The Couple Recovery Development Approach: A Relational Approach to Addiction Treatment

the couples recovery development aproach - a relational approach to addiction treatment

Addiction Recovery: Why We Don’t See Couples

Evolution in the field of addiction research and treatment over the last 60 years, supports a relational perspective when treating substance use and compulsive behavior disorders. (Jacob, 1992; McCrady & Epstein, 1995; O’Farrell, 1992; Rotunda, Scherer, & Imm, 1995; Steinglass, 1976). Understanding the importance of relationships in addiction treatment provides treatment options and strategies to help not only the person with the substance use disorder (SUD), but also the people most impacted, especially the partner and family. In this article when referring to SUDs, I am also referring to compulsive behavioral disorders (process addictions).

Yet, for some reason, the prevailing model of treatment emphasizes individual recovery as the single priority. Couples are typically discouraged from talking to each other about the impact of addiction and recovery on the relationship until recovery is well established, perhaps a year or more. The advice to avoid or postpone couple recovery is often bound up in the fear addiction professionals have of partners losing sight of their individual recovery if the relationship issues are addressed too early in the process. What this really boils down to is the belief that the most appropriate treatment of choice, when it comes to couple relationships in transitioning from active addiction to recovery, is no treatment at all beyond education. The message is clear, “We do not encourage dialogue between partners about individual or couple recovery”.

How was this approach to recovery determined? Are there any studies that support this position?

Research Tells a Different Story

At first glance these concerns may appear reasonable;
it seems too much to expect people in early recovery to also manage relationship issues. Addressing relationship issues too soon is risky, increasing the possibility of triggering a relapse if partners get too upset or start to put their own recovery on the back burner by focusing on the relationship.

However, it may be surprising to find out there aren’t any empirical studies that actually support the position that couples work should be avoided in early recovery. In fact, research suggests just the opposite, relationship health and wellness is one of the strongest predictors of successful long-term recovery. Humphreys, Moos, and Cohen (1997) conducted a study to determine what predicted successful long-term recover at three – and eight-years after primary treatment and found that a satisfactory family relationship is one of the best predictive variables for long-term sobriety. Not surprisingly, additional support from external sources, such as mutual aid groups and outpatient psychotherapy, were also were pivotal to successful long-term recovery.
We now know that partners play a crucial role in relapse and recovery dynamics (Fichter, Gylnn, Weyerer, & Liberman, 1997; O’Farrell, Hooley, Fals-Stewart, & Cutter, 1998); for treatment professionals and the recovery treatment industry to not account for relationships in recovery is missing a critical piece in treatment. In a meta-analysis of studies across 1,571 cases of family-couples therapy with adult and adolescent drug abusers, Stanton and Shadish (1997) found family therapy as more effective than individual and group counseling, with results still apparent even 4 years after treatment ended.

Why We Need Couple Recovery Sooner Than Later

So how can couple recovery blend with and not work against, individual recovery? White and Cloud (2008) refer to “recovery capitol”, the internal and external resources that increase the likelihood of beginning and sustaining recovery from severe substance use disorders. White and Cloud identify three areas of recovery capital that addiction professionals can address and influence: a) personal recovery capitol, b) family and social recovery capitol, and c) community recovery capitol. The more recovery capitol accessible in each of these areas, the better the likelihood for successful, sustainable recovery. Family recovery capital includes intimate partner relationships with both partners supportive and a part of the recovery process and recovery efforts. Rather than viewing partners and couple work as a threat to individual recovery, family recovery capitol reinforces the importance of the couple relationship as an added support and potential resource in the recovery process. Combining and integrating individual and family treatment methodologies appears to maximize chances for long-term successful recovery. While it is crucial for partners to establish their own recovery, couple recovery serves to strengthen individual recovery making recovery an integral part of the relationship. Couple recovery does not replace or minimize in any way the importance of individual recovery.

