1 Addiction and Emotionally Focused Couple Therapy, A Replication Case Study Kara Fletcher ...

218 Pages·2017·0.95 MB·English

by  Kara Fletcher

Addiction and Emotionally Focused Couple Therapy, A Replication Case Study
Kara Fletcher, School of Social Work, McGill University, Montreal
March 2017

A thesis submitted to McGill University in partial fulfillment of the requirements of the degree
of Doctor of Philosophy
© Kara Fletcher 2017

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TABLE OF CONTENTS
ABSTRACT .................................................................................................................................................. 6
RÉSUMÉ ...................................................................................................................................................... 7
ACKNOWLEDGEMENTS ........................................................................................................................ 8
PREFACE AND CONTRIBUTION OF AUTHORS ............................................................................... 9
INTRODUCTION ..................................................................................................................................... 10
SUBSTANCE ADDICTIONS IN THE SOCIAL CONTEXT ..................................................................................... 10
ADDICTIONS IN THE COUPLE CONTEXT ...................................................................................................... 12
COUPLE FUNCTIONING AND SUBSTANCE ADDICTIONS ............................................................................... 13
THEORIES OF THE DEVELOPMENT OF SUBSTANCE ADDICTIONS ...................................... 15
NEUROBIOLOGICAL THEORIES .................................................................................................................. 16
EVOLUTIONARY PERSPECTIVE ................................................................................................................... 18
ADDICTION AS A PSYCHOLOGICAL SYMPTOM ............................................................................................ 18
FAMILY SYSTEMS PERSPECTIVE ................................................................................................................. 19
CHILD MALTREATMENT AND TRAUMA ....................................................................................................... 20
MULTIGENERATIONAL TRANSMISSION PERSPECTIVE ................................................................................. 21
PEER INFLUENCE ...................................................................................................................................... 21
NEIGHBOURHOOD .................................................................................................................................... 22
CRITICAL ADDICTION THEORY ................................................................................................................... 22
ATTACHMENT THEORY ...................................................................................................................... 23
ATTACHMENT AND ROMANTIC RELATIONSHIPS .......................................................................................... 25
ATTACHMENT THEORY AND SUBSTANCE ADDICTIONS ................................................................................. 27
DEFICITS IN SELF-REGULATION ................................................................................................................. 29
SELF-REGULATION AND ADDICTIONS ......................................................................................................... 30
CURRENT RESEARCH ON COUPLE THERAPY AND ADDICTION ........................................... 32
BEHAVIOURAL COUPLES THERAPY ............................................................................................................ 32
ALCOHOL BEHAVIOURAL COUPLE THERAPY (ABCT) PROGRAM ............................................................... 33
EMPIRICAL STUDIES .................................................................................................................................. 33
EMOTIONALLY FOCUSED THERAPY ........................................................................................................... 34
OTHER THERAPEUTIC MODELS .................................................................................................................. 36
RATIONALE FOR THE CURRENT STUDY: EFT WITH ADDICTIONS ................................................................. 37
CURRENT STUDY ................................................................................................................................... 40
EFT MODEL ............................................................................................................................................. 41
EFT AND ADDICTIONS ............................................................................................................................... 43
Intake ................................................................................................................................................... 43
STAGE ONE ............................................................................................................................................... 44
STAGE TWO ............................................................................................................................................... 44
STAGE THREE ........................................................................................................................................... 45
EFT: LIMITATIONS .................................................................................................................................... 45
METHODOLOGY .................................................................................................................................... 45
RESEARCH STRATEGY: REPLICATION CASE STUDY, MULTIPLE CASES ....................................................... 45
PARTICIPANT RECRUITMENT ..................................................................................................................... 46
PARTICIPANTS ........................................................................................................................................... 47
THERAPISTS AND SETTING ......................................................................................................................... 49
DATA COLLECTION ................................................................................................................................... 50
SELF-REPORT MEASURES .......................................................................................................................... 51

