Couples and Substance Use: a Different Treatment Approach – Part 2

Next, I’ll describe how a “systems approach” helps when I am in the beginning stage of building a client relationship.


When a couple enters therapy, there is often a tendency for one partner to blame the other person for the difficulties.  Also, our culture explicitly (and sometimes vehemently) encourages scapegoating, especially when there is an extramarital affair or a substance use problem. I feel strongly that a couple will benefit by developing a much more complex understanding of their difficulties.  This includes being able to explore the meaning and utility of the substance use to both the person who uses the substance and the relationship (for example, it might help enhance sex or help with anger management).  Just as importantly, the couple needs to understand that the way their relationship functions can make any particular type of change more difficult or less difficult, depending on the specifics.  I help couples see their “system” or relationship more objectively and avoid scapegoating, and learn what is moving them toward their goals and what is moving them away.

The stigma of substance use embedded in our culture is powerful.  Even though many advances are being made in understanding the science of addiction, the prevailing social view is that a character flaw is the heart of the problem.  The belief is simple: Once you understand the harm that substances cause, that should be enough incentive for you to stop using.  Therefore, if you do not stop, there is something flawed about you.  But as a couple shifts to a more complex understanding of the problem both within each member and between the two (the “systems perspective”) the person using the substance feels less stigmatized, and the couple is more able see how complex the problem is, both within each member and between the two.



I work from a harm reduction vs. abstinence only perspective.  Harm reduction focuses on helping the individual make changes that reduce the negative consequences of their use.  In contrast, the abstinence only approach holds that abstinence is the fundamental goal, and any use indicates a failure to reach the goal.  Harm reduction theory says that the therapist should collaborate with the couple to create goals. The goals may or may not ultimately include abstinence.  Any changes that reduce harm are supported, even if other harmful consequences have not yet been addressed.  This harmonizes beautifully with the way a systems perspective encourages discovery of goals through exploration, rather than relying on an external “authority” to determine what is good or bad.  But in the traditional abstinence only orientation, the goal of abstinence is already established before the couple even begins their first session!  If they do not agree with this goal, then they are supposedly “in denial” which the therapist must help them “break through.” I believe that such a rigid stance can do harm to both the couple and to the therapeutic relationship.

Next time, we’ll look at additional dimensions of treatment in this model.

Thank you for reading!