The Effects of Alcohol and Substance Use on a Couple System

Theoretical and Research Basis

Case Introduction

This case study will analyze the effects of alcohol and substance use on a couple system at a community agency. Privacy rights and informed consent were reviewed and signed. Progress notes were completed following sessions, and information was collected via self-report at the beginning of treatment and again at the end of treatment. The clinician was an independently licensed professional clinician. The clients participated in couples counseling for 20 sessions and lasted for 8 months. The couple system is comprised of a heterosexual, African American, couple in their early 30s. For the purpose of this case study, the couple’s identity will be masked in order to protect confidentiality; they will be referred to as male (Ben) and female (Anna). Ben self-referred the couple for counseling services to resolve issues of infidelity. The couple reported dating for over 5 years and recently became engaged. The couple began cohabitating after their second year of dating. Both Ben and Anna reported struggling with GAD since childhood and major depressive disorder in early adulthood. The couple had been diagnosed with V61.10 Relationship Distress with Spouse or Intimate Partner.

The couple presented in crisis due to infidelity by Ben occurring within the week of the first session. Anna reported “finding out” Ben was unfaithful when he sought out sexual interaction from unknown women via social media. Ben admitted to seeking sexual interactions and noted remorse. The couple expressed a desire to resolve trust issues and heal from infidelity. The couple reported utilizing alcohol to cope with stress of infidelity and difficulty communicating. They also reported preexisting limited social supports, individual interests outside of the relationship, difficulty expressing thoughts and emotions in a healthy manner, and limited coping skills. Ben expressed that there was a lack of intimacy in the relationship and sense of disconnect prior to infidelity. After infidelity, the lack of intimacy and disconnect increased. The couple noted using substances and alcohol to cope with increased relational strain and reported consuming liquor and beers and smoking marijuana nightly. Ben reported weekly opioid and benzodiazepines such as Percocet, Xanax, Ativan, and OxyContin as well. Both clients reported prior individual mental health counseling treatment and were individually diagnosed with GAD and major depressive disorder. They reported struggling to manage anxiety symptoms and wanted to “move on” from infidelity quickly. Ben and Anna attempted to rush the process of moving past infidelity, increased relational strain, and increased individual mental health systems, and therefore did not allow for appropriate processing and healing.

The couple’s relational structure prior to infidelity was inconsistent and dysfunctional. The clients reported not having clear boundaries, expectations, roles, rules, or responsibilities. The clients also reported living two independent lives in the same home. Anna explained that she had her separate friends, hobbies, finances, and daily routine. Ben noted having his own hobbies, friends, managed his finances independently, and made unilateral decisions for himself. The couple did not make decisions as a couple system. They struggled to make joint decisions such as wedding planning. Anna noted not having to “act” as a united couple system before wedding planning. The couple also struggled to seek help and comfort from one another, creating distance in their relationship. The couple attempted to seek help and comfort from their family of origin and close friends. Anna’s mother was often triangulated into wedding planning decisions due to the couple’s difficulty communicating and resolving conflict. The clients noted utilizing substances more frequently, increased arguments, and difficulty resolving conflict together. Anna noted less desire to assist Ben with household duties or communicate financial concerns. In response, Ben limited his interactions with Anna. The couple no longer fulfilled their role obligations to one another as they once did. The couple was unsure who was making dinner, doing the laundry, and completing other household tasks. The increased relational strain impacted the couple’s boundaries by exacerbating the inconsistent and rigid boundaries.

This case has been selected for analysis due to the negative impact of substance and alcohol use on the couple’s ability to establish a cohesive marital structure. Long-term substance and alcohol use was reported during the diagnostic assessment. Both clients reported daily alcohol and marijuana usage to cope with relational stress and preexisting Major Depressive Disorder (MDD) and GAD. Ben reported abusing opioids and benzodiazepines regularly. Ben’s pattern of utilizing substances to cope with life stressors and mental health symptoms impacted his physical health and was a barrier in the couple relationship. Anna struggled to communicate her needs due to worry of exacerbating Ben’s physical and mental health. The couple struggled to get out of their toxic pattern. The clients’ individual toxic patterns contributed to the hesitancy in creating a cohesive couple system.

