcher acknowledges several study limitations, she concludes by stating “BCT is arguably the relational approach to treating substance dependence most based on evidence” (p. 344). In this case the evidence appeared to be based on data that may or may not have undergone some form of manipulation as over the half the studies reviewed were conducted by Fals-Stewart.

While there are plenty of supporters of BCT who continue to find results with the modality (Klostermann, Kelley, Mignone, Pusateri, & Wills, 2011; McCrady, 2012), and Division 50 of the American Psychological Association has given the protocol its highest level of empirical support recognized (Klostermann et al.), there is some evidence that the pattern of results vary as a function of time (Powers, Vedel, & Emmelkamp, 2008).

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Unfortunately, this is in keeping with statistics compiled by the Office of Applied Studies (2000) that has recognized that most individuals entering into treatment for addiction are not finding sustainable progress.

Despite the clear evidence that couples therapy is highly beneficial in the treatment of individual partner trauma (Monson, Schnurr, Stevens, & Guthrie, 2004), childhood sexual abuse (Johnson & Williams-Keeler, 1998), anxiety and depression disorders, agoraphobia, and eating disorders (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998), and the knowledge that non-addicted partners can present with as many psychosocial problems as the addicted partner (Dethier, Counerotte, & Blairy, 2011), couple treatment for SUD is rarely included in treatment programs. One study (Vaillant, 1988), dismissing couple therapy actually suggests “an AA sponsor or a new spouse may be more useful than the dyadic relationship with a long-suffering family member, which must repeatedly re-awaken old guilt’s and old angers – conditioned reinforcers of alcohol use” (p. 1154). In other words, if you want recovery you will first need to trade in your old car for a newer, less cranky model.

Regardless of the skepticism, Stanton (2005) states: “there is evidence for the inclusion of interpersonal factors more thoroughly in substance abuse treatment and relapse prevention”, arguing for psychotherapy that includes relational interventions to help stabilize emotional disturbances that can precipitate relapse (p. 340). One behavioral treatment modality that seeks to include these interpersonal factors is Systemic Couple Therapy (SCT) which is an integration of Structural, Strategic and Bowen Family Systems theory (Trepper, McCollum, Dankoski, Davis, & LaFazia., 2000). In one particular study, patterns and themes in the addicted individual’s family of origin as well 74

as the couple relationship were measured using various instruments, with findings indicating a clarification of family roles, improvement in communication and problem solving skills, improvement in emotional involvement and behavioral control, and improvement in both individual and couple degrees of happiness (Trepper et al.).

Unfortunately, the data was only descriptive in nature given the poor return in posttreatment assessments completed by patients, and no information was obtained from the non-addicted partners due to a low response rate (Trepper et al.).

Two additional forms of behavior-based couple approaches to addiction treatment include reflective system therapy (Flynn, 2010), and a brief substance-abuse motivational intervention treatment program for couples struggling with intimate partner violence (McCollum et al., 2011). Neither has utilized a randomized clinical trial approach to date, so there is little data as of yet on either method.

Network therapy (Galanter & Kleber, 2011), has been included under the American Psychiatric Association’s 1995 practice guidelines for treating substance dependence, and according to the authors has shown effectiveness in treatment and training. The approach utilizes individuals within the addicted person’s network to help the therapist sustain abstinence. The couples’ component of the model utilizes “a simple, behaviorally oriented device” that enhances the effectiveness of disulfiram therapy in the treatment of alcohol addiction (Galanter & Kleber, p. 255). Here the spouse or partner of the addicted individual attends an initial therapy session to give a history of the partner’s substance use behaviors, and then is asked to observe whether or not the patient takes their medication and reports to the therapist if noncompliance has been observed

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(Galanter & Kleber). This model is also supported by SAMHSA and recommended in its National Registry of Evidence-based Programs and Practices (2006).

Psychodynamic therapy for couples with addiction.

A promising approach to couple therapy and SUD’s is Emotionally Focused Couple Therapy (EFT; Johnson & Greenberg, 1987) which works to modify insecure attachment responses and foster a secure attachment bond (Johnson, 1999b). EFT has been shown to be an effective intervention in couples struggling with depression, PTSD, and chronic physical illness (Johnson & Williams Keeler, 1998), and has begun to research the efficacy of the model as it relates to treating couples with addiction (Bassett, 2014). The EFT model is comprised of three stages (de-escalation, restructuring, and consolidation), with nine steps within the stages, and begins with assessment and identification of the interactional cycle maintaining insecure attachments (Johnson). As the process begins to access acknowledged and underlying emotions the problems are reframed in terms of attachment needs (Johnson). The therapist next works on changing the couple’s problematic interactional positions by having partners acknowledge and accept individual, and partner, disowned needs and being able to express them to each other thereby softening former defensive patterns (Johnson). During the third, and final, stage new solutions to old problems are discovered and integrated and new cycles of attachment are strengthened (Johnson).

EFT has two basic therapeutic tasks; the examination and reformulation of couple emotional experiences, and the restructuring of couple interactions that allows for the development of a more secure bond between the couple (Johnson, 1999b). Examining 76

and exploratory interventions used by the therapist are tracking and mirroring of emotional experience, validation, evocative responding, heightening, and empathic interpretation or speculation (Johnson). Restructuring interventions include tracking, reflecting and replaying interactions, reframing in terms of the couples communicative style and attachment experiences, and through the restructuring and shaping of interventions (Johnson).

In the treatment of substance addiction, EFT asserts that addiction is about altering negative mood states, but also about “seeking pleasurable mood-enhancing experiences” which the addicted individual comes to expect and use as an “emotional defense and regulator much as a felt sense of secure connection operates in positive relationships” (Landau-North, Johnson & Dalgleish, 2011, p. 197). From an EFT perspective, addiction is a combination of interpersonal and intrapsychic variables which shape each other (Landau-North et al.). Consequentially, EFT interventions for couples with SUD’s works to instill coping skills and help with decreasing conflict while increasing “predictable positive emotional experiences” (Landau-North et al., p. 197).

In working with couples with substance dependence the original EFT model, as outlined above, is expanded. The therapist is less interested in a problem-centered approach, instead accepting that the addicted individual has developed the addiction for very good reasons that include problematic early attachments (Landau-North et al., 2011). In stage one of the addiction model the SUD is outlined as a part of the couples negative interactive cycle (e.g., demand-withdraw) in an effort to join the couple in working together to defeat and overcome habitual reactions and patterns (Landau-North et al.). This differs, for example, from Network Therapy in which one partner assumes 77

the role of watchdog and the other as the identified patient, effectively redistributing relational power and responsibility. In EFT, the couple becomes the patient.

Stage two of the EFT model with addictions works to create positive and loving interactions between the partners which are then framed alternative responses to the addictive behaviors, and which serve as “the antidote to addictive regulation strategies” (Landau-North et al., 2011, p. 204). Prior to beginning stage two the therapist “needs to make sure that the addiction is being contained” so that risk for relapse is lessened as the addicted individual becomes more emotionally exposed (Landau-North et al., p. 203).

This does not mean that EFT demands abstinence, but it does posit that the best case scenario for treatment is when the addicted individual acknowledges their struggle and is motivated to seek help (Landau-North et al.).

In the final consolidation stage of EFT and addiction, couples are asked to create a narrative as to the role of addiction in their relationship and how, even though the addiction has been contained, problems might continue to emerge and how the couple will manage them (Landau-North et al., 2011). In effect, the couple is asked to think about the role the addiction played in their selfdyad and how it contributed to the couple’s organization (Zeitner, 2012). As a final step the couple joins together in outlining possible risk factors for relapse including “trigger into the emotional states that set up these relapses” (Landau-North et al., p. 204).

Only one research study has been conducted thus far on the use of EFT with couples managing an addiction. Using a pre-test, post-test design Bassett (2014), examined the efficacy of EFT with two couples where one partner was recently treated

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for addiction at an urban recovery treatment program. The researcher used the Revised Pre-Post Inventory (PPI; Davignon, 2011), the Experiences in Close Relationships (ECR; Brennan et al., 1998), and the Dyadic Adjustment Scale (DAS; Spanier, 1976) instruments to examine the effects of 15 weeks of EFT which included one intake session and one individual therapy session for each participant and 13 weeks of once-weekly EFT therapy. The PPI was administered pre and post treatment, while the ECR and DAS were administered thrice-weekly. Bassett found that while the effect of EFT on quality of substance use recovery was inconclusive, as was data correlating relationship satisfaction with EFT, evidence of a beginning attachment shift from insecure to secure was confirmed. Bassett concluded that a longer-term focus may be more appropriate given the slow shift from attachment anxiety toward security that was witnessed. In addition, it was noted that relationship satisfaction became increasingly erratic as the study wore on, supporting EFT theory which suggests that improvements are followed by regression due to increased transparency and emotional risks (Bassett).

EFT is about utilizing attachment to develop healthy dependency within the couple relationship. This is in keeping with Felitti (2003) who argues that addiction is experience-dependent during childhood and that the condition must be treated with this in mind. It is also in sync with Maté (2008), who writes “if the developmental roots of addiction lie in insufficient attachment, recovery includes forming attachments” (p. 402).

The only additional article/study that could be located in the literature pertaining to the psychodynamic treatment of couples with addiction, combining clinical material with psychoanalytic theory, was written by Wanlass (2014). The researcher presents two clinical examples of couples whereby one partner presented with addiction, and both 79

couples struggled with co-occurring disorders as well as early developmental trauma. In both cases Wanlass works to maintain a dual focus on both the couple dynamic and the management of the illnesses, constantly examining possible roles in which the addiction or mental health issue plays within the couple dyad. Wanlass writes: [First] one partner holds the unacknowledged psychotic, disorganized, destructive aspects of the couple relationship. Second, the symptomatology itself may express some aspect of the couple dynamic. For example, a husband’s pull toward cocaine represents an attempt to bring liveliness into an emotionally deadened marriage.

In some instances, the diagnosed addiction or mental health issue serves as a couple defense. For example, I will discuss a couple where the wife attributes any marital disagreement to her husband’s bipolar disorder. Any problem in couple relating is simply evacuated into the bipolar illness, viewed as a biologically caused, medical problem (p. 311).

When viewing the issue as a medical problem, instead of examining the role it plays within the relationship, the couple dynamic may cause the illness to further deteriorate, or the illness itself might confound the couple treatment (Wanlass, 2014). In both cases presented Wanlass states that the illness became the receptacle for the unacknowledged couple dynamics and much work needed to take place in order to move the perspective away from the “identified patient” towards an “identified couple.”

Wanlass writes that a psychiatric diagnosis can be a very powerful message that can overshadow the couple’s ability to tackle the illness as a couple. While Wanlass stems from an object relations background, the researcher attests to an integrated approach in best treating couples presenting with addiction and other forms of mental illness, which 80

besides couple therapy includes medication, recovery groups, hospitalization, and individual therapy.

Chapter Summary This chapter has presented a summary of the relevant literature as it pertains to biopsychosocial theory, therapeutic factors, addiction research and treatment, and couple treatment for SUD’s. This was no small task and no doubt there are gaps in what has been presented, but that offered is arguably sufficient for the purposes of this dissertation.

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Chapter III

Methodology

Introduction The intent of this phenomenological study was to explore couple therapists’ ‘lived experiences’ in working with couples with addiction to better grasp and identify psychotherapeutic factors. From a design perspective this study utilized Interpretative Phenomenological Analysis (IPA), as outlined by Smith, Flowers and Larkin (2009). IPA engages the researcher in a ‘double hermeneutic’ endeavor as they try to “make sense of the participant trying to make sense of what is happening to them” (Smith, Flowers & Larkin, p. 3). Given the role that hermeneutics plays within the model’s paradigm, IPA seeks to uncover and interpret the depth and meaning of individual encounters by helping participants pause, and fully reflect, on their experiences (Smith, Flowers and Larkin).

In seeking to appreciate and better comprehend this phenomenon this study pursued the following research questions: 1.

How do couple therapists experience working with couples with addiction?

2.

What is the understanding of therapeutic factors for couple therapists who work with substance dependent couples?

3.

What is the understanding of couple therapists as to what works?

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4.

What about the process feels helpful to couple therapists who work with substance dependent couples?

5.

What do couple therapists who work with substance dependent couples view as consistent markers of change?

6.

What understanding do couple therapists who work with substance dependent couples perceive might harm or impede the process?

Rationale for Qualitative Research Design Qualitative research seeks to explore and understand individual experiences as related to social and human problems (Creswell, 2014). It starts with philosophical assumptions and seeks to explore the meaning and significance that individuals and groups assign to circumstances, states and conditions. Qualitative research is seen as a “constructivist philosophical position, in the sense that is concerned with how the complexities of the sociocultural world are experienced, interpreted, and understood in a particular context and at a particular point in time” (Bloomberg & Volpe, 2012, p. 118).

According to Creswell (2013), qualitative research is used when we require a “complex, detailed understanding” of a “problem or issue [that] needs to be explored” and when we seek to “understand the contexts or settings” in which participants are involved (p. 47 & p. 48). Different from quantitative research which utilizes hypotheses, statistical significance and generalizations, this research sought to explore how couple therapist’s experience working with SA couples so as to understand and interpret therapeutic factors taking place. These subtleties are difficult to measure using a quantitative lens, nor do they lend themselves to a quantitative statistical analysis.

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Rational for IPA Methodology While IPA is a relatively new approach to qualitative inquiry, it contributes well to research emerging from several disciplines including psychology and the human, social and health sciences (Smith, Flowers and Larkin, 2009). IPA fosters an inductive approach which places participants in the role of expert, and where a priori hypothesis are regarded as restrictive, assumptive and thereby counter intuitive. In general, phenomenology strives to “give a direct description of our experience as it is, without taking account of its psychological origin and the causal explanations which the scientist, the historian or the sociologist may be able to provide” (Merleau-Ponty, 1996, p. vii).

IPA also utilizes a ‘cyclical approach’ which is based on the concept of the hermeneutic circle whereby one looks simultaneously to the whole to understand each moving part and to the parts in order to understand the whole (Smith, Flowers & Larkin, 2009). IPA is based on phenomenologist and philosopher Edmund Husserl’s argument that “we should go back to the things themselves” in order to “identify [the] essential qualities of [the] experience” in “its own terms” (Smith, Flowers and Larkin, 2009, p.

12). As such, phenomenology is exploratory in design, whereby the researcher asks themselves “is anything going on out there?” (Steinberg, 2004). It is especially suited when working to understand a new phenomenon or a phenomenon where little is already known (Steinberg), which is the case of this research, as outlined in Chapter 2.

The Research Sample Purposeful sampling was used given study criterion and suitability. This form of sampling is in keeping with the IPA model whereby “participants are selected on the 84

basis that they can grant us access to a particular perspective on the phenomena under study” (Smith, Flowers & Larkin, p. 49). The sample consisted of four licensed therapists who met the following study criteria: 1. A minimum ten years’ psychodynamic experience treating couples; 2. A minimum 5 years’ experience in treating SA couples; and 3. A minimum three months active engagement in working with at least one SA couple over the past year.

In IPA quality is valued above quantity, and in student projects “between three and six participants can be a reasonable sample size” in which to deeply explore the multifaceted layers of human experience (Smith, Flowers & Larkin, 2009, p. 51).

Furthermore, in IPA small research samples are common when specifically examining therapist and primary care clinician experiences in working with a variety of populations ( McNulty, Ogden & Warren, 2013; McPherson, Walker & Carlyle, 2006; Westland & Shinebourne, 2009).

Respondents were recruited for this study through academic and professional contacts across the United States (U.S.) and Canada. These colleagues were contacted by me via email informing them of the research and the inclusion criterion. Many chose on my behalf to contact additional colleagues, or post my study criteria on national psychodynamic list serves, to inform them of the study. Those interested in participating either contacted me directly through email, or respondent contact information was forwarded to me by colleagues whereby I reached out via email to confirm interest and suitability. An email script was created specifically for this initial communication (Appendix A). While eight candidates expressed interest in the research, one did not meet 85

the study criteria of psychodynamic experience, and three did not meet the criteria for length of time working with couples nor couples with substance dependence. The remaining four respondents, located throughout the U.S., were emailed the study consent form (Appendix B) and questionnaire (Appendix C). Once these were returned, first interviews were scheduled.

The sample was homogenous in the sense that all participants identified as psychodynamic couple therapists. IPA attests to purposeful homogenous sampling because it seeks to understand “particular phenomena in particular contexts,” but it does not treat members of the sample as an “identikit;” instead arguing that this form of sampling best reveals “psychological variability within the group by analyzing patterns of convergence and divergence which arise” (Smith, Flowers & Larkin, p. 49 & p. 50).

Data Collection Methods In qualitative research the utilization of numerous forms of data collection, some of which are redundant, is called ‘triangulation’, and is thought to add rigor, depth and validity to participant meaning and experience (Bloomberg & Volpe, 2012). In keeping with this perspective, this research utilized a pilot interview, questionnaire, an initial oneon-one interview through VSee, member checking, and a second one-on-one interview through VSee. The various phases evolved as follows:

Phase I: Personal interview.

I was the first participant in this research and answered the interview schedule questions by way of digital audio recording before all other interviews took place. This 86

recording was then promptly transcribed and analyzed. Creswell (2013) writes that the process of “describing [ones] own experiences with the phenomenon” is in accordance with ‘bracketing’ procedures which allow researchers to perceive subsequent data “as if for the first time” (p. 80). Personally partaking in the interview process whereby my thoughts, perceptions, and experiences could be prerecorded prior to participant interviews helped me to distinguish between participant measurements of meaning and my own. It also allowed me to adjust interview schedule questions that were confusing, or that were too closed-ended.

Phase II: Pilot interview.

In keeping with IPA, the first phase of the research consisted of a pilot interview with a colleague who was a psychodynamic couple therapist working with couples with substance addiction. As per Creswell (2013) and Smith, Flowers & Larkin (2009), the colleague was selected outside the research sample on the basis of convenience and accessibility. Pilot interviews are highly recommended in order for researchers to become comfortable with the interview process, assess researcher bias, and allow testing and further development of research instruments (Creswell, 2013; Smith, Flowers & Larkin).

The pilot study also allowed for familiarization of the video conferencing software, VSee.

Phase III: Questionnaire.

The questionnaire consisted of demographic questions, queries about professional qualifications, and a final question which asked participants to think about the very first couple they had worked with that was dealing with substance addiction. In addition, the questionnaire

asked respondents to identify a pseudonym which they would like to use throughout the 87

study. The questionnaire was developed with guidance from my methodology advisor and a colleague familiar with research methods. Questionnaires are known to be very reliable while also providing a high degree of validity when participants are able to complete them in the privacy of their own space and have plenty of time to process their answers (Steinberg, 2004). For the purpose of this study, besides offering demographic information, the questionnaire served as a useful addition to other forms of data collection by providing participants an opportunity to begin reflecting on their work with SA couples and what drew them into the field.

Phase IV: VSee first interviews.

One week prior to scheduled interviews, I emailed participants a copy of the proposed interview schedule (Appendix D) so they knew what to expect, in keeping with IPA methodology (Smith, Flowers & Larkin, 2009). In this study the eight interview questions, along with possible prompts, consisted of three topic areas: 1. How couple therapists experience working with couples with substance addiction; 2. How couple therapists conceptualize couples therapy; and 3. How couple therapists conceptualize substance addiction.

The questions were open ended and sequenced from those considered general to those thought to be more specific and sensitive in nature, which IPA refers to as ‘funneling’ (Smith, Flowers & Larkin, p. 61). Questions were all designed to explore the experiences, understandings, perceptions, and views of clinician experiences in working with couples with substance addiction (Smith, Flowers & Larkin, p. 46).

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I then conducted initial interviews with each of the four participants, each interview lasting between 90 and 120 minutes. Given that respondents were located throughout the U. S., interviews were conducted in participant homes or offices through VSee and audio taped digitally using a professional audio tape recorder. On three occasions, due to poor quality in the audio connection, the VSee video option was used with participant consent. Interviews were transcribed by a professional transcriber who had signed a confidentiality agreement. Digital audio and video recordings, along with transcriptions, were stored on my password protected personal computer in a file marked with additional password protection under participants’ pseudonyms. The personal computer was stored behind locked doors.

The primary interviews were semi-structured which is the preferred method in IPA (Smith, Flowers & Larkin, 2009). The one-on-one semi structured format offers a “rich, detailed, first-person account of experiences [allowing for] facilitation and elicitation of stories, thoughts and feelings about the target experience and [is] therefore optimal” (Smith, Flowers & Larkin, p. 56). Semi structured interviews have the added advantage of providing participants with more control over the process, effectively placing them as the “experiential authority” allowing them to take the interview to ‘the thing itself’ (Smith, Flowers & Larkin, p. 58).

While qualitative data collection approaches commonly include video conferencing (Creswell, 2013), there contain advantages and disadvantages. In a study examining possible differences between video conferencing compared to face-to-face interviewing on the subject of suitability for supportive dialogue between faculty and health care students, Taylor (2011) identified reduced eye contact, difficulty viewing 89

non-verbal cues, discomfort, decreased confidence, and effects on dialogue flow as challenges to video conferencing techniques. Participant discomfort and confidence were associated with self-consciousness related to a lack of video conferencing experience, and concerns about dialogue flow again appeared centered on participant awkwardness and unfamiliarity with the technology. While reduced eye-contact and challenges in seeing subtle movements of participants was noted, researcher awareness regarding potential camera angles and logistical issues were suggested as possible solutions that could be discussed prior to the interview process, along with anticipated awkwardness associated with the artificial environment and circumstances.

Overall, Taylor’s study determined no significant differences between the effectiveness of video conferencing and face-to-face interviews, consistent with research supporting the application of video conferencing as a medium for providing effective, satisfactory, clinical services to patients struggling with mental health issues (Germain, Marchand, Bouchard, Drouin, & Guay, 2009; Simpson, 2009; Troster, Paolo, Glatt, Hubble & Koller, 1995; Tsai, Tsai, Wang, Chang & Chu, 2010). The importance of patient satisfaction in the provision of mental health treatment via video conferencing format is highly relative as it requires ability, on behalf of the clinician, to access deep emotional content in a gratifying, fulfilling, and effective manner.

This correlates to concerns related to the fundamentals of the IPA approach, whereby the ability of researchers to access an in-depth understanding of participant experiences is key to gathering data that fully describes the phenomenon (Smith, Flowers & Larkin, 2009). In a review of the research examining the use of video conferencing as a medium for undertaking semi-structured interviews as an online research technology, 90

several studies support the methodology and found the format highly beneficial in many ways, including its ability to achieve rapport, sensitivity and collaboration (Deakin & Wakefield, 2014; Hanna, 2012; & Oates, 2015).

Additional advantages to the use of VSee in phenomenological research include the ability to reach sought after participants that live outside the researchers geographical area (Deakin & Wakefield, 2014; Troster et al., 1995), in a less expensive and sometimes speedier manner (Oates, 2015), and the opportunity to watch and observe each other while participants are in a familiar environment of their choosing allowing them to stay in range of known individuals should they need additional support (Svensson, Samuelsson, Hellstrom, & Nolbris, 2014).

Additional disadvantages, some of which I encountered along with my participants, include technical difficulties and technical support issues such as low bandwidth that affects video feed, verbal communications experienced as choppy, paused, or dropped, issues of confidentiality, and difficulties with observation (Abbass et al., 2011; Rowe, Stern, & Bellamy, 2014). In an email to participants prior to the first interview I made a series of recommendations that would help to ensure a quality experience. Recommendations included: 1. Requests that participants turn off other computer programs to better assure quality and bandwidth speed; 2. asking participants to place the camera face-on where they could be in full view; and

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3. requesting participants to look at the camera during the interview instead of the display screen so that eye contact could be maintained throughout I also shared that we had several options should technological problems develop at any moment, including stopping and restarting the video conferencing if either party is having difficulty hearing, seeing, or understanding one another, or turning off the video camera and going to audio if bandwidth could not be maintained and the interview could not be rescheduled (Abbass et al., 2011). On three occasions the VSee audio had to be disabled and cell phones were used to improve the audio. These were the occasions, as mentioned above, when the VSee video was utilized.

Finally, with regards to confidentiality and security issues related to the implementation of research using technological approaches, it is significant to note that VSee video conferencing is HIPAA compliant, meaning that it uses a 256 bit advanced encryption system (AES) that allows for End-point to End-point encryption. It does not pass through VSee servers where VSee has access to any information transmitted via video (Nina Aboganda, personal communication, September 21, 2015). In addition, use of VSee is free for both the researcher and research participants.

This research also followed technological recommendations from the Association of Social Work Boards (ASWB) as outlined in their publication Standards for Technology and Social Work Practice (2005, Section 8.5). In order to meet these standards, included in the informed consent documents was information outlining the video conference process and summarizing confidentiality procedures. These included the use of the participants chosen pseudonym throughout the interview, the upkeep and

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viewing of audio recordings in a secure physical and electronic environment, and user authentication procedures (i.e., password protected files) (Abbass et al., 2011). In addition, all VSee software security protocols were maintained and reviewed throughout the interview process to ensure that I remained up to date with any software advances (Abbass et al.).

To assist with contextualization, bracketing, and analysis, and in keeping with IPA protocols (Smith, Flowers & Larkin, 2009), after all interviews I made notes regarding impressions of participant/researcher interaction, any striking nonverbal and verbal communications, and any issues related to the interview that may have impacted participant or researcher contributions. These notes were considered as part of my overall process of reflective journaling which was ongoing throughout the dissertation process (Creswell, 2013). These notes contributed to the section titled: Member-Checking, Journal Notes and Researcher Countertransference in Chapter IV of this dissertation.

Phase V: Member checking.

In order to check researcher bias, assure quality and accuracy of researcher findings, and allow the process to remain iterative as it unfolds, participants were emailed detailed themes and descriptions gathered from first interviews one to two weeks prior to second interviews (Creswell, 2014, Rubin & Babbie, 2005). Please refer to Chapter IV: Member-Checking, Journal Notes and Researcher Countertransference for a detailed description of how member checking practices unfolded during this research, and results thereof.

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Phase VI: Second interviews.

Three things occurred in accordance to IPA before the second round of interviews began. First, transcriptions of all interviews from the first sequence were complete and the first round of analysis finished (Smith, Flowers & Larkin, 2009). Second, all participants had received their member checking information (Smith, 1999). And third, the interview schedule, interview strategies, and all data collected up to this point in the research had been fully discussed with my research chair, and methods supervisor, for the purposes of ‘bracketing’ and taking the phenomenon to an even deeper level of exploration (Brocki & Wearden, 2005; Smith, Flowers & Larkin, 2009; Tufford & Newman, 2010).

Once this sequence of events had occurred I then conducted second interviews with each of the four participants, each interview lasting between 90 and 120 minutes.

Multiple interviews are common, and highly recommended, within the IPA framework (Smith, Flowers & Larkin, 2009). The primary purpose of the second phase of interviews were to explore the member-checking materials and any additional thoughts, experiences, and/or questions that rose upon participant reflections. I also took the opportunity to explore questions that were asked during initial interviews that had since been reworked, reimagined, or restructured in response to participant responses and my experiences.

Data Analysis This research followed the protocols of data analysis as per IPA whereby the primary purpose is to present a thorough picture of the phenomenon studied as seen through the ‘lived experiences’ of each participant (Smith, Flowers & Larkin, 2009). This 94

process was a collaboration between myself and participants, with “the end result always an account of how the analyst thinks the participant is thinking” which is in keeping with IPA’s double hermeneutic lens (p. 80). Analysis in IPA is flexible while at the same time methodical and rigorous, constantly moving back and forth between the transcript as a whole and each individual statement. In reference to the hermeneutic circle “each little bit of text is looked at in the context of the whole transcript; the whole interview is thought of from the perspective of the unfolding utterances being looked at” (p. 81).

While IPA requires a semantic account of each interview it does not expect a detailed description of the rhythm, stress or intonation of the speech as the purpose of analysis is to “interpret the meaning of the content of the participant’s account” (Smith, Flowers & Larkin, 2009, p. 74). Significant nonverbal communications were also accounted for, as were lengthy pauses and hesitancies (Smith, Flowers & Larkin). A professional transcriber was used, and was instructed to record nonverbal nuances including pauses, laughter, and interruptions (Bloomberg & Volpe, 2012).

The first stage of analysis began with a reading and re-reading of the text while I listened to the original recordings to re-familiarize myself with each individual interview process (Bloomberg & Volpe, 2012; Smith, Flowers & Larkin, 2009). With the third review of the material I began to record notes in the right margin of the transcript, logging anything of interest. This stage of data analysis is termed “initial noting” whereby exploratory comments take the form of descriptive, linguistic, and conceptual analysis (p. 83). Descriptive comments “described the content of what the participant has said; the subject of the talk within the transcript” (p. 84). Linguistic comments “focused upon exploring the specific use of language by the participant” (p. 81).

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Conceptual comments “focused on engaging at a more interrogative and conceptual level” (p. 81). Different colored markers were used for each type of comment allowing for easy differentiation between the trio (Smith, Flowers & Larkin).