Conceptualizing addiction as a “family disease” but treating it in a compartmentalized, individually-oriented approach that excludes the couple and family relationships eliminates the possibility of strengthening family recovery capitol. Sadly, we see the consequences of not addressing relationship issues early enough in recovery with divorce statistics estimated at four times higher for couples who have been impacted by an SUD (Clarke-Stewart & Irentano, 2007). The damage to relationships from SUDs follows couples well into recovery with many of these divorces occurring after starting recovery. For so many couples the transition from active addiction to recovery is in itself traumatic with the uncertainty of, “What now?”

Without some kind of guidelines most couples simply don’t have a model for how to talk about addiction and recovery in a healthy way. We abandon couples when they seem to need help the most, at an intense level of recovery and relational vulnerability. Additionally, when we advise partners to not talk about recovery with each other, we may inadvertently and unintentionally re-traumatize couples by creating recovery as the new “elephant in the room”, something that everyone knows is there, but can’t be acknowledged or talked about.

Couple Recovery Development Approach

My own research at the Mental Research Institute (MRI) in Palo Alto, California, began with my dissertation, a qualitative study on couples and long-term recovery from alcoholism (Navarra, 2002). The Couples Focus Group was a component of The Family Recovery Project directed by Stephanie Brown, Ph.D., and Virginia Lewis, Ph.D. (1999), the first study to ask the question, what happens to relationships after entering recovery? My research led to creating the “Couple Recovery Development Approach” (CRDA), a model and theory to explain the changes and challenges couples face in recovery over time (Navarra, 2007). Subsequently I was invited by MRI to continue research as a Senior Research Fellow, with the work still ongoing.

It turns out that the CRDA closely aligns with and is consistent with the research-based Sound Relationship House (SRH) model developed by Julie Gottman, Ph.D. and John Gottman, Ph.D. (Gottman, J. S., 2004) which evolved from John Gottman’s original ground breaking research on divorce prediction and factors that predict relationship stability (Gottman, 1999). My training in Gottman Method Couples Therapy with Drs. John and Julie Gottman eventually led to a journey of collaboration in research and writing (Navarra & Gottman, J. M., 2011; Navarra, Gottman, J. M., and Gottman, J. S., 2016). We are now establishing a randomized clinical trial to test these methods in treatment programs (Gottman, 2015).

The connection with the Gottmans and the Gottman Institute provided an avenue to develop the CRDA model from theory to practice. While CRDA was developed as a theory to explain the tasks for successful couple recovery, the model lacked interventions. In blending these models, the CRDA model now had interventions with adaptations from the SRH model aimed specifically for couples impacted by substance use and behavioral disorders.

In collaboration with the Gottmans and the Gottman Institute, I designed a two-day program called Roadmap for the Journey: A Gottman Workshop for Couples in Recovery. The workshop structure includes brief presentations, role-play demonstrations, and experiential exercises designed to help couples address relationship recovery at multiple levels. We provide couples: tools to acknowledge and process the trauma of addiction and the trauma of recovery; strategies for establishing a couple recovery; strategies for managing conflict; and techniques for moving forward to strengthen both individual and couple recoveries concurrently. After the demonstrations couples break out and practice the skills privately.

Addiction and relationship specialists trained in this model are on hand to assist couples who might need extra help or guidance in completing the exercise. Couples then meet in small groups, facilitated by the counselors to talk about the exercise and to process how it went. Over the two days, these process groups provide couples the opportunity to share and support one another. Each couple receives a workshop kit that includes the manual with the lecture content and explanation of each of the interventions, plus materials to continue working with the tools at home.

Before launching the workshop, I gave workshops to addiction professionals and therapists teaching participants the core interventions, setting up role plays, and asking for feedback. Finally, I was ready to give the workshop to the clinical population. Sponsored by treatment programs in each location, the Roadmap for the Journey workshops were offered to small groups of couples in Los Angeles, the San Francisco Bay Area, Arizona, and Seattle.

