Couple therapy must consider how "…a disproportionate number of individuals manifesting 'substance abuse' form relationships with partners that also manifest 'substance abuse.' Longitudinal studies document that couples display similar patterns of 'substance abuse' that cannot be explained by sociodemographic factors alone (Leonard and Das, 1999; Windle, 1997). In some populations, concordant couples may be the rule, rather than the exception. Pivnick and colleagues studied 126 women on methadone, and noted that more than half of the women who resided with a sexual partner reported that their partners currently used drugs (Pivnick et al., 1994). As the gender gap in 'substance abuse' continues to narrow, concordant couples are likely to become even more prevalent. The 2001 U.S. National Household Survey on Drug Abuse documented that men continue to manifest a higher rate of current illicit drug (8.7%) compared with women (5.5%) (Summary of Findings from the 1999 National Household Survey on Drug Abuse, 2001). However, this gap is to narrowing with time (Summary of Findings from the 1999 National Household Survey on Drug Abuse, 2001). Furthermore, among youths ages 12 to 17, the rate of current illicit drug use is only slightly higher for boys (11.4%) than for girls (10.2%). In other words, we have a situation in which there are high rates of substance use in both men and women, and we know that a disproportionate number of these individuals will form relationships with other substance users. It is time we recognized that many couples dealing with substance use-related problems do not fit the classic codependency model. Indeed, the relationships of individuals manifesting 'substance abuse' are as varied and complex as those in the rest of society. In failing to recognize this, we do a profound disservice to both those working in this field, as well as to the substance users" (Cavacuiti, 2004, page 646-47). Tamlyn and Phillip had never had a relationship without substance use and abuse. Mutual and respective addiction was a foundation of their relationship. The stress for the couple occurred when Tamlyn sought to stop or curtail her bulimia and her alcohol use. Tamlyn's desire to stop compulsive behaviors and substance abuse threatened to remove the glue that held their dysfunctional relationship together.
Broadening the definition of excessive compulsive behaviors or addiction beyond substance abuse also changes the standard couple's model of an addict and a non-addict. This is often a fundamentally inaccurate assessment of the partner's functioning and the couple's dynamics. Designating and naming the second partner as the co-addict exposes and implicates their mutually reciprocal dysfunctional relationship. The co-addict, as well as the addict often comes from an addictive family-of-origin where alcoholism, for example was an issue. The co-addict may consider that he or she had avoided alcoholism or drug abuse but not recognize his or her other addictive or compulsive behaviors. The co-addict is essentially also an addict, which may not be apparent to the unsophisticated therapist unless he or she was already identifiable as a substance abuser or addict. The inclusion of non-substance behavioral abuse and addiction coincides with the high incidence of concordant substance abusing or addicted partners. Both partners may not be substance use problems at the beginning of the relationship. However, it appears that partners who are not abusing or addicted initially, sometimes eventually copy the user/abuser/addict's problematic use. A common attempt to influence or control the alcoholic or drug abuser or addict's use is to join him or her. The non-drinking partner becomes the alcoholic partner's drinking buddy. The assumption is that by joining him or her, the other partner can keep an eye on and hopefully, minimize use and associated problems. As a teenager and young adult, Tamlyn had indulged herself with alcohol and marijuana, but it was with her relationship with Phillip who was about ten years older and also more experienced with various illicit drugs that she was introduced to a pharmacy of hard drugs. Bulimia came much later. "Interestingly, women tend to emulate their male partner's behavior far more than the other way around (Brady and Randall, 1999; Leonard and Das, 1999). It has also been shown that women who are 'problem drinkers,' heavier marijuana users, or cocaine users manifest an approximately twofold rise in the likelihood of marrying a problem-drinking spouse (Windle, 1997). In other words, a disproportionate number of substance using individuals tend to be in intimate relationships with other individuals who have similar problems" (Cavacuiti, 2004, page 650). This suggests that substance abusers of a feather flock together, rather than the converse- that associating with a drinker or drug user influences one to emulate use. Cavacuit suggests using the term concordant couple to describe couples where both partners are abusing substances.
