Addictions in Couple and Family Therapy
Behavioral addictions, sometimes referred to as impulse control disorders, are becoming increasingly recognized as treatable addictions. In 2011, the American Society of Addiction Medicine (ASAM) departed from traditional conceptualizations of addiction as being limited to substance dependence and instead referred to addiction as a chronic disease affecting brain reward, motivation, memory, and related circuitry. Though debate continues regarding the nature, etiology, and terms used to describe various behavioral addictions, evidence suggests that these behaviors often involve a natural reward which maintains the behaviors despite the presence of aversive physical, mental, or social consequences.
Gambling disorder is the only behavioral addiction recognized by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association 2013). However, a growing body of research has applied the addiction model to a number of behaviors, including sexual intercourse, pornography use, shopping, video gaming, and Internet and computer use. Like substance dependence, these behavioral addictions contribute to a number of emotional, interpersonal, physical, spiritual, and financial difficulties for individuals and their families. Such difficulties pose a significant threat to an individual’s recovery process and to the structure and process of their family system. As such, clinicians and researchers have made efforts to address the impact of behavioral addictions on couples and families. The efficacy of these treatments remains limited.
Sexual and Pornography Addiction
Theoretical Context and Description. An increased awareness of sexual addiction among researchers and clinicians developed following Carnes’ (1992) publication. Sexual addiction, also known as hypersexuality and compulsive sexual behavior, refers to compulsive, excessive, out of control, or otherwise problematic sexual behaviors (e.g., sexual desire/drive, sexual intercourse, masturbation, pornography use, sexual chat/video use, and/or engagement in sexual fantasy). According to the behavioral addiction model for sexual addiction, individuals who engage in these behaviors experience craving prior to engagement in sexual activity, impaired control over sexual behaviors, and continued engagement in sexual activity despite negative consequences. Sexual addiction affects both men and women of all ages and ethnicities though it is more often reported among men than women. Individuals with sexual addiction often endorse co-addictions, including substance use disorders, which are often intricately intertwined with sexual activity.
Application of Concept in Couple and Family Therapy. Individuals with sexual addiction experience a range of consequences including sexually transmitted infections, unwanted pregnancies, abortion, financial loss, marital- and work-related problems, legal issues, and psychiatric comorbidities. Partners of such individuals often share the experience of these consequences in addition to feelings of shame, distrust, betrayal, anger, traumatization, helplessness, poor self-esteem, isolation, and diminished sexual intimacy. As such, a growing number of couples are seeking therapy with sexually based compulsive behaviors as the primary presenting concern. Couple therapy is considered an important method for rebuilding trust, communication, and intimacy among couples affected by sexual addiction. Despite recognition of this importance, limited resources are available for the treatment of sexual addiction within couples.
Of the few resources available to clinicians working with this population, the following treatment aims consistently emerge: psychoeducation regarding the nature of sexual addiction, restore trust in the relationship, examine cognitive and emotional effects of addiction on each member of the couple, develop adaptive communication patterns, reorient the addicted partner away from egocentrism and toward relationship responsiveness, address the broad systemic effects of sexual addiction within the family system (e.g., sexuality and withdrawal), facilitate forgiveness, establish healthy boundaries, reduce shame, and increase intimacy within the partnership and family (e.g., increase time together; Zitzman and Butler 2005). Structural and emotionally focused couple therapy demonstrated efficacy in accomplishing many of these aims. Due to the complex relations between the development of sexual addiction, the presence of early life traumas, and the role distortions observed in the family of origin for both members of the couple, couple therapy should supplement or follow individual or group therapy.
Therapists working with couples in which one or both members are affected by sexual addiction must provide a safe, nonjudgmental environment while promoting good boundaries (Turner 2009). It is important that therapists have well-developed self-awareness of their own beliefs and experiences regarding sexuality and accept the broad range of sexual expression. Identifying with one member of the couple could result in the other feeling alienated, leading to treatment termination. Research in this understudied domain remains limited to primarily white, heterosexual, married couples. Marriage and family therapists should therefore consider the potential limitations of applying existing treatment modalities to diverse populations affected by sexual addiction.
Theoretical Context and Description. Gambling disorder, sometimes referred to as problematic gambling, pathological gambling, or compulsive gambling, was reclassified by the DSM-5 (APA 2013) as a substance-related and addictive disorder. Gambling disorder is broadly characterized by difficulty in limiting time and resources spent on gambling and unsuccessful attempts to cut down on gambling despite significant psychological, financial, medical, occupational, or interpersonal consequences. The conceptualization of problematic gambling as an addiction followed after observed similarities between substance use disorders and problematic gambling with regard to symptom presentation, genetic vulnerabilities, neurological mechanisms, cognitive deficits, and motivations (Petry 2007). For instance, gambling is used by many to cope with aversive internal and external events. Gambling disorder often co-occurs with various other psychiatric conditions, including substance use, mood, anxiety, and personality disorders. Though gambling disorder is observed across multiple populations, young, nonwhite men with low socioeconomic status who are separated or divorced are at an increased risk (Petry 2007).