The Arizona workshop was given to the White Mountain Apache Tribe as a part of a three-day couple’s retreat sponsored by Rainbow Treatment Center. Concerns I had about cultural sensitivity and relevance were unfounded; there were very positive results and feedback from the participants and I was invited to return the following year to give another workshop. Since then, the model has been adapted and continued by therapist Michael Brown, MFT, Clinical Coordinator at Rainbow Treatment Center, and Certified Gottman Therapist.

Despite very different demographics in each of the groups, we found the responses to be very overwhelmingly positive. We learned a tremendous amount about what resonated with couples and received suggestions for changes in the curriculum going forward. Here are some results from 34 of the participants of the Seattle workshop:

91% of all workshop respondents felt the workshop was helpful to develop a couple recovery
94% reported the workshop was helpful, or somewhat helpful for their individual recovery
97% endorsed “Very important” when asked “How important is it for couples to address their relationship as a part of recovery?”

C.A.R.E.—Couples Addiction Recovery
Empowerment

A new recovery movement, Couple Addiction Recovery Empowerment (CARE), is a concept or approach in recovery that advocates addressing three recoveries concurrently: both individual recoveries, and the couple recovery. Recovery may be from a substance use or compulsive behavioral disorder. Central to the CARE concept is the position that each person is responsible for their own recovery, but both partners are responsible for the relationship. This concept is easily extended to apply to any serious medical or mental health issue that has “invaded” the relationship with partners addressing the reality of the impact of that disorder and the process of managing (recovering from) it, be it cancer, chronic pain, bipolar disorder, etc.

While “codependency” is characterized by unhealthy adaptations to addiction, “interdependency” in relationships is healthy and is characterized by having good boundaries and the ability to discuss and support individual needs and relationship needs without blame and without either partner taking on all the responsibility. We must include strategies that create empowerment through engagement at the social action level, advocating for recovery, and couple recovery even more specifically, in the political, social, and health care policy reform arenas.

For some couples the non-addicted partner may not identify with the term “being in recovery”, but in fact, both partners and the relationship have been affected by the substance use or compulsive behavioral disorder and by recovery. For those that may not relate to the word recovery, consider the concept and perspective of your own “wellness” as the focus for these discussions.

Couple Addiction Recovery Training

Despite the fact that addiction professionals and addiction-savvy psychotherapists will readily agree that addiction is a “family disease,” professionals simply don’t have a model for how to work with the family or the couple system, especially in early recovery. Even in long-term recovery, when there is less professional resistance to the idea of working with couples in recovery, there are not many comprehensive models to work from. Behavioral couples’ therapy tends to focus on reducing or eliminating use, not on treating a family system impacted by the trauma of addiction.

Tammy Shelton, MFT, is a friend and colleague who has been involved from the beginning in the development of the recovering couples workshop. As an addiction treatment specialist herself, she suggested I create a training workshop for therapists and addiction counselors on the tools and techniques I developed adapting and blending my research with the Gottman’s research. The end result was a one-day training sponsored by the Gottman Institute and National Marriage Seminars. I have presented the workshop in Seattle, Austin, San Diego, Chicago, Tampa, and Mission Viejo.
Participants receive a manual, workshop tools and handouts for clients, and learn 15 interventions to help couples develop a “couple recovery”, with tools to manage their relationship and integrate recovery into the relationship. Topics covered include: identify substance use and compulsive behavioral, break through denial, navigate the challenging road from active addiction to recovery, improve conflict management skills, learn the difference between “codependency” and “interdependency” and how to identify and set appropriate boundaries, develop a relationship recovery, while supporting each other’s recovery and strengthening individual recovery, heal from the aftermath of addiction and move toward wellness as individuals and as a couple.