Presenting Problems

The couple presented with difficulty communicating, lack of intimacy and connection, limited social supports, trust issues stemming from recent infidelity, individual mental health symptoms, regular alcohol and substance use, and lack of healthy coping skills. Ben self-referred the couple for counseling due to seeking sexual contact with individuals outside of the couple relationship via social media. Anna noted seeking sexual contact outside the relationship as a form of infidelity and became aware of Ben’s actions when borrowing his phone. The couple reported that infidelity had severely exacerbated their previously strained relationship as well as their alcohol and substance use.

History

The couple reported dating for 5 years, cohabitating for 3 years, and engaged for less than a year. The couple met in college through mutual friends and began dating soon after meeting one another. Ben reported alcohol and substance use in college before meeting Anna. Ben reported abuse of heroin, opioids, benzodiazepines, marijuana, alcohol, synthetic drugs, and methamphetamines. Ben reported taking various substances together with alcohol to “experiment and have fun” while in college. Anna reported Ben became paranoid, experienced SI, withdrew from peers and family, increased irritability, acted impulsively, and hid in his basement frequently when abusing a variety of substances in one evening. Ben denied health complications from alcohol and substance use while in college. Ben reported difficulty maintaining and making friends, strained relationship with family members, poor academic performance, and increased depression symptoms while intoxicated. Ben also noted utilizing alcohol and substance to cope with increased depression and anxiety symptoms. Anna reported regular alcohol and marijuana abuse while in college as well. Anna reported utilizing alcohol and marijuana to reduce GAD symptoms when socializing with peers. Anna reported the need to increase alcohol and marijuana use in college due to increased desire to socialize with peers. Anna reported experiencing reduced appetite, interruption in sleep patterns, difficulty completing academic assignments, difficulty maintaining finances, fatigue, increased irritability, decreased self-worth, and decreased ability to cope with social anxiety without alcohol and substance use. Ben reported no longer abusing heroin or methamphetamine after cohabitating with Anna. Anna reported abusing alcohol and marijuana on a daily basis after cohabitating with Ben. Anna reported increased alcohol and marijuana usage to “bond” with Ben. Ben reported ending heroin and methamphetamine use due to worry and fear Anna experienced when Ben was not sober.

Assessment

Clients completed the AUDIT-C to assess for alcohol abuse. The AUDIT-C is a 3-item alcohol screen to assess for problematic alcohol use (Bush, Kivlahan, McDonell, Fihn, & Bradley, 2008). The AUDIT-C was reported as a valid and reliable assessment of screen for risky drinking and alcohol abuse. However, the assessment did not test for validity on minority populations. The effectiveness of the AUDIT-C with minority populations was completed and found the AUDIT-C to be a valid measure with minority populations including African Americans as well (Frank et al., 2008). A positive screen for problematic alcohol use is four or more for men and three or more for women. Both clients scored positive for problematic alcohol use. Further assessment of alcohol consumption was assessed verbally with open-ended questions during the initial session.

The Drug Abuse Screen Test (DAST-10) was also completed to screen for substance use. The self-reported assessment consisted of 10 yes or no questions and was condensed from the 28-item DAST. The assessment was normed on adult and adolescent populations (Skinner, 1982; Yudko, Lozhkina, & Fouts, 2007). DAST-10 indicated both clients used substances. Further substance use was assessed verbally by clinician utilizing open-ended questions.

Case Conceptualization

Most couple and family therapy models share the assumption that the presenting difficulties are inextricably tied to the relational patterns of behavior of the systems in which they exist, usually the family (Stratton et al., 2015, p. 2). Therefore, authors deemed the most appropriate modality of CBT and alcohol and drug abuse treatment to be in the form of couple’s therapy. The following case conceptualization will take the many variables of this case and view it from a systemic lens.