Application of Concept in Couple and Family Therapy. Couple and familial distress is both a contributor and consequence of problematic gambling. Partners of problematic gamblers often share the burden of financial distress associated with gambling in addition to feelings of guilt, shame, anger, betrayal, and loss of trust and the burden of upholding responsibilities for the family alone. These experiences paired with difficulty in communicating, resolving conflict, and maintaining sexual intimacy further exacerbate relationship dissatisfaction within such couples. Children and other family members of problematic gamblers often report adverse effects of gambling, including neglect, lying, deception, alcohol and drug problems, and family violence (Kalischuk 2010). Alternatively, couple conflicts, partner’s efforts to exert control over the gambler, poor social support, and conflictual attitudes from family members are major elements of relapse for individuals who engage in problematic gambling. Indeed, gambling may be such an integrated component of the family system that eliminating gambling by means of individual treatment alone may disrupt the dynamics within the family, leading to relapse or separation. To address these issues, researchers and clinicians advocate for the inclusion of couple and/or family therapy in the treatment of problematic gambling.
There is a paucity of resources for evidence-based, couple-focused treatments for problematic gambling with a majority of resources focusing on individual or group approaches to treatment. Congruence Couple Therapy (CCT), a short-term, integrative, humanistic, and systemic approach, aims to reduce problematic gambling while healing the emotional pain within the couple relationship (Lee and Awosoga 2015). In CCT, gambling is targeted within couples’ broader and deeper concerns. CCT accomplishes these aims during 12, 1-h weekly sessions which span across six phases of treatment: (1) engaging the client, (2) aligning with the couple and assessing couple communication and gambling, (3) facilitating congruence within the couple, (4) deepening experiencing, (5) linking the past to the present, and (6) consolidating changes. Similarly, Adapted Couple Therapy (ACT) for pathological gamblers (Bertrand et al. 2008) aims to support and encourage the gambler’s recovery while relieving the distress experienced within the couple. ACT involves two overlapping phases of treatment. In the first phase, management of the gambler’s problems and symptoms occurs (e.g., a functional analysis of gambling behaviors is performed, irrational cognitions are addressed, and emphasis is placed on developing empathy between partners). In the second phase, couple dimensions are addressed (e.g., developing caring behaviors, intimacy, constructive communication, and problem-solving skills). The efficacy of ACT for gambling has yet to be determined.
Other Behavioral Addictions
Theoretical Context and Description. Research examining addictions to various technological devices and activities (e.g., gaming, browsing, social networking, etc.), and compulsive buying (sometimes referred to as shopping addiction), remains controversial and limited. These behaviors are oftentimes conceptualized as being more closely associated with impulse control disorders and obsessive-compulsive disorders than with addiction. Nonetheless, terms such as “Internet addiction” and “shopping addiction” have received increased attention among researchers and clinicians who characterize these phenomena as excessive or poorly controlled preoccupations or urges to engage in these behaviors, leading to impairment and distress (Granero et al. 2016; Shaw and Black 2008). The growth of technology and the Internet contribute to significant overlap among these behaviors and other behavioral addictions (e.g., cybersexual addiction, online gambling addiction, and online shopping addiction). As with substance use disorders, neurological evidence suggests individuals with these behavioral addictions have abnormalities in reward-processing regions of the brain. Similarly, both reinforcement and punishment systems appear to contribute to the onset and development of these behavioral addictions. Unlike substance use disorders, these behavioral addictions depend on specific cultural mechanisms (e.g., market-based economy and materialistic values). Whereas more women than men endorse compulsive buying behavior, findings on gender differences in computer and Internet addiction are mixed.
Application of Concept in Couple and Family Therapy. Excessive use of technological activity (e.g., gaming, browsing, social networking, etc.) interferes with relationship functioning and flexibility within the family system in various ways. Partners’ concerns may include issues with the amount of time an individual spends on a technological device, how the technological activity interferes with familial responsibilities and relationship intimacy, and the extent to which a partner maintains appropriate boundaries with other individuals with whom she/he interacts through technological devices. Consequences of excessive or compulsive technology use may result in disrupted sleep, which may then affect the time and energy an individual puts into relationships. Couples in which one or both partners engage in some form of technology addiction may experience neglect, betrayal, jealousy, and reduced intimacy within their relationship. Similarly, compulsive or excessive buying behaviors may create hostility, lack of trust, and financial difficulties within couples, which may then subsequently and negatively affect buying habits.
