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Be aware of relationship dynamics in women's treatment

November 1, 2007
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Moving beyond the ‘identified patient’ can enhance clinical success

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

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

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

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

Education around communication

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

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

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

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

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

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

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