Ben’s continued substance use throughout the relationship interfered with the couple’s ability to establish clear boundaries, repair trust, increase positive communication, and intimacy in the relationship. The couple bonded over marijuana usage and alcohol consumption nightly as a destressor per clients’ report. The difficulty maintaining sobriety in the evenings hindered the couple’s ability to resolve conflict, engage in positive communication, and process through Ben’s infidelity. Ben reported a past history of substance and alcohol usage beginning in young adulthood and reported utilizing substances as a coping mechanism. Anna reported engaging in alcohol and substance use as a coping after cohabitating with Ben. Anna noted feeling “hung over” frequently, fatigue, increased irritability, difficulty regulating mood, short temper, headaches, and increased mental health symptoms due to continued substance and alcohol usage. Anna noted a commitment to reduce alcohol consumptions and stop marijuana usage to increase her health and relational satisfaction. Anna made this commitment half way through the counseling process after beginning individual counseling sessions. Ben reported similar symptoms along with difficulty concentrating, reduced sexual drive, erectile dysfunction, SI, aggression, and panic attacks. Ben noted fear of depression becoming worse if he were to reduce substance usage. His struggles of low self-worth have led to rigidity in the couple system and the individual conflict avoidance pattern have led to disengagement in the couple system. The couple noted underlying fears of being left by their partner if they were completely open and vulnerable. The negative core belief of not being good enough or “toxic” fueled the rigid and inconsistent boundaries. Ben acknowledged using substance to self-sabotage the relationship and to also “test” Anna’s commitment to him. Anna noted worrying about Ben’s physical and mental health throughout the counseling processes. The Ben experienced withdrawal symptoms halfway through the counseling session and noted intense SI, tearfulness, unbearable physical pain, headaches, change in sleeping pattern, and increased aggression. Ben was referred to the local emergency room for treatment and to assess for SI. Anna reported Ben’s behaviors in the emergency room were scary and upsetting. Anna noted worrying for Ben’s mental stability, physical health, and potential legal ramifications if Ben continued alcohol and substance use. Ben reported desire to attend counseling services for alcohol and substance use but struggled to make an appointment.

Ben was referred to AOD services and individual counseling. Anna maintained individual counseling and reduced alcohol and marijuana usage. Ben attempted to reduce alcohol and substance use multiple times during the course of therapy with limited success. Ben did not engage in AOD treatment or individual counseling. Ben noted a desire to receive services but struggled to follow through with referrals. As a result of continued alcohol and substance use, Ben’s mental health, physical health, and relationship were negatively impacted. Ben reported three incidents of public intoxication in which Ben became verbally aggressive, incoherent, engaged in risk-taking behaviors, and refused to stop drinking. Ben reported “blacking out” and not remembering the three incidents of extreme intoxication. Ben noted he will attempt to reduce alcohol and substance use on his own and “did not need professional help.” Anna reported frustration and worry regarding Ben. Anna also reported in counseling session feeling unable to communicate her emotions and needs due to fear of upsetting Ben. Anna reported feeling powerless and increased depression symptoms due to Ben’s difficulty reducing alcohol and substance use. Anna was able to notice the extent of the Ben’s substance use after gaining sobriety from alcohol usage, per Anna’s report. The couple no longer bonded over alcohol and substance use around the 13th counseling session. Anna’s resistance to using leads Ben to withdraw and utilize alcohol and substances alone.

