Often in recovery, it takes two

In cases where a couple in a committed relationship is affected by addiction in one or both partners, conventional wisdom has advised that healing the relationship should take a back seat to establishing a track record of stable recovery first. As the notion of addiction as a family disease has taken greater hold across the field, however, professionals and programs are breaking from that tradition and directly addressing relationship dynamics earlier in treatment.

What is resulting from this evolving mindset includes the establishment of defined treatment programs or tracks for couples in early recovery, including in residential facilities where in some cases couples will live together during their stay.

“My overall philosophy is they're going to live together anyway, so let's treat them the best way we can,” says Fredi-Ruth Levitt, a director at Behavioral Health of the Palm Beaches in South Florida. “These couples don't know how to have a positive relationship—it has been more of an enabling relationship.”

Robert Navarra, PsyD, LMFT, a family therapist and consultant based in San Carlos, Calif., says the addiction treatment field's tendency to postpone addressing relationship dynamics until recovery is more fully established actually flies in the face of research evidence. Studies have demonstrated that satisfying family relationships constitute one of the greatest predictors of long-term recovery, Navarra says.

“There are the individual partner recoveries, and then there is relationship recovery,” says Navarra. “We work to create a language for the couple to talk about recovery in the relationship.”

Newly developed programs

Over the past year, the Addiction Reach luxury treatment program in Palm Beach County, Fla., has developed a track available to couples who want to share the experience of early recovery. “Our clients have researched couples programs countrywide and have not found any other integrated programs that let them support each other on their own terms,” says Addiction Reach CEO Sue Merklin.

Nicholas S. Aradi, PhD, oversees clinical care in Addiction Reach's couples program. Although a daily recovery contract that seeks to establish a few-week period of abstinence serves as a cornerstone of the center's work, relationship-focused intervention begins fairly early in treatment, Aradi says.

“When you do the relationship piece, there is a higher likelihood of success,” says Aradi. He saw the drawbacks of narrowly defined individual treatment during his time as a school psychologist, where he would observe that children would regress after consistently being returned to a dysfunctional family system.

The level of trust has declined to basically nothing in a relationship where one partner has a substance use disorder, says Aradi. He points out that the dynamic differs when both partners have a substance use problem. “The partners will con each other in that arrangement,” he says.

Developing better communication skills becomes critical during the course of treatment. Aradi finds several therapeutic techniques to be useful here; one involves educating partners by employing videotapes of other couples talking. Another involves teaching couples to adopt a “7-to-1 ratio” pledge: agreeing to make seven positive comments or reactions to their significant other for every negative one. Because of the damage that negative acts or thoughts can inflict on the relationship, “You've got to have seven positives in order to neutralize one negative,” says Aradi.

Merklin says Aradi will see the couple up to five times a week while the partners are in the treatment setting. The goal becomes one of helping each partner express oneself in a respectful way, while being able to see things from the perspective of the other person. Problem solving strategies and negotiation of behavioral change agreements also are important components of the process.

It is also necessary to emphasize within couples treatment that the relationship did not cause the addiction, Aradi says.

More recently, Morningside Recovery in Orange County, Calif., formally announced in December that it has launched an inpatient center designed to treat couples in recovery. Hand in Hand Recovery combines individualized therapy and couples counseling, with an early goal of establishing autonomy for each partner, says Jennifer Friend, a primary therapist in Morningside's residential detox program.

Couples admitted for treatment have to be willing to work on their own issues separately as well, says Friend. The partners will be together during meals and recreational time at Morningside, but they are housed in separate sleeping quarters, she says.

The latter is more in keeping with tradition in addiction treatment, with this approach used partly because of concerns that couples living together could contribute to triggering other patients in the treatment setting. But that is not a universally held view. Levitt says that at Behavioral Health of the Palm Beaches, couples in treatment are housed together but advised not to remain so close as to compromise the therapeutic environment. “We try to separate them in process group so that they each have different experiences,” Levitt says.

Friend says it is also important that the couple be committed to sobriety and to each other. “This is not a program for someone to do with someone they just met in [treatment],” she says.

Both partners experience trauma

Navarra emphasizes in his presentations to professionals on couples therapy that a relational approach to recovery has been a critical missing piece in substance use treatment. At a time when a couple is most vulnerable as the result of damage caused by a partner's addiction, the message from traditional treatment has been one of, “Now we'd like you not to talk to each other,” he has said.

Navarra is certified in the Gottman framework for couples therapy, an approach that focuses on enhancing friendship, managing conflict, and creating shared meaning between partners. A therapeutic technique that Navarra himself developed is called Healing Emotions from Addiction and Recovery Trauma (HEART), which acknowledges that trauma is present in both addiction and the process of recovery, and that each partner is affected.

He explains that under his highly structured intervention, a partner will identify a pivotal event in the couple's history and explain how that moment affected him/her. The other partner can ask questions related to the experience. Navarra's role involves making sure that both partners are protected during this process—no blaming is allowed.

The session helps to demonstrate that addiction has affected each partner as an individual, as well as affecting the couple relationship. Sometimes the partner who does not have the primary substance use issue will be left saying to the other, “It never occurred to me that you were traumatized by your own addiction,” he says.

Navarra adds, “I think the couples movement reflects a recalibration of how we're approaching recovery.” He welcomes this, believing that “separating [partners] in treatment is a huge mistake.”

In fact, he would like programs to think in terms of three, maybe even four, components of recovery for individuals in a committed relationship: each partner's recovery individually, the relationship's recovery, and the recovery of the entire family unit.

When couples treatment is not advised

Treatment professionals interviewed for this article state that couples therapy is not indicated for every couple affected by a substance use disorder. These are some of the circumstances under which they say couples treatment would not be advised:

• A history of partner violence, creating an environment where one partner feels unsafe, means that this treatment could not unfold productively.

• Each partner must be able to communicate and hear accurately in this highly structured therapy, so this treatment is not effective when a psychotic disorder is present, says Addiction Reach's Nicholas Aradi.

• Aradi adds that this treatment approach can become challenging in cases where treatment has been court-mandated. “The partners must be personally invested,” he says.