Final Notes

O’Farrell (1992) advocates development of a family therapy specialty, suggesting the title “Families and Addictions” with emphasis on “…the study of the role of the family in the etiology, course, treatment, and prevention of addictive behavior problems, to include problems with alcohol, drugs, smoking, and obesity” (p. 339).
To be clear, there are sometimes good reasons to focus only on a client’s individual recovery and not try to deal with the relationship. It may be a matter of timing, or the client’s lack of interest or desire to deal with the relationship. A partner’s intense anger, issues of domestic violence, and readiness are all possible reasons (among many other possibilities) which may lead to the conclusion that couples work is contraindicated. The path will not be easy, recovery isn’t easy, and there are risks.
However, when having to manage things like shared parenting responsibilities, joint decision-making, or a desire for healing in the relationship, then a relational approach to recovery should be considered with specific goals in mind, which could vary greatly for each couple.

Supporting each other’s recovery isn’t “codependent” when boundaries are clear and the focus is on finding ways to appropriately discuss individual needs and relationship needs without blame, and without either partner assuming all the responsibility. Every relationship has its ups and downs, even when not dealing with recovery. What helps is to find ways to connect that work for both partners.

The Evolution of Addiction Treatment Conference
I have the privilege and honor of co-presenting at this year’s 2017 Evolution of Addiction Treatment Conference with Tammy Shelton, MFT. We look forward to sharing what we have learned about couple recovery with demonstrations of assessment, interventions, and a framework for helping couples to establish a couple recovery. Together, let’s join in supporting and advocating for Couple Addiction Recovery Empowerment.

References
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Clarke-Stewart & Irentano (2007) Divorce: Causes and consequences. New Haven: Yale University Press.

Fichter, M. M., Glynn, S. M., Weyerer, S., & Liberman, R. P. (1997). Family climate and expressed emotion in the course of alcoholism. Family Process, 36,(2), 202-221.

Gottman, J. M. (1999). The marriage clinic: A scientifically-based marital therapy. New York: W.W. Norton.

Gottman, J. M. (2015). Principia amoris: The new science of love. New York: Routledge.

Gottman, J. S. (2004). The Marriage clinic casebook. New York: W.W. Norton.

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McCrady, B. S., & Epstein, E. E. (1995). Directions for research on alcoholic relationships: Marital- and individual-based models of heterogeneity. Psychology of Addictive Behaviors, 9,(3), 157-166.

Navarra, R. J. (2002). Couples in recovery from alcoholism: Long-term and developmental processes (Doctoral dissertation, California Institute of Integral Studies, 2002). Dissertation Abstracts International, 63-02B, 3042888.

Navarra, R. J. (2007). Family response to adults and alcohol. Alcoholism Treatment Quarterly, 1(2), 85-104.

Navarra, R. J., & Gottman, J. M. (2011). Gottman method couples therapy: From Theory to practice. In D/ K. Carson & M. Casado-Kehoe (Eds.), Case studies in couples therapy: Theory-based approaches (pp.331-343). New York: Routledge.

Navarra, R. J., Gottman, J. M., and Gottman, J. S. (2016). Sound relationship house theory and marriage education. In J. J. Ponzetti, Jr. (Ed.), Evidence-based approaches to relationship and marriage education (pp. 93-107). New York: Routledge.

O’Farrell, T. J. (1992). Families and alcohol problems: An overview of treatment research. Journal of Family Psychology, 5,(3 & 4), 339-359.

O’Farrell, T. J., Hooley, J., Fals-Stewart, W., & Cutter, H. S. G. (1998). Expressed emotion and relapse in alcoholic patients. Journal of Consulting and Clinical Psychology, 66,(5), 744-752.

Rotunda, R. J., Scherer, D. G., & Imm, P. S. (1995). Family systems and alcohol misuse: Research on the effects of alcoholism on family functioning and effective family interventions. Professional Psychology: Research and Practice, 26,(1), 95-104.

Stanton, M. D., & Shadish, W.R., (1997). Outcome, attrition, and family-couples treatment for drug abuse: A meta-analysis and review of the controlled, comparative studies. Psychological Bulletin, 122, (2), 170-191.

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White, W. & Cloud, W. (2008). Recovery capital: A primer for addictions professionals. Counselor, 9(5), 22-27.

Robert Navarra bio