The couple struggled to alter their dysfunctional systemic hypothesis. The systemic hypothesis, an assessment offering theoretical assumptions regarding individual members’ interactions and impact of symptoms maintaining dysfunction, highlighted the couples pursue and withdraw pattern when conflict arises (Selvini, Boscolo, Cecchin, & Prata, 1980). Figure 1 displays the couple’s initial systemic hypothesis impacted by alcohol and substance use. The systemic hypothesis noted the couple’s difficulty resolving conflict as needed suppresses emotions and thoughts when a crisis arises with alcohol use. The client’s difficulty expressing thoughts and emotion in a positive manner combined with individual insecurities regarding the relationship become overwhelming. The couple reported utilizing alcohol and substance to cope and “move past” conflict. The conflict never resolves and builds up over time. As conflicts build up, the couple noted increased use of alcohol and substances to cope and ignore issues. Ben noted a fear of the relationship ending if problems and conflict were discussed. Ben noted withdrawing from the conflict in an attempt to have Anna pursue him and seek him out. Ben noted feeling “toxic” and did not feel he deserved to be in the relationship, which also motivated his withdraw pattern. Anna noted a need have a role or purpose in Ben’s life due to not feeling “good enough.” Individual self-efficacy can greatly impact the couple relationship (Mannarini, Balottin, Munari, & Gatta, 2017). The couple’s negative self-efficacy aided to the distance and lack of communication within the couple system. The couple noted negative core beliefs and worry of abandonment by their partner fueled their withdraw/pursue pattern. Both Ben and Anna were referred for individual counseling to address negative core beliefs and learn positive coping skills and resolve individual mental health symptoms. Anna began individual counseling sessions, half way through couples counseling. Ben noted hesitancy to reduce substance usage and did not seek out individual counseling. Anna was able to challenge negative core beliefs and interrupted her individual pattern of withdrawing when a crisis occurs and then pursuing Ben. The change in Anna’s behaviors led to a change in Ben’s behaviors. Ben longer received the same response when withdrawing from Anna during an argument. Figure 2 illustrates the ending systemic hypothesis after progress in counseling has been made. Anna was able to express her thoughts and emotions in a positive manner. Ben struggled to do so and “shut down” and continued to withdraw. Anna no longer pursued Ben in an attempt to comfort and rescue him. Ben then increased substance use and his depression symptoms increased, per Ben’s report. Ben’s increased substance use and inability to cope with depression symptoms was worrisome to Anna, motivating her to pursue and comfort Ben. Eventually, Ben was able to cease the negative cycle, thus prohibiting the relational system from continuing the prior structure of dysfunction.

OPEN IN VIEWER

Figure 1.

Initial systemic hypothesis.

OPEN IN VIEWER

Figure 2.

Ending systemic hypothesis.

The couple’s treatment plan consisted of clarifying the hierarchy, rules, roles, and boundaries within the couple system. Ben and Anna will practice actively listening to one another and practice communicating thoughts and emotions in a clear manner. The couple boundaries will also be clarified and agreed upon by both clients which will increase relational satisfaction.

Course of Treatment and Assessment of Progress

The couple’s treatment plan consisted of clarifying increasing trust, communication, and intimacy. In order to meet the couple’s goals, individual goals of using healthy coping skills, reducing alcohol and substance use, and addressing individual negative beliefs had to be addressed as well. The first few sessions centered on the couples trust issues stemming from Ben’s infidelity and barriers to communication. The couple struggled to make progress due to continued alcohol and substance use. The couple had been in therapy for 8 months. The early stage of therapy consisted of joining the couple system, understanding their cultural and world perspective, and analyzing structural patterns and interactions (Minuchin, 1974). The therapist explored the clients’ understanding of the presenting problem and assessed individual and couple system dynamics, family history, and medical history. The individual and couple system strengths were observed as well. The therapist acted as a coach and collaborated with the couple to assist in exploring and utilizing resources in order to maintain second-order change. Individual dysfunctional patterns were explored as well as resistance to creating couple system.

The couple struggled to alter their dysfunctional systemic hypothesis. The systemic hypothesis, an assessment offering theoretical assumptions regarding individual members’ interactions and impact of symptoms maintaining dysfunction, highlighted the couples pursue and withdraw pattern when conflict arises (Selvini et al., 1980). Initial and ending systemic hypotheses were utilized to assess the couple’s progress resolving conflict and impact of alcohol and substance use. Figure 1 displays the couple’s initial systemic hypothesis impacted by alcohol and substance use. The systemic hypothesis noted the couple’s difficulty resolving conflict as needed suppresses emotions and thoughts when a crisis arises with alcohol use. The client’s difficulty expressing thoughts and emotion in a positive manner combined with individual insecurities regarding the relationship become overwhelming. The couple reported utilizing alcohol and substance to cope and “move past” conflict. The conflict never resolves and builds up over time. As conflicts build up, the couple noted increased use of alcohol and substances to cope and ignore issues. Ben noted a fear of relationship ending if problems and conflict were discussed. Ben noted withdrawing from the conflict in an attempt to have Anna pursue him and seek him out. Ben noted feeling “toxic” and did not feel he deserved to be in the relationship, which also motivated his withdraw pattern. Anna noted a need have a role or purpose in Ben’s life due to not feeling “good enough.” The couple’s negative core beliefs fueled their withdraw/pursue pattern. Both Ben and Anna were referred for individual counseling to address negative core beliefs and learn positive coping skills and resolve individual mental health symptoms. Anna began individual counseling sessions, half way through couples counseling. Ben noted hesitancy to reduce substance usage and did not seek out individual counseling. Anna was able to challenge negative core beliefs and interrupted her individual pattern of withdrawing when a crisis occurs and then pursuing Ben. The change in Anna’s behaviors led to a change in Ben’s behaviors. Ben no longer received the same response when withdrawing from Anna during an argument.