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RESEARCH PROCEDURES .......................................................................................................................... 53
DATA ANALYSIS ......................................................................................................................................... 53
POTENTIAL LIMITATIONS ................................................................................................................. 54
MANUSCRIPT OUTLINE ....................................................................................................................... 54
CONCLUSION .......................................................................................................................................... 55
REFERENCES .......................................................................................................................................... 57
MANUSCRIPT ONE: EMOTIONALLY FOCUSED THERAPY IN THE CONTEXT OF
ADDICTIONS: A REPLICATION CASE STUDY ............................................................................... 82
ABSTRACT ................................................................................................................................................ 83
INTRODUCTION ..................................................................................................................................... 84
LITERATURE REVIEW ......................................................................................................................... 84
EMOTIONALLY FOCUSED COUPLE THERAPY ............................................................................................. 85
EMOTIONALLY FOCUSED COUPLE THERAPY AND ADDICTION ..................................................................... 86
Steps and Stages .................................................................................................................................. 87
Figure 1. Emotionally Focused Therapy: Steps and Stages. .............................................................. 87
Objectives ............................................................................................................................................ 89
METHODOLOGY .................................................................................................................................... 90
RECRUITMENT .......................................................................................................................................... 90
INTERVENTION .......................................................................................................................................... 90
STUDY DESIGN .......................................................................................................................................... 91
PROCEDURE ............................................................................................................................................. 93
MEASURES ................................................................................................................................................ 93
RESULTS ................................................................................................................................................... 94
PARTICIPANTS ........................................................................................................................................... 94
COMPLIANCE ............................................................................................................................................ 96
STAGE ONE ............................................................................................................................................... 97
STAGE TWO ............................................................................................................................................. 102
STAGE THREE ......................................................................................................................................... 105
SELF-REPORT MEASURES: DESCRIPTIVE OUTCOMES .............................................................................. 107
THEMES .................................................................................................................................................. 109
DISCUSSION AND RECOMMENDATIONS ..................................................................................... 111
LIMITATIONS ........................................................................................................................................ 114
CONCLUSION ........................................................................................................................................ 114
REFERENCES ........................................................................................................................................ 116
CHAPTER ONE CONCLUSION .......................................................................................................... 122
MANUSCRIPT TWO: NAVIGATING RELAPSES IN COUPLE THERAPY FOR ADDICTIONS,
RESULTS FROM A CASE STUDY ...................................................................................................... 123
ABSTRACT .............................................................................................................................................. 124
INTRODUCTION ................................................................................................................................... 125
THE CHRONIC RELAPSING NATURE OF ADDICTION ................................................................................... 125
CLINICIAN ATTITUDES TOWARDS RELAPSE ............................................................................................... 127
MANAGING RELAPSE IN THERAPY ............................................................................................................ 128

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WORKING WITH RELAPSES IN THE CONTEXT OF COUPLES ........................................................................ 130
EMOTIONALLY FOCUSED COUPLES THERAPY FOR ADDICTIONS ................................................................ 133
Figure 1. Emotionally Focused Therapy: Steps and Stages. ............................................................ 134
METHODOLOGY .................................................................................................................................. 134
TABLE 1. UTTERANCES RELATED TO TOPIC OF SLIPS AND RELAPSES BY EFT STAGE ................................ 137
PARTICIPANTS ......................................................................................................................................... 137
REVIEW OF SLIPS AND RELAPSES AS THEY OCCURRED IN THE STUDY ........................................................ 139
DISCUSSION ........................................................................................................................................... 143
RECOMMENDATIONS ............................................................................................................................... 143
1. Create open dialogue around slips and relapses .......................................................................... 144
2. Allow couples to ascribe their own meaning to slips and relapses .............................................. 145
3. Provide ongoing psychoeducation on addiction ........................................................................... 147
4. Help the couple develop a relapse prevention plan and a relapse plan ....................................... 148
5. Use attachment language .............................................................................................................. 149
6. Respect the integrity of the couple and their desire to stay together in spite of an addiction ...... 149
CONCLUSION ........................................................................................................................................ 150
REFERENCES ........................................................................................................................................ 152
CHAPTER TWO CONCLUSION ......................................................................................................... 160
MANUSCRIPT 3: EXAMINING PERCEPTIONS OF POSITIVE OUTCOMES IN COUPLE
THERAPY IN THE CONTEXT OF SUBSTANCE ADDICTION .................................................... 161
ABSTRACT .............................................................................................................................................. 162
INTRODUCTION ................................................................................................................................... 163
COUPLE THERAPY OUTCOMES ................................................................................................................. 163
SUBSTANCE ADDICTION INDIVIDUAL TREATMENT OUTCOMES .................................................................. 164
OUTCOMES WITH COUPLES IN THE CONTEXT OF ADDICTION ................................................................... 166
CURRENT STUDY ..................................................................................................................................... 167
Figure 1. Emotionally Focused Therapy: Steps and Stages. ............................................................ 168
METHODOLOGY .................................................................................................................................. 168
PROCESS OUTCOME MEASURES .............................................................................................................. 169
QUANTITATIVE OUTCOME MEASURES ..................................................................................................... 170
PARTICIPANTS ......................................................................................................................................... 171
RESULTS ................................................................................................................................................. 172
OUTCOME MEASURES ............................................................................................................................. 172
Table 1. Dyadic Adjustment Scale Pre- and Post-Test Results ......................................................... 173
Table 2. Experiences in Close Relationships Scale Pre- and Post-Test Results ............................... 173
Table 3. Difficulties in Emotion Regulation Scale Pre- and Post-Test Results ................................ 174
PSRQ RESULTS ....................................................................................................................................... 174
Figure 2. Post Session Resolution Questionnaire Couple A ............................................................. 175
Figure 3. Post Session Resolution Questionnaire Couple B ............................................................. 175
Figure 4. Post Session Resolution Questionnaire Couple C ............................................................ 176
Figure 5.Post Session Resolution Questionnaire Couple D ............................................................. 176
BEST RATED SESSION- PSRQ ................................................................................................................... 176
LOWEST RATED SESSION- PSRQ .............................................................................................................. 177
SESSION ONE- PSRQ .............................................................................................................................. 177
SESSION SEVEN- PSRQ ........................................................................................................................... 179
SESSION FIFTEEN- PSRQ ........................................................................................................................ 180