The second stage of analysis these notes were developed into emergent themes or concepts whereby participant experiences and my interpretations joined together in an attempt to reflect conceptual accounts that represented the data (Smith, Flowers & Larkin, 2009). Here, I broke down the original interviews into ‘parts’ which, once revealed, took on a ‘whole’ of their own as the analysis was completed. Focus was on “discrete chunks of transcripts” as I attempted to “maintain complexity in terms of mapping the interrelationships, connections and patterns between exploratory notes” (p.

91).

The third stage of analysis looked across the findings and required the ‘clustering’ or ‘mapping’ of emerging themes in accordance to conceptual similarities (Smith, Flowers & Larkin, 2009). Specifically, after emerging themes were ordered into an initial list of categories, I cut the list up so that each theme was represented on a piece of paper, placing the pieces on a large table so as to explore “spatial representations of how emergent themes relate to each other” (Smith, Flowers & Larkin, p. 96). Themes that were similar were placed together, those that were opposing were placed at opposite ends of the spectrum; all the time seeking to cluster the themes so they could be given a descriptive label, a ‘super-ordinate’ theme, that expressed the conceptual characteristics of the themes in each cluster. Themes were validated and supported by examples of explicit and implicit participant communications and which were not thoroughly substantiated were discarded.

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All themes had individual Word document files where relevant transcript extracts were pasted and identified with the transcript line numbers. Transcripts during this stage of data analysis were checked and rechecked to assure that participant communications were well represented in the labeling process. Once I felt the descriptive process had been exhausted, a table representing the structure and development of the super ordinate themes and subthemes of the data was recorded (Smith, Flowers & Larkin, 2009).

All preceding steps were repeated for each of the four participants, with individual tables completed and recorded for every transcription. Here I sought to represent each participant’s experience “on its own terms, to do justice to its own individuality [and so as to] allow for new themes to emerge” (Smith, Flowers & Larkin, p. 100). This is in keeping with IPA’s idiographic perspective and the model’s attempts to understand individual’s unique experience of the phenomenon as it unfolds.

In the fourth and final stage of IPA data analysis I took each of the four tables and placed them on a large open surface, again comparing similarities and differences between participants (Smith, Flowers & Larkin, 2009). I looked at how one might shed light on another, and considered which themes seemed to be the most significant. A superordinate themes summary table was used at this point in the analyzing, in order to measure recurrences across the cases. This looked at the superordinate themes collected for each participant and then calculated whether the theme was prevalent in most of the cases. This was challenging as while each participant indicated a prevalence for each superordinate theme presented, there was considerable variation of how these themes manifested amongst each participant.

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During this final stage of the research I continued to relabel and reconfigure themes finally resulting in a Master Table of superordinate themes for the group (Smith, Flowers & Larkin). Throughout this process my dissertation chair, and my methods chair, performed periodic reviews of my coding and thematic analysis, and assisted in the coding itself, to substantiate identified super-ordinate themes and subthemes. This resulted in a continuation of labeling and relabeling and continued collapsing of both subthemes and superordinate themes which was then presented in transcript excerpts, along with a thorough discussion of what was found, in Chapters IV and V.

Ethical Considerations All participants in this research were volunteers. As per Creswell (2013), informed consent procedures, confidentiality, and disclosure were managed and maintained with the rights of all human subjects made the highest priority.

All participants received, and completed, an informed consent document (Appendix A) prior to participation in the study. The form, as per the Institute of Clinician Social Works’ IRB protocols, included a detailed description of the research including: 1. Explanation of the study including type of topics to be discussed 2. Inclusion and exclusion criteria 3. Duration of participation 4. Description of procedures 5. Description of foreseeable risks (minimal) and benefits (no compensation)

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6.

Limitations of confidentiality (i.e., raw, unedited data was seen by my research team and professional transcriber), and a description of how confidentiality of records would be maintained

7. My direct contact information in the event of a research-related injury 8. A statement confirming that participation was voluntary, and could be withdrawn at any point in the research process without penalty or loss of benefits 9. Any anticipated circumstances whereby participation may be terminated 10. A statement that findings developed through the research will be provided to the participant upon research completion Informed consent was approved by the Institute of Clinical Social Work’s Internal Review Board, as per standard protocols, prior to the commencement of research.

Per IRB guidelines, and The National Association of Social Workers’ Code of Ethics publication (1999), anonymity and confidentiality of all participants and data obtained, including backup copies, was rigorously maintained in password protected digital files and locked drawers located behind locked doors that were themselves protected by a digital security system. All individuals reviewing data, including the dissertation committee and professional transcriber, signed agreements regarding confidentiality given their access to the raw, unedited, data. Participants were informed that the final product of the research including other articles and books, are permanent and public records, but that any data used for article or book publication will be further edited for anonymity unless prior consent is given. They were also informed that IPA requires that verbatim extracts of participant narratives be included in the finished research, but that they would have opportunity, through member checking procedures, to 99

audit, change, and rework personal accounts. Finally, all participants were fully informed that the data will be maintained for period of 5 years in a secure location, after which all files would be destroyed. The VSee video portion of this research, which was utilized strictly as a precaution in case of poor audio, was destroyed once the interviews were fully transcribed.

While it was anticipated that no serious ethical threats were posed to any of the participants or their wellbeing, it was acknowledged that potential for strong emotional reactions remained as each participant considered and communicated ‘lived experiences’ of working with SA couples. I hoped to keep this distress at a minimum by using personal skills and knowledge gleaned over many years of practice as a licensed clinical social worker. However, as discussed in Chapter IV under the heading MemberChecking, Journal Notes and Researcher Countertransference, it was not always easy to maintain my research persona without reverting back to my usual role of therapist. At no point in the research however, did a participant ask to be removed from the study.

Issues of Trustworthiness As per Bloomberg & Volpe (2012), this study sought to address issues of trustworthiness, described as “the credibility, dependability, confirmability and transferability [found within] qualitative research [whereby] control for potential biases that might be present throughout the design, implementation, and analysis of the study” are employed (p. 125).

Credibility is the qualitative version of the quantitative term ‘validity’, and is used to question the accuracy and credibility of the study at hand (Bloomberg & Volpe, 2012).

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Methodological credibility requires that the research purpose, design, questions and methods logically interrelate (Bloomberg & Volpe). Given that this research study conformed to entrusted IPA protocols which have been utilized and validated by hundreds, if not thousands, of research studies utilizing the methodology, I argue that its methodology is sound. Furthermore, this study sought data from several sources through more than one collection method including questionnaire and individual interviews.

Termed ‘triangulation’, the gathering of numerous forms of data collection from numerous sources adds rigor, depth and validity to participant meaning and experience, which in turn adds rigor, depth and validity to the research itself (Bloomberg & Volpe).

While this study does not seek to verify conclusions given the subjective nature of the research design, it does intend to “test the validity of conclusions reached” through the studies interpretative validity (Bloomberg & Volpe, P. 125). To do this Bloomberg & Volpe (2012), state that data analysis must be rigorously performed whereby participant accounts are accurately reflected and analyst interpretations are validated. In this research, my assumptions have been clearly articulated in Chapter I and were further recorded and transcribed as I became the study’s first interview participant. Moreover, research findings throughout each level of data collection were thoroughly reviewed and discussed with my dissertation panel and challenged as deemed necessary.

In qualitative research confirmability is about eliminating, as much as possible, researcher subjectivity so that research findings reflect participant experiences and not researcher biases (Bloomberg & Volpe, 2012). In order to work from a qualitative phenomenological approach, the challenge is to set aside, or ‘bracket’, personal experiences and subjective understandings of the phenomenon, especially if the 101

researcher has ‘insider status’ and is a member of the group being studied (Smith, Flowers & Larkin, 2009). As a psychoanalytic couple therapist who regularly treats SA couples, as well as an adult child of alcoholic parents, my personal biases must be acknowledged. Please refer to Member-Checking, Journal Notes and Researcher Countertransference in Chapter V for an understanding of member checking procedures that took place during this research.

Transferability is described as “the ways in which the reader determines whether and to what extent this particular phenomenon in this particular context can transfer to another particular context” (Bloomberg & Volpe, 2012, p. 126). This research does not seek to generalize findings, but it does hope to add to the psychoanalytic literature regarding the therapeutic factors in treating couples with addiction. To this end, all aspects of this study including the overarching research question, subquestions, design, data analysis, and researcher assumptions, biases, interpretations and findings were kept as transparent as possible. Contextualized, in-depth, detailed descriptions from participants were analyzed using repeated and thorough checks and balances and applying the most rigorous and accurate means available.

Chapter Summary This chapter discussed the rationale behind this study’s qualitative phenomenological design, and specific use of IPA. It also presented the methodology step-by-step including how the research sample was obtained along with inclusionexclusion criteria. The six phases of data collection were detailed as were the four stages of data analysis; per IPA. The chapter concluded with a discussion pertaining to ethical 102

considerations and issues of trustworthiness. We now turn our attention to the study’s findings; Chapter IV of this dissertation.

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Chapter IV

Findings The purpose of this phenomenological study was to explore couple therapists’ experience in treating couples with substance addiction (SA) to better understand and identify psychoanalytic psychotherapeutic factors. The research questions this study sought to answer were: 1. How do couples therapists experience working with couples with SA? 2. What do couples therapists who work with substance dependent couples experience as being therapeutic in working with couples with SA? 3. What is the understanding of couple therapists as to what works when working with couples with SA? 4. What about the process feels helpful to couples therapists who work with SA couples?

5. What do couples therapists who work with SA couples experience as consistent markers of change?

6. What understanding do couples therapists who work with SA couples perceive might harm or impede the process?

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Introduction to Participants Using Interpretative Phenomenological Analysis (IPA; Smith, Flowers & Larkin, 2009) methodology, four participants located across the United States were interviewed by means of video conferencing software. The sample consists of two males and two females, with ages ranging between 53 and 73 years (Avg = 64 years), who have practiced as couples therapists with SA couples for between 12 and 37 years (Avg = 26 years) (see Table 4.1). All participants are licensed to practice in their home state, have a doctoral level education, and have treated a couple with SA for a minimum of three months during the past year. Three of four participants identify as object relations theorists; the fourth identifying as a phenomenological contextualist in combination with self psychology. All names are participant-chosen pseudonyms to protect confidentiality.

A brief introduction of each participant follows.

Table 4.1 Sample Characteristics (n=4) Triker 37

Emma 15

Mr. B. 35

Stella 25

Number of years of clinical practice with SA couples

37

12

30

25

Highest level of education

PhD

PhD

DSW studies

PhD

Theoretical orientation

Phenomenological Contextualism/ Self Psychology

Object Relations

Object Relations

Object Relations

Gender

Male

Female

Male

Female

Age

73

57

74

53

Ethnicity

Caucasian

Caucasian

Caucasian

Caucasian

Marital Status

Married

Single

Married

Married

Number of years of clinical practice with couples

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Triker.

Triker is a psychologist in the Midwest who specializes in marriage and family psychotherapy. He describes himself as an autodidact given his interest in analytic literature since college, and his active participation in three psychoanalytic organizations.

He is currently in private practice with his wife, and works as an instructor at an institute for psychotherapy and psychoanalysis where he has been involved for many years. Prior to private practice he was a professor at a state university where he taught and performed research as well as counseling. Fifty percent of his practice is couples work wherein he specializes in sexuality issues as well as SA. Triker became involved in the SA community when a young woman, with whom he and his wife were close, overdosed and was disowned by her biological mother. Triker and his wife petitioned to serve as the young woman’s parental guardians and immediately sought treatment for her substance dependence.

My wife and I joined Al-Anon and in the process of doing that we met a lot of people involved in the treatment community, and in conversation with them came to know them and actually started doing some work with presentations and things for the treatment programs; some of these chemical dependency units across town. (Triker) Not only did this young woman’s illness expose Triker to the SA community, it also provided him with significant insight and an emotional connection to families struggling with a family member with SA.

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You know, where, uh, somebody who’s not as connected to someone who’s chemically dependent might say, you know, “screw it, I don’t need this in my life,” and might leave, but if you are connected with this person in some way, if they are your partner in some way, or certainly if they are your child or parent or something, you don’t just say, “screw it, I’m getting this person out of my life.”

(Triker)

Emma.

Emma is a psychologist and psychoanalyst in the Western U.S. where she serves as a director of a psychoanalytic institute and a professor at a liberal arts college. Her private practice includes both children and adults, with approximately 20 percent of her client base consisting of couples. She is an accomplished author on the subject of psychoanalytic couple’s therapy including couples therapy with SA couples, and frequently teaches, consults, and coordinates training on couple relationships both nationally and internationally. Emma’s interest in couple’s therapy evolved from her work with children as she noted “in working with parents that the couple’s issues were much broader than just the issues with their child.” After obtaining additional training in couple’s therapy she began to see more couples in her practice, but when faced with couples who presented with SA, she sent them elsewhere: I have to say that I really avoided it. At the beginning it was certainly not my desire. In fact when I had a couple with a substance abuse issue I tended to refer them. Um, and I think that was for a couple of reasons. One was that, although I have some training in substance abuse, um, my training was not as extensive as 107

some of my colleagues and I thought they would be better suited to address the problems. (Emma) Her second motive for referring them out was closer to home. She shared “The other reason for it was personal, in that my brother has a serious substance abuse issue and I felt like it was too close. That trying to help him and support him was too hard if I were already seeing couples.”

Mr. B. Mr. B. is a psychodynamic psychotherapist in private practice in the Eastern U.S. who specializes in child, couples and family therapy. He is an instructor at a psychoanalytic institute, a prolific writer and published author, and a well-known presenter in his field. Couples represent 70 percent of his international practice. He was introduced to clinical social work through field assignments during his undergraduate program, and became familiar with substance addiction while interning at a drug treatment program and a state prison. He grew up in the culture of the 60’s and 70’s where he experienced “heroin as a major destroyer of young lives”, and in a family setting where wine at the table was customary. “I tasted wine at a fairly early age; I didn’t like it all that much, but it wasn’t something withheld. Nor was it poured down my throat, it was simply, like, part of the meal.” Mr. B’s father drank wine which exasperated his mental illness. “It did have an effect on him. It aroused him, rather than sedated him, it sort of stimulated him and he could become really quite violent.”

Mr. B. came to recognize that his father could be violent without alcohol, but his countertransference to passivity, first experienced by his mother’s inaction to the 108

violence, needed to be addressed early on in his work. “So it’s the passivity in the sedated, which to me is too much of a mystery. I have to find out where the person is hiding.”

Stella.

Stella is a licensed mental health counselor in the Midwest with a master’s degree in psychology and a PhD in sexology. Seventy percent of her private practice clientele are of couples whereby she specializes in both sex therapy as well as SA. She is a frequent speaker and consultant on both topics, and an active participant in a psychoanalytic institute where she has been involved for several years. Stella was first exposed to SA as a student when she worked as a researcher at a center for chemical dependency. After completing school she remained with the treatment center for several years where she focused on their family program. After leaving the center to do crisis and inpatient work, she decided to return to couple’s therapy and over the years has received training in psychoanalytic couples therapy as well as Imago Relationship Therapy. When asked how she began working with people who were struggling with SA, given she had no personal connection to the disorder, she replied: You know I think it was—this is really kind of a silly association I’m having, but there’s this quote by Mr. Rogers, “I never met a person I couldn’t love, once I knew their story.” And so, you know, you have a stereotypic, um, the culture has a stereotypic thing about addicts and alcoholics and how bad they are, you know, and how you don’t want to be around them. And in fact, they are some of the most lovely and wonderful people, once you know their story. (Stella) 109

Presentation of Findings This section presents key findings collected during eight, 90-120 minutes, indepth interviews from the four participants resulting in over 400 pages of data and more than 125 emerging themes. Through an analytic process that consisted of reading and rereading, initial noting, development, interpretation, pruning, regrouping, and memberchecking, the data was organized into five superordinate themes and twenty subordinate themes which are detailed in Table 4.2.

Subordinate themes, as described by Smith, Flowers and Larkin (2009), are the result of a gathering, or clustering, of individual emerging themes that “Produce a structure which allows you to point to all of the most interesting and important aspects of your participant’s account” (p. 96). Superordinate themes, as per Smith, Flowers and Larkin, are descriptive labels that express the conceptual characteristics of the subordinate themes in each cluster, and “represent instances of higher order concepts which the cases share” (p. 101). Included within the description of each superordinate theme is a psychoanalytically acquired “essence” which stems from a combination of my interpretation of the raw data and actual participant extracts, the ‘I’ and ‘P’ in IPA (Smith, Flowers & Larkin, 2009). Creating an overall understanding of the “essence” of experience is in keeping with qualitative phenomenological research (Creswell, 2013).

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Table 4.2 Summary of Findings Superordinate and subordinate themes 1. Personal and Professional Journey 1.1 The significance of personal experiences (use of self) 1.2 The significance of early work experiences (use of self) 1.3 In the eye of the storm: The therapist’s challenge 1.4 As time goes by: Reflections of greater life and work experiences 2. Conceptualization of SA 2.1 The dynamic role of SA: A symptom and a defense 2.2 The biological considerations of SA 3. Therapeutic Action 3.1 Modality: Couples therapy 3.2 No approach is an island: Treatment integration 3.3 The value of language 3.4 The good-enough therapist 3.5 Psychodynamic theory: Conceptualization of the couple and techniques used 4. Markers of Change 4.1 Reaching a conjoint perspective: Insight 4.2 Let’s refocus: When SA takes up less space in the dyad 4.3 Emotional development 4.4 Differentiation: A recovery of projections (in the service of greater coupledom) 4.5 Abstinence: Yes or No? 5. Trial and Error 5.1 Insisting on abstinence or drug and/or alcohol treatment 5.2 Viewing SA through a narrow lens 5.3 Coordination, cooperation and conversation 5.4 Social, cultural and generational challenges

Superordinate theme no. 1: Personal and professional journey.

This superordinate theme embodies therapist ‘lived experiences’ in working with couples with SA. Learned experiences that are developmental, social, cultural, and professional influence the manner in which participants approach and practice this work.

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Clinicians experience working with SA couples as extremely challenging, resulting in the construction of communities of care for themselves enabling them to withstand the difficult issues they encounter, including relapse and, much worse, loss of life. With experience comes confidence that includes an understanding of one’s personal and professional limitations. The four subordinate themes under this heading are: 1. The significance of personal experience (use of self); 2. The significance of work experience (use of self); 3. In the eye of the storm: The therapist’s challenge; and 4. As time goes by: Reflections of greater life and work experiences.

The psychoanalytically fostered “essence” of this theme recognizes that experiences acquired throughout one’s lifetime affect the manner, and uniqueness, in which each participant undertakes the work at hand as well as the manner and uniqueness in which they, themselves, are experienced.

1.1

The significance of personal experiences (use of self).

This subordinate theme contains participant accounts of how personal experiences influence the manner in which they understand their SA couples.

(Triker) So I’m maybe saying to the non-drinking partner, the partner that doesn’t seem to have a problem with alcohol, “so how has it been for you, your partners’ drinking? You mention you think he drinks too much; what is that like for you?”

And she says, “well, it’s a real problem for me. I don’t know what to do about it,

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but I think it’s caused a lot of problems in our marriage.” And he is saying, something along the lines of, “well, I wouldn’t drink so much if you weren't such a bitch.” So I am going to be pre-disposed toward what in my particular approach to practice is called an inner-subjective conjunction with her point of view. In other words, I’m gonna be automatically kind of seeing it the way she sees it.

When somebody has come in to see me in treatment, that certainly puts them in a different place than when I’m a dealing with somebody who is a member of my family. There are certain things that I can do; first of all I’ve got the power to do certain things with them that I wouldn’t have with a family member. And secondly I’ve also got the power to remain at a certain emotional distance for my own self-preservation. And if it turns out that this is not going to work and they are not going to get into treatment, I don’t have the same sense of grieving about that as I would if this were a family member.

(Emma) Another piece of it is [pause] my brother’s own struggle. Alternating in a personal way between feeling very frustrated and discouraged and also seeing up close the difficulty of trying to manage an ongoing addiction. So, you know, I think [pause] as one of—probably one of his primary support people, it is personal to me. I think that for people like me who have a personal connection to addiction, and that frankly includes a huge number of clinicians, I think that [consultation] is even more important because you have to be aware of the things going on in you which might allow you to not see something, or to over react to something.

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Maybe [the couple in addiction] see me as – it’s almost like I am the probation officer who’s supposed to bust the person for using, you know...there are different ways in which they sort of relate to me.

And it isn’t so much that I’m – certainly they talk about, you know, relapse and how they can deal with that, but I think that comes up a lot at the end, this fear of, what if we slide back? Which is a reality for many couples and how will they keep it from going back to the way it was before? And it’s interesting because I think a lot of times what’s voiced is that, if we slip back now it’s harder, because we have more, sort of, awareness. And I think that’s a challenge and a burden.

(Mr. B.) So, right in this moment I would probably say that, the stimulant aspect of [the substance] would depend on whether it produces hyper vigilance, hyper sensitivity, hyper speech and verbalization, as compared to violence. If it’s not violent, ah, I can work with it.

In fact, that was their problem. You know, they weren’t aggressive.

Maybe that was fortunate for me at the time. Less wear and tear on my emotions.

[So] sometimes I was bored. Sometimes I felt they were redundant and their affect was rather bland, you know.

Another counter-transference is to be careful about judging the addict when the addict is willful. When the addict insists it’s not a problem, but the rest of the world thinks it is, but they don’t. This is particularly ah, um, infuriating to me

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[laughter]. How could you say that, you know – you’re leaving blood and guts all around you, you know, and you’re blasé?!

One is to be protective. To be protective before I understand what they need protection from. That is, simply to become parental.

(Stella) To want to manage the codependent parts of us that want to fix this person, right? I’m real clear that I can’t work harder than they do. And really try to help the unaddicted partner to adopt that kind of approach. You know, we aren’t here to fix him and the harder we try to fix him, the less he has to fix himself. But, you know, those are the feelings you get in the countertransference; somebody has to do something here, you know?! [laughter].

1.2

The significance of early work experiences (use of self).

This subordinate theme contains therapist accounts of how early work experiences with SA couples affected their professional development.

(Emma) I, probably like you, looked up the writing and thought it was appalling; there was nothing, or very little. Even though substance abuse appeared in case histories, in couple histories, it wasn’t talked about directly in the analytic literature. So that really, sort of, prompted me to think more about what is the dynamic that operates in couples with an ongoing addiction.

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There is a certain type of anxiety that I think you carry as the couple therapist. So, for instance, if the use is escalating and there is an element of danger in terms of overdose or death, there is a reality that I think is sometimes frightening and anxiety provoking.

(Mr. B) So I would say as a novice, or a rather green and naïve and zealous fellow, I came face to face with addictions of various kinds, from the street to the prison to the rehab setting, and so on. Sort of learning by the seat of my pants and trying to survive my own counter transferences [laughter]. I couldn’t wrap my mind around what is this really all about and how does it operate to cause misery and pseudo-happiness, so to speak, depending on your drug of choice? So my concretization of SA, I think, was a defense and also based on limited training or research which I later of course became more interested in.

The counter-transference when we are dealing with alcoholism or heroin addiction or whatever, is that – the drugs that frighten me the most, the ones that I think are more lethal than the others I have to watch myself not to hurry beyond their capacity to take in my interest or concern. That is, what I sometimes find is that my capacity for concern can shame addicts.

(Stella) There was one group called the blue group and they were all like street addicts. You know, like cocaine and heroin, and mostly they were all men and kinda rough. And here comes, you know, “Buffy does therapy.” And so they are 116

like, what do you know about – welcome to our world, you know? I learned early on from some of the best people there at the treatment center to first of all not be fettered by that kind of attack, saying something like, “well, you didn’t come here to learn about using did you? You know way more about using than I do, but I know way more about recovery than you do. So if you want to learn it, let’s get to work.”

(Triker) I mean there have been times in the fairly distance past where it’s felt to me like what I’m hearing from my clients is I’m really doing it wrong, and if I really understood something about chemical dependency I would know that the approach to this couple has to be different and it has to be done the way they do it in that treatment program so I’m doing my clients a disservice. And it was hard not to feel shamed by that, you know. As time went on I began to develop a different view about that.

1.3

In the eye of the storm: The therapist’s challenge.

This subordinate theme discusses the challenges participant therapists face with couples presenting with SA including denial and resistance, and hopelessness and chaos.

It also addresses challenging feelings that include a sense of alienation, and situations that are life and death. These challenges inspire participants to create a caring community of treatment professionals who accept, and appreciate, their psychodynamic focus while providing them with information outside their scope of expertise.

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(Mr. B.) I’m always getting chopped up by couples who are nasty, angry or whatever.

Now I’m dealing with life and death - I’m dealing with crisis intervention.

Now I’ve got to use whatever tools I have with respect to assessing suicideology [clears throat], you know, or self-destructiveness.

I don’t have to tell you, I don’t think, that practicing psychoanalytic therapy is alienating in this world. [laughter]. I mean we’re not naïve, right?

I have to become a substitute for the substance, and boy, look what I’m competing with right? See, the thing about a substance is, it’s always there when you need it….will I disappear; will I be consistent?

The people I refer to need to be amenable to my way of thinking. So that we are sort of a team in a way, but respectful of each other’s particular approaches…I mean, working with somebody with fibromyalgia, for example, or neuropathy, who is then using oxycodone, I mean, I have to ask my medical friends, explain that to me. I don’t know what’s going on chemically with this woman.

OK, psychoanalysis is not a treatment of choice by in large for addictives, for addictive behavior. So the tension is that I might move too quickly, or because I’m compensating for being too patient, as though if I start connecting with a potential patient, somehow they are going to want to give up the addiction through having a relationship with me that is both a comfort and evocative. I’d like to believe that I’m looking for signs that will tell me clearly enough that they 118

need something else and thinking about A) do no harm, and B) don’t be naïve that your approach is really going to have a beneficial effect on a cocaine addict.

(Stella) I think denial is one of the most powerful defenses on the planet. I think that you haven’t lived till you see this otherwise sane, competent, productive individual in abject denial of SA. The irrational, bordering on psychotic, way that they can show up.

I think [SA] couples, on the front end at least, are desperate to be given hope. They come in saying they are at the end of their rope or that they don’t know their way out, or it can’t get any worse than this [laugher]. Or sometimes they come and they don’t even know that they are dealing with an addiction.

They just know it’s chaotic and out of control...

Most of the time I leave work at work. But, you know, certain couples do get into you and ride around in your brain a little more often as you think through the puzzle of it all.

He just could not humble himself to say “I need help”; it felt too painful for him. So that was a heartbreak because of the kids and everything. And his suicide was because she left him. But he wouldn’t stop drinking and he was really destroying the family, so, you know... I would count that as a failure, only in the sense of what you could do, right?

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You know, I have my go-to people; most people that I work with in the wrap around professions are people I’ve worked with over time.

(Triker) “I don’t see why the hell you are so concerned about my drinking, I go to work every day, I earn a great income, people like me, we have fun at parties, we go away on vacations all the time, I’ve given her the life that she wants, ah, what the hell’s the problem here?” And I’m wanting to say, “look asshole, [both laugh], your wife is saying you don’t relate to anybody very well. Wake up!” I’ve learned not to say that! [Both laugh].

Obviously it can be hard work and difficult, because when we are dealing with couple therapy we don’t have an impartial observer in the other partner…and so the stakes are high here and both partners are emotionally vulnerable.

Yes, it’s been alienating and off-putting and that depends on what the attitude of the therapist in the treatment center happens to have about not only their particular approach to therapy, but about working with people on the outside in general.

When I’m talking to new therapists about situations like this that would certainly be my suggestion. You know, “Is there a support group of peers that you can connect up with about this or do you have somebody who can be in supervision with about this?” Because I think that’s really crucial under those circumstances. You know, it allows you to, in a relatively safe environment, ask yourself “am I crazy?” or is this, “am I stepping on my own feet here?” “Should I 120

be thinking about this in different ways?” That kind of thing. What we all need, I think, is an environment that feels emotionally safe enough for us to consider that we might be wrong.

I can’t do CD treatment, that’s something that has to be done separately, but it has to be coordinated carefully. Ideally, the person in the treatment center would be telling me what they know about the seriousness of the addiction.

Because frequently I won’t know that.

(Emma) If I counted every sort of relapse as a failed treatment I’d have a lot of failed treatments. I also think there is a lot of chaos in SA treatment; you know, people drop in and out of treatment. They drop out for a while, and then they come back. That’s something that is a challenge.

The only patient who I have lost to death, I lost through a substance abuse, to an overdose. And while that wasn’t a couple therapy, it was an individual therapy, that was a very difficult experience for me. And so that may be part of it, part of the emotion as well. It was somebody who also had young children and I think that as a child therapist that part of the picture is always in my mind.

I frequently feel alienated in the sense that, you know, they are working one way and I’m working another and they think that the way that I’m working is wrong.

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I’m somebody who thinks everybody should have ongoing consultation. I would say having a really good support system myself, even if I’m not talking about cases, but, you know, having people close to me that are caring and supportive, I think that helps.

1.4 As time goes by: reflections of greater life and work experiences This subordinate theme presents participant reflections garnered from their years of working with SA couples; with experience comes confidence, awareness, a sense of agency, identification, and an acceptance of limitations.