CBT interventions were utilized to challenged negative thoughts and cognitive distortions enforcing alcohol and substance use as well as dysfunctional communication. Epstein and Zheng (2017) noted CBT was helpful when working with couples in challenging negative thoughts to reduce emotional distress. The clients’ negative individual and relational beliefs were challenged allowing for healthier problem-solving and communication. Anna was able to challenge her negative thoughts and beliefs which intern assisted her to increase her self-worth and reduce GAD and MDD symptoms. Ben struggled to challenge negative beliefs and thoughts and was unable to consistently increase self-worth and reduce GAD and MDD symptoms. When both clients were able to challenge their individual and relational thoughts, they were able to respond to each other’s emotions and thoughts in a positive manner. When the couple or one of the clients struggled to utilize CBT interventions, one partner interpreted the other’s behaviors as a rejection, triggering their negative systemic hypotheses to continue.

The middle phase consisted of implementing structural changes to alter the couple’s dynamics and reduce dysfunction. The couple system and individual clients were empowered and strengthened, boundaries were clarified and agreed upon, and the hierarchy between Ben and Anna was adjusted. Figure 2 illustrates the ending systemic hypothesis after progress in counseling has been made. Anna was able to express her thoughts and emotions in a positive manner. Ben struggled to do so and “shut down” and continued to withdraw. Anna no longer pursued Ben in an attempt to comfort and rescue him. Ben then increased substance use and his depression symptoms increased, per Ben’s report. Ben’s increased substance use and inability to cope with depression symptoms was worrisome to Anna, motivating her to pursue and comfort Ben. Ben eventually was able to continue the negative cycle and prohibit the relational system from relieving their structure of dysfunction. Toward the end of the counseling process, Ben was able to challenge negative thoughts and utilize CBT interventions more consistently, allowing for healthier communication and conflict resolution in the couple. Figure 2 illustrates Ben’s attempts of challenging negative thoughts to increase positive behavioral responses to Anna.

The couple struggled to move onto the final phase of therapy due to resistance of creating functional individual patterns. Both Ben and Anna noted with struggling with negative cognitions and negative belief of “not being good enough.” Ben and Anna’s fear of “ruining,” the relationship inhibits the couple system from creating a functional homeostasis. Ultimately, Ben struggled to reduce alcohol and substance use and alter the couple’s conflict resolution patterns. Couples counseling ended after 20 sessions due to Ben’s difficulty reducing substance use. Ben was referred to alcohol and other drug assessments and counseling agencies for individual treatment. Anna continued her individual counseling. The couple will return to couples counseling after Ben gains sobriety for alcohol and substances and develop copings skills to address GAD and MDD. The clients reported a desire to resume couples counseling and a commitment to individual counseling services. The couple’s termination AUDIT-C and DAST-10 reported decreased alcohol and substance use. Verbal assessment of client’s alcohol and substance use indicated Anna no longer uses marijuana and drinks socially with peers. Ben attempts to no longer drink alone and noted reduced opioid and benzodiazepine use.