"There may be profound differences between these two types of couples. The study by Fals-Stewart et al. is one of the few studies to specifically compare couples where one partner is a substance user vs. couples in which both partners are (Fals-Stewart et al., 1999). The results are quite edifying. In couples in which only one partner is a substance user, relationship satisfaction and stability is associated with decreased drug use both in terms of the amount of a drug used and the frequency of its use. In couples in which both partners manifest 'drug abuse,' relationship satisfaction and stability is associated with increased drug use" (Cavacuiti, 2004, page 650). Further research found that when there are two drinkers, already existing negativity increased when there was drinking. In contrast, when there was just one alcoholic partner, especially if it is a female drinker, high negativity during drinking went down during drinking. The therapist may speculate and check with the partners if drinking medicated or soothed negative feelings and/or when the drinker indulged, the partners reframed from interacting for fear of explosive conflicts.
"In modern western culture, the stage of life when intimate relationships are at their most important is also the stage at which patterns of drug and alcohol use are established. One can see that many of these essential developmental tasks may be quite difficult for the concordant couple to achieve. Added to this is the fact that many youth seem to be developing 'substance abuse'-related problems at younger ages (Summary of Findings from the 1999 National Household Survey on Drug Abuse, 2001; Ontario Student Drug Use Survey, 1999). The U.S. 2001 National Household Survey on Drug Abuse documented 10.8% that of youths ages 12 to 17 were current drug users compared with 9.7% in 2000 (Summary of Findings from the 1999 National Household Survey on Drug Abuse, 2001). The Centre for Addiction and Mental Health's Ontario Student Drug Use Survey, which is the longest ongoing study of adolescent drug use in Canada, documents that drug use is on the rise among adolescents (Ontario Student Drug Use Survey, 1999). One of the implications of increased drug use in youth is that a growing number of today's young people may never have had a meaningful intimate relationship where drugs or alcohol were not a factor. Obviously, treating young couples who have never known a relationship that did not significantly involve drugs or alcohol will be very difficult" (Cavacuiti, 2004, page 648). As noted earlier, this was true of Tamlyn and Phillip. In contrast, Mitchell and Kat both drank and used drugs sometimes to excess as a couple in their early twenties, but while Mitchell got worse, especially with his injuries and prescription pain medications, Kat had stopped abusive use and drank only rarely and without ill effects. At the point the couple decides to use couple therapy, sometimes both partners may still be using and abusing substances. The therapist would shape therapeutic strategies based on Tamlyn and Phillip being a concordant couple while working with a couple such as Mitchell and Kat somewhat differently.
"Substance abuse' can be a very potent force in a relationship. The connections between drug use and relationships are only partially understood. However, several studies have demonstrated that drug use can affect relationship stability and vice versa (Fals-Stewart et al., 1999; Haber and Jacob, 1997; Halford et al., 1999). Rolland used the term 'triangulation' to describe how a chronic disorder (such as substance use) can become a powerful third member in any dyadic relationship (Rolland, 1994). One can see that triangulation will be a particularly potent force for the concordant couple, where both members of the couple may be struggling with their relationships to drugs and each other. Interestingly, the term 'triangulation' is particularly apt when applied to couples with substance use-related issues. Triangulation conjures up images of a love triangle in which the couple has a love/hate relationship with a third party, in this case, their drug" (Cavacuiti, 2004, page 649). The therapist will need to help the partners uncover the role of the addiction in their relationship. Addictive use or behaviors may give one partner just enough distraction or soothing to maintain his or her illusion of mastery and control in life. It is possible that without the addiction, the relationship may not be viable. Distress and relationship disconnection may be so profound that without the self-medicating effect of the substance use or compulsive behavior, staying with the partner would otherwise be impossible. Fighting and arguing about the substance abuse or addiction as upsetting and debilitating as it may be, may be safer than bringing up the soul sapping relationship devastating issues they have colluded to avoid. Therapy may identify addiction as the "mistress" in the relationship, or as the cohesive force, or as a key counter-balance to other corrupting forces.