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FINAL SESSION- PSRQ ............................................................................................................................ 182
DISCUSSION ........................................................................................................................................... 184
LIMITATIONS ........................................................................................................................................ 186
CONCLUSION ........................................................................................................................................ 187
REFERENCES ........................................................................................................................................ 188
DISSERTATION CONCLUSION ......................................................................................................... 193
REFERENCES ........................................................................................................................................ 197
APPENDIX A: RECRUITMENT POSTER ......................................................................................... 198
APPENDIX B: INFORMED CONSENT FORM ................................................................................. 199
Purpose of this Research Project ...................................................................................................... 199
APPENDIX C: DEMOGRAPHIC QUESTIONNAIRE ...................................................................... 202
APPENDIX D: DYADIC ADJUSTMENT SCALE .............................................................................. 203
APPENDIX E: EXPERIENCES IN CLOSE RELATIONSHIPS- RELATIONSHIP SPECIFIC .. 207
APPENDIX F: DIFFICULTIES IN EMOTION REGULATION SCALE ........................................ 211
APPENDIX G: UNDERSTANDING YOUR NEGATIVE CYCLE ................................................... 213
APPENDIX H: POST-SESSION RESOLUTION QUESTIONNAIRE ............................................. 214
APPENDIX I: TRAUMA SYMPTOM INVENTORY II .................................................................... 215

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Abstract

Substance addictions represent a serious social problem in North America, negatively
impacting family relationships and couple functioning. Research is increasingly considering the
potential for couple therapy as a model within this context. Using a replicated case study design,
this study explored a proposed theoretical extension of Emotionally Focused Couple Therapy
(EFT) in the context of substance addictions. Results are presented in a three-article manuscript.
The first article explicates the overall results of the study. Comparisons between the normative
EFT model and the theoretical extension are made, and recommendations are provided for
further adaptations to the model. The second article discusses the impact of substance relapses in
couple therapy and recommendations are made for addressing these occurrences in the context of
EFT. Finally, the third article assesses outcome interpretation in therapy for couples in the
context of addiction. Study outcomes are analyzed and compared with client interpretations of
outcome. Results from this study indicate the important place of couple therapy in addiction
treatment and provide important rationale for future research in this context.