Complicating Factors

A major limitation during the course of therapy was a lack of alcohol and substance use treatment within the community agency. The community agency did not have the proper resources to assess and treat the client’s alcohol and substance use. The agency also did not have the resource to address the physical health complications related to the alcohol and substance use. Alcohol, substance use, and medical resources and professionals would have greatly impacted the course of treatment by providing biological, psychological, and social treatment interventions. Resources within the agency may have assisted in reducing Ben’s hesitancy to addressing alcohol and substance use, allowing for the couple’s dysfunctional pattern to be altered.

Access and Barriers to Treatment

The clients’ had access to couples and individual counseling within the community agency. The clients however did not have direct access to medical, alcohol, or substance use treatment within the facility. The clinician was able to refer Ben to outside agencies with the corresponding services and resources. Ben was also advised to seek treatment from the community emergency room when experiencing SI related to substance use. Ben reported self-medicating with alcohol and substances to cope with GAD and MDD symptoms. Ben could have benefited greatly from psychiatric resources to address mental health, physical health, and substances use concerns.

Follow-Up

The couple counseling sessions were prematurely terminated due to the need for Ben to address alcohol and substance use concerns. Ben’s continued alcohol and substance use was hindering the couples’ ability to end their toxic pattern of communicating and resolving conflict. Anna continued individual counseling in the community agency and Ben was referred for individual counseling at an alcohol and other drugs agency. Ben was encouraged to seek individual counseling to address substance use, depression, and anxiety symptoms. Anna’s individual growth has altered the couple’s structure and systemic hypothesis. Ben’s hesitancy to work on individual issues hindered the couple system’s ability to achieve lasting change, create a structure without dysfunction, or work toward an ideal systemic hypothesis. Future sessions will include challenging Anna’s pattern of rescuing Ben as well as the function of Ben’s substance use in a relational context.

Treatment Implications

The clients presented with difficulty resolving conflict, lack of intimacy, sense of disconnect, rigid and inconsistent boundaries, and difficulty creating a relational structure which were exacerbated by alcohol and substance use. The couple struggled to make joint decisions and reported “tense” conversations surrounding wedding planning. Ben and Anna’s negative core beliefs motivated negative patterns of interaction and reluctance to become vulnerable and clarify boundaries. As individual negative beliefs were challenged, the couple felt more comfortable clarifying boundaries, needs, and desires. The couple noted later in the counseling process feeling more secure in the relationship and comfortable communicating needs as the alcohol and substance use declined. The clients noted increased intimacy and having a fulfilling sexual relationship half way through the counseling process after Anna began individual counseling. The clients also noted increased success resolving conflict and making joint decisions regarding wedding planning, finances, and future family planning. Ben reported increased connections with Anna and feeling like “best friends” again. The couple noted attempts to clarify expectations, roles, rules, and responsibilities in order to determine appropriate boundaries and hierarchy in the couple system. The therapist will continue to address barriers to altering their consistent withdraw and pursue pattern and work toward alleviating the structure of dysfunction after resuming couples counseling. Addressing alcohol and substance use in addition to presenting relational concerns assisted the clients individually and relationally. Ideally, if the couple abstained from substances completely, there would be further progress in reducing relational issues. The couple’s inability to maintain sobriety during the course of treatment impacted their systemic hypothesis and reduced effectiveness of treatment interventions.

Recommendations to Clinicians and Students

It is recommended that clinicians and students assess for alcohol and substance use from the initial session through the termination session. Substance abuse treatment for couples is most effective when couples counseling and abstinence from substances are simultaneously in effect (Fals-Stewart, O’Farrell, & Birchler, 2004). Alcohol and substance use served as a function in Ben and Anna’s relationship, it was discovered to be a bonding activity between the couple. They also initially explicitly stated not wanting to reduce usage. With further assessment on the impact of alcohol and substance use on individual and relational functioning, the couple was able to gain insight on the negative impact of using alcohol and substances to cope. The couple avoided conflict due to individual and relational insecurities, leading them to use alcohol and substances. The continued alcohol and substance use increased their difficulty to resolve conflict as well as fueled their toxic relational interactional patterns. The couple was unsure how to end their dysfunctional pattern and noted “drifting further apart.” Therefore, addressing addiction concerns is necessary in order to work through relational issues, which ultimately ensures long-term growth and change.