(Stella) You see couples in the most painful times and then you see them, you know, a year, two, three years later and their lives are so dramatically improved. I can’t think of you know [pause]; I started to say nothing is more gratifying, but that’s not true there are other things more gratifying [laughter]. But it makes me really love my work and so I feel blessed and privileged to be a part of that, with people on their journey.

I also know I can only do so much and you can lead a horse to water… So I don’t get consumed by that. I think you have to know where you can and can’t influence. You know, [addicted people] are just regular people like everybody else, they just happen to have this as cross to bear.

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So I think, again, if you pull out, “I’m going to use my empathy tool here”, and it’s someone who doesn’t tolerate empathy, you’re going to be barking up the wrong tree.

There are times when you tell people what they need to hear, specifically an addict, and you do the best you can and they have to go out and try some more and then they’ll come back later and say “I should have listened to you” [laughter]. But I mean that’s a success in the sense that you did what you could in that person’s process.

I think it’s important to first stabilize the person so they cannot use, and I think it’s ultimately important to go looking at where the original wound or longing. Maybe it was not a secure attachment or maybe it was a trauma. But I think we might have made a mistake back when I was young in [the field], going too fast into the wounding before there was a solid recovery established. I think that one of the biggest mistakes therapists make is thinking that because there is this wound, it needs to be healed [first] in order for the person to be sober. [That can be] a relapse trigger. They might skip the step of first getting sober.

(Triker) One of the things that I’ve learned is that when you are dealing with couples where addiction is an issue, they are going to end up saying something that is going to piss you off as a therapist [laugher].

[Where I live] there is a correct way of going about treating couples where chemical dependency is an issue. You set limits in certain ways, there is tough

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love and all these things, and that’s something I have never been very comfortable with. And so I guess in some ways I’ve lightened up on that sort of approach. I’ve gotten more comfortable with the fact that that’s not actually my approach.

But again circumstances are different and when somebody has come in to see me for treatment, that certainly puts them in a different place than when I’m dealing with somebody who is a member of my family. There are certain things that I can do – first of all, I’ve got the power to do certain things with them that I wouldn’t have with a family member.

An alcoholic is not always the guy in the Salvation Army overcoat with the bottle in a paper bag, in a doorway down on [First] Avenue. They exist in the boardrooms and in the operating rooms and all of that…

As I’ve gotten to know on a much more emotionally deep level the people who I’m working with who are struggling with chemical dependency, I have an expanded sense of their humanity and of who they are. And maybe in some ways, you know, an expanded view of how vulnerable we all are, and how close we all are to wanting something to sooth our pain or get away from shame.

(Emma) I think my whole view of couples has changed somewhat over time as I have more training and get more experience. I’m more able to think about the couple as a sort of a unit or [pause], kind of how each is involved in the couple issues, what they create together as a couple. I think at the beginning I tended more to see [SA] as an individual issue. Which had an impact on the couple.

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And I still think that there are the individual issues, but I’m much more likely to think about, for instance, how did this partner end up with someone who abuses substances? What is it expressing on behalf of the couple, not just the individual?

So I’ve made a shift to what I would say is a couple state of mind in the therapist.

I’m also not afraid to say “this isn’t working and we need to think about what else needs to happen here”, or, “is there some other treatment alternative that we either need to add in or consider?” I don’t give up easily, but I do think that we have to be willing to admit when something isn’t effective.

I can say no. I don’t have to treat this person. You know, I can choose to do so, but I don’t have to. And I think that helps me because I can’t choose the fact that my brother has a substance abuse problem. I can’t choose out of that.

I think often times people with SA issues have to come back into treatment multiple times. And in that way I think of it as, ok, maybe that’s what was what was possible at this point in time and hopefully they will come back again.

I think also being too grandiose, like, oh, this couple treatment is going to fix all of it. You know, probably not unless there are some other things going on.

(Mr. B.) I’m painting you an idealized picture. But also one born of many years of getting it wrong, or partly right or trying this or trying that. Although I’ve always been faithful to psychoanalytic thinking I’ve been very selective with respect to what I do about meta-psychology and certain theorist’s that don’t appeal to me.

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So I’m more particular with whom I read and what I’ve learned from them, as part of my preference, you know.

Experience, of course, is the best teacher, and so as I again tell my students, who want to learn couple or family work, the first challenge is to get a family or a couple and then try and sustain them. You know the goal of the first session is to have a second session, right? [Laughter].

Now I’ve gotten used to telling patients, when necessary, “cocaine wins and I lose.” In other words, I can’t compete with that hunger of yours. I can work with you but there’s something else in the room that’s just too powerful and I’m not going to be naïve about it.

Be careful of zealousness because when you are zealous as a therapist you are taking the world away from them. You have to respect they are a couple.

Their lives are what they are and you have to let them be.

What that has essentially taught me, all those hours in the trenches, is that there are times that I will start sooner with recommending adjunctive therapies.

I’m a marriage junkie in the sense that I think that when people invest in a marriage for a long time it’s always better to see if they can reclaim it depending on what’s gone wrong.

When the therapy is somewhat effective the one thing that I think that comes out of it is that the next generation has a better chance of not being addicted.

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Superordinate theme no. 2: Conceptualization of SA. One of the research questions in this dissertation asks: “What about the process of working with SA couples feels helpful?” The manner in which participants conceptualize SA – the way they theorize, hypothesize, and conceive of the role of the substance itself and the role of the substance in the couple dyad – is essential if they hope to make any headway with the couples with whom they work. This section is broken down into two subordinate themes: (a) The dynamic role of SA: A symptom and a defense; and (b) The biological considerations of SA. The psychoanalytically fostered “essence” of this theme is the concept of mutuality of impact – the power of SA on the individual and the couple relationship, and the influence of the relationship on the SA.

2.1 The dynamic role of SA. This subordinate theme examines participant’s conceptualizations of SA and its psychological role as a symptom and a defense.

(Emma) I’m over simplifying it, but I saw [SA] more as trying to communicate something. So in other words, what does the symptom itself mean? What does the symptom cover up? How is the symptom a defense? I think I’ve always thought about it as a symptom of an underlying problem and a complex presentation of difficultly.

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It’s both an individual symptom and a couple symptom, so that’s certainly relevant to treatment. The severity, the types of substance used, the severity of use, the risk factors involved with that.

Those kinds of things, I think are quite common [with SA], where the grieving or mourning over loss is somehow thwarted.

I’d see someone who was very depressed and where the substance seemed to, at least temporally, help them feel better. So it was a way of up-regulating their mood, but again a way of staying out of contact with the underlying issues that contributed to their depression such as maybe a plethora of bad object identifications. Or a painful childhood history with critical parents.

What is the meaning and function of the addiction for the couple? You know, does it upregulate a dead marriage? Does it keep them distant from each other so they don’t have to deal with their sexual difficulties?

So thinking about what is the function, what is the actual physical action of the drug? Is it that, you know, with heroin you feel a kind of warmth that you don’t ever remember feeling anything like?

The containment in their couple coupling became insufficient. So I think she could not tolerate his need for reassurance, and had what I would see as dependency issues. Both her own and his, and those got located in the alcohol.

I think there is a way in which sometimes the difficulties with intimacy, which predates the substance use, are sort of covered up or the difficulty gets displaced into the substance abuse. Now that’s not to say that substance use itself doesn’t cause couple difficulty because I think it does.

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(Mr. B) So I went from addictionism illness, DNA, 12-step programs, rehab – right, to let’s do psychoanalytic couple work as though addiction is not the major problem, it’s the symptom of something else. So, it’s not a thing in itself. Now [in my work] it is a thing in itself and it has these other components.

It’s a balancing kind conceptualization which is neither too wedded to instinct theory, nor so overly relational where there is no ‘other’. So it’s a nice sort of between theoretical orientation, which feels like my secure base I might say [laughter], you know, and of course if you add attachment theory it’s really quite useful too.

What they’ve been doing with substances has been trying to get their mind back under their control. Which, look, what we are talking really about is their emotional life, not just their thinking. Usually these folks are trying to manage emotion that is very frightening and disconcerting and often they are afraid they are going to break down if they feel certain things.

I suspect that they each have trauma histories somewhere, because they married each other. Now you might have the rescuer marrying someone that they sensed is vulnerable and they want to save them, but then are failing. Then we have the one who is fearful of dependency in any other form, but to be totally wasted once a week [laughter] and then fall on the mercy of their partner.

I see this as a couple issue with individual manifestations, and someone is of course is ‘doing it’ and the other is not doing it, but it’s more complicated than that.

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The mushrooms and the psychedelics and the amount of marijuana and so forth, all which, from my point of view, are mind regulating and brain regulating agents towards sedation and excitability given his traumatic past.

Sometimes you can trace the addiction dynamic to the couples unmet oral needs. And sometimes you can trace it more to the annexed unmet oral needs which the spouse was supposed to provide the answer to.

I must tell you that when people get sober it’s amazing what the other partner says; “God, I liked you when you were drunk, you were much more fun.

Now you’re just kind of depressed.”

So what I’m saying is that there is a kind of system here of two minds affecting each other significantly in which substance abuse plays a part. So rather than it being merely the cause, or in a real serious way, the cause of everything that has gone wrong, it’s sometimes partly the result of many things that have not gone right.

(Stella) It’s still probably a symptom of underlying intimacy issues between them.

In most ways I don’t think that addicted couples are different than any other couple, but what might be some of their issues or their lack of issues—or lack of dealing with their issues, might be being eclipsed by the dynamics of an addiction process.

I mean if you look at alcohol as a substance that’s being used to keep a lid on something or to not expose something else, or to make someone feel more

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under control. I think underneath almost every addiction I’ve ever worked with is some source of intense pain that somebody doesn’t know how else to live with.

I think shame is a dynamic of addiction that is under rooting a lot of it.

And so I’m seeking it, and I notice it, and I name it very early.

The addiction is a problem and it’s also the solution [i.e. defense] depending upon the stage of it or the particular couple you’re looking at.

I’ve seen couples where the addiction serves a defensive purpose. You know, where focusing on the addiction keeps us from focusing on other things.

And the addiction would preclude intimacy and preclude something that might be scarier for the partners. And so you see a sabotaging of the recovery by one partner or the other because the addiction is holding them in a certain place that’s maybe more, at least on the surface, palatable.

I think addiction is attachment originated in a lot of cases. I also— I’ve always conceptualized it in the context of the couple or family relationship, as I don’t think it’s as effective to treat an individual’s addiction without treating the context in the family or the couple that it lives in.

(Triker) The substance abuse is a symptom and I’m looking for some of the underlying causes of the symptom. I mean, it’s a serious symptom. Just like if a person is diabetic and they’ve decided they aren’t going to take insulin, that’s serious, there’s no question about that, but it still is a symptom of something.

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Alcohol destroys intimacy; alcohol will stand in the way of emotional intimacy because you can’t relate through a fog.

If you don’t learn how to symbolize the anger when you are very young, and you don’t know how to experience this, it’s basically an inchoate-affective state that you get into and it makes it all the more likely that one of the things that you end up learning how to do is to drug it out of existence.

My point of view is that alcohol can create problems in a couple relationship, and it’s a vicious cycle where the problems in a couple relationship can also create the grounds for more drinking.

Her husband was not a passive participant in all of this; he was part of the issue and he was part of her drinking. But as she began to describe that, it occurred to me just exactly how chemical dependency was playing a role in the couples ongoing relationship. She had come into their relationship basically already alcoholic and he had come into the relationship from an alcoholic family, though he’s not a big drinker, but he was very depressed, and controlled.

Typically both partners, even when one isn’t abusing a substance, have had intimacy difficulties in their life. They are coming from a particular place where intimacy has meant something in particular to them. Frequently it’s been dangerous.

More than just an issue of brain function, but [with experience] we started to think about the sedating effects of alcohol or the numbing effects of alcohol.

The role that played in a person’s psychological development and in the psychological development of the, of the couple.

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2.2 The Biological Considerations of SA. This subordinate theme examines participant conceptualizations of SA from a biological or physiological perspective.

(Mr. B) I think that this person is probably coming from four generations of deeply addicted heroin addicts. And they’re doomed. In other words, I can’t find a foothold there. I’m gonna fail, you know, I’m not going to be able to find a way in. And then I wonder about addiction, as I started the interview with you, as something that is in a way simple; it’s DNA. It’s just there.

(Stella) I certainly came from a disease model because I worked in a [drug] treatment center in the 80’s. And I think I still keep parts of that….like someone else has cancer or someone else had diabetes or someone else has whatever disease they have. You have this one. And it has a predictable trajectory; it has a whole body of knowledge about how it works, just like every other disease.

(Triker) And again, when a chemical gets involved, then we are dealing with it at that level too, some physiological level. But here you’ve got an extraneous thing, you know, which is kind of like coming in with a partner who is diabetic and that’s causing problems in the relationship because of how they handle it.

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(Emma) He went on Antabuse for a period of time. He didn’t seek other treatment other than—well, I mean that is other treatment, right?—so he sought a medical intervention at the same time that he pursued the couple treatment.

It’s sort of hard to tease out in a way because you could say, alright, is it that they have a genetic vulnerability to substance abuse or is it that they have a genetic vulnerability to the impact of stress? How much of that is influenced by their environmental factors? I’m not someone who is in favor of nature versus nurture. I think that’s a ridiculous dichotomy that’s not supported by the neuroscience research.

Superordinate theme no. 3: Therapeutic action.

This superordinate theme answers the research question: “What do couples therapists who work with substance dependent couples experience as being therapeutic?”

The five subordinate themes that fall under this heading are: 1.

Modality: Couples therapy;

2.

No approach is an island: Treatment integration;

3.

The value of language;

4.

The good-enough therapist; and

5.

Psychodynamic theory: Conceptualization of the couple and techniques used.

While the term ‘therapeutic action’ is defined in the Introduction of this dissertation as the means by which psychoanalytic treatment affects therapeutic gain

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(Auchincloss & Samberg, 2012), readers will quickly note that participants present numerous ways of working that embrace, at varying degrees, concepts outside their psychodynamic frame. Given the broadness of the original research question, and the simple fact that the data continued again and again to reflect this embrace, the data was included despite the narrowness of the operational definition.

The psychoanalytically fostered “essence” of this superordinate theme is a theoretical strategy derived from the principle of ‘complementarity’; whereby the biological, psychological, and social can stand in complimentary relation to each other and are simply ‘other’ perspectives on the phenomenon of couples with SA.

3.1 Modality: Couples therapy.

The first subordinate theme in this section describes participant’s perspectives about the use of couple’s therapy itself when working with substance addiction.

(Triker) The power in couple therapy is that this is being done in real time in the presence of the partner who also is there to develop more of an empathic connection with her partner, and vice versa.

Substance abuse will interfere with intimacy, it will make intimacy difficult, and, you know, if you conceive of couple therapy as a project that increases intimacy, which presumably it is…

(Emma)

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addiction. You hear about the pain that is experienced by partners, by children, and I think that is helpful to know about and I also think it is helpful for the addict themselves.

(Mr. B) I have respect for people who can’t do couples therapy – they can’t share the space. They may need individual therapy, they may need anger management, they may need pharmacology, among other things, whatever they need. I don’t have the early zealousness that I once had. That one size fits all and that if I do it, it must be pretty great [laughter].

(Stella) I think there is something really sort of, I don’t know, spiritual, about the fact that you are going to find the person who can help you to grow if you are willing to look at what’s going on with yourself and what’s getting activated or triggered by that other person. So it’s doing your own work in the presence of someone; it’s a relational understanding of how you show up in the world.

3.2 No Approach is an island: Treatment integration.

This subordinate theme focuses on treatment integration as a therapeutic factor.

(Emma) I think that for some couples they are just not—the psychodynamic approach is not a good fit for them. And if they want somebody who is going to 136

be structuring assignments and incorporating things like DBT, then I’m not the best treatment provider for them.

I’ve never presented it like this is the better approach. It’s like this is an approach, this is a way of thinking about it. But if you want that person to also attend a CBT group, I don’t see why that’s a problem. I don’t have to be purist or elitist about it.

If somebody has a serious addiction I’m not just going to treat them in couple’s therapy. I’m going to recommend that they do some individual therapy.

I’m going to recommend that they pursue some form of support like AA for example. And sometimes they do have to enter treatment programs or some sort of intensive outpatient program.

I probably am more likely though to suggest something like, if the partner is not in individual therapy, which is often the case, right, the couple is going to see me and maybe the substance abusing wife is in individual therapy and the husband is not. Oh, I will get all over that.

You know, a couple of cases that have turned out quite well, I don’t think I could have done it if they at some point had not been willing to get an AA sponsor.

I think that the team itself holds different aspects of the couple dynamic sometimes. And also when one person is sort of discouraged or wearing out somebody else is there to help contain and hold, and I think containment of these couples is a huge challenge.

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(Mr. B) As a matter of fact, to me it’s sort of a no brainer. That is, I think that whether it’s the Alateen approach for the teenagers or the Al-Anon approach [for adults], at least I’ll make the recommendation and encourage that everyone needs support during a time of change. Particularly when hope is really quite fragile.

And it’s all often been very supportive and helpful to me when they are coming back for couple work.

If I believe there is active life and death or destructive aspect based on the addictive behavior, the place of my approach [clears throat] may become an adjunct to other more powerful interventions; lifesaving or life affirming interventions, or behavior modifying interventions. Otherwise my approach won’t work anyways.

When I read about addictions and compulsions within the community of psychoanalysis and then read about it from a neuroscience perspective, or based on addiction psychology, or trauma theory, these are very useful, helpful ideas that will sometimes help me with a particular case but not another case. Sort of like you look for mentors where you can find them [laughter].

When they are multiply addicted individuals and I don’t have a clue, I want them to have a good addiction specialist you know, or a whole crew of them, for that matter, before I know what I’m dealing with to see if this is the greatest concern and the largest use of someone’s time and resources. [Sometimes] they are obsessed with whatever the thing is and they can’t think of anything else until we take care of that menace or that obsession.

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I suppose the EMDR therapists, for example, or the people who do Reiki, or the people who do dance movement therapy, know a lot more about it than I do; they want to free the body up of traumatic experience. I suspect that there might be some of this that would work well for addicts, by the way. I’ve never actually really thought about that. Because the body sometimes is stonewalled and it has all the poison in it…

(Stella) Imago would put the focus on the couple and the transference between them and an object relations or psychodynamic model would look at the relationality between them and between them and the therapist. It’s a different model for couple therapy and so my challenge is to blend the hybrid of the two approaches.

Because it’s theoretically similar, and technically very different.

I learned this from a model called the developmental model of recovery (DMR) [where] you have to take the person in their context and in their developmental place. The [DMR] model is based on what does the client need in order to get to the next phase of the recovery? So you would do something really different with someone who’s still in a lot of denial and not sure they have the disease, than you would with someone who’s already been in some kind of treatment or at least admitting they have a problem.

I also, unlike other people, am willing to do adjunctive therapies. I might do EMDR with one partner if there is a stuck place, an early trauma, that is just not moving and we know it. I think addiction in couples work requires a lot of

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resourcing. I think you have to be willing to bring in every resource there is including AA, Al-Anon, sponsorship…there aren’t a lot of alternatives out there for people, for support and connection in recovery. So, even though AA isn’t perfect and it’s got its flaws, I definitely think it does, but it’s the best there still is right now.

Where the disease model is helpful is that it helps people to hear that it’s not you. So it helps a lot with the shame. I like that they think somebody understands and that it isn’t a personal flaw.

There is no substitution in my mind for the therapists understanding and knowledge of addiction and the processes that are so typical for it. If I had a sister who had an addiction problem and her marriage was in trouble, I would want to find someone who understood addiction; I wouldn’t send her to just any couples therapist.

(Triker) If [drug and/or alcohol] treatment is involved, the hope is that that it’s going to be integrated into what they are doing in [couple] therapy. First and foremost, if chemical abuse is actually an issue for a couple and they don’t get to a place where that abuse is going to be dealt with, that’s almost a death warrant for the work.

It’s about how to understand what you see in front of you as a therapist and what’s going on between the partners and acting accordingly. It’s not a set of rules, it’s not a cookbook, you know, it’s not something to be manualized.

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I’ve thought a lot about working with these couples and I guess one of the interesting things, especially if they have been through treatment, is that they have learned a psychological language and they have become more psychologically minded. For that reason it gives me a platform, even if I don’t necessarily agree with the psychological outlook, which frequently I don’t. I mean, I’m not a cognitive behavioral type person, although I do use some of the procedures, but even if not we share a common language in knowing that we have to figure out how to deal with the emotional sources of certain behaviors.

3.3 The value of language.

This subordinate theme explores the manner in which participants use and express language in their work with SA couples.

(Mr. B) I was never all that successful about heroin for some reason; I could not budge heroin addicts very much. Occasionally I was able to do it. That was a tough drug to contend with, I couldn’t compete with it. And I would tell people that. There’s no magic here. Heroin just feels too good, feels too good.

I tell them denial is not just a river in Egypt, you know, or something like that. Which gets me in trouble, but sometimes loosens us up a little?

I’m at least wanting to believe that there are periods of time that I’m actually present. Trying to have reverie available to me. As the mother with the baby who can’t tell us. So you have to read their body and their non-verbal’s and

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their signs of distress and so on, and imagine a baby that is calm and then [ask ourselves] how do we implement that? It’s a terribly difficult job as parents know.

I rarely use the word addiction. I like descriptions and illustrations, rather than diagnostic language.

If a couple is more regressed, which means they are suffering more core characterological difficulties, or they really seem like they have been traumatized, I do a lot of holding and very little interpreting. I do a lot of holding, mirroring and reflecting back, and I try not to introduce the language of insight very quickly. I want them to find a safe space.

I want the substance to have a history; I want it to have a language that matters to the patient who’s using it. I’m not going to accept, “it just makes me feel good.” I’m going to ask, “Well, compared to what?”

(Stella) If I stay present, if I stay engaged, if I keep the couple in dialogue, we go places. If I let myself start thinking too much about dynamics it’s just me being fascinated with my own ideas; it’s not helping that couple.

There is something about being able to hold your own and banter a little bit and be playful in situations that are dire.

I can use AA speak, I can use Al-Anon speak. I can quote clients that I’ve had before who had really integrated the ideas of AA or of the recovery model.

There is a connection that happens when I can speak their speak, or when I can

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say something and they say that’s what their sponsor says, or, that’s from AA isn’t it?

In the case where it’s really dire, I just say it: “This is really dire and I don’t think you see it and here’s why”, and I fill out the data you know. And I might empower the partner [by saying] “I really hope that you understand that you don’t have to go down with the ship.”

The metaphor I use sometimes is [that of] a burn victim who may want a hug, but a hug is the last thing they can tolerate right now because they are so raw. I think that when we ask an addict to let go of their way of coping, their Band-Aid or their salve or whatever it is, we don’t have any idea what we are asking them to do. We take away their medicine at the same time their partner is so angry and so sick of it and so over it and so wanting to tell them how hurtful they have been, how much damage they have caused. I tell both partners, yes, both of you have really valid pain and both of you deserve to get that said and both of you deserve for me to hear it and understand it, but we are going to have to make the ground safe to have those conversations.

(Triker) Therapeutically speaking the person has come to understand that their sense of reality involves something larger than just their own personal thoughts, like the blind men and the elephant. You know, they lead them up to the elephant and they feel it and then they are supposed to describe the elephant and one says, it’s a long, cylindrical thing and the other says it’s flat and floppy. Through

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dialogue they come to a closer description of what we might say is the reality of the elephant.

Whenever I feel like I’ve lost somebody or there is something I’ve missed about them and it seems like I’m not attuned to them or able to empathize with them, my anxiety state goes up. Because I don’t want to create that kind of connection. So that feels bad, but what I’ve learned to do over the years in my work in general is to stop and say something along the lines of, “It looks like I just lost you,” or “Did I get that wrong?”

“What’s the deal here, how come you’re not taking care of yourself?” [I ask them] why are you doing this to yourself? And you know, that’s a serious and [often] unasked question.

(Emma) I talk to couples openly about what they need around additional support. I think that makes a lot of sense, but the sort of, “here’s how you do substance abuse treatment, you go to all these AA meetings you do, you know, this many AA meetings a day”; that kind of thing I have not found to be particularly helpful.

I don’t use a lot of psychodynamic lingo; I think about what is the way to make my point. So for example, identification, the word that I just used has a psychodynamic meaning, but it also has a colloquial meaning that people can understand. So I think about the points of similarity and what I can say about internal objects that overlap with core beliefs of a cognitive behavioral.

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When something happens very early to somebody you may get a sensory feeling about it, you may get a schematic projection about it. You may get a large amount of affect, but there’s a kind of attack at the same time on a linking capacity or it’s hard to think about. I had this happen just the other day.

Someone who has a SA history who said, “I can’t even wrap my head around it.

Like I can’t find any kind of way to sort of tell you about it.” Now I could feel some of what he was talking about, but this is somebody who has a really awful history prior age five who was trying to represent the experience of that history.

So you know it’s hard to, it’s hard to; it’s ironic isn’t it that I find myself having difficulty finding the words to describe it to you?

3.4 The good-enough therapist.

The couple therapist is not required to be perfect and, in fact, must fail at times in order to allow the couple opportunity to develop. But failure must be tolerated which means that couples must be able to count on the therapeutic environment. This subordinate theme shares participant experiences in being good-enough therapists, given the unique and various ways in which SA couples present.

(Stella) It’s not a one size fits all intervention with any client, and particularly with any addict. So like we learned early in graduate school, right, we just start with where the client is and it’s the same with a couple. And then they set the pace and you titrate it.

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You know, unless it’s really dire, I tread lightly. I say things like, “Hmm, I’m seeing familiar things that I’ve seen before that I think might be operating here, but all I can do is predict for you some things that might be coming.”

I see my role a lot as creating a safe container, a safe space for their work to happen. My personal opinion is that compassion and empathy attuned to a person’s tolerance level is the best tool I’ve got. It’s not magic, but?

(Triker) One of the variations on that is that both partners drink and that becomes part of their routine [which] adds other elements to it.

I guess what I’ve come to realize over the years is that we do make mistakes. You know, it’s just part of the human condition; certainly it’s part of my condition.

I’m not going to put myself forward as the expert who can tell you what to do and what not to do. I want to start by understanding what it is you are going through and why it is you are going through it. If the net effect of that is what it typically is, which is that the person feels heard and listened to, and begins to feel understood, then that’s going to generate a sense of safety in the room. It doesn’t mean that I’m always going to agree with this person, but it does mean that we are going to create an environment where each person can be heard and understood and we can put our heads together to figure out what’s the best thing to do.

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(Emma) If this is a couple where the person never had an issue with substance abuse until after the couple formed, I think that’s quite a bit different from a couple where a person has a long history of substance abuse and they got together with both people knowing about the issue. Or a couple where they got together, but the substance abuse was hidden.

I think there has to be a lot of space for them to be able to talk about the impact of the addiction; the anger, frustration, the sense of loss they’ve experienced. I think you have to leave a lot of space for that.

At the beginning, containment and alliance are the things that help the couple stay in treatment because usually by the time they get there, there have been many rounds between them either of discussing the issue, of attempts to stop, [or] attempts to talk about it and avoidance. They have gone through a lot before they ever get to me. And usually, if they are coming in for couples treatment, it’s at a point of desperation.

I was thinking, what about success rates with these couples? But, you know, couple therapy with traumatized individuals like I tend to see, I suppose if you were counting successes, it’s not a high success population. I think it sort of depends on how you see success. I don’t see success in couple therapy as necessarily being that the couple stays together.

(Mr. B) I think that if we are talking about one kind of addiction, when it is really

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quite devastating and having many negative effects upon the daily life of the couple, as compared to other forms of addiction, which may be more moderately impairing a couple’s functioning… if I make the distinction between the more serious and the less serious, the couples who are suffering with at least one addict, sometimes both are, by the way, but you don’t find that where the pills are hidden for a while…

I think that couple treatment lasted quite a while; it was probably a couple of years. I would say that I learned from them a great deal and I think they learned from me enough [laughter]. Maybe more than I even think I offered them.

And somehow the way we matched up was good enough as they say.

Couples for a long time will insist that even though they are miserable, they need to keep doing what they are doing the way they do it. You have to sit with this a long time to get a word in [laughter].

My basic assumptions are, accept the couple as they are, recognize how regressed or how developed they are, and ask if they have the potential for being a creative couple. In other words, I let couples back out the door when they come in. I never tell them we are going to do couple therapy. I only tell them they are coming to consult about their relationship and we have to determine in one or two, three sessions if this is for them.

I really try not to have an agenda. I have a personality, I have memory, I have feelings, and they do too. If you notice something new, you’ll notice it because you didn’t tell them what they are supposed to talk about today and then they can make something up [laughter].

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3.5 Psychodynamic Theory: Conceptualization of the Couple and Techniques Used The final subordinate theme in this category shares the influence that psychodynamic theory has on both participant conceptualization of the SA couple, and the methods in which they practice.

(Triker) I conceptualize couples work in a particular way, and when alcohol or other chemicals are involved I see that as entering into the picture in a certain functional way that has to be dealt with.