CO-DEPENDENCY, ENABLER, OR CO-ADDICT
On the other hand, one partner may have stopped using alcohol or drugs and substituted some other more socially acceptable compulsive behavior or more readily hidden behavior. This can be some behavioral compulsion or addiction or what is alternately called enabling, caretaking, or co-dependent behavior. Co-dependency can be considered another form of addiction. As an interpersonal/relational addiction- in other words, one partner is an enabler (co-dependent, co-addict, etc.), a similar approach to the approaches to substance and other behavioral addictions, to his/her addictive relationship to the other may be indicated. The significant concordance of two partners both with substance abuse or addiction may be well overshadowed by a much higher concordance of two addicted partners with one partner's substance addiction complemented by the other partner's behavior-based addiction. In couple therapy with an individual who is a substance abuser or behaviorally compulsive, there is a strong likelihood of the partner having at least an interpersonal addiction. Rather than problematic use or addiction to some substance or a behavior, in an interpersonal addiction, the other half of the concordant couple has problematic use or addiction with or to the person of the addict. The therapist's goal is to get the co-addict partner to acknowledge his or her "craving," continued use despite adverse consequences, withdrawal, and other criteria for dependence.
The compulsive habitual behavior including craving and withdrawal symptoms could be the consequence of being unable to but still needing to establish healthy attachment and stable mutually beneficial intimacy. The therapist should consider this as another form of a concordant couple and adapt therapy appropriately. Once the therapist identifies this structure and dynamic, therapy should work to have the partners, especially the non-substance abusing partner acknowledge themselves as an addictive couple. Then the question arises of what makes the partner give permission to the addict to continue to use or act out can be asked. This leads to the issue of relational "self-medication." Relational self-medication includes giving second chances, settling for occasional nurturing, pleasing behavior, and so forth. In other words, the co-addict is getting a relational "fix" for such issues as attachment loss, abandonment or rejection anxieties, old trauma, family-of-origin abuse, and other emotional or psychological stresses. The underlying motivation for the co-addict to continue to giving permission (that is, staying in the relationship) for the addict to persistently act out needs to be uncovered. This is intrinsic and fundamental work in couple therapy with an addicted partner. The co-addict may finally come to understand his or her need and detach it from the present relationship. He or she may subsequently remove permission for the addictive use or behavior to continue. It is only at this point, might the addicted partner finally have sufficient motivation for terminating the relationship or seeking treatment in couple therapy. Or, not. At this point, the co-addict may have enough clarity to make an appropriate decision about leaving the relationship versus staying in the relationship. Or, perhaps to use therapy to work and recover from addiction together as a couple.
Couple therapy has a potentially powerful role in treating addiction. The couple therapist assists and empowers the partner as a facilitator to the addicted partner's change and growth against addiction. The partner is present and offers intimacy and attachment security. The addict looks to the partner for how he or she is received and responded to. He or she has fundamental needs for the partner's commitment, understanding, compassion, and support. These are the same needs that are waylaid, distorted, or forgotten when addiction entered the relationship. The intimate partner relationship often suffers the greatest destruction from the individual's addiction. At the same time, the couple as a natural dyad is the primary support system for the addict. And, is more important and powerful than other communities. Self-help or twelve-step program, groups, church, and other community or professional support systems can be beneficial but are less compelling than the intimate life partner. "…conjoint therapy provides an implicit acknowledgment of the relationship as the recovery unit and promotes the therapist's and addicted partner's sensitivity and responsiveness to the healing of the non-addicted spouse" (Zitzman and Butler, 2005, page 330). Treatment changes when the partners- David and Diane in their example "in conjoint therapy talked about the problems and solutions as if they owned them as a couple, not individually. Some participant couples explicitly noted this change: 'When you first start out, both parties are like, 'It is all about me and you don't understand'' (David). Diane's collaborative or 'we' orientation is implicit in her report that she became able to recognize that relapses weren't 'an attack against me,' but a 'severe temptation' or struggle that her husband was fighting against" (Zitzman and Butler, 2005, page 329).