12. Therapist as Witness - RonaldMah
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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12. Therapist as Witness
Therapist Resources > Therapy Books > Mine Yours Addiction- Cpl
Mine, Yours, and Ours, Addiction and Compulsivity in Couples and Couple Therapy
Chapter 12: THERAPIST AS WITNESS
Deception that is missed when all the charms and skills of the addict is focused on him or her, may be more readily recognized when the co-addict observes the addict directing the lies at the therapist. At the same time, the therapist is a new person present to observe the addict spinning his or her web. The partner and the therapist take turns being the other person in the room with the addict. The therapist is the third person observing and giving feedback to both partners. "...contributing to restoration of trust... was a 'second witness' or confirmation from an outside, presumably non-biased and credible professional source. In conjoint therapy, the therapist's validation or ratification of thoughts, feelings, or experience of either the addicted or supportive spouse served to increase its acceptability and validity for their partner. The therapist became a 'third party, a neutral party that we trusted and could quote' ... The significance of this role was further explained... 'The addicted person is going to say anything that he can to hold on. It is a conflict of interest, basically.' This conflict of interest made the addicted spouse's words alone suspect. Clarification and validation from an outside, professional source authenticated the communication as something more than '[the husband] trying to cover it up or set something up for the future, manipulate the situation'" (Zitzman and Butler, 2005, page 321-22).
The entry in couple therapy creates the third person observer in another important way. Each partner becomes a third person observing the other partner and the therapist interacting. The therapist may become an alter ego of one partner to advocate or interact as one wishes to act with the other partner. The observing partner closely evaluates the "performance" of the other partner. The observer realizes that the therapist is experiencing what he or she has been experiencing all along. Watching the addict evade, distract, distort, and lie to the therapist makes the co-addict also realize that the addict has been lying to him or her all along. This may occur with or without direct feedback from the therapist about how he or she has experienced the addict. The therapist may have or not have directly challenged the truth of the addict's communications. "Also through conjoint couple therapy, wives became participant observers of the clinical process. Four couples noted direct observation of their husband's efforts, involvement, and progress in recovery as a factor in the restoration of trust. A key component of 'effort and progress' was the husband's consistency in recovery. David described his challenges during recovery, giving insight into what might make consistent effort a significant factor in restoration of trust for wives: 'That day, that hour, that session [I] might honestly want to give it up and [I] might feel that way, honestly… But you'll wake up the next morning and it is not the same desire . . . That kind of commitment is not going to get it done' (David). Mary added insight into how joint marital therapy conveyed awareness of progress and thereby contributed to restoration of trust: 'I never would have known [of his progress and how he felt about addiction] if I hadn't gone [to therapy with Mike]. I think that helped us . . . as a couple because it helped me kind of see that part that I never would have seen'" (Zitzman and Butler, 2005, page 322). The therapist can be active and provocative to draw attention of the partner to the addict's efforts and prompt judgment as to his or her sincerity and commitment. The partner will be hyper-attentive irrespective of the therapist, but may tend to withhold commentary for fear of becoming over-confident and disappointed. This feeds into the victim stance of the addict about never getting any credit for good effort. The therapist can modulate this interaction so credit and acknowledgment can be given and received appropriately. And, help the partners process this communication issue.
Each partner may not be clear whether he or she wants to stay in the relationship. The addict may be uncertain whether the relationship with the addiction or keeping the relationship with the partner is more important. The addict may be conflicted whether he or she can have both the relationship with the addiction and the relationship with the partner. The co-addict may decide that the relationship with the addict is too unhealthy or too painful to stay. Or, the co-addict may be conflicted that the relationship with a broken sense of self can co-exist with the relationship with the addict. The co-addict contemplates whether he or she can tolerate a relationship with unstable trust. The addict contemplates whether he or she can tolerate being mistrusted in the most intimate relationship. The therapeutic process requires tremendous fundamental change in their relationship. The long history of betrayals that have corrupted or destroyed trust cannot be readily, quickly, or easily remedied. Broken trust comes from repeated experiences of lies and deceptions. The lies and deceptions do not have to be constant. In fact, if they were consistent, separation or termination of the relationship is much easier or more likely for the betrayed partner. The unremitting lies without any positive experiences break down any delusional system to justify staying.
Betrayal is intermittent as is characteristic of addicts. Unpredictability, inconsistency, and instability of occasional negative experiences (however profoundly devastating) is mixed with positive experiences (often intensely fulfilling and rewarding due to desperate needs). As a result, it takes a profusion of subsequent consistent positive experiences to heal. Therapy attempts to foster the accumulation of positive experiences that can rebuild trust, and minimize, reduce, and mitigate the negative experiences that broke down trust. The process is much more than identifying trust-destroying choices and behaviors and trust-building choices and behaviors. The addict and co-addict already know that substance abuse and behavioral compulsivity are trust-destroying choices to be avoided. The issues and forces that cause use or behavior to become addiction have to addressed. The biochemical effects of substances on brain chemistry, compulsion, and addiction are relatively identifiable. Most informed children, teens, and adults know what substances have potential for abuse and addiction, and therefore to be avoided. However, the addict and co-addict often avoid examining the other issues that motivate self-medication.