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Résumé

La toxicomanie représente un problème social sérieux en Amérique du Nord qui a une
influence négative sur les relations familiales et le fonctionnement du couple. De plus en plus de
recherches considèrent le potentiel de la thérapie de couple comme une approche dans ce
contexte. À l'aide d'un modèle d'étude de cas répliqué, cette étude a exploré une proposition de
prolongation théorique de la thérapie de couple axée sur les émotions dans le contexte de
toxicomanie. Les résultats sont présentés ici dans un manuscrit de trois articles. Le premier
article explique les résultats généraux de l’étude. Des comparaisons entre le modèle normatif de
la thérapie de couple axée sur les émotions et la prolongation théorique sont faites. Des
recommandations sont également formulées pour de future adaptation du modèle. Le deuxième
article examine l’impact des rechutes sur la thérapie de couple. Des recommandations sont faites
pour aborder ces incidents dans le contexte d’une thérapie de couple axée sur les émotions.
Finalement, le troisième article s’appuie sur les résultats de l’étude de cas pour analyser
comment le succès est défini dans le traitement des dépendances et dans la thérapie de couple. La
diversité dans les définitions des résultats positifs du traitement était présente dans l'étude.
Certains couples se sont concentrés sur l'abstinence comme mesure du succès, tandis que d'autres
ont utilisé d'autres paramètres pour évaluer le succès. Les résultats de cette étude révèlent
l'importance de la thérapie de couple dans le traitement de la toxicomanie et fournissent une base
importante pour la recherche future dans ce contexte.

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Acknowledgements

I would like to acknowledge the FQRSC and the Faculty of Social Work for their
financial support throughout my PhD and this dissertation project.
The eight individuals who participated in this study made this study possible. They
enthusiastically committed to attending therapy. I was moved by how seriously they took the
process; their bravery in being recorded each week, and their desire to help other couples
living with substance addictions. I am very grateful and indebted to them for their
contributions.
I would also like to acknowledge and thank my committee members, Dr. Sharon Bond,
and Dr. Tom Brown for their thoughtful feedback and support over the past five years. I
would especially like to thank my supervisor Dr. Heather MacIntosh who was a constant
source of support and guidance throughout this process. Heather was a safe haven, and a
never-ending source of humour, and inspiration. Thanks Heather!
Thank you with all my heart to my colleagues Lise, Jen, Aline, Denise, Sonia, Shawn-
Renee, and Jaime. Thank you also to my U of R colleagues who have also been a wonderful
support during the final months of writing.
Thank you to my family for being encouraging of my never-ending student status, and
Miles and Monk for the constant snuggles and reminders that life shouldn’t be so serious.
Last, but by no means the least, my partner Daniel, my steadiest and most encouraging
cheerleader, I love you, thank you for everything.

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Preface and Contribution of Authors

This dissertation is original, independent work by the first author, Kara Fletcher and second
author, Heather MacIntosh. All three manuscripts have been submitted for publication
however they are currently unpublished. The research in this thesis is original scholarship and
aims to provide distinct contributions to knowledge on treating couples in the context of
addiction using a theoretical extension of Emotionally Focused Therapy.

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Introduction

Substance addictions represent a serious social problem in North America, negatively
impacting family relationships and couple functioning. Research is increasingly considering the
potential for couple therapy as a model within this context. Issues presented by an addiction can
be exacerbated by other issues present in a couple relationship. Using a multiple case replication
study design (Yin, 2009), this dissertation evaluated a proposed theoretical extension of
Emotionally Focused Couple Therapy (EFT) in the context of substance addictions. Comparisons
between the normative EFT model and the theoretical extension are made, overarching themes
are discussed, and recommendations are provided for further adaptation to the model. Results
from this study support continuing to evaluate EFT as a treatment model in the context of
addiction.
Substance addictions in the social context
In Quebec, 39.6% of the population reported they have suffered the negative
consequences of excessive drug or alcohol use by someone close to them (Kairouz & Nadeau,
2010). Substance addictions are seen to co-occur with and exacerbate numerous social problems
such as poverty, crime, and conjugal violence (Cunradi, Mair, Todd, & Remer, 2012). Studies
have found that drug and alcohol use are both independent predictors of intimate partner violence
(Moore & Stuart, 2004; Stuart, Moore, Kahler, & Ramsey, 2003). Substance abuse has also been
attributable to more than 80 disease conditions, reflecting a significant impact on the health care
system (Rehm et al., 2006).
Substance addictions in the individual context
In 2012, about 21.6% of Canadians (approximately 6 million people) met criteria for
having had a substance use disorder in their lifetime (Pearson, Janz, & Ali, 2013). A wide variety

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