We start to think about why the drinking has developed to that level or may have already been at that level when they first started their relationship, but they didn’t realize that and are just now starting to realize some of the implications of this.

I’m going to want to know something about their developmental history and their history of what intimate connections have come to mean to them because of how they felt connected, or not connected, to their parents and what they saw of their parent’s intimate connection with one another. As we begin to explore that, I’m going to want to know things about what they felt they might get from each other when they met.

I talk about coming into an intimate relationship with a set of hopes and fears or what Steven Mitchell called “hopes and dreads.” So I explain [to the

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couple that] we typically get involved with someone because we hope that maybe, for the first time in our lives, we’ll feel affirmed and accepted and not judged.

In self-psychological terms we are talking about the provision of selfobject functions, which, because they were interfered with or were never present earlier in a patient’s life, there was a stunted developmental track which is now being picked up and continued. So there’s a re-parenting aspect of that which has been called, by people in contemporary psychoanalysis, a developmental second chance.

The goal is to make and empathic connection, not just with the anger and the rage, but with what may be underneath that. What some of the fears are, the anxieties about what’s just happened, you know, what the significance of that is and what it means to the person, and what the rage and the fury and the shame may be about and where that came from.

It’s a perspectival realism approach to this. I want to see the world through their eyes and the nature of their relationship through their eyes. The focus is not so much on repairing and deficits as it is on revisioning our emotional convictions or our organizing principals about who we are and how we relate.

(Emma) How I intervene is different in some ways, but I don’t think I would say there is a fundamental difference in the way I conceptualize [couples with SA and couples without]. No.

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I generally do an assessment at the front end of any kind of couple treatment where I meet with them for 3-5 times to see if I can get some understanding of their difficulty, and also to see if they are a couple that can work with an analytic approach.

I think we really have to be careful about making global statements like, “all substance abusers this,” because I think that each individual couple has their own relationship with the substance; in a way it’s a shared object between them.

You know there’s an article; you may have read it, by Chris Vincent. It’s about the couple void and he says that in couples where there is addiction there is this feeling that you get as a therapist of a complete, sort of, void. A type of emptiness; something that’s undefined, unsymbolized, or unrecognized. I think that has an impact on me, in trying to think about what is not symbolized and acted out in the addiction itself.

I think there is an unconscious couple fit that sometimes is a repetition of their internal couple.

I would say I use the typical sort of treatment techniques. In terms of interpretation, for instance, illumination of childhood patterns that are present in the couple and in the addiction itself. I certainly interpret in various ways and levels.

OK what, what do you need, what does the couple need, what does the addicted person need as well to contain and address this problem? I think it’s a constant thinking about both the individuals and the couple as a whole.

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I rely a great deal on my counter transference reactions to help me in treatment. For instance, when I experience a tired or kind of dissociated feeling in the counter transference I wonder what this might say about the couple. Is it similar to how the addicted person feels around the use of their substance, is it a way of obscuring trauma? What is it?

(Mr. B) People marry because they think they will be completed by all the good stuff the other person thinks about them.

Psychic development starts very early and splitting starts very early.

Addicts have splits and that's when Klein becomes helpful. They’re split between love and hate and good and bad, which are synonymous. Of course addicts have tremendously impoverished, benevolent, super egos. They have an overabundance of either narcissistically infused self-justification, which means they are god like, right? Or they’re so tyrannized by a superego that says, “You’re just a little shit and always will be.”

The addictive substance is the bad mother, or the mother who sooths but doesn’t really help you grow. Sometimes these are reenactments of actual parental experiences.

You want to offer you as a kind of object to be shared, good and bad, right?

The idea is to make the conscious, unconscious and unconscious, conscious.

In other words, you want consciousness to recede so unconscious material can

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come up. So there is always opportunity for dreams, slips of the tongue, and new behaviors to offer a way to explore and probe a little bit.

I don’t get into histories too quickly because the history is in front of me, sort of dynamically repeated, you know. So with addicts I believe that with every death wish they have they have a life fear. With every death wish they have, they want to control it, so it’s not controlling them.

When there is substance addiction I always try to factor in its impact. Its conscious impact, interpersonal impact, medical impact, and its unconscious impact tells me a lot about what they are trying to treat.

I treat [the substance] as a third object. I treat it as a mysterious, or another figure in the shadows, that seems to be needed.

What I tell couples is, I’m treating each of you, I’m treating your relationship, and it will take time for you to recognize what I mean. That means that I’m not here to take sides; I’m on the side of the relationship.

Since I have to be a receiver of unprocessed and unconscious stuff, how they feel about me and how they treat me is very instructive in terms of where we are in the love and hate situation. Am I idealized and then trounced? Am I trounced then and then trounced some more? Are they afraid that I’m going to get rid of them if they don’t cooperate and don’t please me? Love and hate is so important in the transference and countertransference.

(Stella) Even if I conceptualized it differently, and I don’t – I mean, couple issues

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are couple issues and the content of what they are struggling with ends up being so across the board. You have the addiction dynamics to complicate it, but you still have the same underlying hurt and pain and misunderstandings, longings and lack of communication.

Couples fit together not coincidentally. And their partner will be their perfect challenge and their perfect opportunity to grow if they can become conscious of what’s going on dynamically between them.

I’m usually very interested in knowing at what developmental level each person is, and usually they are not that different. You know what developmental level some of the wounding might have occurred.

Is it a walking on eggshells feeling? Is it a pull to sooth? Is it a pull to defend? Is it a pull to comfort, or whatever? There’s a lot that the energy will tell me about what’s going on with one partner or the other based on how they are pulling me to intervene.

I follow the couple, I follow the affect, and I deepen when I can if I see an opening. And sometimes I wait and just interpret the dynamics. You wait and then you interpret and you are going for really primitive psychic states or psychic defenses.

Containment, neutrality, staying present to the dynamics and holding the [various] pieces and parts in my mind for the couple when they can’t to do that.

Having a couple state of mind, right, instead of an individual working model, because I think that’s a whole different thing. Having the couple as the client, you know.

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I’m interested in helping them differentiate and see each other as an ‘other’ as opposed to an extension of the self, or a part object.

I’m always thinking that I want to move that person to being able to work on that original wound when they are sturdy enough and strong enough.

Superordinate theme no. 4: Markers of change.

This superordinate theme specifically addresses the research question: “What do couples therapists who work with SA couples experience as consistent markers of change?” Markers of change are the shifts that research participants observe within the couple dyad that indicate healing and development. This theme is broken down into five subordinate themes: 1. Reaching a conjoint perspective: Insight; 2. Let’s refocus: SA takes up less space in the dyad; 3. Emotional development; 4. Differentiation; A recovery of projections (in the service of greater coupledom); and 5. Abstinence: Yes or No? The psychoanalytically fostered “essence” of this theme is the understanding of mental representation, defined as when “goal-directed actions develop in which multiple models or perspectives can be contrasted and, ultimately, meta-representation becomes possible” (Allen, Fonagy & Bateman, 2008, p. 76). Here, the use of mental representation stems from both an individual, and a couple, standpoint.

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4.1 Reaching a conjoint perspective.

This subordinate theme discusses the importance of the conjoint perspective, garnered through insight, as a marker of change with SA couples.

(Emma) Do they have an understanding of repetitive patterns from their past and how they repeat in the couple dynamic so they have more agency about how they can be addressed? When they can do this it shows a shift to me to more of a couple state of mind, a way of thinking of the problem as a couple dynamic as opposed to an individual addiction.

I think there has to be some insight and understanding of how did you get to this place? You know, when did you start using? What was going on at the time you started to use? How is that related to your conception of yourself? Of your interaction as a couple?

I think that insight and understanding is important. I think that being able to; in essence, take in new objects and new experiences as a way of modifying old experiences is important. I can think of a couple where neither of them had the presence of an attentive, sort of parent, kind of person. I value insight, and it’s a way—it’s something that I think is important for change to occur.

If it’s going well, they are more able to experience each other perspectives.

So for instance, if it’s a couple where only one of them have a substance abuse problem, the non-abusing partner is able to hear more about the struggle, hear more about how the whole process began and the history of it. They have more of

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an understanding. And I think the person who’s abusing the substance is equally, hopefully, able to step back from the role of “I’m such a problem,” and also see what the genuine impact is of the substance use [on their partner].

(Mr. B) Generally speaking, the markers come and go, they ebb and flow, they overlap, and they never come at the same time [laughter].

Are they capable of having a shared reality, which is what I call the creative couple reality. Which is a very sophisticated notion, which advances monogamy to the extent that differences, that love and hate, that troubles and problems can somehow be worked through or lived with sufficiently to have a good enough relationship and enough satisfaction.

The role of insight it seems to me is twofold. Insight within the idea of an emotional experience is therapeutic. Insight that only reinforces what one already knows or can intellectualize is what I’ve encountered in some folks who have used 12 step, but they don’t want to know who they are, they don’t want to know where they have been, and they sure as hell want to know that where they are going is abstinence. Now these are really fine people, or people I wouldn’t even like necessarily, but my point is that for people for whom insight might be a possibility they are going to have to suffer more in the pursuit of it.

(Stella) I think that both partners have to buy into the fact that each has a role to

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play in the recovery; that the addiction belongs to the couple and the aspects of the addiction are in both, even though one might be the identified client. In here we are trying to work on how else we see and interpret each other and understand our role in perpetuating this stuckness.

It’s so couple specific, but I think with any couple relationship when they can find a way to mentalize and see the other, the otherness, the multiple meaning of things [this creates change].

(Triker) When this couple engages in dialogue about who they are and where they have come from and what their issues are from their point of view. When they have a conversation and dialogue with each other about this they begin to arrive at a larger conception of the reality of the relationship and their ongoing intimacy that they both can feel comfortable with that creates the connection. {When couples] begin to understand what the effects are of the use of the substance and are able to decide honestly whether they want that to happen.

So instead of saying, “This is one of those times when you get weird, you know, and I hate your guts when you do this,” they begin to say, “OK, I’m starting to get it. What I just said to you, this is how you must have been hearing that, and this is what you must have thought I meant.” And each of them is starting to understand each other and themselves better in terms of how they react, and that’s starting to change.

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4.2 Let’s refocus: When SA takes up less space in the dyad.

This subordinate theme asserts that a marker of change occurs in the couple when the SA begins to take up less space in their relationship.

(Mr. B) I’ve seen couples where the so-called abuser or the alcoholic really started to curb it once they started getting something they could accept in the marriage, because these couples don't often feel they deserve a good life. They only feel they deserve a good after life [laughter].

So the question is how much is drug addiction going to be affected by couple therapy, and to what extent the marriage is affected for the better, will the need for the substance reduce itself because of the greater satisfaction? So the marker of course is that addiction is less necessary; satisfaction is improving within the concept of the marriage.

(Stella) If they are willing to look at those underlying dynamics they can make choices that will make it easier for each of them to stretch and grow into a position, or a place where they are aligned more with their core happiness.

(Triker) This new sense that vulnerability is ok, and is in fact empowering and it’s safe to do that with this particular person. This gives them a whole new lease on life and their intimate relationship and they end up feeling much richer with one 159

another and within themselves, and that’s a revelation to them. That is a major outcome and in fact, in a lot of the cases, it’s when they start to realize that and start to move forward with their relationship, that the substance abuse and the use of the chemical becomes more and more of a non-issue; it becomes more and more of a take it or leave it thing.

(Emma) I think the other thing that happens as time goes on is the addiction doesn’t fade into the background entirely, but whatever the couple issues are that have emerged in the treatment, like for example trouble with intimacy; those dominate the discussion much more than the addiction. So there is a shift in focus.

I think for some people for whom substance use is a problem, it’s more a problem in response to a specific life stressor and when that stressor has been addressed, the problem isn’t so big.

4.3 Emotional development.

This subordinate theme discusses the importance of emotional development as a marker of change in the couple dyad. While emotional development occurs in unison with differentiation and the reclaiming of projections, which is the context of the next subordinate theme under this heading, from participant comments it felt important enough to be a stand-alone classification.

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staying out of their way; you just trust the process and stay patient and keep the couple connected and safe enough to go into the places where they can really, really feel each other.

(Triker) They’re hearing “You know, when you are angry with me it seems like you hate my guts” whereas, what their partner is saying, is “when I'm angry with you I’m feeling scared that you’ve done something because you don’t like me and I have a lot of fears, and it’s not that I hate your guts, it’s that I’m afraid you hate mine.” When we start to find that out about each other and we engage in a dialogue, a dialogical move toward a greater reality that includes both partners realities, that shapes the couple therapy. That’s how couples begin to see each other’s framework and become more empathically connected to one another and begin to feel safer and feel they can express their own points of view more openly.

(Emma) I think when there is greater empathy for the partner in a real way, and for one’s self, I think I would see that as improvement. When partners are able to see each other’s vulnerabilities and be supportive.

If the treatment is working then there would be a deepening of exploration, understanding, and expression of affect.

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The thing that was most upsetting was not the pot; it was the emotional distance between them, which both partners contributed to in different ways.

(Mr. B) You would look at what is it that the couple is doing to regulate emotionality in favor of feeling, and acknowledge that there are differences in opinions that can be comprised, resolved or they can take turns being the leader.

4.4 Differentiation: A recovery of projections (In the service of greater coupledom) This subordinate theme discusses the process of differentiation as a marker of change.

(Triker) So it’s less about developing a particular role in childhood and carrying that to adulthood than it is about developing a certain set of emotional convictions about who we are and how we relate to others that since has become our sense of reality. That's the same thing that we do in adult intimate relationships and that may or may not work for us at that point.

As soon as the person gets us—gets to know us better, we’re going to end up feeling judged or rejected, not affirmed or, you know, not validated, whatever it is, and we have fears about that. And we’re predisposed, given those fears, to interpreting our partner’s actions in a certain way.

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(Emma) I look a lot at what the projections are that get extended into the other and can those be taken back. For instance, in one case that I can think about, I think it was at the point at which the wife acknowledged that she had intimacy issues of her own. That really sort of shifted the couple treatment, and the addiction.

Because I think as she could hold her own piece, what happened to her partner was that he no longer had to be the sick person in the relationship and it relieved him of a fair amount of shame.

I see success as maybe more along the growth continuum. Does this couple have greater understanding of…what they have located or displaced or projected into the other, which they are able to take back and look at, like the woman I described who was able to think about her own intimacy issues.

(Mr. B) So in object relations terms, have they taken back their projections? Are they more attendant to difference without it becoming a split situation where they can’t differentiate? If they are frustrated, angry and feeling short changed, can they address these things and rebound better. In other words, is there a good enough fit now, and how could they work toward that too?

(Stella) I mean these polarizations that happen when the aspects of any dimension that end up with one partner more so than the other. So whether it’s competency,

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whether it’s wounding, whether it’s dependency, whether it’s anger, you know, if it seems to be an imbalance located in one person, I immediately start to think, ok, where is that in the other person?

They are projecting parts of themselves into their partner and then hating them or envying them or longing for them … So there’s a lot of partitioning off parts of the self into the other in a protective process. Once they understand they need to take back those projections and own them and claim them, the balance gets more alive between the partners rather than one having to hold all the happiness, the competence, or the dependency.

I think that in order to be an integrated couple you have to be a differentiated self.

4.5 Abstinence: Yes or no?

The last subordinate theme in this section discusses the role of abstinence as a marker of change in the couple dyad; is it necessary, or not?

(Emma) I don’t think all couples need [drug and/or alcohol treatment] and I also don’t think all couples will pursue it and what I have often found is even couples who may need it won’t pursue it initially. Until I have a better therapeutic alliance with the couple. And then I might be able to say, “You really have been working on this, it’s been tough. You haven’t been able to make much headway

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with the addiction part of it, would it be helpful to consider adding in some piece?”

I think for people that have that degree of a substance use problem, abstinence is probably the best outcome for them, but there are some people where that should be the goal for them but that’s not the goal they’ve endorsed.

My wish might be that their use can be better managed, so I don’t know that I would classify that as success, but maybe it is a process, you know, maybe that’s what they can do at this point time.

There are other people that simply can’t use because they are just are not able to moderate their use at all. So if they use they use to excess. You know I’m not much of a believer in controlled drinking. If you look at the literature, you know it works for a little while, but it doesn’t tend work over the long term.

(Mr. B) [Success would be] of course abstinence or reduction. I never think about cure, but I think about management or abstinence.

My assumptions that I’m treating human beings who have problems rather than problems that are afflicting human beings is sometimes something that I move back and forth from. Because when addiction is really threatening because they may be overdosing, they may be in the emergency room; when it’s really clear and present danger, I shift my assumptions. And so there we have, you know, quite a shift from the first approach, which is let the couple evolve and see

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if the addiction becomes modified or reduced, and so forth, when other related issues are sufficiently worked through.

When abuse is really running rampant there is no consciousness about what the abuse is really about. It’s so totally unconscious in its sort of force, you know, its impulse, that it has no mind. And until someone has a mind the best that they can do is abstinence, if that’s possible.

Abstinence to me is sometimes the best that you’re probably going to be able to do and if more can be done, I certainly want to offer that.

(Stella) To me the ultimate success is if you can get both people on board in terms of deciding to live a recovery lifestyle. Whatever recovery represents to them; therapy, or 12-step, or working on showing up as individuated partners who can enhance each other’s life and raise healthy children.

I really do have a bias that the couple without an active addiction has a lot better long term viability for success. I don’t think there are a lot of really successful, healthy, actively addicted couples.

(Triker) And to go along with that, when substance abuse is part of the picture, when you talk about success, I don’t know if I believe if abstinence is a necessary outcome of that process.

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But on the other hand, it’s fairly clear that to the extent that alcohol or other substances remain an issue for one or both partners in the relationship, the couple therapy is pretty much doomed. It’s not going to get anywhere so that’s the biggie about what doesn’t work.

Superordinate theme no. 5: Trial and error.

The final superordinate theme answers the research question: “What understanding do couples therapists who work with SA couples perceive might harm or impede the process?” Together, research participants have accumulated more than a century of experience in working with SA couples in a variety of different settings including inpatient and residential, intensive out-patient programs, and private practice.

With this experience has come an understanding of what is not helpful in working with these couples, and what can interfere with the healing process. The four subordinate themes under this heading are: 1. Insisting on abstinence or drug and/or alcohol treatment; 2. Viewing SA through a narrow lens; 3. Coordination, cooperation and conversation; and 4. Social, cultural and generational challenges.

The psychoanalytically derived “essence” of this superordinate theme is the concept of “interdependence”, defined by Barker (2003) as “the sharing of responsibilities and benefits that are required for survival or wellbeing” (p. 222).

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5.1 Insisting on abstinence or treatment.

This subordinate theme discusses how insisting on treatment or abstinence can be unhelpful when working with SA couples.

(Mr. B) Change is frightening and therefore change creates trouble depending on how rigid a couple is and how set in their ways. So you have to be mindful of what change means to the couple before you actually say much about it or consider that they might be there to change something.

And then we have addicted doctors [and] addicted airplane pilots. I mean there are certain professions where I can’t wait [for them to decide on treatment].

I’ve got to get involved with – for example, with a physician I worked with recently I had to get in touch with the State because they had a physician’s care program which wasn’t going to humiliate him and since it wasn’t in [our State] he was willing to go and get involved in rehab. But he was operating on patients and he was addicted to stimulants.

(Stella) I used to know of people who would say, “I won’t see you until you get treatment.” I don’t think that’s a good approach. I think it goes back to [my belief that] I will treat you where you are. In the back of my mind am I going to hope that we can move you to a place where you can get help for your addiction?

Absolutely. But if you’re not ready to do that, you’re not ready to do that. So I will work with what you bring me.

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I certainly have let go of what I was taught early on about “you can’t deal with the couple and you can’t deal with other things until the addiction is addressed.”

(Triker) I can stomp around all day and tell them what they should do and what they should not do and if they were sober they would understand that, and that part of their sobriety is getting to that, you know. I could tell them all those things, and seem to make some kind of rational sense, but I know as a psychotherapist that that is mostly doomed to failure.

They have friends who have good wine with dinner and so forth – she is not going to give that up. And I say, “And why is that?” and she says – and we go round and around about this and I say, “I’m going to continue to needle you about this.” But what I have also said to her is that I’m not going to make it a hill that we die on.

I’m not the kind of person who you find often here in our treatment community that says I won’t see you unless you get involved in [drug and/or alcohol] treatment. That’s never been my approach.

That’s related to the issue of I won’t see you unless you go to treatment.

Well, you know, what my client is likely hearing from this professional is, “You’re too defective to do this work so go away and do something about that and then you can join the human community.” I’m hoping to contradict that message 100 percent.

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(Emma) I don’t say to somebody, “I won’t treat you unless you do this.” Which is interesting because with somebody who has a serious eating disorder I will say “I will not treat you unless you are supervised by a medical professional.” I do say that. So it’s not that I haven’t done that. I just find that it doesn’t work. It works with eating disorders, but it doesn’t work with substance abuse.

My insistence on hospitalization would be if there is an imminent suicide risk. Which is not always easily determined, right, because you could say there is always risk. I mean somebody can drink too much, have a seizure and die, right?

Somebody can miscalculate or get a bad batch of drugs and die. I actually think even the overdose that occurred in my practice, I do think that was likely an accident. But that is a risk I think you just live with in treating this population that to me is not, “ok, it’s time to hospitalize.” I suppose it’s a judgment call.

I can think of one instance where I thought the person needed more intensive [drug and/or alcohol] treatment to the point that I thought that continuing to treat them was not ethical. And so I did speak with them about, this isn’t [drug and/or alcohol] treatment and the risk is too great.

5.2 Viewing SA through a narrow lens.

This subordinate theme discusses how a simple view of SA can be unhelpful when working with SA couples given the complexity of its makeup.

(Stella) I mean you just can’t check out of life and go and get yourself dealt with.

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Unless you happen to have a lot of money or a lot of really good insurance or, you know.

I think [the disease model] is too simplified. I think it’s not everything.

(Triker) The issue of chemical dependency is not just an issue of getting sober.

The theoretical orientation that I have helps in giving me a way to understand or make sense out of what it is that I’m experiencing in the couples that I’m working with. And it’s going to do that no matter what. It certainly may blind me to certain things that are happening. Somebody else observing what I’m observing may have a different way of interpreting it. So, you know, I guess it make sense to say that it might help or hinder, but it might or might not apply some clarity in terms of making sense of what it is that is going on and what I have to do about it.

(Emma) I will often hear, ‘Like well, I’m addicted. You know people are addicts and I have an addiction.” And yes, I get that. I want to understand what that means from the person’s point of view, but it’s as though we don’t need to talk about it [anymore]. We don’t need to talk about the particular drug. We don’t need to talk about what gets evacuated when that drug is used. We don’t need to talk about how that use began.

So sometimes you have somebody who comes in, or you know the other thing is that, they’ve read some literature, so they are like, “I know I’m co-

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dependent and I’m an enabler.” But that’s a kind of simplistic understanding in some ways.

I do think that some people have more of a genetic vulnerability addiction.

But to me that didn’t really explain the whole picture. I was not—I was never enamored with the disease model because I felt like it was too simplistic, sort of like, well this is a disease and you have to stop using; kind of that’s the answer?

(Mr. B) Addicts have a right to free associate. Maybe some can’t. Maybe some would if you waited that extra minute. When there are people who can actually do analytic work about their addiction it’s amazing what they come up with.

Be very careful about pathologizing. [We need] to be open to issues such as neglect, oppression, a lack of tools, helplessness, subjugation, as conditions that have influenced development.

I’ve had patients who will never go to a 12 step, they just won’t. They either have memories of it or experiences with other people or they are afraid that it’s too authoritarian or that it’s religious and they will be taken over by it.

Does ones frame add to knowledge and skill in dealing with addiction, or can it lead you away from it and substitute something else that’s part of your frame when you don’t know what to do about the addiction, or you don’t have that frame to integrate into your frame? So again, the limits of psychoanalytic thinking.

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I, in effect, naïvely took [SA] out of the context of it being within, dwelling within, a system of human beings, a human environment, a context, and trauma.

So the development of a human being and the environment that they grew up in and live in was not really part of my contextualization early on. So I was naive and I think some people are still very naive about what they call this.

5.3 Coordination, cooperation & conversation.

This subordinate theme discusses how difficulties in treatment coordination, problematic cooperation from other treatment providers, and a wariness to engage in open conversations about SA in the psychoanalytic community, impede the process of working with SA couples and interferes with the very concept of interdependence.

(Triker) Sometimes there isn’t any coordination because the attitude of the people in the treatment program is, we have our own couples therapists and our preference would be to have them work with them. And you know sometimes that’s an economic issue for the treatment program. Sometimes it’s an issue of professional pride, or whatever. So again there are many variations on this theme.

Ideally I would like to have that kind of coordination [but] it happens less frequently than I would like, let’s put it that way.

Interestingly, some of those options are programs that are not terribly interested in coordinating with an outside psychotherapist, so there are different outcomes depending on what their attitudes are.

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Some of the approaches to CD treatment involve approaches that I consider directly shaming and that’s not ok with me. I’ve never approached it that way and I have had it said to me that I’m risking coddling some of my CD clients by not directly confronting them on certain things.

(Emma) For example, if I am thinking that the person needs to look at the underlying trauma, somebody [in a drug and/or alcohol treatment setting] may say “Well, no, that is going to set them off. It’s going to push them into a relapse.”

Whereas my thought might be, if they don’t deal with the underlying trauma the addiction is going to continue.

I had one person who I was seeing in couple treatment and their individual therapist said, “Well, we need to pull them out of this treatment because she doesn’t understand the disease model”, and they did.

Sometimes they do have to enter treatment programs or some sort of intensive outpatient program. And I think for it to go well there has be coordination between treatment providers and sometimes those treatment providers have a very different orientation than I do. So they are not necessarily psychodynamic in the way they look at things. I think that doesn’t have to be a hindrance, but it can make it challenging.

I just wish as a profession we’d think about [SA] more and I wonder why we don't. What is it in our psychoanalytic community; I mean why aren’t we talking about [SA] more? Thinking about it more? There must be some kind of

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collective defensiveness. And I don’t know what the answer to that is, but I think it’s a problem. I think it’s a problem at the institutional level that affects individuals.

Well relapse rate are high, and I think that’s part of [why we don’t talk more openly about SA]. I also think we like to work in our own individual offices for the most part. We’re not big networkers or collaborators and often times treating substance abuse requires a team effort. I also think that we don’t do a lot of research focused on this issue in the psychodynamic sense and that’s probably to our detriment in terms of getting funding and that kind of thing. I think it’s a lot of things.

(Mr. B) I believe that while we know the evidence in termination processes, there are very few terminations that are mutually agreed on and ideal. The majority of terminations are not planned for nor do they actually work out all that well. And we don’t like to talk about those.

(Stella) I don’t think this is just true for substance abuse, but on occasion, when I’m working with a couple and I don’t know the therapist who’s working individually with the partners, there can be a tendency to have the partners feel polarized by their own personal therapist not really getting the couple dynamics.

I believe that Imago puts the focus on the couple and the transference between them, and a more object relations or psychodynamic model looks at the

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relationality between them and between them the therapist. It’s funny because Imago might say that object relations isn’t relational because psychodynamic typically has an individual focus. But that doesn’t mean that you can’t make it relational. And I resist the idea, in some psychoanalytic circles, that Imago is just a process technique. Because I think it’s theoretically based in object relations theory, analytic theory, and attachment theory. So I just think that my frustration is with the one group not getting the other and acting like it’s wrong to do one or the other. I actually think both are very valuable. And to be honest it’s a struggle for me professionally right now because I feel like in both of those camps there is a suspicion of the other one.

5.4 Social, cultural, and generational challenges The last subordinate theme under this heading discusses participant views on the environmental issues surrounding SA and how they may impede the process when working with SA couples.

(Emma) I can think of one young couple where the woman is really shy and I think really her drinking started because she was so overwhelmed by social settings.

I think that when somebody comes from a, let’s say family history, where there has been substance use for generations, treatment does look different. If I am the SA person, I am coming from an environment or a history that is filled

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with this at some level and where maybe it’s part of belonging, maybe it’s what my family does every night.

There are always life stressors, right? There are certain jobs where drinking is sort of part of the job, or environments where access to drugs and alcohol is much easier than others. But I don’t really see that as a cause, I see that as an environment that aids the addiction in a sense.

I also think there is a greater amount of shame [in SA] than in a lot of other problems. I think that’s partly societally induced, you know, that there is a lot of judgment of people who are substance abusers. That they are out of control, for example, that it’s something they do to themselves. Somebody who is bipolar, for instance—even though I think that has psychodynamic implications as well—but mostly people don’t say, oh, that’s something you did to yourself. But I think that people who are addicted face much more social stigma and I think that that creates more shame. And it’s not just for the person who is addicted it’s also, I think, for the partner.

When you read an obituary and you can absolutely, one hundred percent, tell that the person has died of an overdose or a drug related problem, but it’s not said. But if they died of a heart attack or if they died of cancer or if they died of this or that—and I don’t think it’s just about drugs. I think it’s also about mental health issues – I mean it’s a lot of things. But occasionally you’ll see somebody say it and it’s up to the family whether they say it or not. But I do think it represents something collectively about something that’s just really hard to say.