ROOM OF PAIN
In this crucial exploration in therapy, deep, distressful, and painful vulnerabilities will be exposed that can trigger further substance abuse or behavioral compulsion or relapse. The therapist needs to anticipate that the work of therapy to reduce or eliminate addiction, rather than reducing the use or behavior may cause an increase. Couple therapy becomes the "room of pain" where what has been avoided for fear of triggering great pain must be faced. The delicacy of this process is intensified because the replication or acting out of addiction is often much more disruptive and destructive than for other issues. When the therapeutic focus is on stress, confusion, anxiety, depression, or emotional volatility for example, vulnerabilities may trigger further stress, confuse, anguish, depress, and so forth. These reactions may be intensifications of existing issues. Triggered alcohol or drug responses or triggered addictive behaviors however can often be much more severe. Alcohol or drug abuse interrupts sobriety or non-problematic use. Compulsive acting out introduces destructive behaviors that disrupt healthy functioning. Whereas, triggering, allowing, or intensifying the problematic reaction may be a relatively normal and necessary part of growth, the therapist and the couple may see any repeat of use or behavior as a failure. The consequences may in fact be very destructive to the relationship, health, employment, academic progress, social status, or parenting.
The couple in the early stage of recovery from addiction is often very emotionally volatile and prone to explosive interactions. Partners have rudimentary levels of understanding and sophistication about what recovery is all about- what aids and what harms recovery. Simplistic perspectives lead to simplistic and failed attempts to abstain and to support or intervene despite highly complex dynamics. The therapist needs to present, advocate, and guide "a multifaceted yet flexible approach to both personal and relationship concerns. Early recovery-oriented interventions include tracing the consequences of addiction, positively envisioning recovery, undertaking a forensic analysis of relapse risk factors, and managing cravings through social support" (Seedall and Butler, 2008, page 80). The therapist can use motivational interviewing to prompt change. Motivational interviewing helps each partner explore and work through uncertainties about using or stopping and about continuing or ending the relationship. The therapist attempts to evoke and trigger the personal motivation of each partner to end addiction and the dysfunctional relationship. This is a key goal of the early stages of therapy. Both the addict and the co-addict may admit that he or she needs to change, but are at different levels of readiness not only for changing behavior but whether and how to use therapy. One or both partners may have contemplated changing behavior or use, but not acted on it in any substantial manner. Or, may have been trying for years to change but failing or unable to sustain positive behavior.
The therapist needs to ask open-ended questions, provide affirmations as appropriate, practice reflective listening, and occasionally review and summarize the therapeutic process and the progress of the partner and the couple. The therapist takes care to not be judgmental, confrontational, or adversarial, which could trigger shame and/or defensiveness. Each partner needs to feel safe enough to become aware of how problems have developed, what the results of his or her choices about use and behaviors, and especially what he or she and the couple risk as a result. Each partner is assumed to have been unconsciously to consciously contemplating the pluses and minuses of addiction or co-addiction. Questions prompt greater self-awareness and insight through a blend of both a client-centered approach and direction from the therapist. The therapist helps the partners see and anticipate a healthier life and a mutually supportive fulfilling relationship without dysfunctional compulsive behaviors or addiction. Therapy primes, sustains, and increases the partners' motivation to achieve their goals. The therapist tries to get the partners to think differently about choices and behavior and what could be better in life and relationship with change. Motivational interviewing emphasizes attention to the current circumstances, which hopefully clarifies for the addict and partner that their actions are not in sync with their values or relationship goals.
Seedall and Butler (2008, page 80-81) described consequence tracing in early therapy. "The recovering partner leads out in constructing the shared couple narrative of the personal and relationship devastation of the addictive experience (consequence tracing) followed by the non-addicted partner's attachment-anchored plea for a better relationship (positive envisioning). Consequence tracing is a motivational dialogue designed to (1) highlight the positive, functional elements of addiction and the incentives for overcoming the addiction (this has been referred to in motivational interviewing as outlining the client's decisional balance; Miller & Rollnick, 2002); and (2) link choices to consequences, enhance personal responsibility, and encourage increased conviction of conscience and motivation for change. Subsequent dialogue with the non-addicted partner focuses on his/her feelings, views, and experience of the addiction's influence on the recovering partner, the couple relationship, and the family. This conversation validates the partner's experience with a loved one's addiction while also making explicit the reasons that s/he has stayed in the relationship and hope for the future." The partner watches the addicted partner express his or her personal "devastation, recognition, and remorse rather than callous indifference. In addition, the recovering partner observes his/her partner's attachment-based plea for change coupled with hope that individual and relationship healing can occur" (page 81).
