Fall 1998
Imago Therapy & Substance Abuse

As mental health professionals, substance abuse is a familiar theme we often suspect with many of our couples. When we do confirm it, or it is voiced by one or both partners, many of us wonder how Imago Therapy fits in. Is addiction a problem of the individual therefore to be treated separately until it is stabilized? Or should the individual receive simultaneously individual addiction treatment and couples therapy? Or can addiction be treated within the context of couples therapy only? A recent on-line discussion with the Imago Therapists prompted me to think if Imago's metatheory still holds true. Are there exceptions to the belief of seeing couples together and never separately? Is conflict always growth trying to happen through the restoration of connection, even within the addiction framework? Is the addictive personality a product of context and a result of childhood wounding?

When substance abuse is present in a marriage/committed relationship, it is often the addict-codependent dynamic, each feeding the other's realities and roles. For example, the active addict may use relationship problems as excuses to take a drink or a snort or an all night binge "every once in awhile." The codependent may continue with barrages, blaming the addict for all of his/her pains and feelings of low self-worth. There may be many factors that causes addiction--genetic, psychosocial, and/or environmental. But this push and tug dynamic--which is an attempt to remain connected albeit negatively--seems to be standard across the board. As in the relational paradigm, these two entities co-create, maintain, and influence one another. Therefore, on a foundational level in order for recovery to occur, the dynamic of the relationship needs to fundamentally change.

In addition, it is often the case that the alcoholic-codependent relationship has childhood origins where at least one parent or caregiver was an active addict. This Imago match is an unconscious attempt to recreate the childhood scenario in order to begin the process of healing. Given all of that, is it really feasible to see the couple together where active addiction is occurring?

Recently, an innovative rehabilitation program called Counseling for Alcoholics Marriages (Project CALM), a program of the Harvard Medical School, treats the drinker and spouse together. In APA's Professional Psychology: Research and Practice (1997, Vol. 28, No. 3), Robert J. Rotunda and Timothy J. O'Farrell describe the program and corresponding results in their article titled, "Marital and Family Therapy of Alcohol Use Disorders: Bridging the Gap Between Research and Practice." The overall purpose of the project is to increase relationship stability which in turn helps clients maintain sobriety. The project uses four distinct phases: (1) initial engagement of the patient and partner; (2) 10-12 weekly couple sessions; (3) 10 weekly couples group sessions; and (4) quarterly follow-up visits for the final 24 months. Although two-thirds of CALM clients start the program after discharge from an inpatient detoxification or rehabilitation program, the remaining third are direct outpatient referrals from the community and are often still drinking.

In the program the couples commit to not threaten divorce or separation during the course of therapy and to complete weekly homework assignments. Couples learn exercises to increase positive activities, improve communication skills, and negotiate desired behavior changes using positive specific language. Each couple by the end of the formal program completes a continuing recovery plan. The results? Compared with individual alcohol counseling, Project CALM produces couples with fewer relapses and fewer divorces.

All of Project CALM's objectives stated above are standard Imago Therapy practices. Adding an addiction-codependent component to Imago's psycho-education process would facilitate a greater understanding of the progressive disease and its effects. Additionally, the use of the Couples Dialogue would have several positive affects unique to the addict-codependent relationship. For instance, empathy, often achieved through the awareness of the childhood wound, may have a similar affect as an intervention process: when the addict (the Receiver) participates in the emotions of the affected spouse (the Sender), the wall of denial is often broken and s/he will seek to close this catastrophic exit. Lastly, our colleague Bruce Wood, CSW* estimates that it takes between five and seven years from the point of diagnosis to achieve stable abstinence. Therefore, as Imago Therapists, maintaining our neutral and non-judgmental stance, moving slowly, and letting go of expectations become essential when working with this type of couple.

Ideally, the addict-codependent relationship can begin the road to recovery within the context of their relationship, as outcome studies like Project CALM are beginning to show. However, there are times when an immediate detoxification or intense rehabilitation program is necessary to overcome the acute physical urges an active addict may experience. And it is often the case where an addict and codependent in recovery need intense therapeutic support which is not financially feasible in a couples therapy setting. Therefore, participation in additional resources such as AA for alcoholics and Al-Anon for partners may be a necessary complement to the Imago Therapy office. Bruce Wood, who has extensive experience in working with individuals and couples with addiction, recommends that in such cases, the therapy sessions become a place where the partners can share their separate experiences thus bridging the relational healing rather than fostering separate "healing" experiences.

Personally, I would love to see a program available for the addict-codependent couple, an ongoing support group that is free and widely available. The dynamics of the relationship that continue to play out, the unique relationship and individual experiences, will find mirrors in such an accepting atmosphere, thus fostering continued sobriety, lesser divorces, and ultimately greater connection.

* Bruce Wood covers his thoughts and experiences on addiction in his chapter "Addiction, Couples and Recovery" in the Healing in the Relational Paradigm available through IIRT.

"If you see separate therapists or the same therapist at different times, you might inadvertently focus on issues that would help you live more autonomously, not help you live more harmoniously as a couple." Harville Hendrix, Ph.D. Getting the Love You Want