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(Triker) First of all, the understanding [is] that we don’t exist in a vacuum.

He likes to have a glass of wine at dinner also and realizes that there are pressures on her to do that, under certain social circumstances.

If you’ve grown up in a world where let’s say alcohol is always been part of socialization this is a new world for them, and it turns out for lots of couples it’s a new world that’s very freeing.

(Stella) The comment, “alcohol use is so socially accepted that [the couple] cannot see where addiction enters the picture.” I think that’s probably very true. What was in my mind was a specific couple where they came in to deal with his affair, and her anger about his affair and his—just trying to figure out how to move forward with it, and in the course of the interview I become aware that he’s an alcoholic. I think he’d go out after work; he was in a kind of high level professional thing where drinking was a big part of it.

I look for the addictive pieces and parts in the family of origin, in the partner who’s not the identified patient. For example, a lot of wives of alcoholics have alcoholic fathers or mothers so we talk about their adaptations through that family system.

(Mr. B) OK, then there is the DNA part, [but] even with an inheritance that seems to

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forecast a destiny of addiction, given an environment that tunes into it—isn’t that what therapists try to do – maybe they have a better chance to give this kid a different family.

With respect to sub-cultures where addiction is sort the norm, oh, there is no question that I and the couple are up against it, but again they may be the only people in their family group that ever went to therapy too.

If the couple has a history, sub-culturally, in which all of their friends are addicts or a good number of their associates have been traditionally part of a subculture of addiction, my work is much more difficult because I represent an alien kind of world. A world of non-addiction.

Member-checking, journal notes and researcher countertransference.

At this point in the research process it is appropriate to address member-checking procedures as well as the roles of journal notes and researcher countertransference throughout the course of this study. In keeping with IPA’s concept of ‘bracketing’, I engaged in ‘reflexive journaling’, cast myself as the first participant in answering, recording, and transcribing personal responses to the research questions prior to participant interviews, and engaged in member checking practices which were fully discussed in participant second interviews.

After the first interviews were conducted, initial descriptive, linguistic, and conceptual notes, along with emerging themes, were sent to research respondents for validation purposes. During this phase of data collection respondents had opportunity to review the material to make note of any changes, comments, or questions they have 179

regarding researcher accuracy and participant clarity. This process is known in qualitative research as member checking, and is a well-recognized standard for evaluating qualitative studies (Rubin & Babbie, 2008). All four participants engaged in the process to varying degrees, auditing, changing, and reworking personal accounts as necessary. These were emailed back to the researcher, and then addressed during the second interviews to confirm accuracy.

Triker reviewed these themes very carefully using Microsoft word professional formatting and highlighting changes in yellow, but making few changes overall. The changes he made were related to statements deemed too absolute, or incorrect in their representation of his theoretical orientation. An example of the second occurrence was when I stated “He is working from a deficit model of psychodynamic theory.” Triker corrected this to read “He is working from an inner subjective developmental 2nd chance model.” This was in keeping with Triker’s rich description of his work, and his natural tendency to view things from a strengths-based perspective. Triker’s presence throughout both interviews was engaging, humorous, confident and professorial in nature.

Stella was the most meticulous out of all the research participants in reviewing themes from her first interview and we spent the majority of her second interview discussing changes made. This was because I had not received a copy of changes she had sent, so they had to be reviewed verbally to ensure accuracy. Stella’s changes were more augmenting in nature as compared to modifying. For example, I wrote “It isn’t effective to treat individual addiction without treating the context in which it exists within the couple.” Stella corrected this to read “It is more effective to treat SA in its relational context/wouldn’t say can’t be effective without it.”

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Stella was also very conscientious about pitting object relations clinicians against IRT clinicians, or vice versa. She was very open about the challenges she had with clinicians who felt that the two models could not be blended, but shared that this was her issue and that she was quite happy with the ‘hybrid’.

Both of Stella’s interviews took place in her home over a weekend, with family and pets occasionally passing by her laptop camera. She was very amicable and engaged throughout both interviews, laughing frequently, considering and responding to questions thoughtfully and very self-confident. Towards the end of the second interview she shared that the interviews had stimulated thoughts that it had been some time since she had been to an addiction conference, and that perhaps it was time for a refresher.

While Mr. B took the most amount of time to review the initial notes from the first interview, he made very few changes. He also used Microsoft word professional, formatting and highlighted the changes in red. Changes made pertained mostly to verbiage around theoretical constructs and ways of working. For example, I wrote “His assumptions can shift depending on the seriousness of SA.” Mr. B corrected this to, “His assumptions and approach can shift depending on seriousness of SA.” At the beginning of the second interview when I asked if there was anything he wanted to share before we began, Mr. B said that in thinking about the first interview it had felt as though he had reviewed his career “five years at a time”, allowing him to “reevaluate my own evolution and how my current thinking actually got to be my current thinking and theoretically my practice approach.” After some thought he had determined that his approach to working with SA couples was well grounded, albeit he felt it was important that he continue to be receptive and engaged to ongoing research.

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Throughout both interviews Mr. B was reflective, engaging, and a bit selfdisparaging but in a humbling, humorous, way. At one point during the first interview I found myself fantasizing about being one of his students, and how much I could learn.

Mr. B perhaps felt this transference, as the first interview also had him thinking about what his motivation had been in agreeing to this research and if he had been perhaps too pleasing? After some reflection he felt he had done an “honest job” in representing who he is and how he works with SA couples.

Emma’s changes to the notes and themes from the first interview were definitive and clear. If I was too conditional, Emma modified the text so there could be no misunderstanding to her intent. For example, I wrote “The medical model can be narrow in its focus with SA” in which Emma responded, “It’s not that it “can be” narrow; it’s that it is too narrow.” When I wrote “A large number of clinicians who work with this population have a personal connection to SA,” Emma clarified, “Most people have a personal connection to SA.” Throughout the first interview Emma was careful with her words but candid in her disclosure about her brother’s SA and her patients overdose. During this part of the interview she was reflective and vulnerable, and I struggled to maintain my research persona, resisting the pull to revert back to the role of therapist. This part of the interview stayed with me for several days afterwards as I felt I had not been supportive enough, or compassionate enough, throughout Emma’s disclosure. In the initial analyzing of the interview this countertransference was apparent in the manner in which Emma’s patient’s overdose was addressed. I wrote that Emma had “experienced deep loss in working with SA” but failed to mention specifically what the loss was.

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At the beginning of the second interview, when Emma was asked if she would like to talk about anything from the initial interview, or member checking procedures, she shared: Now I’m remembering this reaction I had when I first sort of saw the notes [from the first interview], because you said “she has a personal loss”, or whatever. But you didn’t say she had a patient overdose. Now you could say that’s for confidentiality reasons. And I totally understand that. But I sat there thinking, hmm, I mean, I thought this is a way maybe in which we shield ourselves and we don’t talk as openly as we might about what has actually happened. (Emma)

While it is true that I have been very conscientious of confidentiality throughout the dissertation process, I did not disclose that I am a couple therapist who works primarily with SA couples. In addition, like three of my four participants, my family of origin has a history of SA. I have not however, experienced a patient suicide due to overdose. So while I may have been interested in maintaining the confidentially of Emma’s disclosure, there is no doubt that there were other factors at play in referencing Emma’s experience as simply a ‘deep loss.’ In the second interview when asked how she would like me to refer to her patient’s suicide, she replied: I don’t know. I mean, you know I think I noticed it and I did have that question myself. I think I would just say—you know I did have a patient die of a drug related issue…you know, uh, I mean could somebody—it’s also been many years since that has happened and I probably feel differently about it. And maybe that is my need to make something good come out of something horrible.

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All research participants shared in varying degrees that the member checking aspects of this research was comforting. This seemed apparent especially during the second interviews where participants all seemed a little more relaxed. But that certainly could have been my projection. At times I felt frustrated in not being able to pin down definitive differences in how research participants diverged in their work with SA couples compared to non-SA couples. For the most part participants were clear that these processes were dynamic and could not be understood as either-or. In fact, one of the most common responses from research participants when asked to be more specific about a marker of change for example, was “it depends.”

Chapter Summary Outside of describing member checking procedures and researcher countertransference, this chapter attempted to organize findings into five superordinate themes: Personal and Professional Journey; Conceptualization of SA; the Therapeutic Action; Markers of Change; and Trial and Error. Twenty subordinate themes were identified and included which can be seen in Table 4.2. Research participants provided a rich narrative of ‘lived’ experiences in working with SA couples which is well reflected in the data. Chapter V will discuss these findings and place them in the context of the wider literature to examine how they illuminate or challenge the findings of other studies, and to evaluate what has been done (Smith, Flowers & Larkin, 2009).

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Chapter V

Discussion The purpose of this phenomenological study was to understand how couple therapists treating couples with substance addiction (SA) identify, and understand, the various psychodynamic elements that influence healing. Current interventions used in treating couples with addiction are primarily behavioral, meaning they focus on eliminating the symptom (i.e., the alcohol and/or drug use) and operate from the medical model of treatment. Conversely, psychodynamic therapy seeks to understand the underlying dynamics that contribute to SA, and historically places less focus on the visual manifestations of the symptom. There is little research available at present that examines the psychodynamic treatment of SA in couples, and this study hoped to identify firsthand knowledge for both new and seasoned clinicians that will ultimately benefit the SA couples they serve.

This research used a form of phenomenology called Interpretive Phenomenological Analysis (IPA) developed by Smith, Flowers and Larkin (2009), to gather data from eight in-depth semi-structured interviews, as well as member-checking techniques throughout to support and strengthen findings. As per IPA, where quality is valued above quantity and smaller sample sizes are recommended, four participants with doctoral level educations and extensive experience in working with couples with SA through a psychodynamic lens were chosen. Data obtained was coded and analyzed using 185

IPA guidelines which are outlined conceptually in Chapter III. The study was centered on the following six research questions: 1. How do couples therapists experience working with couples with SA? 2. What do couples therapists who work with substance dependent couples experience as being therapeutic in working with couples with SA? 3. What is the understanding of couples therapists as to what works when working with couples with SA? 4. What about the process feels helpful to couples therapists who work with SA couples?

5. What do couples therapists who work with SA couples experience as consistent markers of change? And 6. What understanding do couples therapists who work with SA couples perceive might harm or impede the process?

The purpose of this chapter is to discuss the findings as previously presented in Chapter IV, and place them in a wider context with reference to the selected literature (Smith, Flowers & Larkin, 2009). While this dissertation engaged in a thorough literature review prior to engaging participants, themes have emerged during the analytic process which were not anticipated, requiring the introduction of literature previously unreferenced. In IPA this is not unusual and, in fact, indicates a sensitivity to context; which is a principle used in assessing the quality of qualitative research (Smith, Flowers & Larkin, p. 180). The overarching goal of this chapter is to examine how this study illuminates or problematizes the findings of other studies, and to evaluate what has been done (Smith, Flowers & Larkin).

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Please note, all of the findings in this study reflect the majority of the participants, albeit in some cases one or more participants may not be in agreement with their colleagues perspectives.

The double hermeneutic.

This research is very much a collaborative endeavor between researcher and respondents, with “the end result always an account of how the analyst thinks the participant is thinking” which is in keeping with IPA’s double hermeneutic lens (Smith, Flowers & Larkin, 2009, p. 80). This concept is reflected in the analyzing and categorization of the data which experiences an organic evolution from initial noting and emerging themes to the development of smaller clusters referred to as subordinate themes. This process concludes with superordinate themes that express the conceptual characteristics of each cluster.

Throughout the process, I have moved back and forth between the data as a whole and each individual statement in reference to the hermeneutic circle whereby “each little bit of text is looked at in the context of the whole transcript; the whole interview is thought of from the perspective of the unfolding utterances being looked at” (Smith, Flowers & Larkin, 2009, p. 81). This cyclical approach theorizes that one must look to the whole to understand each moving part and to the parts in order to understand the whole (Smith, Flowers & Larkin).

Within the parameters of this study, readers will have already noted in Chapter IV that while each subordinate theme has its own degree of substance and significance each is exquisitely interconnected and unified in their overall objective, which is to help us to 187

understand therapist experiences in working with SA couples to better determine therapeutic factors. And while each subordinate theme is relevant and necessary to our overall grasp of the research findings, we look to the superordinate themes, both individually and as a ‘whole’, to develop a richer and fuller understanding of the phenomenon as it unfolds within the subthemes or the ‘parts.’

Essentially this means that there is an interdependence within and throughout the subordinate and superordinate themes in this research that is difficult to isolate into distinct, discrete categories that are independent of the ‘other.’ So while each section of Chapter V will be organized identically to Chapter IV, thereby teasing the subordinate themes apart where they stand alone in relation to the literature, and each other, there will be naturally occurring overlay throughout.

Personal and professional journey.

The first superordinate theme discusses how participant therapists’ personal and professional experiences have impacted their work with SA couples. It also discussed the challenges these therapists have faced over the years in the work they have done, as well as reflections garnered as a result of these experiences. This theme answers the research question: “How do couple therapists experience working with couples with SA?” All participants voiced that use of self, which evolved from personal and professional experiences, was a dynamic process in their work with SA couples. Triker’s predisposition to see SA from the non-addicted partners’ perspective, Emma’s experience in feeling like a “probation officer”, Mr. B’s “boredom” with non-aggressive couples, and Stella’s management of her codependent parts that wanted to “fix the abuser”, are 188

countertransferential responses or reactions that participants needed to recognize in order to evolve from a beginning stance of ‘doing’ (i.e., prematurely recommending 12-step, drug and/or alcohol treatment, etc.) as inexperienced therapists, to an advanced psychodynamic position of ‘being’ where therapists are more comfortable sitting with the unknown. Reported feelings of “anxiousness”, “zealousness”, “fear”, “protectiveness”, “unpreparedness”, “judgment”, “dissociation”, “tentativeness”, and “shame” in their work with SA became more comprehensible with time and experience, but due to the serious nature of their work, as demonstrated by two participants having experienced patients who overdosed and died, managing the tension between ‘doing’ and ‘being’, is an ongoing process.

The idea that therapist’s personal backgrounds, interests, and ways of thinking will impact treatment is certainly not new. Unfortunately, there are just very few clinical examples in the psychoanalytic literature on transference and countertransference with SA couples. Siegel (1992) presents a case illustration of a young married couple who both present with denial and deflection of alcohol addiction. The only countertransference Siegel speaks to in this case illustration is feeling compelled to avoid discussion of the problem for fear of the couple’s rejection or anger.

None of the research participants in this study shared having an avoidant response to discussing SA in the process of working with their couples, but this could be because of their significant experience in working with SA couples whereby fear of addressing the problem directly is not an issue. And Siegel does not articulate where, in her lengthy career as a couples therapist, this particular case presented itself; albeit the book in which the case is featured was written almost 25 years ago. Just as research participants became 189

more familiar and adept at managing countertransferential responses with time and experience, Siegel’s experiences with SA couples in present day have also most likely evolved.

Another explanation as to why these research participants do not report countertransferential avoidance in addressing SA could be that Triker and Emma became accustomed to meeting the illness head-on in their family members over the years, while Stella and Mr. B began their careers working with SA individuals in confrontational settings (i.e., bare bones treatment centers and a correctional facility) which advocated direct, and sometimes provocative, approaches.

Study participants do share however, that sometimes, in the dilemma of when to initiate drug and/or alcohol treatment and when to wait, they are more apt to tread lightly in recommending inpatient if they have the impression that the SA is not critical and lack of safety is not an issue. Is this because they are fearful that they might lose the couple if they move too quickly? Or again, is this an example of a greater understanding that has evolved with time and experience that trying to move couples faster than they are ready to move is counterproductive?

In a further examination of the psychodynamic literature on the subject of use of self with individuals with SA, Lightdale, Mack & Frances (2011) propose that clinicians can become victim to three types of countertransference when working with SA: 1. That which is evoked by clients through the transference in recreating relationships with close SA family members;

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2. That which stems from therapist attitudinal problems that are then projected due to the therapist’s poor understanding and knowledge about SA and its treatment; and 3. That which is grounded in the therapist’s “mostly unconscious transference related to his or her past or present problems” (p. 241).

Just as therapist feelings of uselessness, unpreparedness, persecution, detachment, anger, guilt, despair, and protectiveness are common when working with SA individuals who are themselves feeling deprived and shameful, therapist feelings of invincibility and omnipotence can also transpire when the patient is getting their ‘drug’ through the therapy (Lightdale, Mack & Frances).

To help combat these issues greater therapist awareness, good-quality training, personal therapy that includes work around stereotypical thinking, consultation, supervision, and team collaboration are highly recommended (Lightdale, Mack & Frances, 2011).

Three of four participants in this study discussed the necessity of ongoing consultation, and all four recognized the need to create communities of care around themselves that not only provided “emotionally safe”, “caring”, and “supportive” environments, but which also consisted of “go-to-people” who were “amenable” to their way of thinking and working, and where they could engage as “respected” members of a “team” that had the couples best interests at heart. This last piece is of particular importance, given participant accounts of alienation at times amongst other treatment

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professionals who differ with their psychodynamic focus. Some participants felt this alienation more deeply than others, but all voiced an awareness of the division.

Managing the intensity of the transference and countertransference when working with SA couples goes hand in hand with the chaotic and out of control nature in which these couples can present. Research participant examples included challenges in addressing denial and resistance, couple reports of hopelessness and despair, interruptions in treatment due to relapse and the use of other adjunctive therapies, and the realities of overdose and death. An excellent example of the chaotic presentation of a couple dealing with SA is that which Shaddock (2000) presents in the opening pages of Contexts and Connections, whereby Beth arrives at her first couple session in an extreme state of intoxication: Slurring her words, she disclosed that she had been drinking steadily for several weeks and was an alcoholic. The alcohol heightened her already bitter affect. She denounced Richard sarcastically every time he tried to speak, with comments like, “Why don’t you go tell that to cutie pie” (p. 1).

Frankly, there is no shortage of literature discussing the difficulties in working with some couples, including those who present with aggression (Scharff, 2014; Vincent, 2014), acute couple distress (Scharff & Scharff, 2014), infidelity (Leone, 2013; Scheinkman, 2005), and intergenerational trauma (Mann-Shalvi, 2014). But addressing SA in couples presents with its own unique challenges, as demonstrated in the illustration above, not the least of which involve the threat of suicide and/or homicide in extreme cases.

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It is one thing to be working with individuals, one-on-one, who are dealing with SA, but when the couple is involved, as research participant’s voice in the next superordinate theme, SA Conceptualization, both partners have an unconscious vested interest in maintaining the SA making it doubly challenging. Shaddock (2000) writes that in response to his couple’s initial presentation detailed above, it was “tempting to protect myself with diagnostic labels” (p. 2), not unlike Mr. B’s initial concretization of SA that he felt was based on lack of knowledge and limited research.

Only with time, clinical experience, training, supervision, and consultation were research participants able to become more comfortable, and less reactive, in their work with SA couples. Mr. B shared that he now “rarely use[s] the word addiction”, preferring to use instead “descriptions and illustrations.” Research participants over time have come to the understanding that they are limited in their ability to convince couples to seek out drug and/or alcohol treatment when they are unwilling, indeed, as Stella states “I also know I can only do so much and you can lead a horse to water…”

When therapists have ‘skin in the game’ due to a family member with SA, they are constantly reminded of the trials and pitfalls of the disorder, and the road to ‘being’, instead of ‘doing’ can be rather bumpy. Emma’s heartfelt account of being a primary support for her brother is of particular note, as is her resulting emphasis on the necessity of ongoing consultation to increase awareness of possible “blind spots” and “overreactivity.” Both Emma and Triker discuss the sense of agency they have when they are able to choose the couples with whom they work, given their inability to choose the fact that their family members have a SA problem.

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There is a significant amount of literature in the field which discusses the benefits and detriments of working with SA when therapists have a personal connection to the illness (Lightdale, Mack & Frances, 2011; Mosse & Lysaght, 2002). Three of four participants in this study fall into this category in varying degrees which begs the question: Are these statistics typical of the numbers of clinicians currently working in the SA field? While exact percentages are unknown, research examining this phenomenon posits that most people entering into the field of chemical dependency have a personal connection to the problem, with many having family members or friends who are, or were, addicted (Forester, 2011).

Pertinent for these individuals in particular is that they have a thorough understanding as to why they have chosen to work with SA, and what their attraction might be to risk-taking and dependency needs (Read, 2002). Frequent mistakes include over-involvement and under-involvement with patients, as well as feelings of hopelessness, jealousy, avoidance, and burnout (Lightdale, Mack & Frances, 2011). In this research, participants with SA family members have all done a significant amount of personal work around personal triggers and motivations, and continue to use consultation in their practices.

While there are many challenges in working with SA couples, research participants in this study also express a connection and appreciation to their work which might explain why, after so many years in the field, they still do what they do despite the hurdles. Stella describes loving her work, and feeling “blessed and privileged to be a part” of people’s journeys. She also sees addicted individuals as “regular people like

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everybody else, they just happen to have this cross to bear.” Triker’s experience with SA couples has given him “an expanded view of how vulnerable we all are, and how close we all are to wanting something to sooth our pain.” Mr. B reports that he is a “marriage junkie in the sense that I think that when people invest in a marriage for a long time, it’s always better to see if they can reclaim it, if possible.” He also believes that if the couple therapy is successful, “future generations have a better chance of not being addicted.”

Participants all insist that an empathic connection to the couple and their circumstances is extremely important in the ability to maintain a therapeutic alliance, a subject that will be further explored under the superordinate theme, Therapeutic Factors.

Suffice it to say at this point in the discussion that research tells us that an accepting approach towards couples, combined with a lack of criticalness, can account for as much as 76 percent of total alliance scores on The Couple Therapy Alliance Scale (CTAS; Reif, 1997).

Summary of personal and professional journey.

Research participant experiences of transference and countertransference issues when working with SA couples is similar in many regards to those therapists who work with SA individuals. These reactions become clearer, and therapeutically useful, with time and experience that includes clinical work, consultation, supervision, and personal therapy. With so few examples in the literature of use of self when working with SA couples, less is known about what is typical or atypical, but fear of addressing SA directly may be a countertransferential reaction in less seasoned couples therapists who are just beginning to understand their own vulnerabilities.

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Couples with SA can present as chaotic and out of control, challenging therapists to keep a clear perspective, engage in consistent self-care, understand personal and professional limitations, and to create a community of care that includes professionals amenable to, and considerate of, a psychoanalytic lens. With experience and success come confidence, awareness, agency, empathic acceptance, personal gratitude and appreciation for the work, and a deeper knowledge of oneself and ‘other’.

There are times when you tell people what they need to hear, specifically an addict, and you do the best you can and they have to go out and try some more and then they’ll come back later and say “I should have listened to you” [laughter]. But I mean that’s a success in the sense that you did what you could in that person’s process. (Stella)

Conceptualization of SA The second superordinate theme answers the research question: “What about the process of working with SA couples feels helpful?” The manner in which participants conceptualize SA – the way they theorize, hypothesize, and conceive of the role of the substance itself, and the role of the substance in the couple dyad, is essential in making headway with the couples with whom they work. This section is broken down into three subthemes: 1. The dynamic role of the substance; 2. The dynamic role of SA in the couple; and 3. The biological considerations of SA.

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The dynamic role of the substance.

All four participants view the role of the substance itself as dynamic, and insist that understanding the substance abusers’ allure to their drug(s) of choice is paramount to understanding what the abuser is trying to medicate. Emma questions “is it that, you know, with heroin you feel a kind of warmth that, um, you know, you don’t ever remember feeling anything like this?” Mr. B understands one patient’s drug cocktail of mushrooms, psychedelics, marijuana and alcohol to be “mind regulating and brain regulating agents towards sedation and excitability.” Stella posits that alcohol is a substance, at times, that is “used to keep a lid on something, or to not expose something else, or to make someone feel more under control.” And Triker comments on the sedating and numbing effects of alcohol, and the “role” this has played in the psychological development of the individual and the couple.

The notion that the drug of choice has a dynamic role in its continued use by the addicted individual is well documented in the psychoanalytic literature as previously discussed in Chapter II of this dissertation. As a review Khantzian (2003) argues that opiates are used by individuals struggling with aggression and rage, and that these people may have suffered early physical abuse or deprivation. He views alcohol as a substance that is used by people who feel lonely, empty and isolated and who are trying to manage symptoms of anxiety. Khantzian’s research connecting affective experience to drug of choice has been duplicated in additional studies, including that by Suh, Ruffins, Robins, Albanese and Khantzian (2008), who found repression and depression to be linked to alcohol use, cynicism to predict a preference to heroin, and psychomotor acceleration a predictor of cocaine use.

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But this perspective is not shared by all psychodynamic practitioners and researchers. As introduced in Chapter II, Dodes (2002) argues against the premise of a specific drug-to-feeling-state, stating that users frequently swap out drugs which induce different mind states at any point in time. Opponents of the self-medication hypothesis also argue that feeling states of dysphoria, for example, are not being medicated by people in order to feel better, but instead are the consequence of withdrawal from cocaine, morphine, amphetamines, and alcohol (Dackis & Gold, 1985; Pickens & Calu, 2012).

The dynamic role of the substance in the couple dyad.

While the dynamic role of the substance has been addressed to some degree in the psychoanalytic literature, the dynamic role of the SA in the couple dyad has been far less explored. Research participants view the role as both a symptom and a defense of underlying issues in the couple relationship which are hidden. The SA becomes the symptom or the defense in keeping these issues at bay, and is sustained by both partners in the relationship, who unconsciously collude in its upkeep.

From a dynamic perspective, Mr. B perceives early trauma histories, unconscious affect including fear (i.e. of dependency and intimacy), and hidden desires to rescue as some of the factors directly related to SA. He also posits that couples managing SA have early developmental needs (i.e., oral) that have been thwarted, resulting in a dissatisfaction with interpersonal relationships.

I suspect that they each have trauma histories somewhere, because they married each other. Now you might have the rescuer marrying someone that they sensed is

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vulnerable and they want to save them, but then they are failing. Then we have the one who is fearful of dependency in any other form, but to be totally wasted once a week [laughter] and then fall on the mercy of their partner. (Mr. B)

Stella understands some of the dynamics of SA in the couple to be a symptom and a defense of underlying intimacy fears, intense pain and/or shame, and early attachment difficulties. Like all four participants, she believes that the underlying factors affecting SA couples are similar to the underlying factors affecting non SA couples, and that the couple keeps the focus on the SA in order to avoid these issues from becoming apparent.

It’s still probably a symptom of underlying intimacy issues between them. Yeah, I’m saying that [pause] in most ways I don’t think that addicted couples are different than any other couple, but what might be some of their issues or their lack of issues—or lack of dealing with their issues, might be being eclipsed by the dynamics of an addiction process. (Stella) Triker’s dynamic conceptualization includes SA acting as a defense and a symptom against fears of intimacy and change, unsymbolized rage, deep feelings of shame, trauma histories, and developmentally missing selfobjects.

If you want to say it this way, the substance abuse is a symptom and I’m looking for some of the underlying causes of the symptom. Yeah, and you know, I mean it’s a serious symptom. Just like if a person is diabetic and they’ve decided they aren’t going to take insulin, that’s serious, there’s no question about that, but it still is a symptom of something.

Emma sees SA as a symptom and a defense “trying to communicate something”, including thwarted attempts to mourn over loss, trauma histories, attachment 199

complications such as fear of dependency, bad object identifications, and fear of intimacy.

If you think about it more from an attachment perspective there’s the secure base, or the containment, to say it more from a more analytic perspective, the containment in their couple coupling, I think, um, became insufficient, and, um, so I think she could not, she could not tolerate his need for reassurance, um, and kind of what I would see as dependency issues. Both her own and his, and those got located in the alcohol.

So what does the research tell us about the dynamic role of the SA in the couple dyad? Are participant conceptualizations in keeping with the psychodynamic literature?

With little SA couples analytic literature to choose from, we again turn to Chapter II of this dissertation and refer to Wanlass (2014), who substantiates the concept in a case illustration involving a partner with a dual-diagnosis: Adam’s bipolar illness and addiction served a dynamic function for the couple.

His alternating moods of deep depression and mania captured their relational deadness and periodic uncontained affective flooding…we can see that Adam’s bipolarity and addiction express both the rejecting and exciting bad objects that dominated the couple’s childhoods, their internal self-constructions, and their couple relating (p. 313).

Wanlass captures research participant views on how SA is both a symptom and a defense, serving to starve the couple relationship and working to suppress overwhelming emotions.

In a case illustration of a couple who present with narcissism and SA, Bagnini

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(2014), argues that cocaine functions defensively to keep deeply rooted anxieties at bay on the couple’s behalf: Patients’ unconscious anxieties, feared impulses, or persecutory object representations are often associated with affective or cognitive splits. We view these as defensive maneuvers against the surfacing of unbearable anxieties, and appreciate their function as self-preservative necessities. Cocaine as selfmedication functions to block unbearable anxieties but at a high price in the marriage (p. 184).