No research has investigated the efficacy of couple or family therapy for couples in which one or both partners exhibit a technology addiction or compulsive buying. Nonetheless, therapists can work to help couples establish boundaries and rules within their relationship. Exploring couples’ conflicting value systems, motivations for and patterns of engaging in compulsive behaviors, and level of intimacy within the relationship may provide important therapeutic directions. Therapists should work to address couples’ use of disparate leisure activities, perceived neglect, and poor communication skills. In cases in which the entire family system is disrupted by such behaviors, family therapists can work to set boundaries on such behaviors within the family and replace disparate activities with family activities.
Steve and Sally have been married for 16 years and have a 12-year-old son. They recently sought couple therapy stating that their relationship was negatively affected by Steve’s pornography use. They viewed pornography together during sexual activities when they first married, which Sally described as a comfortable, intimate experience. However, over the past 10 years, Steve became increasingly secretive about his pornography use and began to use pornography alone on a daily basis. Sally reported she was uncomfortable with the type of pornography Steve used and the extent of his use. As a result, she had asked him to discontinue and Steve promised he would not use pornography anymore. When Sally and Steve’s 12-year-old son stumbled across a secret file on their computer where Steve had saved pornographic material, Sally became suspicious that Steve was continuing his pornography use. Again, Steve promised to quit using pornography. Sally became distrustful of Steve and frequently searched the house, his computer, and his Internet history on his cell phone to monitor his pornography use. When Sally found evidence of Steve’s pornography use, they would get in an argument, causing Steve to become more secretive about his pornography use. This process transpired throughout the last several years of their marriage. Sally stated that she did not trust Steve anymore, they lacked intimacy, and she began to perceive herself as unattractive. She recently threatened to end their marriage over his pornography use. Steve argued that he did not have privacy. He maintained that he found Sally attractive and that his pornography use did not affect his commitment to her.
Steve repeatedly promised he would stop using pornography, but was unable to stop and had in fact began using more graphic and novel forms of pornography. Steve was addicted to pornography. Just as many therapists suggest addressing substance use prior to beginning couples’ concerns, Steve and Sally’s therapist chose to address the addiction components prior to working on their relationship concerns. Once the addiction decreased, the couple system was restructured to improve marital functioning. Using a structural approach, the therapist focused on reducing the alliance Steve has with pornography in place of an alliance between Steve and Sally against the pornography. The therapist hypothesized that Steve’s relationship with pornography has strengthened over the years, while his relationship with Sally weakened. Steve relied on pornography, instead of Sally, for comfort. As a result, Sally grew to feel rejected from Steve.
After providing some psychoeducation regarding pornography addiction, the therapist helped Steve and Sally identify pornography as a third party in their relationship. Sally agreed that Steve’s pornography use felt like he was having an affair with another woman and that trust could be restored by Steve’s pornography discontinuation. The importance of trust and boundaries within the relationship were discussed, and they conceptualized what would constitute betrayal of trust and boundaries. The couple agreed that cheating, lying, and secretive behavior impeded trust, and attempting to cover up pornography use was similar to secretly meeting with an extra-dyadic partner. Sally expressed a desire to discontinue monitoring and detective work as a way to determine Steve’s honesty. Steve developed a realization that his addiction interfered with the type of relationship he wanted with Sally (e.g., one that included trust, open communication, and intimacy).
After developing these realizations and goals, Steve agreed to keep all of his pornography (e.g., movies, magazines, websites, etc.) in one clearly identified location so that Sally would no longer feel the need to search for it. Sally was pleased and discontinued searching for evidence of Steve’s use. Steve then agreed that he would only review pornographic materials in the established location with Sally’s permission. This pleased Sally as she began to trust Steve more, and Steve eventually decided to get rid of his materials as trust and intimacy further developed in their relationship. Furthermore, Steve began to feel closer to Sally as he began to receive help and comfort from Sally, as opposed to shame and anger, when he experienced urges. Sally also received comfort and consolidation from Steve as they focused on healing the wounds pornography placed upon their marriage. Future sessions focused on maintaining this process and increasing the time spent with one another. Follow-up sessions revealed Steve and Sally experienced increased relationship satisfaction.
- Carnes, P. (1992). Out of the shadows: Understanding sexual addiction (2nd ed.). Minneapolis: CompCare.Google Scholar
- Granero, R., Fernández-Aranda, F., Mestre-Bach, G., Steward, T., Baño, M., del Pino-Gutiérrez, A., Moragas, L., Mallorqui-Bagué, N., Aymami, N., Gómez-Peño, M., Tárrega, S., Menchón, J. M., & Jiménez-Murcia, S. (2016). Compulsive buying behavior: Clinical comparison with other behavioral addictions. Frontiers in Psychology, 7, 1–9.Google Scholar