Bagnini goes on to note that “failed dependencies”, in both partners’ early histories, as well as infidelity, and an “ongoing addiction that prevented authentic participation” created a complex couple dynamic where the SA played a necessary role (p. 187).

Psychodynamic treatment for SA individuals supports research participants dynamic understanding, even though it is presented in an individual, as compared to a couple perspective. These clinicians utilize treatment that “focus[es] on core areas or sectors of vulnerability to access and modify substance abusers’ problems” (Khantzian, 1995, p. 39). These core areas include exploration into states of helplessness (Dodes, 2002), disturbances in affect forms and function as well as capacity for self-care and alexithymia (Krystal, 1997), the roles of narcissistic rage, regressive gratification, shame, hurt, loneliness, abandonment, and rejection (Wurmser, 1974), and vulnerabilities involving emotions, relationships, and self-esteem (Khantzian). Treatment requires the clinician “to pay very close attention to [the] addiction while understanding the psychology behind it” (Dodes, p. 230). In other words, do what needs to be done from a

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practicality standpoint (i.e., hospitalization, detoxification, etc.), but do not lose sight of the disorders’ psychological roots.

The biological considerations of SA. This dance of attunement between the biological and the psychological components of SA is no less difficult in SA couples therapy, as research participants have attested. While all participants recognize the physiological component of SA, they differ somewhat in their conceptualizations.

Stella compares SA to other illnesses “like someone else has cancer or someone else had diabetes or someone else has whatever disease they have. You have this one.”

She looks at the biological component of SA as something that has a “predictable trajectory; it has a whole body of knowledge about how it works, just like every other disease.” While her dynamic conceptualization of SA in the couple relationship recognizes the couple’s role in maintaining the addiction, Stella appears more comfortable than other participants in providing her couples with medical model-related “tools” in the early stages of the couple therapy such as 12-step groups and literature. No doubt this stems from the five years she spent early in her career at drug and/or alcohol treatment centers, where she came to appreciate many of the components of the medical model, including its ability to decrease shame, when working with couples and families.

Triker’s conceptualization of the biological component of SA is that it adds another level to the complexity of what he is dealing with in the couple therapy. Similar to working with a couple where one partner has diabetes and is refusing medication, when he is working with SA partners who are uninterested in seeking drug and/or alcohol 202

treatment, he asks “How come you’re not taking care of yourself?” In both cases partners are causing undue stress on the relationship because they are not taking care of themselves.

Triker also considers that couples who enter into drug and/or alcohol treatment for SA emerge more “psychologically minded”, even though he often believes the treatment teams approach at the facility lacks an understanding of the couple dynamic at hand. He states that the SA “clearly needs to be dealt with in some separate way [because] frequently I won’t know [about] the seriousness of the addiction.”

Emma discusses the complexities of SA in general, and speaks to the tendency of the medical model to want to conceptualize the illness strictly from a biological perspective. She states “is it that [SA individuals] have a genetic vulnerability to SA or is it that they have a genetic vulnerability to the impact of stress? How much of that is influenced by their environmental factors?” The idea that there are those who appear to favor nature over nurture is “a ridiculous, um, dichotomy that’s not supported by the neuro-science research.”

Emma appreciates components of the medical model including certain 12-step programs and SA drug and/or alcohol treatment, but she appears least likely of the research participants to make early recommendations for medical model interventions outside of inpatient or residential treatment for stabilization. This may be because she has experienced on a personal level, with her brother, the limitations that the medical model presents, but it could also be due to her analytic training which she shares has improved

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her ability to contain anxiety, perhaps making her more comfortable with ‘being’ as compared to ‘doing’ in her work.

Mr. B’s biological conceptualization entertains the possibility of certain types of SA having origins in one’s DNA. “I think that, this person is probably coming from four generations of deeply addicted heroin addicts…I’m not going to be able to find a way in.

And then I wonder about addiction…as something that is in a way simple; it’s DNA.” While he goes on to weigh the effects that a nurturing familial and/or therapeutic environment can have on DNA, his point is well taken and may explain the treatment flexibility in which he appears to approach SA couples. He is very comfortable referring out to addiction professionals, and shares that quite often “when they are multiply addicted individuals and I don’t have a clue, I want them to have a good, a good addiction specialist [to help me] know what I’m dealing with.” Mr. B openly acknowledges his lack of knowledge around the biological, or physiological, components of SA and seeks out assistance from other professionals in the field who can help him to fill in the blanks.

In fact, all participants, as discussed earlier, set up communities of care that include other treatment professionals that can help them in various ways, including assistance in bridging the gap between the couple therapy and their need to better understanding the biological or physiological processes in play.

So what does the SA research tell us about SA in comparison to other forms of disease, as well as environmental and intergenerational considerations? Again, we return to Chapter II of this dissertation for possible answers.

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The biomedical model understands drug addiction to be a disease of the brain whereby ensuing “abnormal behavior [is] the result of dysfunction of brain tissue, just as cardiac insufficiency is a disease of the heart (Maté, 2008, p. 133). This model focuses on the biological processes that impact health and seeks to resolve pathology by getting at the underlying biological components which are seen as operatizing objectively. Like other inheritable diseases such as PKU, Down’s syndrome, and Huntington’s disease, it has long since been argued that SA is inheritable, with twin, family and adoption studies estimating that 40 to 60 percent of individual susceptibility towards addiction stem from genetic factors (NIDA, 2014).

Enter here Mr. B’s questioning of possible genetic influences within SA’s presentation under certain circumstances. While Mr. B is specifically interested in the inheritable traits of heroin, of which there is little research, the Collaborative Study on the Genetics of Alcoholism (COGA) in which scientists have been collecting data since 1989 on more than 300 extended families affected by alcoholism, has identified several chromosomal regions which appear to contain genes affecting the phenotypes of these families (Edenberg & Foroud, 2006).

The problem with this approach, however, is that scientists have been unable to find a gene for alcoholism, a gene that increases the chance of developing alcoholism, nor has science proven that alcoholism can be directly inherited as can the diseases stated above (Dodes, 2002). Instead, there appear to be multiple genes that may indirectly affect individual susceptibility in the development of alcoholism, similar to high blood pressure and peptic ulcer disease (Dodes). In conditions such as these science understands that genes can be an indirect factor for their development in certain individuals, but additional 205

factors must fall into place in order for the condition to take hold (Cozolino, 2010; Dodes).

These additional factors, as per Emma’s conceptualization as well as that of other research participants voiced in varying degrees throughout the findings, can be environmental in nature. For more answers we turn to the Adverse Childhood Experiences (ACE) study, which has examined over 17,000 middle-class American adults to better understand how adverse events in childhood might affect health status in adult life (Felitti, 2003). Beginning in the 1980’s, participants provided detailed information about childhood experiences of abuse, neglect, and family dysfunction and, to date, more than 50 scientific articles have been published which ascertain that certain events and experiences are major risk factors for poor quality of life as well as the development of mental and physical illness and early death (Felitti). For further review of the ACE research, including details related specifically to SA, please refer to Chapter II of this dissertation.

The lack of evidence supporting a strictly biological etiology of alcohol might not directly translate into heroin inheritability, but we will have to wait for new research before we know definitively. Meanwhile, what might be helpful to Mr. B, and other clinicians struggling with treating individuals addicted to heroin, is the adjunctive use of naltrexone which works by blocking opioid receptors that are key to the drugs rewarding effects, or the application of either methadone or buprenorphine which are believed to suppress withdrawal symptoms and relieve cravings (NIDA, 2009).

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Summary of conceptualization of SA. All four participants view the role of the substance itself as dynamic, and believe they must understand the substance abuser’ drug(s) of choice in order to understand what the abuser is self-medicating. All participants also view SA as a symptom and a defense of deeper underlying factors that have developmental beginnings. They understand that SA starves, or “deadens” the relationship, exists within a context, has biological components, and is unconsciously maintained by the couple. They experience SA from a cyclical perspective, whereby the SA can worsen problems in the relationship, just as the relationship can exacerbate the SA. While research participants have a genuine interest in the biological components of SA, their dynamic conceptualization of its role in the couple dyad is unique to the practice of psychoanalytic couple therapy, and supplements what little analytic literature exists on this subject matter. The powerful details of participant conceptualizations provides a richer, deeper way in which to interpret observations and understandings which can only serve to benefit those working with SA couples.

So what I’m saying is that there is a kind of system here of two minds affecting each other significantly in which substance abuse plays a part. So rather than it being merely the cause, or in a real serious way, the cause of everything that has gone wrong, it’s sometimes partly the result of many things that have not gone right. (Mr. B)

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Therapeutic Action In Chapter I of this dissertation therapeutic action was described as “the means by which psychoanalytic treatment affects therapeutic gain” (Auchincloss & Samberg, 2012, p. 260). Given the integrative nature of the work as seen consistently throughout research participant narratives however, this section discusses concepts located outside the psychoanalytic frame as first presented in Chapter IV. This theme specifically answers the research question: “What do couples therapists who work with substance dependent couples experience as being therapeutic?”

This section is broken down into five subthemes: 1. Couples therapy; 2. No approach is an island; 3. The value of language; 4. The good-enough therapist; and 5. Psychodynamic theory: conceptualization of the couple and techniques used.

Modality: Couples therapy.

It makes sense that research examining the therapeutic factors in working with SA couples would at some point be interested in whether research participants valued this treatment paradigm above others. Their responses varied, with Triker making the argument that SA “will interfere with intimacy…and if you conceive of couple therapy as a project that increases intimacy, which presumably it is” then it would make sense that the SA is addressed within this context. He also likes that the couples therapy is being 208

“done in real time, in the presence of the partner”, allowing for a deeper empathic connection to develop within the dyad through the therapists modeling of an empathic stance with both partner’s perspectives.

Stella has a similar perspective, sharing that there is something “spiritual” in the process of partners “doing [their] own work in the presence of someone, because it is a relational understanding of how you show up in the world.”

Emma’s preference for couple’s therapy lies in the understanding that “in couple treatment you hear much more the other side of addiction.” She feels that being able to facilitate a safe space where the couple is able to hear about the “pain that is experienced by partners, by children” is helpful to all involved, including the SA partner.

Mr. B does not specifically articulate in either of his interviews that couple therapy is particularly valued in the treatment of SA, in fact, he shares that when couples present with an active addiction crisis his therapy can become adjunctive to other, “more lifesaving, interventions.” He tells us as well that some couples struggle in their ability to “share the space” within the couple therapy paradigm, and that he has to be respectful about this. But he shares that he is a “marriage junkie”, and believes that when “people invest in a marriage for a long time, it’s always better to see if they can reclaim it”, intimating that couple therapy can be helpful in this regard. In addition, the fact that 70 percent of his practice consists of couples would suggest his belief in the modalities’ effectiveness.

So what does the literature say about couple therapy in the treatment of SA? Is it a treatment modality of choice?

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Despite research citing the efficacy of couple therapy in addressing trauma, childhood sexual abuse, anxiety and depression, and eating disorders (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998; Johnson & Williams-Keeler, 1998; and Monson, Schnurr, Stevens & Guthrie, 2004), and the evidence that in some cases including individual partner depression couples therapy may be even more preferable than individual treatment (Baucom, Shoham, Mueser, Daiuto, & Stickle), couples SUD therapy is rarely included in treatment programs across the U.S. Even from a psychodynamic lens there are those who do not believe that couples therapy is appropriate for the treatment of SA. Khantzian (1995) suggests psychodynamic treatment in the form of individual or group psychotherapy is preferred, so that defensive vulnerabilities are given time to reveal themselves in a safe manner and can be examined and modified in the ensuing relationships which result. And Lightdale, Mack and Frances (2011) state that if “the principal problem is marital, family therapy is the treatment of choice” as compared to couple therapy.

When working with patients with co-occurring PD’s and SUD’s, Treece and Khantzian (1986), argue that the problem must be seen from the individual drug user’s self-experience and psychological structure. The researcher’s state that such individuals typically struggle with emotional dysregulation, narcissism, objects relations, self-care and judgment; all developmental and structurally determined problems that find relief in drug taking. At no point in the treatment process do the authors suggest that couple therapy would be helpful when partners are involved.

One study (Vaillant, 1988) dismissing couple therapy actually suggests “an AA sponsor or a new spouse may be more useful than the dyadic relationship with a long-

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suffering family member, which must repeatedly re-awaken old guilt’s and old angers – conditioned reinforcers of alcohol use” (p. 1154).

While there are legitimate reasons as to why there is little analytic research on the efficacy of SA couples therapy, as outlined in Chapter I, it is important to note that research participants are not suggesting that psychodynamic couples therapy should be the primary intervention when working with couples with SA. They are merely stating within this subordinate finding that couples therapy can be a therapeutic factor by helping partners recognize and empathize with the impact of the SA on the ‘other’ by therapist modeling of appreciation and validation for each partner’s perspective in real time, and in the presence of the partner. Research participants also acknowledge the importance of additional interventions when necessary, which brings us to our next therapeutic action.

No approach is an island: Treatment integration.

Despite disagreement amongst some treatment providers practicing from the disease model and some members of the psychoanalytic community regarding the value of psychoanalytic SA couple therapy, all research participants in this study create communities of care for their SA couples that is all-inclusive. Treatment teams often involve addiction specialists, individual therapists, therapy groups, 12-step options, drug and/or alcohol treatment programs, pharmacology, EMDR therapists, and anyone else they think may be able to assist them in containing the couple.

Mr. B shared that his participation in this research even had him thinking about the integration of Reiki or dance therapy, “because the body sometimes is stonewalled and it has all the poison in it…” He also recognized the usefulness of examining SA from

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various theoretical resources, including, the psychoanalytic community, neuroscience, addiction psychology, and trauma theory, which are all helpful to him, “sort of like you look for mentors where you can find them” [laughter].

Stella integrates two forms of couple therapy along with EMDR and aspects of the medical model including the developmental model of recovery, and 12-step groups.

She believes that “addiction in couples work requires a lot of resourcing” and insists that while “AA isn’t perfect and it’s got its flaws, I definitely think it does, but it’s the best there still is right now.” She appears to be the most integrative of all the research participants, but states that “there is no substitute in my mind for the therapists understanding and knowledge of addiction and the processes that are so typical for it.”

Triker acknowledges the importance of drug and/or alcohol treatment but, articulating what all four participants understand, states that couples with SA present in a variety of different ways so there is no ‘one size fits all’ approach “It’s about how to understand what you see in front of you as a therapist and what’s going on between the partners and acting accordingly. It’s not a set of rules, it’s not a cookbook, you know.”

Emma concurs, and believes, as do all four research participants, that the psychodynamic approach is not a certain fit for all couples, nor is she necessarily the right therapist for every couple. She is most likely to bring in individual therapists especially if the non-addicted partner is without one, and is open to incorporating different types of group therapy, including CBT. She also states that an integrated team has the capability of holding “different aspects of the … couple dynamic sometimes… [and] help[s] contain and hold” the couples which she articulates as being “a huge challenge.”

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Integrating other forms of treatment modalities in addressing SA is well researched and in fact, follows a contemporary trend amongst theorists who are open to seeing ‘what works.’ As discussed in Chapter II, there are many who no longer cling to any singular theoretical exclusivity when discussing therapeutic action and instead pursue a much more integrated approach depending on patient needs (Aron, 2000; Frank & Bernstein, 2012; Gabbard & Westen, 2003; Shapiro, 2012; Wachtel, 2012).

In the treatment of SA couples Wanlass (2014) argues that multiple conjoint services including medication, individual therapy, hospitalization, and recovery groups need to be used in conjunction with the couple therapy in order to provide a good wraparound treatment approach. In Bagnini’s (2014) earlier case example of the cocaine addicted husband, while the husband did not attend any outside therapy or support groups, the wife was actively engaged in both individual therapy and Adult Children of Alcoholics (ACOA) groups.

Other treatment approaches familiar to research participants include EMDR which has been particularly successfully in couple therapy in assisting with traumarelated issues (Litt, 2008). EMDR helps with SA by working to shift cognitive structures, create a desensitization of attendant traumata, and increase insight and functional behavior (Shapiro, Vogelmann-Sine & Sine, 1994). It has also helped in the treatment of addiction memory and associated symptoms of craving (Hase, Shallmayer & Sack, 2008).

Additional adjunctive therapies posited by participants as possibly being helpful included Reiki and dance movement therapy. Indeed, Reiki has been found to be effective in alleviating the physical and psychosocial stresses occurring during withdrawal and recovery (Chapman & Milton, 2002), and movement-to-music activities

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have been a contributing factor in decreasing depression, stress, anxiety, and anger amongst female clients in SA rehabilitation (Cevasco, Kennedy, & Ruth, 2005).

As Triker remarked when thinking about integrated approaches that are different from his, nonetheless “we share a common language in knowing that what we have to deal with is looking at what the emotional sources are of certain behaviors, and figuring out how to deal with that better;” which leads us to our next therapeutic action.

The value of language.

Research participants’ use and expression of language when working with SA couples is varied and purposeful, and part of the means by which they create therapeutic environs that feel safe and secure. Stella insists that her use of “AA speak” and “Al-Anon speak” creates a connection between herself and her couples in recovery that helps them to feel understood. She also believes it is important to be able to banter with her patients when times are tough, and to be able to just tell it like it is – “in the case where it’s really dire, I just say that: this is really dire and I don’t think you see it and here’s why.” She shares that her ability to be straightforward with SA couples in telling them what it is she observes contributes to the success she has enjoyed in working with this population.

Both Triker and Stella spoke about their use of metaphor when working with SA couples, and the effectiveness of this approach. In speaking with a non-addicted partner who wanted her husband to understand her pain, Stella told her that he was like “a burn victim who may want a hug, but a hug is the last thing [he] can tolerate right now.

Because [he is] so raw.” This helped her understand that she needed to be patient with

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him but that in time, when he healed, he would be able to come to her and give her what she needed.

Triker uses the metaphor of the blind man and the elephant with couples who are having a difficult time understanding their partners’ perspective. He tells them “you know, they lead them up to the elephant and they feel it and then they are supposed to describe the elephant and one says, it’s a long, cylindrical thing and another says its flat and floppy.” This helps his couples “come to a closer description of what we might say is the reality of the elephant” and the shared reality of the couple.

This attunement to the couples’ needs is also apparent in the way that Emma speaks to trying to understand the language of the implicit, the unconscious – that for which patients have yet to develop expressions for, and cannot articulate. She recounts an experience she recently had with a SA partner who had an early trauma history prior to age five. “He said, “I can’t even wrap my head around it. Like I can’t find any kind of way to sort of tell you about it.” Emma shared that during the session she could “feel some of what he was talking about” from a sensory perspective but during this interview, much like her patient, when trying to describe how she had experienced him in that moment she found herself struggling to find the right words.

Emma also discusses the importance of letting the couple drive the therapy and staying away from language that is too directive or decisive. “Talking to them openly about do they need additional support. I think that makes a lot of sense, but the sort of, here’s how you do SA treatment…I have not found to be particularly helpful.” Moreover, she thinks about how her use of psychodynamic “lingo” might come across as elite,

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instead thinking “what can I say about internal objects that overlaps with the core beliefs of a cognitive behavioral?”

Mr. B, in thinking about the use of language, believes it paramount that at some point SA couples are able to attribute a vernacular to the substance that includes its history. “I’m not going to accept, “It just makes me feel good.” I’m going to ask, “Well, compared to what?” And when there is a drug that he historically has had no success in treating, such as heroin, he is very upfront with his patients. “[Heroin] was a tough drug to contend with. I couldn’t compete with it. And I would tell people that. There’s no magic here.”

In addition, like Stella, Mr. B also trusts in the use of humor, and sometimes tells couples “denial is not just a river in Egypt, you know, which gets me in trouble, but sometimes loosens us up a little?” In keeping with this approach, as mentioned in an earlier subordinate theme, Mr. B prefers to use language that is inclusive in nature and contains illustrations and descriptions instead of verbiage that is diagnostic.

The use of language as a therapeutic action is not a foreign concept to many practitioners. Mitchell (1988) writes that one cannot separate language from experience, and that “experience is understood to be structured through language, making experience essentially and unavoidably social and interactive in nature” (p. 18). Watzlawick (1978) writes that therapists “cannot not influence” (p. 11) in their use of language with patients but the key is in understanding the ‘patients’ language, and in making interpretations that are attuned to their patient’s conceptualization of reality.

Analytic therapists certainly appreciate the concept that language, both verbal and nonverbal, cannot be separated from experience and indeed, is created ‘through’

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experience. They also grasp the necessity in understanding the patient’s unique manner in which they use, and communicate, language. Stella’s practice of “AA speak”, Triker and Stella’s usage of metaphor, Emma’s renaming of psychodynamic “lingo”, Mr. B’s use of illustration and descriptions and his desire that couples develop a personal language for the role of the substance, and Stella and Mr. B’s practice of ‘straight talk’ and humor in their work, are all efforts to create meaningful therapeutic language that bridges the gap between their world and that of their couples’ experiences.

Given the understanding that sometimes these experiences are preverbal and traumatic in nature, as Emma describes, a therapeutic approach that can attune to unrepresented states is required. Here, Clulow (2007) writes that “the modulation of posture, gaze, timing, and tone of voice may be important in matching the affective state of the couple”, whereby the therapist is “building on the language and metaphors that they use, and offering something back that is both similar but noticeably different” (p.

218). This builds on the premise in attachment theory where the mother attunes to her child in such a way that the child feels understood and well represented in their own right, but can simultaneously “recognize their experience as his own, and not that of his mother[s]” (p. 212).

One final note on the use of language as a therapeutic factor as it relates to humor.

Using humor in psychotherapy, and in psychotherapy with addictions, does not detract from the seriousness of the issues at hand (Weaver & Wilson, 1997). In fact, humor can be used effectively to bring home an interpretation, overcome resistances, relieve tension (as in Mr. B’s example), facilitate a corrective emotional experience, help patients see alternative ways in viewing things, and aid in the implicit establishment of a healthy

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identification with the therapist (Reynes & Allen, 1987). And incidentally: Kohut believed that the capacity for humor in the patient was a sign of the success of an effective psychoanalytic result (Kohut, 1971).

The good-enough therapist.

This subordinate theme shares participant experiences in being good-enough therapists, given the unique and various ways in which SA couples present.

Couples with SA present in numerous ways that are unique due to the context in which they developed as individuals, their personalities and beliefs, the manner in which they view their environment individually and as a couple, the ongoing challenges unique to the world they live in, and the strengths and talents which are exclusive to them. They are also unique in the manner in which their SA becomes a part of the treatment.

Is one partner using, or are both partners? Either way, are they using in secret or in collaboration? Is their level of functioning competent enough or clearly compromised?

Are they aware that SA is even a part of their presentation? What is the dynamic role of the substance in the individual and the couple dyad, and what is the couple’s language around the SA? Was someone using before the relationship formalized or did the use begin within its context? These questions are part of the way that study participants assess SA in the dyad and reflect the variations that can occur, leaving us with the understanding, as Stella articulates, there is not “a one size fits all intervention” nor, as Triker states, is treatment a “cookbook” that can be applied to every couple.

In this research, some aspects to being good-enough therapists means that all participants work with their couples compassionately, and create a therapeutic

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environment that is safe enough for the work to unfold. They meet their couples wherever they are in the process, but do not lose sight of the fact that SA can be dangerous and require additional levels of care. They recognize that they are not fallible and will make mistakes throughout the process, and that there are limitations to what they can achieve.

They are human. And they agree that success does not necessarily mean the couple stays together – sometimes, in fact, the best solution is separation or divorce.

Stella asserts “I see my role a lot as container, you know, creating a safe container, safe space for their work to happen.” Triker maintains that mistakes are “just part of the human condition, certainly [they are] part of my condition.” Emma believes that it is “the containment and the alliance that help the couple stay in treatment” and that success varies depending on what success means. And Mr. B recognizes that he has an agenda due to the fact that he has a “personality…a memory…and feelings” but if he can set it aside something new may enter the therapy that had not been previously considered.

Although research reflections are varied and all-encompassing, their commonality is in the desire to create a working alliance and therapeutic environment that is conducive to successful engagement of their SA couples.

This concept is supported by psychodynamic couple therapists practicing from most theoretical orientations, but the corroborative literature here stems from a self psychological approach. While Kohut did not work with individuals struggling with addiction (Weegmann, 2002), he did write about the addictive need for a self-admiring other (Ulman & Paul, 1989), and introduce into the analytic arena constructs such as narcissistic vulnerability, self-deficits, and selfobject functioning which therapists have used in their approach to treatment of SUD’s. Kohut (1971) suggests that addictive

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personalities suffer from having an ‘empathy-defective’ caregiver who cannot fulfill the growth-related functions needed in the development of self-structure that allow the child to acquire the ability to self sooth and provide self-validation. While addiction treatment appears to vary amongst those practicing a self psychological approach, it seems to focus on the development of self-structure through the therapeutic relationship; hence the importance of environ agreeable to this unfolding.

Remarks made by Stella and Emma about the therapeutic action of containment refer to the Bionian concept of container and contained, whereby “psychic states and feelings, like other phenomena, have to be contained in order to be rendered manageable and meaningful” (Williams, 2002, p. 3). This theoretical construct suggests that the search for a form of self-medication stems from a need to find a container, and that the addicted individuals attempts to find containment in their relationships has failed (Williams). While Bion did not study addiction explicitly, his writings on drug taking state that “drugs are substitutes employed by those who cannot wait, [and that] whatever is falsely employed as a substitute for the ‘real’ is transformed thereby into a poison for the mind” (Williams, p. 3).

The examination of therapeutic factors from additional psychodynamic sources, as presented by research participants, brings us to our last subordinate theme under Therapeutic Action.

Psychodynamic theory: Conceptualization of the couple and techniques used.

All four research participants share that they conceptualize couples with SA the

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same as couples without SA. While Mr. B states that in the cases of sub-cultural addiction there are additional complications that make treatment more difficult, his primary conceptualizations and assumptions remain the same.

On an examination of the little analytic literature available, (Bagnini, 2014; Shaddock, 2000; Wanlass, 2014), therapists treating SA couples appear to stay within their theoretical frame, whereby SA is conceptualized as having a functional role that interferes with the couple therapy, and which acts as a barrier in getting at underlying factors. In other words, the SA becomes another layer of complexity that must be addressed in its own right, but it is not seen as the singular problem in the couple’s relationship.

Differences that did appear in this research were related to the theoretical frame that research participants employed, which influenced techniques used.

Triker, who identifies as a self-psychologist and phenomenological contextualist, stated that a primary focus of his work is in providing “selfobject functions which…were interfered with or were never present earlier in a patient’s life.” He shares that in contemporary psychoanalysis this is referred to as a developmental second chance. Triker assesses throughout treatment, and includes the couples’ early developmental history, the history of their “idea of intimacy”, the role of the substance, when the substance entered into the couples’ relationship, and when the couple began to realize the substance had become a problem. From a therapeutic action perspective he pays close attention to creating an empathic connection with anger, rage and “with what may be underneath that” including fears, anxieties, and shame, and sees the substance as providing a selfobject function.

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Triker’s approach to analytic couple therapy from a self psychological frame is in keeping with the literature. Crawley and Grant (2008), state that partners can use affairs, addictions, and rage to protect themselves from fears of intimacy. Livingston (1995) writes that practitioners “share a belief in the unconscious and in a working-through process of treatment and cure based upon an understanding of early childhood experience” (p. 427). As per Triker, Livingston goes on to state that an element that distinguishes self psychology from other psychoanalytic models is its “degree of emphasis on empathic immersion in the patient’s subjective experience as a source of data for both theory and practice” (p. 427). In working with couples through a self psychological lens, Livingston maintains that couple therapists must be continuously mindful of each partners’ narcissistic vulnerabilities and assist them in working through “transference and countertransference-like experiences within the marital dyad” (p. 438).

Shaddock (2000) adds to this, stating that the couple therapist can be helpful by assisting the couple in repairing emotional conflicts which will bolster intimacy and attachment.

Emma, Mr. B, and Stella all identify as object relational couples therapists. In their work with SA couples they rely on transference and countertransference reactions to understand unconscious material, personally maintain a couple state of mind, attest to an unconscious couple fit, see the substance as a third object that is shared between partners, understand their role as being an object to be shared, utilize assessment throughout, utilize interpretation, and help the couple create a shared couple reality.

Subtle differences include Mr. B’s tendency to allow assessment to unfold a little more naturally as well as his emphasis on the Kleinian concepts of love and hate;

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Emma’s understanding and use of the couple void; and Stella’s use of Imago to help deepen affect.

All three research participant approaches are well represented throughout the literature on object relations couple therapy, which tenants the primary intervention as helping partners in reclaiming projections, therein identifying and recovering lost parts of themselves (Scharff & Scharff, 2014). Additional focus is on the frame, holding and containment, couple understanding of unconscious material by way of therapist interpretation (i.e., use of self), processing of dreams and fantasies, assessing the couple and their attachment style, interpretation of conflicts and defenses, and the working and reworking of relevant issues that constantly reappear in different manifestations (Scharff & Scharff). Crawley & Grant (2008) concur, adding that an empathic stance and the assistance in helping the couple process deep emotional experiences are also considered key.

Summary of therapeutic action.

In this study, the manner in which research participants conceptualize SA couples, and the manner in which they conceptualize non-SA couples, appear similar.

Participant descriptions of what makes up the therapeutic action from an analytic perspective depends on the theoretical lens by which they abide. Each psychoanalytic model has its own theory of mind and pathogenesis of which its therapeutic action is implicitly coupled (Auchincloss & Samberg, 2012), and research participants stick close to their frame of reference when working with SA couples.

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In this study, research participant descriptions of what makes up the therapeutic action from an analytic perspective depends on the theoretical lens by which they abide.

Each psychoanalytic model has its own theory of mind and pathogenesis of which its therapeutic action is implicitly coupled (Auchincloss & Samberg, 2012), and research participants stick close to their frame of reference when working with SA couples.

For a complete list of research participant perspectives of that which constitutes the therapeutic action, please refer to Table 5.1.

It’s about how to understand what you see in front of you as a therapist and what’s going on between the partners and acting accordingly. It’s not a set of rules, it’s not a cookbook, you know, it’s not something to be manualized.

(Triker)

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Table 5.1 Therapeutic Action Psychodynamic Therapeutic Action Use of Self Conceptualization The Therapeutic Alliance Containment

Secondary Approaches

Integration

Assessment Use of Language EMDR

Addiction Psychology Trauma Theory Communities of Care Integration of the BioBehavioral Model Inclusive of: • Treatment Centers • Pharmacology • CBT • DMR • Recovery Groups • Neuroscience

Provision of selfobject, or object, functions Empathic Immersion Focus on Affect and Expression of Emotion Interpretation of Conscious and Unconscious Material Focus on Early Development Identification and WorkingThrough of Repeating Themes and Patterns Differentiation through the Recovering and Reclaiming of Projections Creation of a Couple State of Mind in the Therapist

Markers of Change This section specifically addressed the research question: “What do couple therapists who work with SA couples experience as consistent markers of change?”

Markers of change from a psychotherapeutic perspective offer clinicians a

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“convenient and systematic store of clinical knowledge that is accessible and potentially useful to practitioners and researchers” (Honos-Webb, Stiles, & Greenberg, 2003, p.

189). In object relations theory therapeutic markers indicating a successful couple therapy include partner ability to find emotional support in each other and feeling confident and heard when they express feelings, fantasies and dreams (Scharff & Scharff, 2014).

Markers also occur when partners can identify conflicts including intrusive unconscious influences (i.e., projections) and manage them appropriately, and when they can establish and sustain intimacy (Scharff & Scharff).

In self psychology (Livingston, 1995), the therapeutic markers of a fruitful couples therapy occur when the couple can provide “self-enhancing” responsiveness from each other, understand and share narcissistic vulnerabilities, and indicate a willingness to explore and tolerate negative self experiences and partner failures in selfobject functioning. An ability to contain both themselves and their partner also indicates progress, as does capability in maintaining intimacy through the toleration of deeply painful and anxious feelings (Livingston, 1995). Livingston (1998) writes that the primary issue is not the management of rage and conflict, but instead “the strengthening of functions of affect regulation, containment, and self-cohesion” that enable a deepening of intimacy (p. 6).

Findings in this research are in keeping with the literature, although the language used varies. Participants voiced that markers of change included individual and couple insight (i.e., conjoint perspective), a deepening of treatment whereby the SA became less important and underlying issues are worked through, emotional development leading to differentiation, and reduction or abstinence if the SA continued to be problematic.

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Emma, states that “insight and understanding is important [and] being able to, in essence, take in new objects and new experiences as a way of modifying old experiences” indicates growth. The couples’ ability to think “of the problem as a couple dynamic, as opposed to just an individual addiction” and join in a “couple state of mind”, is also distinctive. She also states that when couple issues emerge in treatment, for example trouble with intimacy, and they begin to “dominate the discussion much more than the addiction” and a “shift in focus” occurs, new growth is taking place. Emma believes that when the treatment is working the couple experiences a “deepening of exploration, understanding, and expression of affect”, and has a “greater empathy for the partner in a real way, and for one’s self”. And when the couple “[has] greater understanding of…what they have located or displaced or projected into the other, which then they are able to sort of take back and look at”, they become capable of reflecting on their own issues, which also suggests positive change.

Mr. B understands markers of change to be dynamic, and unique to each couple as to when they make an appearance. A “shared reality, which is what I call the creative couple reality” is one such marker, which “advances monogamy to the extent that differences, that love and hate, that troubles and problems…can somehow be worked through.” The role of insight “within an emotional experience” is therapeutic, as is the couple’s ability to “regulate emotionally in favor of feeling”. He states that a “marker, of course is that, is that addiction is less necessary; satisfaction is improving within the concept of the marriage.” And when the partners “have taken back their projections [and] are more attendant to difference without it becoming a split situation” and there is “a good enough fit”, a significant transformation has transpired.

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Stella experiences a marker of change being when “both partners [are able] to buy into the fact that each has a role to play in the recovery. That the addiction belongs to [them] and the addiction [is] in both.” When the couple is able to “see the other, the otherness, the multiple meaning of things” meaning each other’s’ perspectives, growth is occurring. When the SA becomes less of a focus and the couple is able to “look at those underlying dynamics, they can make choices that will help them actually make it easier for them to stretch and grow.” When the couple is able to “deepen their own work…and feel safe enough to go into the places where they can really, really feel each other”, change and growth are taking place. Stella asserts that “in order to be an integrated couple you have to be a differentiated self” and when that process occurs, when the partners understand that “they need to take back those projections and own them and claim them, the balance gets more alive between the partners”, and meaningful change takes place.

Triker suggests that when couples can engage in a dialogue that accepts individual partner experiences and “they begin to arrive at a larger conception of the reality of the relationship and of their ongoing intimacy”, a conjoint perspective has occurred which signifies growth. When the couple can “begin to understand what the effects are of the use of the substance and...begin to be able to decide honestly whether [they] want that to happen”, a marker of change has occurred. When the couple can be vulnerable with each other and feel safe in this vulnerability, it is experienced as empowering and provides the couple with “a whole new lease on life [whereby] the use of the chemical becomes more and more of a non-issue; it becomes more and more of a take it or leave it thing.” When the couple can express strong feelings towards each other, and deeply rooted fears, the 228

couple “become[s] more empathically connected to one another and begin[s] to feel safer.” This is an important development as Triker expresses that partners have fears about becoming known and that they are “predisposed, given those fears, to interpreting [their] partner’s actions in a certain way.” When this changes, the relationship changes, and a marker of growth occurs.

The final marker of change in this section is the necessity of abstinence. All four research participants in this study agree that in the case of an active addiction where problematic use is creating chaos and obstructing the couple’s ability to examine underlying issues, abstinence is essential. But three of the participants also argue that abstinence is not always necessary. If the use is not life threatening, these participants voice that they are willing to wait and see if the couple therapy will shift the dynamic.

Emma states “I don’t think all couples need [drug and/or alcohol treatment].” She qualifies that “for some people I guess what I would say is there are some people for whom substance use is a problem, but it is more a problem in response to a specific life stressor and when that stressor has been addressed, the problem isn’t so big.”

Mr. B emphasizes that he is “treating human beings who have problems rather than problems that are afflicting human beings”, and that he moves back and forth between dealing with the SA from a “crisis orientation”, and a wait and see approach, which “let[s] the couple evolve and see if [the] addiction really, um, becomes modified or reduced.”

Triker shares that “when SA is part of the picture, when you talk about success,

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[pause] I don’t know if I believe if abstinence is a necessary outcome of that process.”

When Triker sees the therapy evolve to a place whereby the couple “end[s] up feeling much richer with one another and within themselves, and that’s a, um, revelation... that’s a major outcome” that he believes effects whether or not the SA necessarily needs to be addressed through drug and/or alcohol treatment.

Stella’s approach to dealing with the SA from a drug and/or alcohol treatment perspective seems much more directive. While she is willing to wait out resistance and continue working with the couple responsively, she also insists that with SA “the ultimate success is if you get both people on board in terms of deciding to live a recovery lifestyle.” She acknowledges that this means many different things to different people, but ultimately, to Stella, it entails “individually working on showing up as individuated partners who can enhance each other’s life and raise healthy children.”

The psychoanalytic literature differs on the necessity of sobriety, or abstinence, prior to beginning therapy. Lightdale, Mack and Frances (2011), write that an active use of substances is a contraindication for psychodynamic psychotherapy for individuals, and that abstinence “is vital” (p. 234). They insist that to continue the therapy without synchronic treatment of the SA is not only enabling, but has the potential to create additional conflict that can worsen the SA. Vogel (1999) writes that from a short-term couples therapy perspective he excludes partners who abuse drugs or alcohol, and who “refuse to stop” (p. 74). Those partners who are willing to “confront their SA, and who, in the course of treatment, commit to abstinence” are “accepted” (p. 74). His position is somewhat confusing as he

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appears to be saying that he does not accept couples where SA is actively occurring, but at the same time if the addicted partner is willing to address the SA in the course of treatment he is welcoming. At what point in the couple therapy does he decide to stop?

Wolska (2011), writes that SA is a contraindication for couples therapy, but does not articulate any particular concern, only that personal convictions that “the partners are really into it” is not reason enough for its continuance, and that other therapists are in agreement with this position (p. 59). Instead, Wolska recommends referring partners with SA to the “right people/institutions as a means of help in solving the problem”; these include rehab counselling, crisis intervention, and perhaps psychiatry (p. 59). Wolska makes a similar recommendation for couples who present with mental illness.

There are many psychodynamic practitioners of both individual and couple therapy that do not take such a hard line when it comes to requiring abstinence. Dodes (2003) writes that it is “possible, indeed often necessary, to engage in treatment while a person continues addictive behavior, so long as the behavior is not creating an immediate emergency or does not itself interfere with the conduct of the process” (p. 131). This is necessary as well in analytic SA couple therapy, as per research participant accounts.

Wanlass (2014) writes, from the case example previously used, that it was her couples use of the couple therapy that helped them to “find their generative couple potential [that] provided support and motivation for Brad to treat his addiction, particularly once Catherine could see her own contribution to maintain its potency” (p. 320). In this case it appears that Wanlass was able to undertake a wait and see approach until the couple could support the change and seek SA treatment outside the couple therapy.

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Summary of markers of change.

In this study research participants share that some of the markers of change in their work with SA couples include: (1) the reaching of a conjoint perspective through individual and couple insight; (2) a refocusing on underlying issues whereby the SA is no longer the core topic of the therapy; (3) emotional development; and (4) differentiation through a recovering of projections. While abstinence is crucial in cases where the SA is actively destructive, research participants are willing to take a wait and see attitude when possible.

Participant suggested markers of change are consistent with the psychodynamic couples literature related to self psychology and object relations theory, which are the theoretical orientations preferred by this study’s research subjects. However, the psychodynamic markers of change that research participants discussed when working with SA couples does not appear to be any different from the psychodynamic markers of change when working with non-SA couples, according to literature cited.

Finally, participant attitudes regarding the necessity of abstinence are controversial, as demonstrated, which leads us to the last superordinate theme that begins with the discussion about drug and/or alcohol treatment issues that may hinder the process of couples therapy with SA couples.

I look a lot at what are the projections that get extended into the other and can those be taken back. So for instance, in one case that I can think about, um I think it was at the point at which the wife acknowledged that she had intimacy issues of her own. That really sort of shifted the couple treatment, and the addiction.

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Because I think as she could hold her own piece, what happened to her partner was that he no longer had to be the sick person in the relationship and it relieved him of a fair amount of shame. (Emma)

Trial and Error Study participants have accumulated more than 100 years of working experience with SA couples in a variety of settings. This experience gives them a unique perspective and understanding as to what works when treating SA couples and what does not. This superordinate theme examines the research question: “What understanding do couples therapists who work with SA couples perceive might harm or impede the process?”

In the course of this study, research participants suggested that at least four issues had the ability to challenge, and potentially impede, the therapeutic process when working with SA couples: 1. When abstinence or drug and/or alcohol treatment is insisted upon; 2. When the complexities of SA are viewed through a restrictive lens; 3. When efforts to coordinate and cooperate with other treatment providers are difficult and open conversation about SA and its treatment within the psychoanalytic community is ignored; and 4. When social, cultural and generational challenges are involved.

The issue of whether or not abstinence needs to take place prior to therapy, or even during therapy, was discussed in the prior subordinate theme, with the associated literature presented. But what was not addressed were participant views of those in their

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community who still insist on drug and/or alcohol treatment before therapy begins and how their couples feel when this occurs. Triker was empathic to ways in which his SA clients must hear this message when it is conveyed: When I think about [that] from the point of view of my client, what my client is likely hearing from this professional is, “You’re too defective to do this work so go away and do something about that and then you can join the human community.” I’m hoping to contradict that message 100 percent.

Emma and Stella have similar views, Emma sharing “I don’t say to somebody “I won’t treat you unless you do this” [because] I just find that it doesn’t work”. Stella revealed that she used to know treatment providers who refused to see people until they received drug and/or alcohol treatment and that she does not think this is a good approach: I think again it goes back to I will treat you where you are. In the back of my mind am I going to hope that we can move you to a place where you can get help for your addiction? Absolutely. But if you’re not ready to do that, you’re not ready to do that. So I will work with what you bring me.

Mr. B has similar concerns regarding the couple’s capacity for change, and he questions assumptions that the couple is there because they want change.

Change is frightening and therefore change creates trouble depending on how rigid a couple is and how set in their ways. So you have to be mindful of what

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change means to the couple before you actually say much about it or consider that they might be there to change something.

Mr. B also questions assumptions within the psychoanalytic community that addicted partners do not have the capacity to do analytic work which transitions to the next subordinate theme relevant to obstacles encountered while working with SA couples that impede the process: The viewing of SA through a constricted lens. Here, Mr. B insists that “addicts have a right to free associate. Maybe some can’t. Maybe some would if you waited that extra minute.” He asserts that “when there are people who can actually do analytic work about their addiction, it’s amazing what they come up with.”

While Mr. B’s thoughts reflect concerns about narrow perspectives within the psychoanalytic community, Emma can struggle with the simplistic perspective of addicted partners who appear married to the disease model of addiction.

I will often hear, ‘Like well, I’m addicted. You know people are addicts and I have an addiction.” And yes, I get that. I want to understand what that means from the person’s point of view, but it’s as though we don’t need to talk about it [anymore]. We don’t need to talk about the particular drug. We don’t need to talk about what gets evacuated when that drug is used. We don’t need to talk about how that use began. (Emma).

Emma also believes that the disease model itself is too simplistic, as do Triker and Stella. Triker is clear about how he feels, stating “the issue of chemical dependency is not just an issue of getting sober.” And Stella states “I think [the disease model] is too simplified. I think it’s not everything.”

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While all four participants readily embrace aspects of the disease model of treatment, as previously discussed, they also express concern about the rigidness of the model, and the influence it possesses. Participants feel that to take the complexity of SA and insist that the answer is, as Emma so eloquently states “well, this is a disease and you have to stop using, um, kind of that’s the answer?” is oversimplifying.

This segues into participant concerns about the cooperation and coordination of treatment in general, which is another issue that has the potential to impede the process of working with SA couples. Triker states “sometimes there isn’t any coordination because the attitude of the people in the treatment program is, we have our own couple’s therapist and our preference would be to have them work with them.” While he acknowledges that sometimes this is a financial issue for the treatment program, or a matter of “professional pride”, he shares “ideally I would like to have that kind of coordination. That’s actually – it happens less frequent than I would like, let’s put it that way.”

Both Emma and Stella share occasions wherein the work became difficult because of the lack of cooperation with partner individual therapists. In Emma’s case the couple was persuaded by the individual therapist to stop the couple therapy.

I had one person who I was seeing, for example, who somebody was seeing—I was seeing the couple and their individual therapist said, “Well, we need to pull them out of this treatment because she doesn’t understand the disease model” you know, and they did. (Emma) Stella shared that she can be challenged when individual therapists make decisions around partner treatment without the full understanding of the couple dynamic taking place.

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On occasion, um, [pause] I don’t think this is just true for substance abuse, but on occasion, when I’m working with a couple and I know the—I don’t know the therapist who’s working individually with the partners, there can be a tendency to have the partners feel polarized by the therapist, their own personal therapist not really getting the couple dynamics. (Stella)

Relevant to the discussion about cooperation and coordination of treatment is the bewilderment among some research participants about the lack of openness within the psychodynamic community to discuss tough issues. Emma’s frustration is clear when she states: I just wish as a, as a profession, we’d think about [SA] more and I wonder why we don’t. What is it in our sort of our psychoanalytic community; I mean why aren’t we talking about [SA] more? Thinking about it more? There must be some kind of collective defensiveness. And I don’t know what the answer to that is, but I think it’s a problem. I think it’s like a problem at the institutional level, I think that affects individuals. (Emma)

Emma also points out that this reluctance is obvious in the lack of research pertaining to SA in the analytic literature:

I think I thought more about something I said which is, this isn’t written about much. So that was interesting, I thought that was an interesting conversation we had about why is that. I had thought about it more and I thought, you know, really, what is our problem, I mean like as a therapy community, you know where we say hard things should be talked about, but we don’t much.

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Mr. B also expresses concern about the communities aversion to discussing tough subject matter, in this case issues around termination.

I believe that while we know the evidence in termination processes, there are very few terminations that are mutually agreed on and ideal. The majority of terminations are not planned for nor do they actually work out all that well. And we don’t like to talk about those. (Mr. B).

It is not only the lack of open conversation about tough issues, occasional strains in coordination and cooperation, lack of understanding about the complexity of SA, or the insistence of some on abstinence or drug and/or alcohol treatment that can impede the process when working with SA couples. Systemic social, cultural, and generational challenges can make the couples therapy even more compounding.

Emma shares that she feels there is a great deal of shame in individuals and couples dealing with SA, and that the shame is “partly society induced.” She believes that social stigma about addicted individual’s results in a group think that perpetuates the belief that these people lack control, and that the addiction is “something they do to themselves.” Triker and Stella also talk about the social aspects of SA, but from almost a peer pressure perspective. Triker shares that in one of his couples, the husband, who liked to drink a glass of wine at dinner, finally began to see “that there [were] pressures on [his wife] to do that, under certain social circumstances.” And Stella agrees with the thought that “alcohol use is so socially accepted that [the couple] cannot see where the addiction enters the picture” in some cases. These are the couples, she goes on to note, who tend to enter couples therapy without actually realizing that SA is an issue.

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Mr. B talks about the intergenerational, or subcultural, component of SA, sharing “with respect to subcultures where addiction is sort of the norm, oh, there is no question that I and the couple are up against it, but again they may be the only people in their family group that ever went to therapy too.” While being optimistic, he also realizes that what he represents may be very difficult for the couple to embrace.

If the couple has a history, sub-culturally, in which all of their friends are addicts or a good number of their associates have traditionally been part of a sub-culture of addiction, my work is much more difficult, because I represent an alien world.

A world of non-addiction.

The literature.

Research on whether to insist on abstinence prior to couple therapy, or in conjunction with couple therapy, has already been presented, and will therefore be excluded from the following review. Hence, the first finding that will be discussed is the suggestion that SA, when seen through a narrow lens, can be restrictive and unhelpful.

Mr. B’s reflections on the psychoanalytic community’s tendency to view SA individuals as incapable of doing analytic work, and Emma’s bewilderment of the same community’s aversion to an open discussion about SA, are well voiced concerns that are addressed throughout the analytic literature.

Brickman (1988) writes that psychoanalysis has failed to integrate findings stemming from bio-behavioral disciplines that can broaden understandings of SA. He also argues that analytic concerns regarding the integration of fellowship programs, including AA, into the work stems from three misinformed beliefs – that participation

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substitutes one compulsion (attending AA) for another (drug and/or alcohol), that the program opposes psychiatry and medications, and that AA violates “principles of analytic neutrality” (p. 375). He argues each misunderstanding succinctly, and thoroughly, advising that “psychoanalysts or psychodynamically oriented psychotherapists [should] become familiar with the principles and operation of AA as one would the use of any form of adjunctive help as it promotes overall effectiveness in the treatment of SA” (p.

375).

Brickman’s (1988) argument for an integrated treatment approach within the analytic community is clearly supported throughout the literature which states that an incorporation of genetic, sociocultural, historical, sociological, and psychological factors is going to be the most effective (Brickman, 1988; Dodes, 2002; Bennett & Poltrash, 2014; Farmer, 2009; Kalant, 2009; Levy, 2013; Maté, 2008).

Despite efforts over time of these psychoanalytic practitioners to integrate findings stemming from bio-behavioral disciplines into the psychoanalytic work with SA individuals, the same cannot be said for those practitioners working from the biobehavioral model of SA. Here, there is significant research promoting the disease model of addiction as the inarguable treatment of choice (Dackis & O’Brien, 2005; Leshner, 2014; NIDA, 2014). Some researchers even argue that addiction treatment should be integrated into mainstream medicine (Dackis & O’Brien, 2005), and refer to addiction as a bio-behavioral disorder that primarily requires biomedical treatment (Leshner, 2014).

Much emphasis over the years has been placed on the biological and genetic components of addiction, resulting in the relegation of all forms of psychotherapy secondary to non-analytical forms of treatment (Dodes, 2002). These non-analytical

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forms of treatment have the tendency to view SA from a narrow lens, and are overrated in their alleged helpfulness (Dodes).

Regardless of clinician orientation, it is obvious that a narrow focus when working with SA couples or any individual with SA risks losing sight of the uniqueness of the individual, or couple, in question. As Gabbard (2002) states, “no one argues the importance of examining biological factors at work in the etiology and pathology of addiction, but there is more to a person than a neurobiologically based craving” (p. 582).

Gabbard encourages clinicians to ask themselves how addictive behaviors can be better understood empathically.

The third issue that research participants have experienced as problematic in working with SA couples is in the coordination and cooperation of the overall treatment which is due, at times, to their analytic approach. This is not a new idea or challenge to analysts in the field in view of the evolution of psychoanalysis as a profession in general.

Given the current devotion to the medical disease model of treatment (Berger, 1991), any approach that deviates from the addiction is a disease concept, is going to be met with suspicion. This distrust can form on both sides as demonstrated in Binswanger’s historical critique of the biological foundations of Freud’s’ theories (Grossman, 2002).

While the manner in which ideas evolve in every field is unique, their initial development is often met with controversy which can be seen in “the evolution of ideas in an individual development, in psychoanalytic process, in group thinking, in theory formation, and in the development of various fields of knowledge” (Grossman, p. 275).

While I searched the psychoanalytic literature using PEP for further illumination on the challenges of treatment coordination, cooperation, and openness amongst

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treatment providers, outside of the above review nothing relative could be found. Which begs the question: is this another one of those difficult issues in the field of psychoanalysis that research participants feel have been left unexplored? While many papers refer to the fact that debates are ongoing over the unique and shared factors in therapy processes from differing psychodynamic orientations, they serve to argue their perspective rather than discuss therapist experiences.

The final issue that research participant’s share that impedes the process of working with SA couples are the social, cultural and generational challenges which they regularly encounter. Here, Dodes (2002) writes that historically, for the first half of the 19th century, addictions were seen as “a direct expression of drive derivatives” (p. 124), and as such, addicted individuals were largely seen as people engaged in impulsive, irresponsible acts; they were hell bent on achieving immediate gratification and were viewed as morally deficient.

The analyzation of societal influences on the maintenance, and perhaps even development, of addiction is far too large a topic for this paper to cover adequately.

However, Berger (1991) provides a cultural-pathological perspective that may interest readers which discusses the cultural symptoms of education, politics, leadership, morality, physical environment, and consumerism as all possible culprits if readers would like to explore this idea more fully.

From the lens of consumerism, Read (2002) writes that society is fascinated with addiction which is glamorized and denigrated in a manner not typical of deviant behavior, whereby “drug users are outside of both the law and society and many welcome this familiar placing. Identity and belonging are projected onto the drug scene, and society is

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expected to reject. Society reciprocates with stigma” (p. 98). Read goes on to suggest that the addict is mirroring society’s fascination with consumption, and that in working to avoid this introspection, society instead projects it onto the addict.

Summary of trial and error.

In this study research participants shared that there were at least four issues that had the ability to challenge, and potentially impede, the therapeutic process when working with SA couples: 1. When abstinence or drug and/or alcohol treatment is insisted upon; 2. When the complexities of SA are viewed through a restrictive lens, 3. When efforts to coordinate and cooperate with other treatment providers are difficult and open conversation about SA and its treatment within the psychoanalytic community is ignored; and 4. When social, cultural and generational challenges are involved.

When possible, all participants preferred to develop a therapeutic alliance with couples prior to recommending drug and/or alcohol treatment, unless the use was actively destructive. Participants shared that clinicians, from any approach, who refused to work with individuals or couples with SA unless they first underwent treatment sent a message of defectiveness and rejection. Instead, study participants work to meet the couple where they are and do not make assumptions about the couples desire to change, or their capacity to work psychodynamically.

Participants argued that SA couples must be viewed from an all-inclusive lens, and that failure to do so would result in losing sight of each couples’ uniqueness. Patients as well as psychoanalytic and disease model communities all had the capability of seeing 243

substance addiction provisionally, which participants maintained could have a destructive impact on treatment.

Finally, all participants voiced that treatment cooperation and coordination was extremely important when working with SA couples, and failure to do so could impact outcome. Open dialogue within the psychodynamic community about the practices of working with SA couples was called for, with the additional understanding that social, generational, and sub-cultural influences be better addressed.

Revisiting Assumptions from Chapter I It is appropriate at this stage of the research to revisit the eight assumptions presented in Chapter I of this study which stemmed from my personal background and professional experience.

1. The first assumption underlying the research was that mutual dependency in intimate couple relationships is healthy and natural. This assumption held true according to the fourth finding. The research participants state clearly that couples need to be able to depend on each other for mutual support in order to trust and be vulnerable and allow for development and growth. This mutual dependency allows for containment of each other’s projections during difficult times and dyadic emotional regulation whereby disagreements and conflicts can be resolved in healthy ways. Indeed, research participant’s state that fear of dependency, or a need to rescue, can be underlying factors in couples who present with SA. 2. The second assumption was that many individual psychological problems can be best treated with couple therapy. While this assumption has support in the

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research it was not directly addressed by research participants in the course of this study. In Finding 3, all four participants stated a preference to working with the couple when SA was an issue within the context of a relationship, and indeed felt that SA within the couple relationship is best treated with psychodynamic couple therapy. They shared that this modality was ideal when working with couples with SA as it allowed for both partners to express personal experiences associated with the illness which created opportunity for empathic connection and a deepening of intimacy. But they also shared that they would work with the individual SA partner if this was preferred.

Perhaps the confusion lies in the linguistics of the assumption; in the sense that “many” individual problems can be “best” treated with couple therapy. This research suggests that SA within the couple relationship is best treated with psychodynamic couple therapy, along with adjunctive therapies when necessary, but it did not address other forms of psychological problems within its scope. So perhaps this assumption is partially true.

3. The third assumption was that couples has the capacity to heal deep childhood wounds. This assumption held true according to the third finding. All research participants voiced an understanding of an unconscious couple fit whereby partners are attracted to each other partly because of unmet childhood needs and the promise of what their partner might provide.

This understanding is at the very core of each participant’s theoretical frame of reference which could be described as deficiency-compensation models of therapeutic action, albeit Triker preferred the verbiage of “revisioning

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emotional convictions or organizing principals about who we are and how we relate.” Nonetheless, within the therapeutic action each participant describes their role as either operating from an empathic selfobject stance which provides functions the patient is unable to perform due to early deficits, or as an object which serves to heal early relational deficits including negative interactive dynamics that have been internalized. The primary objective within both of these theoretical orientations from a couple therapy perspective is for partners to learn how to provide these functions for each other in order for healing and growth to occur.

4. The fourth assumption underlying this research was that we establish unconscious defensive patterns of relating to shield ourselves from experiencing pain. This assumption was clearly confirmed in Finding 2, whereby SA is conceptualized by all four research participants as both a symptom and a defense of deeper underlying issues.

5. The fifth assumption was that empathy, compassion and validation are key factors in the healing of distressed couple relationships. This assumption held true given that all four participants expressed that the development of empathy and compassion for oneself, and each other, as well as recognition and validation of each partners’ perspective, were key therapeutic markers of change when working with SA couples.

6. The sixth assumption underlying this research was that addiction is a physiological and psychological illness with social constructs and manifestations.

This assumption clearly held true throughout the findings, whereby all

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participants voiced understanding of the biological, psychological, and social elements of SA. 7. The seventh assumption original to this research was that behavioral methodologies, while important, neglect unconscious couple dynamics that are key to sustained healing. Three suppositions are actually being made within this one assumption; firstly that behavioral methodologies are important, secondly that behavioral methodologies neglect unconscious couple dynamics, and thirdly that these dynamics are key to sustained healing. All three notions were held true throughout the research. (a) Regarding the first supposition, that behavioral methods are important, all four research participants understood the importance of work completed during patient stabilization in drug and/or treatment centers which is largely done through behavioral methods. This was apparent in Finding 3, which discusses treatment integration. (b) Regarding the second supposition, that behavioral methods neglect unconscious couple dynamics, all four research participants voiced that work undertaken within the disease model of treatment is usually surface level in the sense that the focus is primarily on the symptom – the SA. This was apparent in Finding 5, where the limitations of the model is discussed. (c) With regards to the third supposition, that a focus on unconscious couple dynamics are key to sustained healing, all four research participants state that insight within the idea of emotional experience is where therapeutic growth occurs both individually, and within the couple dyad. Insight is gained

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through differentiation, or the taking back of projections, whereby unconscious beliefs, defenses, and feelings become conscious and, a couple state of mind begins to develop which research participants agree is key to maintaining treatment gains. This was apparent in Finding 4, which discusses the therapeutic action.

8. The eighth and final assumption was that twelve step programs can cause couples to turn away, rather than towards, each other. This assumption did not hold true.

While research participants shared that outcome improved if partners engaged in the recovery process together, as a team, there was no indication that fellowship programs had the capacity to interfere with couple success. This idea was illustrated in Finding 3, which discussed the importance of treatment integration including, at times, twelve-step programs.

Summary of Interpretation of Findings This chapter has attempted to discuss the findings as previously presented in Chapter IV, and place them in a wider context with reference to the selected literature, as per IPA (Smith, Flowers & Larkin, 2009). This task has been significant, and in many ways difficult because of the enormous quantity of literature available on many of the findings. The Value of Language, The Good-Enough Therapist, and the Social, Cultural and Generational Challenges with SA are three examples that have copious amounts of literature dedicated to their subject matter, whereby it would take a village to accurately reflect their complexity.

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Conversely, this task was also difficult due to the limited research available on the topic of psychodynamic couple therapy with SA couples. Finding sources to corroborate some of the findings, including Use of Self where psychodynamic couple therapists discuss experiences in working with SA couples, was not easy and had to be related through individual therapist experiences due to a lack of available research. Even more challenging were addressing the two superordinate themes of Therapeutic Action and Markers of Change, where there is almost no literature at all.

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Chapter VI

Conclusions and Recommendations

The purpose of this phenomenological study was to explore couple therapists’ experience in treating couples with substance addiction (SA) to better understand and identify psychoanalytic psychotherapeutic factors. As per Bloomberg & Volpe (2012), the following conclusions and recommendations follow the research questions and the findings and therefor address five areas: 1. Therapist personal and professional experiences in working with SA couples; 2. Therapist conceptualization of SA; 3. Therapist experience of the therapeutic action when working with SA couples; 4. Therapist experiences of the markers of change when working with SA couples; and 5. Therapist experiences of factors that impede the process of working with SA couples.

Therapist Personal and Professional Experiences in Working with SA Couples The first major finding in this research is the categorical reminder of the significant role that countertransference plays in working with SA couples. A conclusion to be drawn from this finding is that therapist countertransference will interfere with 250

objectivity and stir up personal needs that will seek fulfillment within the therapeutic environment. If clinicians have a personal or familial connection to SA this will make the work more complicated, especially in the early stages of their careers when first learning about use of self.

Therapist Conceptualization of SA The second major finding in this research is the complexity of the SA symptoms and the defenses, and their underlying causes. The first conclusion from this finding is how difficult and challenging working with SA couples can be, and that not every clinician will find it satisfying or appealing. A second conclusion is that thorough understanding of the biological, psychological, and social factors in the maintenance of SA for couple therapists working with SA couples is critical.

The third major finding in this research is that psychodynamic couple therapy with SA couples is dynamic and constantly morphing. Couples present in unique and challenging ways – no couple presents the same and underlying factors vary. One clear conclusion that can be drawn from this is that treatment for couples with SA cannot be manualized in a one size fits all approach.

The fourth major finding in this research is that research participant couple therapists do not generally distinguish the manner in which they conceptualize couples with SA, and couples without SA, outside the SA (which is seen as a symptom and defense with underlying factors). One conclusion from this finding is that the parameters of theoretical models used within this study to conceptualize SA are dynamic and adaptable for all possible manifestations including SA in couples. A second conclusion 251

might be the very opposite, whereby theoretical limitations impede opportunity for a possibly more distinguishable conceptualization. Given the limited research examining psychoanalytic work with SA couples it is difficult to be certain either way.

Therapist Experiences of the Therapeutic Action when Working with SA Couples The fifth major finding in this research is that the psychoanalytic, behavioral, and disease model of treatment are all interrelated when treating SA couples. A conclusion drawn from this finding is that working strictly from a psychodynamic lens is inappropriate and can be counterproductive. Couple therapy with SA couples requires an integrated means involving a bio-behavioral component in addition, or adjunctive to, a psychodynamic approach.

The sixth major finding in this research is that psychodynamically, research participant understanding of SA couple therapeutic factor is not distinguishable from those deemed therapeutic when working with non-SA couples. Research participants pace their use of psychoanalytic technique depending on the needs of the couple, and the therapeutic action in general includes treatment integration, but respondent understandings of the psychodynamic therapeutic factors appear to be similar. A conclusion that can be drawn from this finding is that non-SA couples and SA couples are similar in their uniqueness, and whether they present with SA or PTSD for example, the psychodynamic therapeutic factors are going to be similar other than symptom presentation.

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Therapist Experiences of the Markers of Change when working with SA Couples The seventh major finding of this research is that researcher participants who work with SA couples do not experience the psychodynamic markers of change (e.g., insight, differentiation) to be any different when working with SA couples, as compared to non-SA couples. A conclusion that could be drawn from this finding is that while research participants seemed to indicate that psychodynamic markers of change did not differ in their work with couples overall, the degree to which these markers occur might be different, as could the length of time it takes for these markers of change to transpire.

Said differently, this research may not have been sensitive enough to measure subtle differences in the manifestation of markers of change when working with SA couples.

Therapist Experiences of Factors that Impede the Process of Working with SA Couples The eighth and final major finding in this study is that SA when seen and treated through a narrow lens is restrictive and unhelpful. This narrow lens can be generated through the psychodynamic community, the medical model and/or behavioral community, or the patients and therapists themselves. A conclusion that can be drawn from this finding is the necessary for clinicians working with SA couples to establish strong relationships with other treatment providers who offer differing perspectives and approaches in the treatment of SA couples. They must be well versed in these approaches in order to offer their couples the highest level of care.

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Recommendations for Psychodynamic Couples Therapists Based on my findings, psychodynamic couple therapists are encouraged to: 1. Understand why they have chosen to work with SA and why they have chosen to work with couples with SA. In particular, clinicians who have a personal connection to SA must recognize how this connection might impact their work.

2. Engage in regular personal therapy, supervision and/or consultation given the intensity of the transference/countertransference reactions and the complexities of SA. 3. Understand the importance in creating personal communities of care. Participants in this study provided rich accounts of the challenges that working with these couples entails. Communities of care are both necessary and practical in their provision of emotionally safe and supportive environments with other treatment professionals who are amenable, and respectful, to a psychodynamic approach.

4. Be well trained and versed on the biological, psychological, and social factors contributing to etiology of SA in SA couples. While a psychodynamic lens is invaluable, understanding the biological components of this illness inclusive of pharmacological options, as well as the behavioral and fellowship possibilities that can enhance treatment, is crucial.

5. Understand that SA within the couple is dynamic and constantly morphing, meaning that couples present in unique and challenging ways that contradict a manualized approach.

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6. Beware of possible limitations when operating within the psychodynamic frame.

Flexibility and openness are needed when working with this population due to its dynamic presentation including life and death implications.

7. Actively assess, beginning in the early stages of therapy, whether or not possible SA is contributing to couple issues. Research participants in this study all state that couples who presented for treatment could genuinely not know that SA was a possible contributor to their problems. Social acceptance of alcohol consumption as well as familial and cultural acceptance of alcohol and/or drug use can contribute to this unawareness. Throughout the process of writing this dissertation I came across several psychoanalytic articles and books on assessment when working with couples, but few included assessment around SA. Given the enormous rise in substance-related deaths across the U. S. over the past 12 months, largely due to prescription medications and opiate (e.g., heroin) use, assessment is a proactive, vs. reactive, response that can save lives.

8. Actively engage in the presentation and publication of their clinical work with SA couples. Psychodynamic couple therapists with varying backgrounds and experiences can provide rich case illustrations highlighting process and technique, and identifying the underlying principles that inform these techniques, which would be invaluable to the field.

Recommendations for Schools of Clinical Social Work Based on my findings, administrators of clinical schools of social work are encouraged to:

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1. Offer curriculum regarding the etiology, conceptualization, and treatment for couples dealing with SA that includes information from the bio-behavioral model of medicine, psychodynamic theoretical constructs, and social and cultural influences. This would provide new clinicians with a theoretical and practical flexibility which would be highly beneficial to the field while helping them establish network communities for their work.

2. Offer curriculum within the parameters of SA in couples that includes assessment procedures for SA which may be hidden due to social, familial, or cultural norms.

3. Offer open dialogues in addressing the collective defensiveness in the psychodynamic community in treating couples and individuals with SA. Hypotheses from research participants as to why this exists include: a) Old fashioned perspectives that people with SA are not capable of insight b) Stereotypes of SA people as morally compromised or lacking control c) A tendency on behalf of psychodynamic therapists to work in isolated environments that do not promote a team approach d) A potential for psychodynamic therapists, especially when they first begin their career, to feel unappreciated and misunderstood by treatment providers working from the disease model of addiction e) Anxiety working with the chaotic manner in which SA couples can present because of issues of relapse and intermittent drug and/or alcohol rehab that take them in and out of the couple therapy

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f) SA work has its challenges. Clinician personal and professional investment is significant which can take a toll on therapists if they are not consistent with regards to self-care.

Recommendations for Consumers Based on my findings, consumers should understand: Psychodynamic couple therapy is the optimal approach when seeking couples therapy for SA given the model’s integration and use of relative resources. This approach utilizes knowledge and application of psychodynamic theory which sees the SA as having a dynamic and functional role in the couple relationship that can disguise underlying problem causing factors. It also employs various aspects of the bio-medical model which focuses on the symptom and assists in both the stabilization and maintenance of recovery.

This model offers a team approach to treating SA couples that acknowledges contributing factors from biological, psychological and social perspectives. Finally, according to this study, psychodynamic SA couple therapists regularly engage in ongoing supervision, consultation, and collaboration with other treatment providers, offering consumers a team approach that is unparalleled. No other treatment model understands the complexity of this disorder and considers all aspects of the SA couple’s needs.

Study Limitations One of the limitations of this study is the effect on outcome in which researcher personal experiences, beliefs and assumptions may have. Given that I am a couple therapist who works with couples with addiction and has a family connection to SA; personal and professional bias is apparent. Recognizing this limitation, I sought to control 257

for this by including myself as the first respondent, whereby assumptions and biases were communicated and analyzed separately from the data at large and made transparent. In addition, ‘bracketing’ and member checking measures applicable to IPA were conducted including reflexive journaling and inter-rater reliability in the data analysis. These procedures are discussed in Chapters III and IV. An additional limitation was researcher lack of experience in performing qualitative research. IPA not only requires the ability to switch hats from that of clinician to researcher, it also functions best when the researcher is able to deepen the level of the interview as well as the interpretation, which can take practice. As Smith, Flowers & Larkin (2009) share “In our experience novice researchers tend to be too cautious, producing analyses that are too descriptive” (p. 103). I sought to control for this by initiating a pilot interview with a colleague thereby developing a comfortable ‘research persona’ which would minimize possible anxiety (Smith, Flowers & Larkin). This interview was personally transcribed in order to improve technique and reconsider interview questions.

This study found that research participants conceptualize couples with and without SA the same. Additionally, in both types of couples participants use equivalent psychodynamic techniques and look for identical markers of change once the SA is stabilized and is no longer the primary focus of the therapy. This finding was puzzling given the diverse and unique manner in which couples with SA present, which is highlighted throughout the findings. But while research participants were located in various corners of the U.S., and had very different personalities and backgrounds, their theoretical leanings and approaches contained more similarities than differences, which 258

may be considered a limitation to this study’s overall findings. Equally, IPA attests to purposeful homogenous sampling because it seeks to understand particular phenomena in particular contexts, which is what this study provides. So perhaps findings here should be interpreted as stemming from the specific psychodynamic leanings of self psychology and object relations theory, with future research focus on other orientations.

Recommendations for Further Research 1. Given the limitations of this research and researcher subjectivity, a larger sample consisting of psychodynamic couple therapists from more varied backgrounds and experiences who work with SA couples should be organized to ascertain whether similar or different findings will be discovered.

2. As stated repeatedly, research participants in this study did not distinguish between the usefulness of psychodynamic technique when working with couples in general, and couples with substance addiction. While this study is exploratory in nature due to the little research available on psychodynamic couple therapy with SA couples, perhaps the next area of research to be explored should be on the overall efficacy of psychotherapy with SA couples. This would be in keeping with the literature presented in Chapter II which discussed the possibility of therapeutic factors having less to do with technique, and more to do with client factors, the therapeutic alliance, and the “placebo effect” which occurs when patients feel hopeful and expectant given that they are working within an accepted approach to successful change (O’Neill, 2002, p. 2).

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3. As discussed in this study’s subordinate theme, The Use of Language as a Therapeutic Factor, clinicians working with SA couples cannot not influence their patients. This also refers to the “placebo effect” stated above. But how influential are clinicians when it comes to addictive behaviors? Research examining how psychodynamic SA couple therapy impacts addictive behaviors from a brain functioning perspective might be a way in which psychodynamic therapy and the medical model can find common ground.

4. Given the current focus on the biological symptoms of SA, and its life and death significances, research examining whether the disease model of addiction creates barriers for psychodynamic therapists when working with SA couples could be very meaningful to breaking these barriers.

5. Given the intensity of the transference relationship and the countertransference reaction, as demonstrated yet again in the scope of this study, research examining psychodynamic couple therapists’ attitudes towards couples presenting with SA, or SA partners, may be beneficial for psychodynamic clinicians in the field.

6. Finally, given the information gleaned in this study, a natural progression from here would be to examine the efficacy of psychodynamic SA couple therapy. Is it more effective than a disease based approach and if so, how?

Personal Reflections As a couple therapist who works with SA couples, I am well aware of the trials and tribulations that accompany this work. Consistent with the research participants, I love what I do but can be challenged by all the nuances involved in treatment. This study 260

has been invaluable to me, personally, in assisting with conceptualization of the substance, the substance as it relates to the couple dynamics, and the understanding from research participants as to what works and what doesn’t when working with SA couples.

This study was indeed a collaborative effort and I am very thankful to Emma, Mr. B, Triker, and Stella for their willingness to share their time and talk about their experiences.

I am grateful for their unique perspectives provided throughout the course of this research, and am inspired by the multiple contributions they continue to make to our field.

Conclusion As stated in the beginning of this study, the societal costs of addiction, both monetary and communal, and its impact on individuals, children, and families, is considerable. In the course of the 18 months it took to write this dissertation, according to statistics from the National Institute on Drug Abuse (NIDA, 2015), there have been more than 30,000 related deaths from prescription medication overdose alone. This country is experiencing an epidemic that shows no signs of dwindling. In fact, the latest national statistics on the use of heroin are staggering. Between 2001 and 2014 there was a 6-fold increase in heroin related fatalities, with approximately 11,000 overdoses in 2014 (NIDA, 2015). Even within the parameters of this research, two of four participants had experienced patients who died of overdose.

This research set out ultimately to promote knowledge of working with couples with SA, inform practice interventions for this population, explain the variations and conflict in current couple SA treatment, and better understand what works when working 261

with SA couples. It posed six research questions that addressed these objectives, and subsequent findings that shed light on the psychodynamic therapeutic factors involved when working with this population. In addition, the research provided a summary of findings and followed up with associated implications, conclusions, and recommendations.

This is one study in a sea of statistics that continue to escalate, with the force of its waves obscuring researcher attempts to gain momentum against its current. As a psychodynamic community it is important to stand up and take notice of the surrounding devastation. By deepening a commitment to understanding SA processes as a whole, and contributing to the research through clinical writings about successful and challenging treatment experiences, psychodynamic therapists can further treatment knowledge and save lives.

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Appendix A Email Script

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Dear ________, ____________ gave me your contact information suggesting you might be interested in assisting me with my dissertation research.

My study seeks to understand how couple therapists treating couples with substance addiction identify, and understand, the various psychodynamic elements that influence healing. As you know, addiction impacts millions of American families. Annually in the United States the National Institute on Drug Abuse (NIDA) estimates the economic cost to society of substance use disorders (SUD’s) and addiction to be over $428 billion, with the annual societal cost of alcohol abuse alone at $235 billion.

While research examining the therapeutic outcome of couple’s therapy over the past two decades has made progress in addressing many ‘individual’ problems, there is a paucity of research examining couples with addiction through a psychodynamic lens.

Psychodynamic therapy examines underlying dynamics, including emotional factors and defense mechanisms, which lead to problematic intrapsychic and interpersonal patterns.

Current interventions used in treating couples with addiction are primarily behavioral, and operate from the medical model of treatment which neglects these dynamics. These interventions are questionable in their ability to maintain long-term benefits.

In this research I am seeking to interview master couples therapists with a minimum ten years’ experience as a licensed, practicing psychodynamic couple therapist, minimum five years’ experience in treating couples with substance addiction, and minimum three months active engagement in working with at least a single couple with substance addiction.

If you would like to partake in the study, I will send you the Informed Consent and Study Questionnaire. Once these have been returned, your first interview will be scheduled and the Interview Schedule containing the study questions will be sent to you one week in advance. The first interviews will be scheduled the last week in October and the first week in November, 2015. You will be interviewed in your chosen surroundings either in person or via VSee. VSee is video conferencing software used by NASA and medical practitioners which is HIPAA compliant and free to download. The first interview will last from one to two hours, with the duration of the second interview determined as needed. Prior to your second interview, I will email or mail detailed themes and descriptions gathered from your first interview for you to make note of any changes, comments, or questions you have regarding accuracy and clarity.

Again, thank you for your interest. Your experience in working with couples with substance addiction is highly valued and I hope you will allow me, and others exposed to this research, to garner a more thorough understanding of the complicated work you do.

264

I look forward to hearing from you.

All my best, Jamie L. Loveland

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Appendix B Participant Informed Consent

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Institute for Clinical Social Work Research Information and Consent for Participation in Social Behavioral Research Therapeutic Factors in Working with Couples with Addiction through a Psychoanalytic Lens

I, , acting for myself, , agree to take part in the research entitled Therapeutic Factors in Working with Couples with Addiction Through a Psychoanalytic Lens.

This work will be carried out by Jamie Loveland, LCSW (Principal Investigator) under the supervision of Karen Bloomberg, PhD (Dissertation Chair).

This work is sponsored by_________________________(appropriate if project is being funded by an outside organization) and conducted under the auspices of the Institute for Clinical Social Work; At Robert Morris Center, 401 South State Street; Suite 822, Chicago, IL 60605; (312) 935-4232.

Purpose This study seeks to understand how couple therapists treating couples with substance addiction identify, and understand, the various psychodynamic elements that influence healing. Addiction impacts millions of American families. While research examining the therapeutic outcome of couples therapy over the past two decades has made progress in addressing many ‘individual’ problems, there is a paucity of research examining couples with addiction from a psychodynamic lens. Psychodynamic psychotherapy examines underlying dynamics, including emotional factors and defense mechanisms, which lead to problematic intrapsychic and interpersonal patterns. Current interventions used in treating couples with addiction are primarily behavioral, and operate from the medical model of treatment which neglects these dynamics. These interventions are questionable in their ability to maintain long-term benefits. This research is significant to clinical social workers, and other mental health professionals, in that it will provide new information about working with couples managing addiction that will allow them to better identify, respond, and treat this difficult population.

Procedures Used in the Study and the Duration After you have agreed to partake in the study, you will be sent the Informed Consent and Study Questionnaire. Once these have been returned, your interview will be scheduled and the Interview Schedule containing the study questions will be sent to you one week in advance. You will be interviewed at least once, and at maximum twice, in your chosen surroundings either in person (if you are in the greater Houston, TX area), or via VSee. VSee is video conferencing software used by NASA and medical practitioners which is HIPAA compliant and free to download. The first interview will last from one to two hours, with the

duration of the second interview determined as needed. With your permission, interviews will be audiotaped using a digital recorder, with audio files then transcribed by a professional service using a pseudonym which you have chosen. Transcripts of interviews will be shared between the study’s principal investigator, dissertation chair, 267

and dissertation method’s chair. Prior to your second interview, I will email or mail detailed themes and descriptions gathered from your first interview for you to make note of any changes, comments, or questions you have regarding accuracy and clarity. This data will be sent to you via a password protected file.

Benefits It is the hope that this research will contribute to the understanding of treating couples with substance addiction, so one possible benefit of the study is an improvement in the manner in which these couples are assessed and treated. A second benefit pertains to the couples themselves. While the study seeks to understand therapeutic factors that will improve practice protocols for couples with substance addiction from the perspective of the treatment provider, the population benefits as well by being able to choose amongst various treatment protocols, instead of one prevailing model, when seeking help for this disorder.

Costs There are no costs associated with participation in this study. There will be no financial remuneration for your participation in this study.

Possible Risks and/or Side Effects This research poses minimal potential risk to you. Any such risk would be associated with possible emotional discomfort as a result of discussing personal perspectives and feelings in working with couples with addiction. You will be asked personal questions about addiction in this study and will be notified of this during the pre-interview process to expect such questions. You reserve the right to refuse to answer any questions at any time during the course of the study, and are encouraged to share information deemed relevant and safe to your emotional well-being and comfort. Should you experience strong reactions during the data gathering experience, and still wish to continue in the study, professional therapeutic help will be provided at your request. If you experience strong reactions and should no longer wish to participate in the study, professional therapeutic help will be provided at your request, and the principal researcher will provide you with a full debriefing.

Privacy and Confidentiality All data you provide for this study will be identified through a pseudonym that you will choose when filling out the initial study questionnaire. Under no circumstances will you be identified by name at any time during this research study, or in any publication thereof. Data from the study will be coded and securely stored on the principal investigator’s private computer which is password protected and kept behind locked doors and a digital security system. Transcribers and dissertation committee members 268

will be required to sign agreements regarding your confidentiality. Files passed back and forth between the principal investigator and dissertation committee will be password protected and sent only through the Institute for Clinical Social Work’s email system.

Audio files containing data will be destroyed upon final completion of the research. All other data will be maintained for period of 5 years in a secure location, after which all files will be destroyed.

Use of Results This research study is to be submitted in partial fulfillment of requirements for the degree of Doctor of Philosophy at the Institute for Clinical Social Work, Chicago, IL. The results of this study will be published as a dissertation and include verbatim extracts of your narratives. In addition, information may be used for educational purposes in professional presentation(s) and/or clinical publication(s).

Subject Assurances By signing this consent form, I agree to take part in this study. I have not given up any of my rights or released this institution from responsibility for carelessness.

I may cancel my consent and refuse to continue in this study at any time without penalty or loss of benefits. My relationship with the staff of the Institute for Clinical Social Work will not be affected in any way, now or in the future, if I refuse to take part, or if I begin the study and then withdraw.

If I have any questions about the research methods, I can contact Jamie L. Loveland (Principal Researcher) or Karen Bloomberg (Dissertation Chair), at this phone number: (713) 636-3910 (day or evening).

If I have any questions about my rights as a research subject, I may contact Dr. John Ridings, Chair of the Institutional Review Board, Institute for Clinical Social Work, at Robert Morris Center, 401 State Street, Suite 822, Chicago, IL 60605; (773) 263-6225.

Signatures I have read this consent form and I agree to take part in this study as it is explained in this consent form. __________________________________________

_______________________

Signature of Participant

Date

269

I certify that I have explained the research to ____________________________, and believe that they understand and they have agreed to participate freely. I agree to answer any additional questions as they arise during and after the research.

__________________________________________

________________________

Signature of Principal Researcher

Date

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Appendix C Study Questionnaire

271

Study Questionnaire Thank you for agreeing to participate in this study! Please complete the questionnaire below and return it via email, or snail mail, whichever your preference. If you have any questions while filling this out please email me at jloveland@icsw.edu. This questionnaire must be completed and returned before your first interview can be scheduled.

Please note that the information in this questionnaire is confidential and will only be used under the auspices of this research study.

This questionnaire consists of 14 questions in three sections. In the first 13 questions please circle the answer that best represents your response, or fill in the blank. On the final question, please answer at length using additional paper if necessary.

Section I: 1. Have you in the last year treated a couple with substance addiction?

Yes No - please stop here and return packet to researcher.

2. Of those couples treated have you actively engaged in therapy with at least one couple in addiction for a minimum of 3 months?

Yes No - please stop here and return packet to researcher.

3. Are you a licensed clinical social worker or equivalent?

Yes - please indicate the license and state in which you are licensed. _______________________.

No - please stop here and return packet to researcher.

4. How many years of clinical practice experience in working with couples do you possess? __________number of years.

5. How many years of clinical practice experience in working with couples with addiction do you possess? __________ number of years.

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6. Please indicate the pseudonym you would like to be addressed by during data collection: ___________________________.

7. Please indicate the theoretical orientation you most identify with: Attachment theory Classical Drive theory Ego psychology Object relations theory Relational psychology Self psychology Other: _____________________.

8. Are you familiar with VSee video conferencing technology?

Yes No Section II:

9. Gender: What is your sex? __________.

10. Age: In what year were you born? __________.

11. Ethnicity: How do you describe your racial background? _________________________.

12. Marital status: What is your present marital status? __________________.

13. Education: What is the highest level of formal education you have completed? ___________________.

Section III:

14. What do you remember about the very first couple you worked with that was dealing with substance addiction? (please use additional paper if needed). __________________________________________________________________ __________________________________________________________________ 273

Thank you for completing this questionnaire! Your time and participation are very much appreciated.

Please scan and return your questionnaire to me via email (jloveland@icsw.edu), or send through snail mail to:

274

Appendix D Interview Schedule

275

Interview Schedule

Can you tell me about your work?

• • • • • •

What kind of setting do you work in?

Can you tell me about your training? Your education? Profession?

Can you tell me about your practice?

How many clients do you see daily, and what percentage of your clients are couples?

What kind of ongoing professional groups do you participate in? CEU trainings?

Workshops?

How did you come to be a couple’s therapist?

How do you conceptualize couples therapy?

• • • • • •

How do you experience being a couples therapist?

What kind of assumptions/beliefs do you have about couples and couples therapy?

What theoretical orientation do you work from?

What aspects of that orientation are most conscious in your work with couples?

How do you arrive at a formulation?

What do you think of when I say “use of self”?

How do you conceptualize substance addiction?

• • •

• •

How do you experience SA? How do you think about the etiology of SA? How do you think about SA psychodynamically? (self-medication hypothesis, moderating ego and self-structures such as emotions, self-esteem; looking forward to a positive experience; defensive experience, etc.).

What kind of assumptions do you work from about people with substance addiction?

How do you think your assumptions/beliefs impact the work you do with couples?

And the couple themselves?

How do you conceptualize couples with SA? • • • •

How did you come to begin working with couples with substance addiction?

How do you experience working with couples with SA? What is it like? Is it any different from working with couples without SA? What are additional assumptions/beliefs you have about couples with SA? 276

• •

•

• •

What does being a therapist who works with couples with SA mean to you?

What kinds of challenges do you encounter when you work with these couples? (affect regulation, early attachment issues, self-deficits, poor object relations, etc.).

What are the differences in working with couples with and without SA? (Is there anything you don’t do with couples with substance addiction that you do with couples without SA?) What are the consistencies in what you notice in working with couples with SA? Similarities? Differences?

How does the pace of work differ?

Personal History • • • •

Is there anything in your personal history that drew you into working with couples with SA? Were/are there any SA issues in your family? Close friends? Colleagues?

What is your personal history with substances?

What about your personal history with SA impacts the work you do with couples with SA?

Please describe the first long-term couple you remember working with where there was SA (If needed) • • • • • • • • •

What did you first notice about them?

What was it like being with them? Is this typical when working with couples with SA? Can you describe a typical session?

What kinds of issues did you find yourself working through with them?

What kinds of techniques/interventions did you use? Is this typical when working with couples with SA? How did the work impact you? (personally, professionally, familial, etc.)

What were your assumptions/beliefs about SA at the time?

What worked? What didn’t work? How could you tell?

What did you learn from working with this couple?

What about the process of working with couples with SA feels helpful?

• •

•

How do you think of therapeutic action?

What do you experience as being therapeutic when working with couples with SA? (interpretation, insight, focus on affect, focus on recurring themes and patterns, 12-step, neurobiology, etc.)

What makes working with these couples unique?

277

• •

What seems to make things worse? How can you tell?

What seems to make things better? How can you tell?

How has the way in which you work with couples with SA changed over time?

• • • • •

Have your assumptions/beliefs about SA changed over the years?

Structure?

What do you attribute these changes to?

How have your thoughts about SA changed?

How has working with couples with SA impacted you over the years? (personally, professionally)

Is there anything I haven’t asked you about working with couples with SA that you think is important to say?

278

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